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Biomedical subjects

D J Muckart

Publications and source records attributed to D J Muckart.

At least 19 recordsLinked to original sources
PubMed2001

Ventilation and the critically ill parturient.

Positive-pressure ventilation is the keystone in the management of pulmonary dysfunction in the critically ill. An increased understanding of both the benefits and hazards has led to a general consensus regarding the optimal techniques to ensure adequate gas exchange. Unfortunately, the same cannot be said for ventilation terminology which, due to a lack of standardization, lends itself to confusion. Pulmonary dysfunction in the parturient may arise from thoracic or extra-thoracic pathologies but both may be defined as acute lung injury. In its most severe form this constitutes acute respiratory distress syndrome. Acute lung injury results in reduced lung compliance and a marked decrease in the volume of functional lung. Ventilation strategies are now designed to recruit as much available lung tissue as possible while simultaneously minimizing the injurious effects of alveolar over-distension. Upon resolution of the underlying pathology mechanical ventilation may be withdrawn. Recent evidence suggests that this final stage need not be protracted, and if certain criteria are fulfilled, rapid weaning is feasible.

Cricoid Cartilage↗
PubMed2001

Retroperitoneal haematoma and related organ injury--management approach.

Retroperitoneal haematoma following blunt or penetrating trauma may arise from injuries to bone, major vascular structures, hollow viscera or solid organs. Clinical significance varies from inconsequential to fatal. Although the guidelines for exploration are clear-cut during laparotomy for associated intra-abdominal injuries, this is not the case with isolated retroperitoneal haematoma. Lateral and pelvic haematomas may be selectively explored and central haematomas always need exploration. All penetrating wound tracts should be explored, irrespective of the site of the haematoma, to exclude vital structural injury.

Fractures, Bone↗
PubMed2000

Abdominal content containment: practicalities and outcome.

BACKGROUND: Alternatives to fascial closure of the abdominal wall are increasingly used in critically ill patients. They pose practical and logistical problems in management which are described in this single-institution study. METHODS: Between January 1994 and December 1997, 157 predominantly young male patients (100 trauma and 57 non-trauma) underwent temporary abdominal content containment (t-ACC) using plastic bags or polyglactin mesh. Indications for t-ACC were severe sepsis requiring reoperation, abdominal compartment syndrome, abdominal wall tissue loss or a combination of these. A total of 385 laparotomies were performed. RESULTS: Two t-ACC procedures failed owing to technical error and two were complicated by enteric fistulas. Six patients underwent early definitive abdominal closure within 15 days. The remaining survivors had a protracted hospital stay (mean(s.d.) 44.6(26.6) days) and all developed incisional hernias which were challenging to repair. The overall mortality rate was 44 per cent. CONCLUSION: Plastic bags were cheaper and as effective as polyglactin mesh for t-ACC. Survivors require a multidisciplinary approach in management, undergo a protracted hospital stay and later need complex incisional hernia repairs.

Abdominal Injuries↗
PubMed2000

Management of penetrating cervicomediastinal venous trauma.

OBJECTIVES: to evaluate the results of management of penetrating cervicomediastinal venous trauma. DESIGN: retrospective study. Materials forty-nine consecutive patients with cervical and thoracic venous injuries treated at a tertiary hospital between 1991 and 1997. Method patients identified from a computerised database and data extracted from case records. RESULTS: forty-five patients were male and the mean age was 25.3 years. Forty injuries were due to stabs and 9 to gunshots. 22 patients were shocked, 25 actively bleeding and 31 were anaemic. Veins injured were internal jugular in 25, subclavian in 15, brachiocephalic in 6, and superior vena cava in 3. Injured veins were ligated in 25 cases and repaired by lateral suture in 22. No complex repairs were performed. There were 8 perioperative deaths and 5 cases of transient postoperative oedema. Venous ligation was not associated with increased risk of postoperative oedema. CONCLUSIONS: ligation is an acceptable form of treatment of cervicomediastinal venous injuries in the presence of haemodynamic instability, or where complex methods of repair would otherwise be necessary.

Adult↗
PubMed2000

Intensive care unit morbidity and mortality from eclampsia: an evaluation of the Acute Physiology and Chronic Health Evaluation II score and the Glasgow Coma Scale score.

OBJECTIVE: To determine the maternal morbidity and mortality in patients with eclampsia admitted to an intensive care unit (ICU), and to establish the efficacy of the Acute Physiology and Chronic Health Evaluation (APACHE) II score, the organ system failure score as defined by Knaus, and the Glasgow Coma Scale (GCS) score in predicting outcome. DESIGN: Retrospective analysis of a 3.5-yr period. SETTING: Surgical ICU in a university hospital. PATIENTS: A total of 105 patients who were admitted with a diagnosis of eclampsia were studied. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The data captured included the reason for admission, maternal age, gestational age, parity, number of seizures, duration of ICU stay, anticonvulsant therapy, drug therapy, GCS score, APACHE II score, and the occurrence of organ failure. Of the 126 patients with eclampsia who were admitted to the ICU, records of 105 patients (83%) were found. The overall mortality was 10.5% (n = 11). The mean age, gestation, parity, number of preadmission seizures, and duration of stay were similar in survivors and nonsurvivors. Although the APACHE II score was significantly higher in nonsurvivors, multiple logistic regression analysis suggested that the goodness-of-fit scores for GCS and APACHE II were similar (38.29 vs. 38.01). The GCS scores of survivors were significantly higher than those of nonsurvivors (10.61 vs. 5.0; p<.001). Respiratory failure was the most common organ failure in both groups. The mean number of organ failures was higher in nonsurvivors compared with survivors (2.9 vs. 1.3; p<.001). An occurrence of more than two organ failures that persisted for >48 hrs was invariably associated with a fatal outcome. Anticonvulsant therapy consisted of magnesium sulfate or phenytoin and a midazolam infusion. Only one patient (0.9%) had a seizure, and this occurred en route to the ICU. No seizures occurred after admission to the ICU. CONCLUSIONS: The organ system failure score and the GCS score are good predictors of outcome in eclampsia. Apart from the GCS score, other variables in the APACHE II score are not valuable for outcome prediction. The low GCS score in nonsurvivors suggests that closer attention to the neurologic management may be beneficial. A prospective study is indicated to validate these findings.

APACHE↗
PubMed1999

Management of sympathetic overactivity in tetanus with epidural bupivacaine and sufentanil: experience with 11 patients.

OBJECTIVE: To determine the efficacy and safety of epidural bupivacaine and sufentanil for the management of sympathetic overactivity in tetanus. DESIGN: Retrospective case review. SETTING: Sixteen-bed surgical intensive care unit in a tertiary care centre. PATIENTS: All patients referred to the unit during a 63-month period with the diagnosis of tetanus were included in the study. MEASUREMENTS AND MAIN RESULTS: All patients (n = 11) had severe tetanus and developed sympathetic overactivity, which was managed by epidural blockade. Three patients died, but there were no fatalities directly attributable to sympathetic overactivity. Before epidural blockade, the average difference between the mean maximum and mean minimum systolic blood pressures was 78 +/- 28 (so) mm Hg. After blockade, this difference was reduced to 38 +/- 15 (so) mm Hg (p < .0001). Similar significant reductions in diastolic blood pressure and heart rate were observed. The mean hourly infusion doses of bupivacaine and sufentanil were 17 mg and 21 microg, respectively. Midazolam was the principal adjunctive sedative agent and was used in all patients (mean dose, 9 mg/hr). Additional pharmacologic agents were necessary in two patients in whom epidural blockade alone was insufficient to control sympathetic overactivity. One patient developed renal failure and there were no instances of pneumothorax. One patient developed an epidural abscess of probable hematogenous origin, which was successfully treated without neurologic sequelae. CONCLUSIONS: Epidural blockade is effective in controlling sympathetic overactivity and the associated complications (renal failure, cardiac injury, and sudden death). Although a serious complication occurred in one patient, the efficacy of the technique deserves further validation.

Adolescent↗
PubMed1999

Universal primary colonic repair in the firearm era.

All patients with colonic trauma treated at King Edward VIII Hospital, Durban, from August 1993 to May 1994 underwent primary repair of the colonic wound. They were evaluated prospectively to assess the mode of injury and outcome variables. Colonic injuries were sustained by 102 patients. These were inflicted by gunshots (62), stabs (22), shotguns (14), and blunt trauma (4). The transverse colon was injured most frequently (53). All shotgun injuries were multiple. Average time from admission to theatre was similar for shocked and non-shocked patients. Eighty-seven patients had simple closure (18 deaths) and 15 required resection and anastomosis (eight deaths). Ten patients died in the first 48 h, and 16 died subsequently owing to multiple-organ systems dysfunction. The mortality rates were stabs 9% (2), gunshots 27% (17), shotguns 50% (7), and 0% for blunt trauma. Septic morbidity was seen in 16 but was not related to breakdown of the colonic repair. Implementation of strategies to reduce preoperative time delays and use damage control principles for the management of massive trauma should be evaluated as methods of reducing mortality.

Adolescent↗
PubMed1999

Inferior vena caval injury in the firearm era.

BACKGROUND: This study compared the outcome of intra-abdominal caval injuries in the current era of firearm injuries with the outcome during the previous era of stab wounds. METHODS: Patients with intra-abdominal vena caval injuries treated at King Edward VIII Hospital, Durban, from December 1990 to December 1995 were reviewed. This group was compared with a similar cohort reviewed a decade earlier. RESULTS: The historical group consisted of 28 patients and the current group of 26 patients. Modes of injury in the historical group were: stabs (15, 53%), firearm injuries (7, 33%), blunt trauma (4, 14%) and iatrogenic injuries (2, 7%). Modes of injury in the current group were: stabs (5, 19%), firearm injuries (17, 65%) and blunt trauma (4, 16%). Mortality rose from 35.7% in the historical group to 88% in the current series. This mortality figure included 5 patients who died later from complications of the associated injuries. CONCLUSIONS: Firearm injuries are more destructive than stab wounds. The increase in firearm injuries partly explains this higher mortality. However, the failure to apply current concepts of abbreviated laparotomy and damage control combined with excessive delays in transferring patients to theatre have contributed to this high mortality.

Adolescent↗
PubMed1998

Patterns of injury and white cell response in critically ill trauma patients who present with leucopenia.

The outcome of critically ill trauma patients who presented to the intensive care unit with leucopenia (total peripheral white cell count < 4 x 10(9)/1) was studied prospectively with respect to the total white cell and neutrophil response. A total of 105 patients, of whom 30 were leucopenic, were admitted to the ICU during a 4-month period. The prevalence of leucopenia was significantly higher in patients with gunshot wounds (P < 0.05) and hollow visceral intra-abdominal injury (P < 0.001). Eight (27%) of the leucopenic patients died. No significant difference was found in initial mean total white cell or neutrophil count, or in the differential percentages, between survivors and non-survivors. The total peripheral white cell count increased significantly in survivors compared with non-survivors (P < 0.001), and significant differences were found in absolute neutrophil counts and differential percentages by days 5 and 10 (counts P = 0.01, P < 0.02; differentials P < 0.01, P < 0.01). These results suggest that granulocyte colony-stimulating factor may have a role in the treatment of trauma patients with persistent neutropenia following intra-abdominal hollow visceral injury.

Female↗
PubMed1998

Superior vena caval thrombosis complicating central venous catheterisation and total parenteral nutrition.

Although venous thrombosis is a common sequela of central venous catheterisation, the vast majority of patients remain asymptomatic. Possible aetiological factors include catheter material, catheter-related sepsis, endothelial trauma, osmotic injury, and hypercoagulable states. Of these, only the first and last have been proven to increase the incidence. Thrombosis of the great veins of the thorax is a rare but life-threatening complication and the diagnosis is suggested by swelling of the head, upper limbs, and torso. Mediastinal widening on plain chest radiography may precede these signs. Confirmation of thrombosis is best achieved using contrast venography or contrast-enhanced CT scan. Acute symptomatic thrombosis is probably best treated by thrombolytic agents, but anticoagulation remains the commonest therapeutic approach.

Adult↗
PubMed1997

Does HIV status influence the outcome of patients admitted to a surgical intensive care unit? A prospective double blind study.

OBJECTIVES: (a) To assess the impact of HIV status (HIV negative, HIV positive, AIDS) on the outcome of patients admitted to intensive care units for diseases unrelated to HIV; (b) to decide whether a positive test result for HIV should be a criterion for excluding patients from intensive care for diseases unrelated to HIV. DESIGN: A prospective double blind study of all admissions over six months. HIV status was determined in all patients by enzyme linked immunosorbent assay (ELISA), immunofluorescence assay, western blotting, and flow cytometry. The ethics committee considered the clinical implications of the study important enough to waive patients' right to informed consent. Staff and patients were blinded to HIV results. On discharge patients could be advised of their HIV status if they wished. SETTING: A 16 bed surgical intensive care unit. SUBJECTS: All 267 men and 135 women admitted to the unit during the study period. INTERVENTIONS: None. MAIN OUTCOME MEASURES: APACHE II score (acute physiological, age, and chronic health evaluation), organ failure, septic shock, durations of intensive care unit and hospital stay, and intensive care unit and hospital mortality. RESULTS: No patient had AIDS. 52 patients were tested positive for HIV and 350 patients were tested negative. The two groups were similar in sex distribution but differed significantly in age, incidence of organ failure (37 (71%) v 171 (49%) patients), and incidence of septic shock (20 (38%) v 54 (15%)). After adjustment for age there were no differences in intensive care unit or hospital mortality or in the durations of stay in the intensive care unit or hospital. CONCLUSIONS: Morbidity was higher in HIV positive patients but there was no difference in mortality. In this patient population a positive HIV test result should not be a criterion for excluding a patient from intensive care.

APACHE↗
PubMed1997

American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference definitions of the systemic inflammatory response syndrome and allied disorders in relation to critically injured patients.

OBJECTIVES: To determine the frequency of the proposed definitions for the systemic inflammatory response syndrome (SIRS), sepsis and septic shock, and to further define severe SIRS and sterile shock as determined at 24 hrs of admission to an intensive care unit (ICU) in critically ill trauma patients without head injury, and their relationships to mechanism of injury, Acute Physiology and Chronic Health Evaluation (APACHE) II score, risk of death, Injury Severity Score (ISS), number of organ failures, and mortality rate. DESIGN: Prospective, inception cohort analysis. SETTING: Sixteen-bed surgical ICU in a teaching hospital. PATIENTS: Four hundred fifty critically injured patients without associated head trauma. Penetrating trauma accounted for 70% (gunshot 202; stab 113) and nonpenetrating trauma for 30% (motor vehicle collision 103; blunt 32) of admissions. Three hundred ninety-four (88%) patients underwent surgical procedures. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Infective and noninfective insults were distinguished by the need for therapeutic or prophylactic antibiotics, respectively, based on an established antibiotic policy. Three hundred ninety-five (87.8%) patients fulfilled a definition of the SIRS criteria. The frequency of the definitive categories was SIRS 21.8%, sepsis 14.4%, severe SIRS 8.4%, severe sepsis 13.6%, sterile shock 9.3%, and septic shock 20.2%. Patients with penetrating trauma had a significantly higher frequency of sepsis, severe sepsis, and septic shock (p < .01). The APACHE II score, risk of death, and number of organ failures increased significantly in both infective and noninfective groups with increasing severity of the inflammatory response. Sterile shock was associated with a significantly higher APACHE II score (p < .02), risk of death (p < .01), and number of organ failures (p = .03) compared with septic shock. Only sterile shock was associated with a significantly higher ISS (p < .01). Organ system failure was significantly (p < .001) higher in nonsurvivors compared with survivors in all categories. The only significant (p < .001) difference in mortality rate was found between patients in shock and all other categories. CONCLUSIONS: The current definitions of SIRS, sepsis, and related disorders in critically injured patients without head trauma show a significant association with physiologic deterioration and increasing organ dysfunction. The only significant association with mortality, however, is the presence of shock. The definitions require refinement, with the possible inclusion of more objective gradations of organ system failure, if they are to be used for stratifying severity of illness in seriously injured patients.

APACHE↗
PubMed1997

Validation of an outcome prediction model for critically ill trauma patients without head injury.

BACKGROUND: The Acute Physiology and Chronic Health Evaluation (APACHE) II system is inaccurate in predicting the risk of death in trauma patients, especially those without head injury. Using multivariate analysis of the APACHE II system in a development set, a new predictive equation was modeled. The four variables that were independently associated with mortality were PaO2/FiO2 ratio, mean arterial pressure, temperature, and the need for inotropic support. This model was tested prospectively in an independent validation set of 300 patients. METHODS: Risk of death was calculated using the APACHE II system with the diagnostic category of multiple trauma and weighting for operative intervention as required. The new model was similarly assessed using the four predictor variables and their beta-coefficients for each mechanism of injury and the entire group. The predicted risk of death derived by both models was compared with the observed mortality rate. Discrimination was calculated using a 2 x 2 decision matrix with a decision threshold of r = 0.5 and receiver operating characteristic curves. Calibration was assessed graphically and by statistical correlation. RESULTS: The observed mortality rate was 28.3% and the predicted mortality risk was 27.4% for the model and 6.26% for APACHE II. The sensitivity and specificity of the model were 58.8 and 90.7%, and the sensitivity and specificity of APACHE II were 1.2 and 100%. The areas under the receiver operating characteristic curves were 0.84 and 0.78 for the model and the APACHE II system, respectively. Calibration of the model was superior within all deciles of risk (model, R2 = 0.93, p < 0.001; APACHE II, R2 = 0.82, p = 0.02). CONCLUSION: The model accurately predicted the risk of death for the entire group. It is superior to the APACHE II system and is the highest reported sensitivity for 24-hour intensive care unit predictive models that have been applied to the critically injured.

APACHE↗
PubMed1997

Obstetric and gynaecological patients in an intensive care unit: a 1 year review.

Management of the critically ill patient forms a significant proportion of obstetric and gynaecological (O & G) practice. There have however, been very few reports on the management of such patients in intensive care units (ICU). We review all O & G patients admitted to the surgical ICU at King Edward VIII Hospital, Durban, South Africa, and make recommendations regarding management of such patients. The medical records of all O & G patients admitted to the surgical ICU between the period January-December 1992 were analysed. Of all admissions to the ICU 13.6% (n = 122) were O & G patients. Eclampsia was the most common diagnosis accounting for 66% of all obstetric admissions. Of all eclamptics in the study period 24% were admitted to the ICU. The overall maternal mortality was 21%. O & G patients form a major workload of surgical ICUs and the majority of these patients are women with eclampsia. Management of such patients requires an understanding of the physiological changes of normal and abnormal pregnancies. Therefore, all large obstetrical units in developing countries should establish their own ICU in order that patient care, health personnel training and continuing health care education may be improved.

Adolescent↗
PubMed1997

Review of 1198 cases of penetrating cardiac trauma.

BACKGROUND: This study was a clinicoforensic analysis of the prevalence and outcome of traumatic cardiac injuries in Durban. METHODS: Between 1990 and 1992, 1198 patients sustained cardiac trauma. Seventy (6 per cent) reached hospital alive and 1128 (94 per cent) were taken directly to the mortuary. Seven hundred victims had suffered stab wounds, 494 gunshot wounds and four blast injuries. Gunshot injuries increased from 34 per cent in 1990 to 50 per cent in 1992. The mean (s.d.) age was 30.5 (5.4) years and the majority (91 per cent) were men. RESULTS: Thirty-five (50 per cent) of those who reached hospital alive died, including all four gunshot victims. Significant factors associated with survival were isolated injury, the presence of cardiac tamponade (univariate and multivariate analysis), right ventricular injury, single cardiac chamber injury and absence of pleural breach (univariate analysis alone). Delay in operative intervention was associated with a higher mortality rate. When analysing the patients who did not reach hospital alive, 202 (18 per cent) with tamponade due to an isolated stab wound were identified as a subset who might have been saved with prompt treatment. CONCLUSION: An increasing number of gunshot injuries in combination with delays in reaching hospital and in receiving treatment accounted for the high mortality rate in this unselected series.

Adolescent↗
PubMed1996

Prediction of the risk of death by APACHE II scoring in critically ill trauma patients without head injury.

The ability of the Acute Physiology And Chronic Health Evaluation (APACHE) II scoring system to predict outcome in 199 critically ill patients with trauma but without head injury was assessed prospectively over an 8-month period. Some 178 patients (89.4 per cent) underwent operation and 50 (25.1 per cent) died, 44 after operation and six without undergoing surgery. The mean(s.d.) APACHE II score was 8.0(5.2) for survivors and 14.5(5.5) for non-survivors (P < 0.001). In patients who underwent surgery the mean(s.d.) scores were 7.7(4.6) and 13.4(5.5) (P < 0.001) and for those managed without operation 11.1(7.2) and 14.7(6.3) (P = 0.31) in survivors and non-survivors respectively. The predicted risk of death and observed mortality rate were 5.1 and 25.1 per cent respectively for the entire group, 5 and 25 per cent for patients undergoing surgery, and 7 and 29 per cent for those not operated on. Although the APACHE II system correctly identified all survivors (specificity 100 per cent), it failed to predict death in any patient (sensitivity 0 per cent). The results suggest that this objective prognostic scoring system is not applicable to the patient with trauma who does not have concurrent head injury.

APACHE↗