Cardiovascular changes after induction of anaesthesia.
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Anesthetics, Combined↗
Biomedical subjects
J Kinsella
Publications and source records attributed to J Kinsella.
Postoperative serum urea is associated with 30-day mortality in patients undergoing emergency abdominal surgery.
BACKGROUND: Emergency abdominal surgery carries considerable postoperative morbidity and mortality. Hypovolaemia is considered to be a cause of renal hypoperfusion, which is associated with a decreased clearance of serum urea and creatinine. This study examines whether the perioperative serum urea and creatinine concentrations are predictors of mortality in patients undergoing emergency abdominal surgery. METHODS: Consecutive patients (n=300) who underwent emergency abdominal surgery were studied. Age- and sex-specific reference intervals were used for the data analysis. Patients with incomplete biochemical (n=51) or mortality data (n=31) or with pre-existing renal failure (n=9) were excluded from the analysis. RESULTS: 209 patients were analysed, of whom 162 (78%) remained alive and 47 (22%) died following surgery. The non-survivors were older (P<0.05), had undergone more extensive surgery (P<0.001) and were more likely to have been admitted to the intensive care unit (P<0.001). The serum urea concentration was higher preoperatively (P<0.05) and on day one postoperatively (P<0.001) in the non-survivors. On multivariate logistic regression analysis, age (odds ratio [OR] 3.27, 95% confidence interval [CI] 1.43-7.47, P<0.005), severity of surgery (OR 2.21, 95% CI 1.14-4.29, P<0.019), admission to intensive care (OR 0.54, 95% CI 0.11-0.54, P<0.001), seniority of anaesthetist (OR 0.50, 95% CI 0.27-0.90, P<0.022) and day one urea (OR 3.33, 95% CI 1.39-7.99, P<0.007) were independently associated with 30-day mortality. CONCLUSIONS: These results indicate that an increased serum urea concentration, but not serum creatinine concentration, in the postoperative period is associated with an increase in 30-day mortality in patients undergoing emergency abdominal surgery.
Abdomen↗
The cardiovascular effects of inspired oxygen fraction in anaesthetized patients.
BACKGROUND AND OBJECTIVE: Increased inspired oxygen fractions (FiO2) have significant haemodynamic effects in awake volunteers. We sought to establish whether these effects are also present in anaesthetized patients. METHODS: We prospectively studied 30 ASA I-II patients, 15 in each of a propofol and sevoflurane group. Their haemodynamic responses, awake and anaesthetized, when the FiO2 was changed between 0.3 and 1.0 were measured with a non-invasive transthoracic bio-impedance monitor. RESULTS: While preoxygenating awake patients in both groups the FiO2 was increased from 0.21 to 1.0. This reduced the mean cardiac index (3.38 +/- 0.5 to 3.03 +/- 0.5 L min(-1) m(-2); P < 0.001); reduced the heart rate (HR) (68.1 +/- 10.4 to 62.8 +/- 9.4 beats per minute (bpm); P < 0.001); and reduced the stroke index (50.4 +/- 9.6 to 48.5 +/- 8.6; P = 0.02). It increased the systemic vascular resistance index (2060 +/- 319 to 2220 +/- 382 dyn s(-1) cm(-5) m(-2); P = 0.002); but did not change mean arterial pressure. In the anaesthetized patients, when decreasing the FiO2 from 1.0 to 0.3, mean cardiac index (L min(-1) m(-2) increased (3.06 +/- 0.57 to 3.25 +/- 0.56, P = 0.008 for sevoflurane; 2.76 +/- 0.46 to 2.89 +/- 0.42, P = 0.002 for propofol). The mean HR (bpm) increased (65.1 +/- 7.8 to 69.1 +/- 7.5, P < 0.001 for sevoflurane; 67.5 +/- 11.8 to 72.7 +/- 11.6, P = 0.001 for propofol). The mean systemic vascular resistance (dyn s(-1) cm(-5) m(-2)) decreased (1883 +/- 329 to 1735 +/- 388, P = 0.008 for sevoflurane; 2015 +/- 369 to 1771 +/- 259, P = 0.003 for propofol). Mean arterial pressure (mmHg) decreased (74.8 +/- 8.7 to 71.4 +/- 8.7, P < 0.001 for sevoflurane; 72.1 +/- 8 to 66.5 +/- 6.8, P = 0.002 for propofol). CONCLUSION: O2 has haemodynamic effects in awake and anaesthetized patients. These effects were of overall similar magnitude for patients anaesthetized with propofol and sevoflurane.
Adolescent↗
Public perception of emergency research: a questionnaire.
BACKGROUND AND OBJECTIVE: Emergency research (e.g. into cardiac arrest or head injury) needs to start immediately, often before the patient, or relative, can give consent. A recent European Directive will prevent or severely limit emergency research. Little is known about the public view of emergency research. METHODS: Patients attending the outpatient department of a university teaching hospital were invited to complete a self-administered questionnaire. Research Ethics Committee approval was obtained and participants gave written informed consent. RESULTS: Three hundred and five of 362 respondents (84%) thought emergency research should start in the absence of consent but should be obtained as soon as possible from the nearest relative (82%) or the patient (90%). If consent was refused 62% felt the data could still be used, as did 81% if the patient died. Despite 62% approving of public meetings to publicize emergency research only 35% would attend one. A previously recommended list of preconditions was endorsed: no other consentable group (47%); advance consent impossible (55%); unable to delay treatment (73%); consent to be obtained as soon as possible (88%); an adequately designed protocol (74%); Ethics Committee approval (71%); patient may benefit (85%); future patients may benefit (92%) and that the treatment was necessary and could not be delayed (91%). CONCLUSIONS: Emergency research must occur to improve the outcome from life-threatening illness or injury. The majority of people are aware of the importance of this research and that the normal rules of consent are not applicable. Alternative methods of recruitment need to be investigated.
Biomedical Research↗
Use of reactance to estimate transpulmonary resistance.
This study examines the relationship of respiratory system resistance (R(rs)) and reactance (X(rs)) measured by forced oscillometry with transpulmonary resistance (R(L)) measured by oesophageal manometry. Simultaneous forced oscillometry using a single frequency of 5 Hz and oesophageal manometry were performed on five asthmatics during bronchoprovocation. The data obtained were used to derive prediction equations for R(L) from oscillometric parameters, which were tested on a further six asthmatics and 35 nonasthmatic subjects. In the first five asthmatic subjects, R(L) correlated more strongly with X(rs) than with R(rs). In the second set of asthmatics, R(L) ranged 0.0005-4.57 kPa.s.L(-1), with a median of 0.21 kPa.s.L(-1). The R(L) values predicted from X(rs) showed a mean+/-sd difference of -0.067+/-0.25 kPa.s.L(-1) compared with the values measured in this set of patients. X(rs) in subjects with other respiratory conditions appeared to follow the same relationship with R(L) as in asthmatics. Lumped element modelling suggested that the linear relationship between X(rs) and R(L) was a consequence of the increasing contribution of central and upper airway wall shunts as peripheral airway resistance rose, and that this effect was much larger than that due to changes in static elastance. In conclusion, the reactance of the respiratory system can predict transpulmonary resistance more accurately than can the resistance of the respiratory system.
Adult↗
Family witnessed resuscitation in UK emergency departments: a survey of practice.
BACKGROUND AND OBJECTIVES: The American Heart Association guidelines from 2000 recommend that family members be allowed to witness cardiopulmonary resuscitation. This is controversial and opponents fear litigation and family interference during family witnessed resuscitation (FWR). The extent of FWR in UK Emergency Departments is unknown. METHODS: A telephone survey of a selection of UK Emergency Departments was performed asking about experience with FWR. RESULTS: One-hundred-and-sixty-two UK Emergency Departments with an average attendance of 47,000 patients per year participated. FWR was allowed by 128 (79%) for an adult patient and 93% for a child. Of these, 50% invited relatives to witness and only 21% did not permit FWR. The perceived benefits were: accepting that all possible has been done (48%), accepting the death (48%) and help with grieving (38%). Two percent did not think FWR was of help. Few had encountered any problems or interference from the family. Never being asked was the commonest reason not allowing FWR followed by staff reluctance. Most respondents would wish to be present if their child (85%), spouse/partner (64%) or elderly relative (52%) was being resuscitated. CONCLUSIONS: FWR is common in UK Emergency Departments. It is more common when children are being resuscitated than adults. Further research is needed to demonstrate whether it is of benefit to the patient or relatives and its applicability to other areas such as intensive care.
Adult↗
Variation in the transcription of laboratory data in an intensive care unit.
Manual transcription of numerical data is prone to error. We quantified the transcription error rate for blood results recorded in a critical care setting by comparing the handwritten and printed laboratory results in 100 consecutive patients in the intensive care unit, Glasgow Royal Infirmary. Nine hundred and fifty-four sets of results with 4664 individual values were analysed. There was complete and accurate transcription in 67.6% (n = 645) of cases, a failure to transcribe in 23.6% (n = 225) and inaccurate transcription in 8.8% (n = 84). Transcription was significantly more accurate in the morning (p = 0.02). This study highlights that our current system of recording blood results is unreliable. These results strengthen the case for computerisation of the patient record in terms of data retrieval and transcription accuracy.
Clinical Chemistry Tests↗
Relatives' knowledge of decision making in intensive care.
BACKGROUND/AIM: The law on consent has changed in Scotland with the introduction of the Adults with Incapacity (Scotland) Act 2000. This Act introduces the concept of proxy consent in Scotland. Many patients in intensive care are unable to participate in the decision making process because of their illness and its treatment. It is normal practice to provide relatives with information on the patient's condition, treatment, and prognosis as a substitute for discussion directly with the patient. The relatives of intensive care patients appeared to believe that they already had the right to consent on behalf of an incapacitated adult. The authors' aim was to assess the level of knowledge among relatives of intensive care patients of both the old and new law using a structured questionnaire. METHODS: The next of kin of 100 consecutive patients completed a structured questionnaire. Each participant had the questions read to them and their answers recorded. Patients were not involved in the study. RESULTS: Few (10%) were aware of the changes. Most (88%) thought that they previously could give consent on behalf of an incapacitated adult. Only 13% have ever discussed the preferences for life sustaining treatment with the patient but 84% felt that they could accurately represent the patient's wishes. CONCLUSIONS: There appeared to be a lack of public awareness of the impending changes. The effectiveness of the Act at improving the care of the mentally incapacitated adult will depend largely on how successful it is at encouraging communication and decision making in advance of incapacity occurring.
Adult↗
Perioperative optimisation.
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Body Temperature↗
Lower concentrations of carotenoids in the critically ill patient are related to a systemic inflammatory response and increased lipid peroxidation.
BACKGROUND: Critically-ill patients have low circulating concentrations of vitamin antioxidants. The functional significance of such reductions is not clear. AIMS: To determine whether the presence of a systemic inflammatory response was associated with reduced circulating alpha-tocopherol and carotenoid concentrations and an increase in lipid peroxidation as evidenced by malondialdehyde. METHODS: Healthy controls (n=24) and critically-ill patients (n=43) had circulating concentrations of C-reactive protein, cholesterol, triglycerides, malondialdehyde, alpha-tocopherol, lutein, lycopene, alpha- and beta-carotene measured during ITU stay. RESULTS: In the critically-ill group circulating concentrations of C-reactive protein and malondialdehyde were significantly higher (P<0.05) and cholesterol, triglyceride, alpha-tocopherol, lutein, lycopene, alpha- and beta-carotene were all significantly lower (P<0.01) compared with the control group. In the critically-ill group alpha- and beta-carotene were below detection limits for many patients. After adjusting for cholesterol, lycopene concentrations remained significantly lower (P<0.001) compared with the control group. In the critically-ill patients circulating concentrations of C-reactive protein and malondialdehyde were significantly correlated (r=0.502,P<0.01). CONCLUSIONS: The systemic inflammatory response is associated with increased lipid peroxidation and low carotenoid concentrations indicating that inflammation driven breakdown of carotenoids is an important factor in lowering circulating carotenoid concentrations in the critically-ill patient.
Adult↗
The effect of normobaric hyperoxia on cardiac index in healthy awake volunteers.
Fifteen healthy volunteers were exposed to a stepwise increase in FIO2 between 0.21 and 1.0, and their haemodynamic responses were measured with a non-invasive transthoracic bio-impedance monitor. There was mean reduction in cardiac index from 3.44 to 3.08 l.min-1.m-2 (10.7%, p < 0.001). The mean reduction in heart rate was from 77.3 to 69.1 beats.min-1 (10.5%, p < 0.001) and the mean systemic vascular index increased from 2062 to 2221 dyne.s-1.cm-5.m-2 (7.7%, p < 0.025). There were no significant changes in stroke index or mean arterial pressure. These changes are similar quantitatively and qualitatively to those previously reported by dye dilution techniques.
Adult↗
Randomizing patients to permit the development of perioperative hypothermia is inappropriate.
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Analgesics, Opioid↗
Yoghurt biotherapy: contraindicated in immunosuppressed patients?
A fatal case of Lactobacillus rhamnosus septicaemia after prolonged oral vancomycin for recalcitrant Clostridium difficile infection is reported. The patient was immunosuppressed with cyclophosphamide and steroids for Sjögren's syndrome. The administration of Lactobacillus spp as "biotherapy" may be hazardous in such circumstances.
Adult↗
Pharyngo-laryngo-oesophagectomy and gastric pull-up for post-cricoid and cervical oesophageal squamous cell carcinoma.
Pharyngo-laryngo-oesophagectomy and gastric pull-up (PLOGP) is a complex and relatively uncommon procedure. The aim of this study is to analyse the results of PLOGP in patients with post-cricoid and cervical oesophageal squamous cell carcinomas. This study was a retrospective review of 26 patients (11 males + 15 females, mean age 63.5 years) who underwent PLOGP from 1988 to 1997. Eighteen (69 per cent) patients were staged as T(3) and eight (31 per cent) T(4). Eighteen (69 per cent) patients had N(0), seven (27 per cent) N(1) and one (four per cent) N(2) disease. Multiple primary tumours were recorded in three (11.5 per cent) patients. Four (15 per cent) patients had pre-operative radiotherapy with poor response and two (eight per cent) required emergency tracheotomy prior to surgery. Feeding jejunostomy was performed on 19 (73 per cent) and neck lymph node dissection in eight (31 per cent) patients. The mean duration of surgery was five hours (range 3.5 to 7.5) with a mean blood loss of 840 ml (range 160 to 1800), a mean stay in ICU of 4.2 days and hospital stay ranged from nine to 84 days (mean 34). Three (11.5 per cent) patients died (pneumonia - one, congestive heart failure - one, pulmonary embolus - one) in the early post-operative period. Eight (31 per cent) patients remain alive from 30 to 136 months (mean 58 months). Two (eight per cent) patients died with no evidence of disease. Thirteen (50 per cent) patients died of their disease between two to 51 months (mean 17.3 months) post-operatively. Kaplan-Meier survival estimates for one year was 65 per cent, for three years 35 per cent and for five years 26 per cent (see Figure 1). Median survival in the whole series was 18 months. Post-operative speech was with an electrolarynx in 16 (62 per cent). One patient (four per cent) used gastric speech and one patient (four per cent) used a Blom-Singer valve effectively. Five (19 per cent) patients had no speech post-operatively. All patients maintained oral feeding. Gastric transposition constitutes a safe and reliable method of restoring the continuity of the upper digestive tract following pharyngo-laryngo-oesophagectomy.
Adult↗
Target-controlled alfentanil analgesia for dressing change following extensive reconstructive surgery for trauma.
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Adult↗
The palm print as predictor of difficult intubation.
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Dermatoglyphics↗
Echocardiographic outcome of infants treated as newborns with inhaled nitric oxide for severe hypoxemic respiratory failure.
OBJECTIVE: To determine the cardiovascular outcome of a group of term newborns treated with inhaled nitric oxide (iNO) for severe hypoxemic respiratory failure with associated persistent pulmonary hypertension. STUDY DESIGN: We performed echocardiographic evaluations in 40 survivors treated for severe neonatal hypoxemic respiratory failure. Each of the 40 had at least 2 follow-up echocardiograms at 3 or 6 and 24 months. These studies were compared with echocardiograms done in infants in a normal, age-matched control group. RESULTS: Three of 31 infants met echocardiographic criteria for pulmonary hypertension at the 3-month examination. Two of the 3 had associated structural heart disease (1 with an atrial septal defect and 1 with a ventricular septal defect). At 24 months only 1 patient had pulmonary hypertension. This infant had an atrial septal defect that was surgically closed shortly after the 24-month echocardiogram because of the pulmonary hypertension. Group comparisons of 3- and 24-month echocardiographic variables showed no differences between the study and control groups. In the 31 infants in whom serial studies were completed, expected age-related changes were demonstrated between the 3- and 24-month examinations. CONCLUSIONS: The incidence of residual pulmonary hypertension in infants treated as newborns for severe hypoxemic respiratory failure is low. The group at highest risk is those with structural heart disease.
Administration, Inhalation↗