Low-molecular-weight heparin for venous thrombosis in a neonate.
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Female↗
Biomedical subjects
A T Cohen
Publications and source records attributed to A T Cohen.
Fatal myocardial failure associated with a propofol infusion in a child.
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Child↗
Volumetric control of continuous haemodialysis in multiple organ failure.
A system for precise volumetric control of continuous haemodialysis and its use in providing renal replacement treatment in the intensive care unit to 10 children with multiple organ failure are described. The system, termed slow efficient dialysis, provided effective clearance of urea, creatinine, potassium, and phosphate. It provided precise control of the volume of ultrafiltrate removed in a prospective manner ('dial up' fluid balance) to reduce haemodynamic instability and fluid management problems. The ease of use of this system for intensive care nurses meant that the system ran without the assistance of a second intensive care or renal nurse.
Adolescent↗
A dose ranging study to evaluate dermatan sulphate in preventing deep vein thrombosis following total hip arthroplasty.
Dermatan sulphate catalyses thrombin inhibition by heparin cofactor II; it has a lower haemorrhagic to antithrombotic ratio than that of heparin in animal models. Consecutive patients aged forty years or more, electively undergoing total hip replacement under general anaesthesia, were randomly allocated to one of three dosage regimens of dermatan sulphate (MF701, Mediolanum Farmaceutici) given intramuscularly. These were 200 mg once daily (n = 50), 200 mg twice daily (n = 52) and 300 mg twice daily (n = 51), administered from twenty-four hours pre-operatively until the tenth postoperative day. The overall incidence of DVT assessed by bilateral venography was 53%, 51% and 34% respectively (Chi-square test for trend p = 0.06). The incidence of major proximal DVT was 10.6%, 8.5% and 2.1% respectively. Pulmonary embolism (PE) and bleeding were assessed in all 153 patients. There was one case of PE in each dose group. The incidence of bleeding episodes, volume of blood lost and blood transfusion requirements were low and showed no increase with increasing dose. The patients were followed up 4-8 weeks after discharge. We conclude that the two lower doses were subtherapeutic in this population, however dermatan sulphate given 300 mg twice daily, proved to be efficacious with an incidence of proximal major DVT of 2.1% and a low incidence of bleeding complications. A trial of dermatan sulphate 300 mg twice daily compared to standard prophylactic agents is needed.
Aged↗
The intensive care unit in paediatric oncology.
There were 70 admissions from a regional paediatric oncology centre to the intensive care unit over a six and a half year period. Patients were divided into those with systemic infections (n = 19), respiratory infections (n = 15), metabolic effects (n = 9), tumour mass effects (n = 10), neurological complications (n = 8), and others (n = 9). The overall survival was 51%. Patients admitted with metabolic or tumour mass related effects had the best prognosis with a survival of 84%. If dialysis is required in this group of patients then continuous arteriovenous haemofiltration is recommended. Patients with systemic or respiratory infections comprised the main poor prognosis group with a survival of 26%. For patients with a systemic infection who required ventilation, the mortality was 100%. The outlook for patients with a generalised encephalopathy was also poor, with no neurologically intact survivors. The median APACHE-II (acute physiology and chronic health evaluation) score for patients who died was 27 and for survivors was 16. There is a need for close cooperation between staff of intensive care and paediatric oncology units. Alternative treatments should be considered for patients with systemic infections who require ventilation.
Adolescent↗
Liver transplantation after paracetamol overdose.
OBJECTIVE: To evaluate the role of liver transplantation after paracetamol overdose. DESIGN: Prospective study of consecutive candidates for transplantation and performance of transplantation over 18 months. SETTING: Liver unit, King's College Hospital, London. MAIN OUTCOME MEASURES: Fulfilment of indicators of poor prognosis, selection for transplantation, transplantation, survival. RESULTS: 30 of 37 patients considered to have a reasonable prognosis with intensive medical care survived. Of 14 of 29 patients considered to have a very poor prognosis and registered for urgent liver transplantation, six received liver transplants, four of whom survived, while seven died and one survived without a transplant. Three of 15 patients with poor prognostic indicators but not selected for transplantation survived. CONCLUSION: Liver transplantation will have a definite but limited role in the management of fulminant hepatic failure induced by paracetamol.
Acetaminophen↗
Changes in intracranial pressure during haemofiltration in oliguric patients with grade IV hepatic encephalopathy.
Seven consecutive patients with grade IV hepatic encephalopathy, due to fulminant hepatic failure complicated by oliguric renal failure were allocated at random to treatment with daily machine haemofiltration (MHF) or continuous arteriovenous haemofiltration (CAVHF). Intracranial pressure (ICP) was continuously monitored using a subdural catheter. Four patients received 17 treatments by MHF, and ICP increased from 8.4 +/- 1.5 mm Hg (mean + SEM) prior to treatment to 12.6 +/- 1.8 mm Hg on completion (p less than 0.05). Active intervention was required on twenty occasions to treat sustained increases in ICP (greater than 25 mm Hg maintained for 5 min or longer). A total of 12 haemofilters were used in the treatment of 3 patients by CAVHF. The ICP showed greater stability during CAVHF therapy, the mean pressure prior to treatment was 15.6 +/- 5.2 mm Hg and fell to 11.7 +/- 2.3 mm Hg at 4 h. Sustained increases in ICP occurred in only 1 patient as a preterminal event. These findings suggest that CAVHF is the preferred method of treatment in patients with fulminant hepatic failure complicated by oliguric renal failure who are at risk of developing cerebral oedema.
Acute Kidney Injury↗
Changes in intracranial pressure during machine and continuous haemofiltration.
Nine consecutive patients with both fulminant hepatic failure and acute oliguric renal failure were treated either by daily machine haemofiltration (MHF), or by continuous arterio-venous haemofiltration (CAVHF). Six patients received a total of twenty treatments by MHF and four CAVHF, mean duration of treatment 56 hours, range 24-160. Intracranial pressure (ICP) was measured using a subdural catheter. During treatment with MHF, the mean ICP increased from 8.9 +/- 1.4 mmHg at the start of filtration to 14.8 +/- 2.1 mmHg at the end of treatment (p less than 0.05), whereas there was no corresponding increase during the same period of time with CAVHF treatment, the mean ICP fell, but not significantly from 19.4 +/- 4.8 mmHg to 11.2 +/- 2.3 mmHg. The mean ICP increased to greater than 25 mmHg on eleven occasions during treatment with MHF, requiring treatment with bolus mannitol or propofol, during the same period of treatment with CAVHF no such surges in ICP were recorded. This suggests that continuous haemofiltration is to be preferred to intermittent machine haemofiltration in the management of patients with acute hepatorenal failure.
Adult↗
Balloon dislodgment: a complication of attempted pulmonary artery catheterization.
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Catheterization↗
Adult respiratory distress syndrome--how many cases in the UK?
Previously reported figures for the incidence of Adult Respiratory Distress Syndrome, based largely on American results, would suggest that the average British Health District of 200,000 people could expect to see 130 cases per year. This figure is greatly in excess of that expected from our clinical experience. We have undertaken a retrospective survey of patients within a British Health Region (population, 3,599,400). Results indicate an incidence of nine for an average Health District of 200,000 population, or 2.5% of all admissions to intensive therapy units, or 0.045 per 1000 resident population.
Adult↗
Assessment of alfentanil by intravenous infusion as long-term sedation in intensive care.
The use of an alfentanil infusion for sedation of critically ill patients in intensive care was investigated in 16 patients who were entered consecutively into the study. The mean duration of stay was 8 days. Supplements of Diazemuls and muscle relaxants were administered if required. The success of the technique was judged by nursing and medical staff and, in particular, the wakefulness of patients was noted. No patient could recall events that occurred during their infusion. An outline protocol is described.
Adolescent↗
Closed-loop administration of atracurium. Steady-state neuromuscular blockade during surgery using a computer controlled closed-loop atracurium infusion.
The advent of newer muscle relaxants with predictable rates of metabolism and times of offset of neuromuscular blockade now makes it possible to use intravenous infusion safely as a mode of delivery. This has many advantages over administration by intermittent bolus. Moreover, it is feasible to use a servo system for their delivery. We have developed and evaluated such a system which is portable and requires little computer expertise to set up and use. It is a useful adjunct to routine anaesthesia, as well as a potentially powerful research tool.
Adolescent↗
Experience with alfentanil infusion as an intensive care sedative analgesic.
A sedative regimen for use in intensive care based on an i.v. infusion of alfentanil has been evaluated in 32 patients. The mean duration of stay was 7.7 days and the total dose of alfentanil given ranged from 7 to 2308 mg. Most patients required 2-3 mg h-1 of alfentanil supplemented with an hypnotic to provide sleep. The technique was judged successful and was well tolerated by patients. No significant side-effects were observed and the wakefulness of the patients was a prominent feature. Weaning from mechanical ventilation was performed while maintaining the infusion in a number of patients, and in these there was no prolonged respiratory depression.
Adolescent↗
A computer-controlled syringe driver for use during anaesthesia. A modification of the Graseby MS16A.
The requirements of a drug infusion device for use in theatre are discussed. A modification of the Graseby MS16A syringe pump and an interface circuit permitting its remote control by microcomputer are described. The pump is controlled via a standard computer interface (RS232) which makes it a unique and powerful research tool. Aspects of safety are considered.
Anesthesia, General↗
Measurement of oxygen uptake: a method for use during nitrous oxide in oxygen anaesthesia.
A new method for oxygen uptake (VO2) measurement based on a constant volume closed circuit is discussed. The accuracy of the method tested in the laboratory was demonstrated to be +/- 1.8% and estimated to be +/- 2.01% in clinical use during abdominal surgery. The 0-90% rise time of the measurement to step changes in VO2 was found to be 42 s, for a change of 15 ml min-1 with a lag time of less than 30 s.
Anesthesia↗
Anaesthesia for laparoscopy: alfentanil and fentanyl compared.
A double blind comparison was made between alfentanil and fentanyl as analgesic components of anaesthesia. Sixty-six women undergoing laparoscopy received methohexitone, alcuronium, nitrous oxide and oxygen, with either alfentanil 0.75 mg or fentanyl 0.25 mg. Ten of the patients who received alfentanil and 1 patient who received fentanyl required supplementation of anaesthesia by enflurane. Recovery from anaesthesia was similar in the two groups of patients though the onset of spontaneous breathing occurred more quickly after alfentanil (P less than 0.002). The injection of fentanyl was followed by a fall in BP (P less than 0.05) and the mean minimum value for pulse rate occurring after fentanyl was slower than after alfentanil (P less than 0.05).
Alfentanil↗
Intravenous anaesthesia for minor surgery. A comparison of etomidate or Althesin with fentanyl and alfentanil.
Eighty patients undergoing minor surgical procedures entered a randomized, double-blind, between-patient comparison of fentanyl or alfentanil, with etomidate or Althesin for induction and maintenance of anaesthesia. Patients were more likely to feel pain on injection when anaesthesia was induced using etomidate or fentanyl, than when Althesin or alfentanil were given. There was no difference between the four groups in respect of the ease of maintenance of anaesthesia. Recovery of consciousness was significantly faster in the patients who received alfentanil than in those who received fentanyl. Overall, alfentanil with Althesin was the best combination studied.
Adolescent↗
A versatile closed circuit.
A versatile closed circuit with new features is described. It may be used in a totally closed manner, without continuous gas inflow. As gas is absorbed from the circuit, it is replaced through a demand valve. Facilities for continuous gas input and use of a ventilator are included, and one control converts it to a non-rebreathing circuit. The circuit has excellent mechanical characteristics in all modes, and has been used extensively in routine clinical practice.
Adolescent↗