DOWNSIDE OF HOSPITAL ADMISSIONS

Having discussed the metabolic requirments of surgical patients we pass on to
the downside of hospital admissions.

HOSPITAL INFECTIONS

1. Hospitals and Nursing Homes being the location for disease
care become hazardous location for Hospital infections.
The principal sources of bacterial transmission are:
a) The patients and relatives coming to hospitals
b) The hospital staff/doctors Nurses and Orderlies harboring bacteria
c) The hospital wards furniture, bedding, and air, lead to transmission in the ward.
d) Instrument, dressing, and equipment, if not decontaminated and sterilized can lead to infection.

Nosocomial (Hospital) infections also occur in hospitals
because of :
a) Debilitated state of surgical patients and
b) Because of physical entry into the body for invasive procedures ie,
-Entry to veins for iv feeding,
-Endotracheal intubation,
-Urethral catherisation and
-Implantation of devices

2. MEASURES TO PREVENT NOSOCOMIAL (Hospital) INFECTION
In case of out break of hospital infection the following are the
sources that need attention regular surveillance and infection
prevention rules need to be out lined and observed by the
hospital staff.
2.1 PATIENTS

The patients harbour bacteria in their nasal passages and
throats.
Wound infection discharges from sinuses and fistulae can also be a sources of infection.
These patients must be identified and isolated and treated to
prevent cross infection to other patients and hospital staff.

2.2 DOCTORS, NURSES AND ORDERLIES
In cases where hospital infection rate exceeds 2-5%, the source
must be looked for.
Hospital staff may also harbour bacteria in
nasal passages and throat or in minor skin infections and the
causative bacteria may be resistant forms since antibiotic are
freely available and used in patient care in the hospitals.
These staff must be withdrawn from ward and OT duties till
treated
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CENTRAL VENOUS ACCESS

INSERTION OF CENTRAL VENOUS INFUSION CATHETER

Insertion of intravenous catheter through the subclavian
Vein.
The patient is placed on his back in a 15 degree head-down
position with a small pad placed bwtween the shoulder blades to
allow the shoulders to drop posteriorly.
- The skin is scrubbed with ether or acetone to clean the surface
and then with an iodophor compound.
- Drapes are used and scrupulous aseptic precautions are observed.
- Local anaesthetic is infiltrated.
- A 2" long, 14-gauge needle attached to a small syringe is
inserted.
- With slight negative pressure applied to the syringe, entry
into the vein is confirmed by the appearance of blood.
- A 16-gauge, 8 or 12 in radioopaque catheter is then introduced
through the needle and threaded into the superior vena cava.
- The catheter is connected to a sterile intravenous
administration tubing and a slow infusion is started while the
catheter is sewn to the skin With a small synthetic suture.
This catheter can be used for parenteral feeding.
This method of intravenous vein access is also required in cases
of SHOCK for quick and effective delivery of fluids and blood to
treat shock.
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LONG TERM FEEDS

6.4 PARENTERAL ALIMENTATION
Parenteral alimentation involves the continuous infusion of a
Hyper-osmolar solution containing carbohydrates, proteins, fats
and other necessary nutrients.
Delivered through an indwelling catheter, inserted into the superior vena cava.

Intravenous Hyper-alimentation is indicated in patients with
* high alimentary tract obstruction gastric carcinoma
* pyloric obstruction, surgical patients with prolonged
paralytic ileus or
* adult patients with functional gastrointestinal disorders
and malignancy.

HOME BASED TPN(Total parenteral Nutrition)
Patients can be discharged, nutrient support continued at home if needed.

Hickman/Broviac cuffed polyurethane catheters Fig 5.3 make it
possible to deliver TPN at home.
Subcutanous implantable systems Fig 5.4 are also advocated to achieve this objective

The information provided in the text of this
section should be adequate to identify the guiding principles for
the fluid electrolyte and nutritional requirements of different
surgical patients.

Definitions


Hyper-alimentation
This is the introduction of large amount of calories either by a
tube (in the unconscious patient) or small intestines if the GI
tract is functioning.
If not special calories containing fluids can be introduced intravenously, this required when the GI tract
is diseased.

Total Parenteral Nutrition
In case of disease of gastro intestinal tract the nutrition of
the patient has to be maintained entirely through the intravenous
route.
Special preparations are available to supply all nutrients
(fats, proteins, carbohydrates) to meet calorie requirements.
Micro-nutrients are also provided.
This is total par-enteral nutrition.

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FEED AND TREAT

SPECIAL enteral FEEDS




Glutamine

Glutamine is as a source of energy for enterocyte.
Glutamine causes a small positive change in nitrogen balance.
In stress and marrow transplants, glutamine shortens hospital stay,and limits infection.

Polymeric feeds

These are made from proteins and 2.5L of this feed can provide
2500 Kcal of energy.
Some recent products also contain fibre to take care of constipation, or diarrhoea complained of by the patients.

Elemental Feeds

These feeds contain pre-digested protein (peptides and amino-
acids).
They are expensive unpalatable (can only be used for
tube feeds).
They may be of value in patients with pancreatic
insufficiency.

Disease specific
These have selected amino acids for specific disease needs e.g/
Glutamine feeds, this non essential amino acid is of value in
renal ammonia genesis, and also as energy substrate for enterocytes,
lymphocytes, and other rapidly dividing cells.

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