Dysphagia in Older Adults and Its Management
K. Rao Poduri in Geriatric Rehabilitation, 2017
The ultimate goal of any dysphagia assessment tool or method is to determine the best path for managing symptoms and rehabilitation. Over the years, the risks associated with aspiration and aspiration pneumonia have driven facilities to require that dysphagia assessments primarily focus on a patient’s safety for oral intake. Previously, the determination of aspiration often led to patients being npo (nil per os, a medical recommendation to withhold all oral foods and liquids). Feeding tubes (percutaneous endoscopic gastric [PEG] tubes or gastric [G] tubes) were then placed in patients, as alternative forms of nutrition to minimize the risk of oral aspiration. Often older adults with dementia, who lived in institutional settings and were diagnosed with dysphagia, had feeding tubes placed as a means to promote nutrition and prevent aspiration. However, there is evidence now that feeding tubes do not eliminate the risk of aspiration as patients can aspirate oral, nasal, and pharyngeal secretions that can result in pneumonia. In addition, oral care may be neglected when a patient has a feeding tube. Poor oral hygiene can lead to pneumonia as a result of aspiration of pathogen-laden oral secretions. In a study on the risk factors for aspiration pneumonia, researchers found that the strongest predictor of aspiration pneumonia was dependence on others for feeding and oral care (19).
Management of Acute Intestinal Ischaemia
Peter Sagar, Andrew G. Hill, Charles H. Knowles, Stefan Post, Willem A. Bemelman, Patricia L. Roberts, Susan Galandiuk, John R.T. Monson, Michael R.B. Keighley, Norman S. Williams in Keighley & Williams’ Surgery of the Anus, Rectum and Colon, 2019
The management of colonic ischaemia depends on the acuity and severity of the disease, but the main stay initially is hydration/resuscitation. As noted previously, most cases of colonic ischaemia are self-limited and require no specific treatment. Because the underlying aetiology is often multifactorial, it may be prudent to ensure that the management of coexisting medical problems is optimised. Any patient with peritonitis or evidence of gangrene or perforation should be taken immediately to the operating room for an exploration and possible bowel resection. Otherwise, the main stay of therapy is supportive treatment and correcting any possible contributing factors. Patients should be made nil per os (NPO) and given intravenous fluids. The administration of broad-spectrum intravenous antibiotics is also recommended as it may help prevent bacterial translocation and subsequent sepsis. A nasogastric tube should be placed in patients with abdominal distention or signs of adynamic bowel. Alternatively, a rectal tube may be placed to provide colonic decompression. It is important to avoid the use of vasopressors that may further decrease mesenteric blood flow.
Better System Performance
Paul Batalden, Tina Foster in Sustainably Improving Health Care, 2022
In 2009, the Northern New England Cardiovascular Disease Study Group adopted a goal of reducing the incidence of contrast nephropathy among its 10 participating centers.10 A key component of this effort was understanding the fivefold variation in incidence across these centers, ranging from a low of 1.9% to a high of 10.1%. Site visits, structured focus groups and local process exploration was undertaken. These revealed marked differences between centers that had a uniform approach to prevention (mandatory protocols and use of prophylactic measures) compared with those that had a nonuniform approach (case-by-case model for prevention). The two centers with a uniform approach led the region with the lowest rates of contrast nephropathy. Both had developed and reliably used mandatory protocols to manage blood volume and to limit the duration of nil per os orders, allowing better patient self-hydration at home prior to the procedure. The remaining eight centers with a nonuniform approach had wide variation in the use of prophylactic measures such as circulating blood volume expansion. In contrast to the centers with lower rates of nephropathy, these centers more commonly restricted fluid intake prior to the procedure for a longer period of time (from 10 p.m. or midnight the night before) resulting in a higher likelihood that patients were volume depleted when they presented for the procedure. The full comparison of centers, data, and appendices can be viewed online.11
Assessment of knowledge, attitude and practice of nurses regarding enteral nutrition at a military hospital
Published in South African Journal of Clinical Nutrition, 2023
Londolani Ramuada, Lizl Veldsman, Nedzingahe Livhuwani, Renée Blaauw
Factors contributing to worsening nutritional status during hospitalisation include the patient’s primary diagnosis (e.g. cancer), loss of appetite, increased nutritional requirements, and immobility resulting in a loss of lean body mass.7 In addition are nil per os status, and interruptions to feeding due to medical and surgical procedures.8 The lack of nutritional screening on hospital admission, unavailability of feeding protocols and the limited number of nutritionist/dietitian posts available at healthcare facilities may further contribute to the development and worsening of hospital malnutrition.2,9 The impact of malnutrition is associated with a longer hospital stay, increased risk for acquired hospital infection, poor prognosis and increased mortality.4
A rare case of intraductal tubulopapillary neoplasm of the pancreas – case report (with video)
Published in Postgraduate Medicine, 2020
Ankit Dalal, Gaurav Patil, Amol Vadgaonkar, Amit Maydeo
Patient was managed conservatively with nil per os, intravenous fluids, and analgesics. He was planned for an EUS guided fine needle aspiration and if need be an Endoscopic retrograde cholangiopancreatography (ERP). A linear echoendoscope was used to perform the EUS, Pancreatic parenchyma appeared heterogeneous with peripancreatic inflammatory stranding and PD was dilated measuring 11.3 mm. A large 1.2 × 1.6 cm hypoechoic lesion in the PD was noted in the head region causing upstream dilatation (Figure 2). Lesion did not show any vascularity on Doppler. Fine-needle aspiration was taken from the intraductal lesion during EUS and sent for HPE which was reported as paucicellular nondiagnostic aspirate. Aspirated ductal fluid showed a CEA of 26.3ng/ml and amylase of 68,814 U/L. ERP was performed which showed a dilated MPD with a filling defect in the head region. After performing a pancreatic sphincterotomy, pancreaticoscopy was done using SPYGLASS DS system (Figure 3). It showed a nodular intraluminal lesion in the head region with irregular and abnormal vascularity and papillary fronds. Biopsies were taken from this lesion using SpyBite biopsy forceps. A 5F pancreatic stent was placed.
Intraoperative presentation of an undiagnosed tracheoesophageal fistula in an adult without history of abdominal or thoracic surgery
Published in Baylor University Medical Center Proceedings, 2023
Jim Z. Sheng, Christopher B. Adcock, James D. Haddad, Samuel H. Dunn, Enas Kandil, Tarek Sawas
A 41-year-old woman with type 2 diabetes, end-stage renal disease on dialysis, and necrotizing soft tissue infection of her foot that extended to her groin presented to the operating room for irrigation and debridement of her left lower extremity and sacral wound. She had been on supplemental tube feeds via a Dobhoff tube due to poor oral intake and malnutrition. In the operating room, she was noted to have a mild nonproductive cough but otherwise normal lung exam and x-ray findings. She had pulse oximetry readings of 100% while breathing air. Due to delays in the operating room schedule, she had been made nil per os for over 24 hours before surgery, including tube feeds. The case began uneventfully with intravenous induction and intubation with a 6.5 mm endotracheal tube (ETT) via direct laryngoscopy without difficulty. Halfway through the case, the patient was turned from supine to right lateral position to access her sacral eschar.
Related Knowledge Centers
- Acute Pancreatitis
- Aspiration Pneumonia
- Gastrointestinal Bleeding
- Parenteral Nutrition
- General Anaesthesia
- Ileus
- Oral Administration
- Preoperative Fasting