No abstract

Although a neurological examination is fundamental to the evaluation of comatose patients, it is less reliable in a medically induced coma. A commonly misinterpreted finding in patients in a pentobarbital coma is altered pupillary reactivity secondary to an exaggerated ciliospinal reflex. Recognizing an exaggerated ciliospinal reflex in patients in a pentobarbital coma is important and may prevent unnecessary intervention. We present a patient induced in a pentobarbital coma for the treatment of status epilepticus who exhibited a nonreactive pupil secondary to an exaggerated ciliospinal reflex confirmed by pupillometry. We also discuss the anatomy of the ciliospinal reflex and literature regarding its clinical relevance.

Appropriate nutritional support is the standard of care for hospitalized patients. Total parenteral nutrition has evolved as a distinct therapeutic reality within the past decade for patients with appropriate indications including but not limited to non/dysfunction of the gastrointestinal tract. Starvation/malnutrition historically associated with prolonged hospital stay and protracted illness course can be somewhat addressed successfully. Though it is a well-established fact that current TPN techniques can be both safe and effective if used with due caution, the prevention and awareness of potential complications must be considered. Changes in technique are to be anticipated as advancement of knowledge and improvement and innovation in materials ensues. The current effectiveness and safety of TPN, particularly in comparison to enteral feeding and the clinical situations most appropriate for nutrition support have been the topic of ongoing discussion. Innovative strategies such as supplementation of TPN with medium-chain triglycerides, glutamine or branched-chain amino acids have been compared with standard treatments. Increasing efforts are being made to mitigate the adverse effects associated with TPN such as hyperglycaemia, central venous catheter infection, and hepatic dysfunction. This review focuses on these issues as addressed by the recent literature.