BACKGROUND:Malnutrition is particularly prevalent among intensive care unit (ICU) patients, being associated with poor clinical results. Enteral nutrition (EN) offers multiple benefits on critically ill patients and its monitoring was established by the Spanish Society of Critical Care (SEMICYUC) as a clinical quality indicator (CQI; EN patients correctly monitorized / all EN patients, as %). However, no results have been published on its regulated monitoring.OBJECTIVES:Assessing CQI's compliance, identifying difficulties and possibilities for its use.METHODS:In a recent 18-month period, the CQI was assessed in ICU patients following SEMYCIUC criteria.RESULTS AND CONCLUSION:This CQI, although offered as a unique indicator, has different components, giving rise to multiple results. The settled standard (100%) was only reached by some of these components, i.e.: feeding tube position control plus verification of vomiting, regurgitation and aspiration. We propose to elaborate a daily checklist, including the different components that integrate this CQI, for its joint completion by nurses and physicians for all patients receiving EN.

Introducción. La desnutrición, es particularmente prevalente en Unidades de Cuidados Intensivos (UCI), asociándose con malos resultados clínicos. La nutrición enteral (NE) presenta múltiples beneficios en pacientes críticos y su monitorización ha sido establecida por la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) como indicador clínico de calidad (ICC; pacientes con NE correctamente monitorizados / todos los pacientes con NE, en %). Sin embargo, no se han publicado resultados sobre su monitorización reglada. Objetivos. Evaluar el cumplimiento del ICC “monitorización de la NE” identificando dificultades y posibilidades para su utilización. Metodología. Durante 18 meses, el ICC fue monitorizado en pacientes de UCI según criterios de SEMICYUC. Resultados y discusión. El ICC, aunque se presenta como único, tiene múltiples componentes, originando múltiples resultados difíciles de compilar. El estándar establecido (100%) sólo fue alcanzado en control de la sonda y verificación de vómitos, regurgitación y broncoaspiración. Proponemos elaborar un listado de verificación diaria, incluyendo todos los aspectos contemplados, para su puesta en común entre los estamentos médico y de enfermería, para cada paciente con NE.

Introduction: Malnutrition is particularly prevalent in Intensive Care Units (ICU) and associated with poor clinical outcomes. Enteral nutrition (EN) has multiple benefits in critically ill patients, particularly when started early at the ICU. A series of studies corroborate this fact; however, other studies present conflicting results. Objective: To assess the clinical results of ICU patients receiving EN, according to EN starting time (early versus late). Patients and method: Basic variables were recorded in all ICU patients who received NE along the study period, as well as time from ICU admission to the start of EN, ICU length of stay, characteristic gastrointestinal complications of EN (gastric residue, constipation, diarrhea, vomiting, regurgitation, abdominal distension and bronchoaspiration) and mortality. Results: There was a significant association between early EN and mortality reduction. However, there were no differences in ICU length of stay according to EN starting time. The most frequent complications in the sample were high gastric residue (17.9%), abdominal distension (22.5%) and constipation (42.2%). However, no significant differences were observed as a function of the EN starting time. Discussion: Our results, although discrepant at times, do not contradict with those of other studies. EN has shown to be effective as a therapeutic strategy. Therefore, it is recommended the early start of EN in the ICU.

Background: First experiences in the operating theatre with real patients are always stressful and intimidating for students. We hypothesized that a game-like simulation could improve perceptions and performance of novices.Methods: A videogame was developed, combining pictures and short videos, by which students are interactively instructed on acting at the surgical block. Moreover, the game includes detailed descriptive information. After playing, students are given feedback on their performance. A randomized controlled trial was conducted with 132 nursing and medical students with no previous experience in surgery. Sixty two (47.0%) were allocated to a control group (CG) and 70 (53.0%) to an experimental group (EG). Subjects in EG played the game the day prior to their first experience in the theatre; CG had no access to the application. On the day after their experience at surgery, all students filled in a questionnaire in a 7-point Likert format collecting subjective data about their experience in the surgical block. Four constructs related to students' feelings, emotions and attitudes were measured through self-reported subjective scales, i.e. C1: fear to make mistakes, C2: perceived knowledge on how to behave, C3: perceived errors committed, and C4: attitude/behaviour towards patients and staff. The main research question was formulated as follows: do students show differences in constructs Cl C4 by exposure to the game?Results: EG reported statistically significant higher scores on the four aspects measured than CG (p < 0.05; Mann-Whitney U tests; Cohen's d standardized effect size d1 = 0.30; d2 = 1.05; d3 = 0.39; d4 = 0.49).Conclusions: Results show clear evidence that the exposure to the game-like simulation had a significant positive effect on all the constructs. After their first visit to the theatre, students in EG showed less fear (C1) and also perceived to have committed fewer errors (C3), while they showed higher perceived knowledge (C2) and a more collaborative attitude (C4).

BACKGROUND Early enteral nutrition (EN) offers multiple benefits on critically ill patients and its monitoring was established as a clinical quality indicator (CQI) for intensive care units (ICU) by the Spanish Society of Critical Care (SEMICYUC). However, no results have been published on the systematized monitoring of this CQI. OBJECTIVE To assess the compliance of the CQI "Early EN" at ICU. METHODS A retrospective longitudinal study was conducted on 386 consecutive ICU patients receiving EN. Data were collected including time from admission until EN was started, as well as clinical results. SPSS statistics software was used for analysis and the CQI was assessed according to SEMYCIUC criteria. RESULTS AND CONCLUSION CQI's compliance was 70.2%, not reaching the settled standard of 100%. Barriers preventing CQI compliance ought to be analyzed and its standard of 100% reconsidered.

Introducción. La nutrición enteral (NE) precoz presenta múltiples beneficios en pacientes críticos y su monitorización ha sido establecida por la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) como indicador clínico de calidad (ICC) para unidades de cuidados intensivos (UCI). Sin embargo, no se han publicado resultados sobre la monitorización reglada de dicho indicador. Objetivo. Evaluar el cumplimiento del ICC NE precoz. Metodología. En 386 pacientes consecutivos de UCI que recibieron NE, se recogieron variables básicas, número de horas transcurridas desde el ingreso hasta instaurarse la NE y resultado clínico de los pacientes. Para el análisis estadístico se empleó el software SPSS Statistics y el ICC fue evaluado mediante criterios de SEMICYUC. Resultados y discusión. El cumplimiento del ICC fue del 69%, no alcanzando el estándar establecido (100%). Es necesario analizar las barreras que impiden el cumplimiento del estándar de este ICC y reconsiderar su valor del 100%.

En agosto de 1976, un joven llamado LeRoy cayó desde una cornisa fracturándose el fémur. Se sospechó una hemorragia interna importante. Durante una laparotomía se comprobó que todos los órganos internos estaban intactos y los cirujanos ortopédicos arreglaron la fractura. Treinta días después, LeRoy murió. Había comido poco; diariamente, tan solo había recibido tres litros de la glucosa, el equivalente a 510 calorías, por vía intravenosa. La glucosa fue insuficiente para satisfacer sus necesidades nutricionales,perdiendo más del 20% de su peso corporal durante su estancia en el hospital. La causa de la muerte se debió a "desnutrición médicamente inducida". Mientras tanto, un artículo científico documentó que la prevalencia de desnutrición en los hospitales de Boston era del 44% y que la desnutrición en sí era un predictor de altas tasas de complicaciones y muerte. Como resultado, los médicos sensibilizados formaron una sociedad que creó programas de formación y alentó la formación de equipos de nutrición en los hospitales. La industria comercializó fórmulas de nutrición y catéteres. Las complicaciones en enfermos hospitalizados cayeron en picado, mientras que las tasas de supervivencia aumentaron. California aprobó una legislación para regular el soporte nutricional. Aunque la industria de la atención sanitaria reconoce la importancia de la nutrición en los cuidados al paciente, el Congreso no proporcionó apoyo fiscal para los equipos de nutrición. Como resultado, los hospitales disolvieron sus equipos de nutrición de reciente creación. La educación y las habilidades en nutrición disminuyeron, y las complicaciones hospitalarias y las tasas de mortalidad aumentaron de nuevo. "No hay nadie más ciego que el que no quiere ver" Matthew Henry Clergyman 1662-1714.

The inflammatory response related to surgery is a systemic reaction considered as the expression of three overlapping trophic phases during which the oxygen consumption progressively increases. However, surgical inflammation could induce old functions in which life on the Earth has based on the expression of two hypothetical extraembryonic trophic axes i.e. coelomic-amniotic and trophoblastic-yolk sac related, when integrated in the interstitium of the injured tissues and organs to induce a gastrulation-related phenotype. This later phenotype would repair the tissues by fibrosis and/or regeneration. A coupling of this recapitulated extraembryonic axis would cause hyperacute or acute-on-chronic inflammation or sepsis. The mechanisms of this systemic inflammatory response could be reminiscences of some phylogenetic mechanisms that ultimately would favor a metabolic cross-talk between the eukaryotic cell and gut microbiome. These ontogenic and phylogenic hypotheses of the surgical inflammatory and septic responses could open new research pathways about the ancient co-evolution of humans with their microbiota.

Backgound Pneumoperitoneum may occur following colonoscopy that may be accompanied by perforation of the colon. Most of these cases are managed by emergency surgery. However, this attitude may result in an unnecessary surgery. Cases report Two demonstrative cases of post-colonoscopy pneumoperitoneum are reported. In both cases the pneumoperitoneum appeared a few hours after uncomplicated colonoscopy plus polipectomy without clinical or laboratory evidence of peritonitis. In the first case, since perforation was suspected, a laparotomy was performed that turned out to be an unnecessary procedure. Moreover, pneumoperitoneum recurred and was satisfactorily treated by paracentesis. In our second case, conservative management under close observation was chosen and the patient made an uncomplicated recovery. Conclusion Our experience, which coincides with others’, suggests that in absence of peritoneal irritation, a conservative management should be chosen. However, if the patient deteriorates with conservative management, one should proceed to surgery.

Tetrapyrrole molecules are distributed in virtually all living organisms on Earth. In mammals, tetrapyrrole end products are closely linked to oxygen metabolism. Since increasingly complex trophic functional systems for using oxygen are considered in the post-traumatic inflammatory response, it can be suggested that tetrapyrrole molecules and, particularly their derived pigments, play a key role in modulating inflammation. In this way, the diverse colorfulness that the inflammatory response triggers during its evolution would reflect the major pathophysiological importance of these pigments in each one of its phases. Hence, the need of exploiting this color resource could be considered for both the diagnosis and treatment of the inflammation.

AIM: To describe our method of transcylindrical cholecystectomy（TC） and its potential advantages over other surgical approaches for treating symptomatic gallstones.METHODS: TC is a modified minilaparotomy performed gas-free through a single cylinder 3.8 cm（or occasionally 5.0 cm） in diameter and 10.0 cm in length. An efficacy, prospective and longitudinal study was conducted. Experience was accumulated over 15 years（1993-2008） and 387 operations, showing the feasibility and safety of TC. Since 2008, we have performed TC under local anesthesia plus sedation in most cases of symptomatic cholelithiasis.RESULTS: Between 1993 and 2008, TC was carried out in 364 consecutive patients, including 78 acute cholecystitis, 37 acute biliary pancreatitis and 48 suspected choledocholithiasis. In another 23 patients（5.9%）, the operation was converted into a subcostal laparotomy. Ten postoperative complications（2.75%） were registered in this series: 5 wound infections, 2 bile leaks（onecausing death）, 2 hemorrhages（requiring reoperation） and 1 residual stones. Since 2008, TC was planned and started under local anesthesia plus sedation in 60 patients. In another 12 patients（16.7%）, the operation was decided, started and completed under general anesthesia. Surgery was satisfactorily completed through the cylinder in all patients of this series. In 13 patients（out of 60; 21.7%）, local anesthesia was converted to general anesthesia. Among patients whose operation was attempted under local anesthesia（n = 60）, postoperative complications were: 1 wound infection（1.7%）, 2 wound seromas（3.3%） and 3 nauseas（5%）. All but two patients in this series were discharged from hospital on the day of surgery and all patients were satisfied with the procedure. In our experience using TC, we have not had any cases of main bile duct injury.CONCLUSION: TC should be considered in the search for the best alternative in the management of gallstone disease, deserving its inclusion in prospective randomized trials.

Pancreaticoduodenal artery aneurysms (PDAAs) are uncommon. The treatment and prognosis for ruptured PDAAs have changed in recent years. A demonstrative case is reported. A review of the literature has been made and the case of a healthy man operated on an emergency basis because of a massive hemoperitoneum secondary to a ruptured PDAA is reported and analyzed with regard to the clinical presentation, radiologic findings, management, and outcome. A bleeding point was not detected at operation. An intraoperative arteriogram did not show active bleeding. The pancreas appeared infiltrated and oozing blood. The abdomen was gauze packed and the patient transferred for endovascular therapy (ET). Then, an arteriogram showed a bleeding PDAA. After embolization, bleeding ceased and the patient recovered. According to our literature survey, less than 200 cases of true and false PDAAs have been reported. For ruptured PDAAs, surgery is associated with high mortality since the bleeding point is usually not identified at operation. Similarly, intraoperative arteriograms are often fruitless due to the patient's poor hemodynamics plus suboptimal quality of the portable equipment. As shown in the present case and according to the specialized medical literature, ET has often been successful in the management of these patients and may be chosen as a first option for the treatment of ruptured PDAAs.

Background Laparoscopic cholecystectomy (LC) has become the standard for treatment of uncomplicated cholecystolithiasis. However, in cases of cholecystitis or cholecysto-choledocholithiasis, technical and skill requirements may make questionable the convenience of laparoscopy. Transcylindrical cholecystectomy (TC) is a modified mini-laparotomy, performed gas-free through a single cylinder 3.8 cm in diameter and 10.0 cm in length. Our study objective has been to assess the efficacy and potential advantages of TC in the treatment of cholelithiasis, cholecystitis, and cholecholithiasis through an efficacy, prospective, and longitudinal study.Method TC was carried out in 364 consecutive patients including 78 acute cholecystitis, 37 acute biliary pancreatitis, and 48 suspected choledocholithiasis. Transcystic cholangiography was selectively attempted in 74 patients (20.3%) and successfully obtained in all but one patient. Twenty-six patients (7.1%) underwent transcylindrical common duct exploration (and calculi removal) through a choledochotomy.Results Operation was converted into subcostal laparotomy in other 23 patients (5.9%). In our series, there were no injuries to the main bile ducts or hemorrhagic accidents. Operating times in minutes (SD) were (i) "simple cholecystectomy'' without cholangiography n = 237: 43.5 (13.3), with cholangiography n = 30: 64.2 (20.7), (ii) "cholecystitis'' n = 78: 66.2 (28.7), and (iii) "choledocholithiasis'' n = 26: 117.0 (24.6). Postoperative complications for the respective patients in groups i, ii, and iii were (a) wound infection: 5 (1.9%), 0 and 0; (b) bile leaks: 2 (0.75%; one causing death), 2 (0.75%) and 0; (c) reoperation for bleeding: 1 (0.4%), 0 and 1 (3.8%); and (d) residual stones in the main bile ducts: 0, 0 and 1 (3.8%).Conclusion TC has been proved to be applicable, efficient, and safe for the treatment of cholelithiasis and its complications.

Background and study aim: The practice of laparoscopic cholecystectomy under local anesthesia is almost anecdotal. For 15 years we have been using a "transcylindrical cholecystectomy" technique for the treatment of cholelithiasis, cholecystitis, and choledocholithiasis. The present study was undertaken to assess the feasibility of transcylindrical cholecystectomy under local anesthesia through a prospective and longitudinal efficacy study.Patients and methods: Transcylindrical cholecystectomy is performed gas-free through a single cylinder 3.8 cm in diameter and 10.0 cm in length. In 60 patients suffering from cholelithiasis (mean age 52.6 years, range 31-83 years; men/women 13/47; body mass index 29.6 kg/m(2), range 24-44 kg/m(2)), transcylindrical cholecystectomy was planned and started under local anesthesia. Patients were reviewed 5 days after surgery; pain was assessed using a visual analog scale (VAS) and procedure satisfaction was assessed following completion of a patient questionnaire.Results: Surgery was satisfactorily completed through the cylinder in all patients. In 13 patients (21.7 %) local anesthesia was converted to general anesthesia due to technical difficulties in 11 patients (two related to patient body volume), respiratory depression in one patient, and poor patient tolerance in one patient. Postoperative complications were: wound infection (n = 1, 1.7 %), wound seromas (n = 2, 3.3 %), and nausea (n = 3, 5%). After surgery, only three patients experienced pain at rest with VAS values of 0.5, 1.5, and 2.9, respectively. All but two patients were discharged from hospital on the day of surgery, and all patients were satisfied with the procedure.Conclusions: Transcylindrical cholecystectomy under local anesthesia is a feasible technique that builds on the benefits of laparoscopic cholecystectomy, and confers an economic advantage and improved safety for patients.

After more than two decades of nutritional awareness, we designed a prospective study to determine whether malnutrition is still a significant issue in hospitalized patients. Patients admitted to an intensive care unit (ICU) were divided into well-nourished and malnourished groups, according to their nutritional status as assessed by serum albumin level and weight/height ratio. Severity of illness, as assessed by the Therapeutic Intervention Scoring System (TISS), was used to further stratify the study population. All patients were followed clinically until discharge or death and their outcome recorded. Of 129 patients studied, 43% were malnourished. Length of hospital stay (p = n.s.), incidence of complications (p < 0.01), and number of patients not discharged from hospital (p < 0.05) were greater in the malnourished patients than in the well-nourished. In patients with less severe degrees of illness, the existence of malnutrition led to a worse outcome than in sicker patients. To further assess the clinical setting in which hospital-related malnutrition develops or is exacerbated, postoperative patients admitted to the ICU (n = 66) were also studied in a nutritional survey; the results of this survey indicate that: (a) the incidence of malnutrition in the surgical population is similar to that in the whole study population, and (b) hospital-related malnutrition in surgical patients mainly develops during their preoperative stay in general wards. Whereas our conclusion that patients' outcome is adversely affected by a poor nutritional status is not new or startling, malnutrition continues to be a persistent problem in hospitalized patients, which can be readily identified using simple and easily available indices and, furthermore, readily treated.

The effects of a continuous intragastric (via a gastrostomy) and intravenous (via an indwelling jugular catheter) infusion of 3% ethanol at 3 ml/h on food intake was examined in rats randomly assigned to a two period crossover study. The 3% ethanol solution provided 19 kcal/day, which was equivalent to about 50% of the daily caloric intake of the rats. Ethanol significantly decreased food intake irrespective of the route administered. But, reduction in food intake did not result in a calorie-to-calorie compensation. Instead, providing 50% of calories as 3% ethanol via the intragastric route led to a 16% reduction in food intake, while only a 9% reduction in food intake occurred when the 3% ethanol solution was given intravenously.

We compared spontaneous caloric intake (SCI) of rats exclusively receiving chow to SCI of rats given the choice of chow or Parmesan cheese, and then examined the influence of parenteral feeding on SCI and food selection. Six rats in a Chow Diet Group were offered Purina chow for 21 days, while five rats in a Choice Diet Group were offered Parmesan cheese or the same chow. Daily SCI (kcal/day) and body weight gain (BWG; g/day) were determined. Rats in the Choice Diet Group ate twice as much cheese as chow for the first 3 days of the experiment. Thereafter, SCI and BWG became comparable in both groups, with no significant differences for the rest of the study. In another group of nine rats, a central venous catheter was inserted. After 7 days, rats were offered chow and water ad libitum during the infusion of normal saline at 3 ml/hour for 3 days (Saline). Then, normal saline was replaced by a total parenteral nutrition (TPN) mixture of glucose, fat, and amino acid providing 85 kcal/day, and rats were randomized to eat either Chow Diet or Choice Diet. In both groups, SCI during TPN was significantly reduced as compared to the SCI on Saline. However, rats in the Choice Diet Group ate three times more chow than cheese during TPN. We conclude that a) food preference can increase SCI for short periods of time; b) TPN reduces SCI; c) TPN modifies food preference; and d) food preference does not increase SCI during TPN.

A series of experiments were performed to determine which components of total parenteral nutrition (TPN) reduce spontaneous food intake (SFI) and to what degree. In Experiment 1, rats were infused with TPN (15% dextrose + 5% fat + 4.3% amino acid) or with one of its three components given independently at the final concentration of TPN for 3 days via an intravenous (iv) catheter. Each solution, at 3 ml/hr, provided a different amount of calories (TPN = 85, dextrose = 37, fat = 36, and amino acid = 12 kcal/day), representing about 120, 50, 50, and 20% of the rat's spontaneous caloric intake, respectively. TPN, dextrose, and fat significantly reduced SFI compared to the infusion of normal saline; however, amino acid failed to reduce SFI. Experiment 2 was carried out to investigate the relative contributions that pre- and postabsorptive mechanisms make in the regulation of SFI. Each rat in four different groups was infused with one of four isocaloric nutrient solutions through an iv catheter and a gastrostomy (ig) for separated periods of time. Nutrient solutions at 3 ml/hr provided each 32 kcal/day (50% of requirements): 13% dextrose, 4.5% fat, 11.4% amino acid, and a mixture (6.4% dextrose + 1.6% fat + 1.7% amino acid). Each solution, either iv or ig, reduced SFI compared to normal saline infused via the same route. However, neither the route of administration nor the nature of different nutrients caused significant differences in SFI reduction.

The purpose of this experiment was to determine the disposition ofd-tagatose, under development as a low-calorie sweetener, in conventional and germ-free male rats. One group of conventional rats was fed a diet containingd-tagatose (100 g/kg) mixed with the nonpurified diet (900 g/kg) for 28 days. Then, [U-14C]-labeledd-tagatose was administered as a single dose (approximately 220–380 kBq) to 4 of these adapted rats, as well as to 15 conventional and germ-free rats with no prior exposure (i.e., unadapted) tod-tagatose. Eleven of the 19 dosed animals (4 adapted conventional, 3 unadapted conventional and 2 unadapted germ-free, all dosed orally, plus 2 unadapted conventional dosed intravenously) were placed in metabolism chambers and samples of CO2, urine, and feces taken at regular intervals. At termination, a complete material balance was obtained based on the recovery of14C. Over the 6-h digestive period,d-tagatose was metabolized to release 39.9 and 13.9% of the oral dose as CO2in the adapted conventional rats and in the unadapted germ-free rats, respectively. Total releases approximated 68 and 22%, respectively. The difference in CO2evolution is ascribed to microbial fermentation ofd-tagatose in the gut of the conventional rats. The role of adaptation was confirmed by finding 93% lessd-tagatose in the feces of the adapted conventional rat than in the feces of the unadapted conventional rat. The intestinal absorption ofd-tagatose in the rat is estimated to be 20%. The results demonstrate thatd-tagatose is metabolized primarily by microorganisms in the gut of the rat, with an upper limit between 15 and 20% of oral dose metabolized by the host.