Preventing hospital malnutrition: a survey on nutritional policies in an Italian University Hospital

BACKGROUND

A proper strategy for fighting hospital malnutrition should include nutritional screening of all hospitalized patients, adequate utilization of the Hospital facilities - such as Clinical Nutrition Services or Nutrition Teams - and an adequate algorithm for the adoption of proper nutrition support (oral, enteral or parenteral) with proper timing. The main aim of the present study was to investigate the current policies of different non-intensive wards of our institution (a 1100 beds University Hospital) in terms of prevention of hospital malnutrition.

METHODS

We conducted a one-day survey to verify the current policies of nutritional screening and the indication to nutritional support in adult patients, interviewing nurses and physicians of our non-intensive hospital wards.

RESULTS

A total of 29 wards were considered, which sum up to 755 hospitalized patients. We found that nutritional screening at admission is routinely assessed only in 41% of wards and that oral nutrient intake is controlled regularly only in 72%. Indication to clinical nutrition support and specifically to artificial nutrition is not consistent with the current international guidelines. Only 14% of patients were receiving artificial nutrition at the moment of the survey and the majority of them were given parenteral nutrition rather than enteral feeding.

CONCLUSION

Our survey confirmed that in large hospitals the main barriers to the fight against hospital malnutrition are the lack of knowledge and/or commitment by nurses and physicians as well as the lack of well-defined hospital policies on early nutritional screening, surveillance of nutritional status and indication to nutrition support.

Blood from the right atrium may provide closer estimates of mixed venous saturation than blood from the superior vena cava. A pilot study

BACKGROUND

As a rule, central venous catheters (CVC) should not be positioned in the right atrium (RA) to avoid the risk of perforation and cardiac tamponade. However, in ICUs where ECG monitoring can detect any initial damage of the atrial wall, CVCs may probably be safely positioned in the RA. We investigated whether mixed venous saturation (SvO2) was better estimated by measuring central venous saturation (ScvO2) in the RA or in the superior vena cava (SVC) in patients undergoing cardiac surgery.

METHODS

A CVC and a pulmonary artery catheter (PAC) were positioned before surgical coronary revascularization in sixty patients. Under transesophageal echocardiographic guidance, CVC tips were randomly positioned inside the RA (group A) or the SVC (group C). In each patient, eight pairs of blood samples were collected from CVC and PAC distal ports and saturation measured. Cardiac arrhythmias that occurred in the first 48 postoperative hours and CVC tip position on chest X-rays were also registered.

RESULTS

ScvO2 and SvO2 correlated better in group A (r=0.95) than in group C (r=0.84). The 95% interval of confidence of the gap between ScvO2 and SvO2 was narrower in group A (-6.9/+ 3.2 vs. -11.6/+5.5; p<.01). The incidence of arrhythmias was equal in the two groups (16.7%). On chest X-rays, CVC tips were 5.4 (SD=3.6) cm below the tracheal carina in group A and 5.3 (SD=3.9) cm in group C.

CONCLUSION

In monitored patients, positioning CVC tips in the RA rather than in the SVC may allow closer estimates of SvO2 and may be safe. Yet, safety should be confirmed by further studies with larger samples of patients.

Diurnal and nocturnal shifts do not influence non-invasive ventilation outcome

AIM

The aim of this study was to assess if diurnal or nocturnal shifts were independent risk factors for non-invasive ventilation (NIV) failure.

METHODS

This was an observational study carried out on 18 patients of the general Intensive Care Unit in Rome. A total number of 189 consecutive patients needing mechanical ventilation for respiratory failure were prospectively enrolled: 82 were treated with NIV as a first line intervention. Of the 107 patients who were initially intubated, 59 patients were extubated; once extubation failed they were treated with NIV. NIV failure was assessed during both the day (between 7 am and 10 pm) and night shifts (between 10 pm and 7 am).

RESULTS

Of the 141 total patients who received NIV, 51 experienced failure during the day shifts and 18 during the night shifts. No difference in the median day and night shift TISS-28 values were observed in any patients who failed NIV during both day and night shifts. Causes of NIV failure were similar during both diurnal and nocturnal shifts. The inability to correct gas exchanges was the main reason for failure.

CONCLUSION

In a center with NIV expertise, notwithstanding nurse understaffing, diurnal and nocturnal shifts did not affect the rate of NIV failure.

Enoximone in cardiac arrest caused by propranolol: two case reports

We report two clinical cases of cardiac arrest, the former due to an adverse effect of intravenous (i.v.) propranolol in a patient with systemic sclerosis, the latter from a propranolol suicidal overdose. In both cases, conventional advanced life support (ALS) was ineffective but both patients eventually responded to the administration of enoximone, a phosphodiesterase III (PDE III) inhibitor. After the arrest, both patients regained consciousness and were discharged home. The chronotropic and inotropic effects of PDE III inhibitors are due to inhibition of intracellular PDEIII and are therefore unaffected by beta-blockers. These cases suggest that PDEIII inhibitors may be useful in restoring spontaneous circulation in cardiac arrest associated with beta-blocker administration when standard ALS is ineffective.

Injury of the vertebral artery after closed head trauma

Two case reports characterized by the complete occlusion of the basilar artery, secondary to dissection of the vertebral artery after closed head trauma are described. These lesions, often clinically silent in the beginning, were able to cause severe neurologic impairment, even after minor head trauma in healthy individuals without predisposing structural disorders. Early detection, based upon the knowledge of the modality of the trauma and upon a correct diagnostic approach, is mandatory to reduce secondary injury. The authors suggest an extensive use of cerebral angiography or angio-magnetic resonance in all cases where clinical conditions are more severe than the computed tomography scan, particularly if the trauma produced a cervical injury with a movement of flexo-extension of the neck. Therapeutic management is discussed. Anti-coagulants, thrombolytic agents or surgical ligation of the vessel has been proposed to prevent the extension of the lesion and to improve the outcome.

[Spontaneous subarachnoid hemorrhage: risk factors]

The precursive factors to SAH are classified into congenital, familial, intrinsic and extrinsic, pointing out the association between cerebral aneurysms and collagenopathies, genetic transmission disease, aneurysm features, habits and systemic disease.

Quantitative cerebral blood flow and metabolism determination in the first 48 hours after severe head injury with a new dynamic SPECT device

OBJECTIVE

To determine cerebral blood flow (CBF) and metabolism in the acute phase after severe head injury by a new dynamic SPECT device using 133Xenon and to evaluate a possible role of CBF and metabolism in the determination of prognosis.

DESIGN

Prospective study.

SETTING

General intensive care unit in a universitary teaching hospital.

SUBJECTS

23 severely head injured patients having CT scan and CBF determination, intracranial pressure (ICP) and jugular bulb oxygen saturation monitoring in the first 48 hours.

MEASUREMENTS AND MAIN RESULTS

CBF varied from 18.0 to 60.0 ml/100 g/min. No correlation was found between early CBF and severity of trauma evaluated with the Glasgow Coma Score (GCS) (F = 2.151, p = 0.142) and between CBF and prognosis at 6 months evaluated with Glasgow outcome score (GOS) (F = 0.491, p = 0.622: rs = 0.251, p = 0.246). CMRO2 was depressed in relation to the severity of injury, specifically ranging from 0.9 +/- 0.5 ml/100 g/min in patients with GCS 3 to 1.7 +/- 0.8 ml/100 g/min in patients with GCS 6-7. In no patient with CMRO2 less than 0.8 ml/100 g/min was a good outcome observed. A significant correlation was found between GCS and GOS (rs = 0.699, p = 0.0002), between CMRO2 and GOS (F = 4.303, p = 0.031; rs = 0.525, p = 0.013) and between AJDO2 and GOS (F = 3.602, p = 0.046; rs = 0.491, p = 0.017). Fronto-occipital ratio (F/O) of CBF distribution was significantly lower than normal values (chi 2 = 18.658, p = 0.001) but did not correlate either with prognosis (chi 2 = 1.626, p = 0.443) or with severity (chi 2 = 1.913, p = 0.384).

CONCLUSIONS

CBF in the first 48 hours after trauma varies within a large range of values and is not correlated with severity and prognosis. Clinical evaluation with GCS and CMRO2 are much more reliable indicators of severity of head trauma and have a significant role in the determination of prognosis. F/O ration is significantly altered from normal values confirming "post-traumatic hypofrontalism" but does not correlate with severity and prognosis.