Right sided circulatory failure (RSCF), a common complication after left ventricular assist device (LVAD) implantation, results in decreased systemic output due to diminished blood flow across the pulmonary vasculature. The authors hypothesized that creation of a venoarterial shunt (VAS) would decompress the right-sided circulation and improve systemic pressure and perfusion with significant arterial desaturation. An experimental model was created in which RSCF was induced acutely in a large animal (n = 6) by beta-blockade after LVAD placement. After VAS creation, hemodynamic and blood gas determinations were performed to compare non shunt and shunt states. After induction of heart failure after LVAD placement, VAS resulted in a 22% elevation in systemic blood pressure (p < 0.0001), a 36% elevation in cerebral blood flow (p = 0.02), and an 18% decrease in right sided filling pressures (p = 0.08). Systemic pH and aortic oxygen saturation remained unchanged from baseline. In a large animal model of RSCF after LVAD implantation, VAS improves systemic hemodynamics without a significant cost in arterial oxygenation to critical organs and without creating acid-base imbalance. Beside implementation, adjustable capabilities, easy removal and salutatory hemodynamic effects suggest that VAS may serve as a first line, short-term therapy for LVAD recipients who develop perioperative RSCF.

Acute Disease↗

PubMedDate not supplied

Practical aspects of enteral nutrition in the management of Crohn's disease.

BACKGROUND: Enteral nutrition regimens achieve remission from active Crohn's disease at rates comparable to steroids and total parenteral nutrition. Despite their increasing use there has to date been no assessment of patient tolerance or practical difficulties involved. METHODS: We investigated 147 treatments with elemental diet in 89 patients and followed this with an anonymous questionnaire. RESULTS: Sip feeding was successfully introduced in 85% with nasogastric feeding being necessary in 22 (15%). Nausea and postural hypotension were common in the first week of treatment but vomiting was only seen in three patients who were sensitive to the formula used. Two patients each had caffeine withdrawal symptoms and hypoglycemia and a further four had food-related night terrors. Our experience suggests that caution is necessary if this treatment is used in elderly subjects. Although the diets are perceived as being unpalatable, only six patients found taste to be a problem after the first week of treatment. The main problem with long-term treatment was the large daily volume requirement, which was overcome by increasing the concentration of the feed. Eighty percent of patients responded to the questionnaire, and 65% stated that they would opt for treatment with elemental diet again in the case of a further relapse. CONCLUSIONS: Elemental diet seems to be an acceptable and well-tolerated form of treatment in Crohn's disease.

Adult↗

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