Biomedical subjects
Publications and source records attributed to D P Breen.
A literature review of first seizures in adults was performed and a management algorithm was constructed. This review highlights the importance of a thorough history and examination, routine biochemistry and haematology, an electrocardiogram, selected neuroimaging, discharge planning with driving and lifestyle advice, and follow-up in a specialist clinic.
BACKGROUND: There are scarce data describing the epidemiology, clinical characteristics, and management of adults who suffer a suspected first seizure. AIM: To describe the epidemiology, clinical characteristics, and management of adults with a suspected first seizure who are referred to a teaching hospital first seizure clinic over a one year period. DESIGN: Prospective descriptive study. METHODS: Data were collected on consecutive adults referred to the Royal Infirmary of Edinburgh between 4 February 2003 and 10 February 2004. RESULTS: 232 patients were referred to the first seizure clinic. Median age was 32 years; 53% of patients were male. Lower socioeconomic groups were more likely to present with a suspected first seizure. Nineteen per cent of patients were admitted to hospital after their suspected seizure episode. Appropriate driving advice was reported in 64% of cases. Seventy two per cent of patients were offered a first seizure clinic appointment within six weeks of referral. Nine per cent of patients had a subsequent seizure while awaiting review. Fifty two per cent of patients were confirmed as having a first seizure at the clinic, of which 56% were provoked by alcohol, recreational drugs, or sleep deprivation. Electroencephalography and computed tomography of the brain were the most common investigations ordered at the first seizure clinic (22% and 22% of patients respectively). CONCLUSION: Adults who suffer a suspected first seizure, and who make a full neurological recovery, can be safely managed as an outpatient. Around half of these patients will have a specialist diagnosis of first seizure and alcohol will be a common precipitating factor.
High continuous flow breathing systems are now available to provide fresh gas flows well in excess of 100 l.min-1 in continuous positive airway pressure systems used for respiratory support. The performance of two commonly used intensive care humidifiers, the Kendal Conchatherm and the Fisher and Paykel FP310 have been assessed at flows of 50, 75, 100, 125 and 150 l.min-1. Their performance when using two humidifiers connected in parallel and in series was also studied. At a fresh gas flow of 100 l.min-1 the single Conchatherm gave an absolute water vapour concentration of 15.6 g.m-3 and the single FP310 11.9 g.m-3. At all flows the best results were achieved using two Conchaterm humidifiers in series. It is concluded that with high continuous flow breathing systems the humidification achieved with conventional humidifiers may be inadequate and it may be necessary to combine two humidifiers to obtain clinically useful humidification.
A 22-year-old female with Bartter's syndrome presented at 40 weeks' gestation for elective cesarean section under general anesthesia. Her usual medication was ibuprofen and potassium supplements. Preoperative potassium was 3.3 mmol/L, and in anticipation of difficulties in fluid, electrolyte, and acid-base management, a central line and urinary catheter were inserted and blood gases measured. In the first 20 hours postdelivery she had a brisk diuresis and required 3.5 L of crystalloid to maintain her central venous pressure and 100 mmol of potassium to prevent significant hypokalemia. The main features of Bartter's syndrome are growth retardation, hypertrophy, and hyperplasia of the juxtaglomerular apparatus, increased angiotensin II, hyperaldosteronism, hypokalemic alkalosis, normal blood pressure, and decreased response to pressors. The precise biochemical lesion is unknown, but it is most probably an abnormality of chloride transport in the loop of Henle. Anesthetic management is a major challenge, requiring a thorough understanding of the pathophysiology of the syndrome. The specific aims of the anesthetist are to maintain cardiovascular stability, control serum potassium, and prevent renal damage. Perioperative fluid balance must be meticulously managed, and drugs dependent on renal excretion must be used with caution. Metabolic alkalosis may interfere with the binding of drugs. The patient's short stature, platelet abnormalities, and reduced responsiveness to pressors all make regional anesthesia theoretically hazardous.
A prospective, open, clinical trial is described in which 20 patients having upper abdominal surgery were randomly allocated to receive fentanyl for postoperative analgesia by patient-controlled demand analgesic computer by either the epidural or intravenous route. Hourly pain, sedation and nausea scores were very similar in the two groups during the first 24 hours after surgery. What few differences there were favoured the epidural group. There was a highly significant difference in fentanyl consumption between the two groups, with the intravenous group demanding consistently more than twice as much as the epidural group.
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Systems for respiratory support are becoming increasingly expensive and complex. Many systems suffer inadequacies when used for spontaneous ventilation. Some modes on newer ventilators are rarely used because of the complex controls and settings. There is no truly universal ventilator that satisfies every intensivist's wishes. CPAP/IMV is becoming accepted as the standard management of many patients with acute respiratory failure and there would be few intensive care units where CPAP/IMV is not used for part of a patient's respiratory support. We describe a cost-effective system that may be used for respiratory support in the spontaneously breathing mode. This system combines a high flow venturi, an efficient humidifier and an inexpensive reliable ventilator that can be used for adult and paediatric patients. The system, primarily for use in patients breathing spontaneously, functions well in patients requiring full ventilation.
AIMS AND METHODS: We prospectively audited inpatient bed use in our hospital for the first three months of this year. While 70% (mean age 54 +/- 20.8 years) of our patients went home on the day they were medically discharged, 30% (mean age 70.3 +/- 18.3 years) remained in the hospital awaiting step-down facilities. The total of 486 bed days occupied by overstaying patients would if available, have allowed treatment of 54% more patients without any increase in the hospital complement of beds, preventing the cancellation of elective procedures and preventing patients remaining on trolleys overnight. RESULTS AND CONCLUSION: These prospective data emphasise (1) a highly inefficient use of acute hospital beds; (2) the need for step-down facilities; (3) efficient use of existing hospital beds is the highest priority both for optimal patient care and optimal use of expensive hospital resources; (4) efficient use of existing facilities should be achieved before the construction of additional facilities.