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Biomedical subjects

J Lipman

Publications and source records attributed to J Lipman.

At least 73 records · Page 4Linked to original sources
PubMed1996

Duration of antibiotic treatment in surgical infections of the abdomen. Antibiotics and the gut.

The inflammatory response of the body to a variety of insults is indistinguishable from that to infection. Antibiotics are neither innocuous nor are they a substitute for correct surgical management. In this paper we stress the side effects of antibiotics particularly affecting the gut and, by means of patient stratification, propose a goal oriented approach to antibiotic use, in conjunction with basic surgical strategies, for the management of intra-abdominal infection.

Anti-Bacterial Agents↗
PubMed1996

Accuracy of pulse oximetry in pigmented patients.

OBJECTIVE: Prospective assessment of the accuracy of three pulse oximeters and two probe sites in darkly pigmented critically ill patients under clinical conditions. PATIENTS AND METHODS: One hundred consecutive, darkly pigmented critically ill adult patients with arterial lines in situ were studied. Patients were excluded if the haemoglobin concentration was less than 7 g/dl and carboxyhaemoglobin or methaemoglobin levels exceeded 2%. Pigmentation was objectively quantified with a portable EEL reflectance spectrophotometer (Evans Electroselenium Company, Diffusion Systems Limited, London). Reflectance was measured at nine wavelengths. RESULTS: The degree of pigmentation as measured by percentage reflectance closely matched that of a control group of black Africans from a pigmentation study. The limits of agreement (2.6% to 5.8%), precision and bias values between pulse oximeter and co-oximeter readings fell within a narrow range. The 95% confidence intervals of the limits of agreement reflected a small variation in the difference between pulse oximeter and co-oximeter readings. These small differences were not clinically significant in the pigmented patients who were enrolled in the study. CONCLUSION: The accuracy of pulse oximetry is not adversely affected by skin pigmentation, and it remains a useful oxygenation monitoring device in darkly pigmented patients.

Humans↗
PubMed1995

Changes in vancomycin pharmacokinetics in critically ill infants.

We aimed to assess the pharmacokinetics of vancomycin in critically ill infants, and to evaluate the standard recommended dose of 10 mg/kg 6 hourly. All infants admitted to the Baragwanath Hospital ICU who had arterial lines in situ, and for whom vancomycin 10 mg/kg 6 hourly was prescribed for an infective insult and who had parental consent, were included in the study. Vancomycin was infused over 60 minutes. Serum samples were taken immediately before the dose and at 30, 60, 120 and 300 minutes after the end of the vancomycin infusion, on days 2 and 8 of therapy. Extrapolated peak concentration (Cmax), trough concentration (Cmin), apparent volume of distribution (Vd), elimination half-life (t1/2el) and clearance (CL) were determined for each patient. Day 2 values were compared with those of day 8. Day 2 serum concentrations were assayed on 20 patients and day 8 concentrations in 15. The mean vancomycin Vd on day 2 (0.81 l/kg) was significantly (P = 0.007) larger than that on day 8 (0.44 l/kg). The change in Vd resulted in a significant change in mean Cmax (29.1 vs 35.5 micrograms/ml) (P = 0.02) and mean t1/2el (5.3 vs 3.4h) (P = 0.01) over the treatment period. Critically ill infants displayed a large initial volume of distribution which probably resulted from aggressive fluid resuscitation. This also results in a large variation in other pharmacokinetic parameters, namely Cmax and t1/2el. Although the routine monitoring of vancomycin serum concentrations remain controversial, we feel that in view of these large pharmacokinetic variations, the critically ill infant is a specific group where monitoring of vancomycin serum levels is indicated.

Anti-Bacterial Agents↗
PubMed1995

Emergency percutaneous balloon mitral valvotomy in a patient with septic shock.

We report an 18-year-old patient with severe mitral stenosis complicated by right lower lobe pneumonia, sepsis, and shock. Intractable low cardiac output led to an emergency percutaneous balloon mitral valvotomy in a patient, resulting in immediately improved hemodynamic parameters. We are unaware of another report of percutaneous balloon mitral valvotomy performed in a patient with sepsis and shock. This case supports previous isolated reports of the benefit from emergency percutaneous balloon mitral valvotomy in critical situations where thoracotomy is not possible due to coexisting medical problems.

Adolescent↗
PubMed1995

Systemic response to gram-positive and gram-negative infections--comparison and contrast.

The concept of the systemic inflammatory response (SIRS) has recently been defined with suggested new terminology and criteria for diagnosis, and this has gained acceptance in the international literature. The importance of Gram-positive organisms as a cause of the SIRS has become increasingly recognised in recent years. This report describes a case of severe staphylococcal infection with a clinical picture similar to 'classic' endotoxic shock associated with Gram-negative organisms. We use this report to discuss the management of severe sepsis with organ dysfunction, outline the clinical complications and specific therapy of staphylococcal infections, discuss the new terminology, and compare and contrast the features of SIRS associated with varying causes.

Adult↗
PubMed1994

Nodular foci in parathyroid adenomas and hyperplasias: an immunohistochemical analysis of proliferative activity.

Samples of normal, hyperplastic, and neoplastic parathyroid tissues were analyzed for proliferative activity to determine (1) whether a higher number of proliferating cells were detectable in adenoma and hyperplasia versus normal tissues; (2) whether there was a difference in the number of proliferating cells in adenoma versus hyperplasia; and (3) whether there was a relationship between nodularity and proliferative rate in both adenoma and hyperplasia. Formalin-fixed, paraffin-embedded tissue from 21 patients with parathyroid adenoma and 10 patients with hyperplasia (two primary, six secondary, and two tertiary) was analyzed by immunohistochemistry with the monoclonal antibody PC10 to proliferating cell nuclear antigen (PCNA) and, in a subset of cases, with Ki-67 (MIB 1) as markers of cell proliferation. The results were that (1) no proliferating cells were found in normal glands or residual rim of "suppressed" parathyroid tissue; (2) the most intense proliferative activity was confined to nodular areas in both adenomas (57% nodular) and hyperplasias (80% nodular); (3) when fields of highest number of labeled nuclei were chosen, PCNA counts were higher in adenomas than in hyperplasia in both nodular and diffuse areas (P < .05); and (4) the number of nuclei immunoreactive for Ki-67 (MIB-1) was consistently and proportionally lower (range, 13% to 45%; mean, 32%) than the number of those immunoreactive for PCNA, although the nodular pattern was maintained. These findings demonstrate that nodules within parathyroid adenomas and hyperplasias contain subpopulations of cells with a consistently higher proliferative rate than nonnodular areas. Cells within these nodules may be more likely to develop genetic abnormalities that have been observed in hyperplastic and neoplastic parathyroid tissues.

Adenoma↗
PubMed1994

Decreased cardiac index as an indicator of tension pneumothorax in the ventilated patient.

We describe three critically ill patients receiving pressure-controlled ventilation who suffered acute hypotensive episodes associated with the development of tension pneumothoraces. In four documented episodes of tension pneumothorax a major decrease in cardiac index was the most consistently detected abnormality. The expected increases in central venous pressure and heart rate did not occur in three of the episodes in two of the patients, both of whom were receiving inotropic therapy. Any increases in airway pressure could not be assessed on pressure-controlled ventilation. The physiology of tension pneumothorax in the ventilated patient is described and the importance of decreased cardiac index as a haemodynamic indicator of tension pneumothorax is discussed.

Adult↗
PubMed1994

A comparison of arterial lines and insertion techniques in critically ill patients.

We compared three arterial line insertion techniques and two types of arterial catheters in 69 critically ill patients. Use of the direct-puncture technique (method A) was associated with a significantly higher failure rate (23%) than use of a catheter with a separate guide wire (method B, 'classical' Seldinger technique, p < 0.001) or a catheter with an integral guide wire (method C, 'modified' Seldinger technique, p < 0.02). Operators randomly allocated to using method A took significantly longer to perform the procedure than those using method C (p < 0.01), used significantly more catheters (p < 0.0001) and made significantly more punctures in achieving a successful insertion than those using either methods B (p < 0.001) or C (p < 0.001). Both catheter types B and C (polyurethane) were significantly less likely to block, thus requiring less likely to block, thus requiring re-insertion, than catheter type A (Teflon) (p < 0.02, p < 0.01 respectively). We recommend the use of a 'classical' Seldinger technique (method B) for arterial line insertion in critically ill patients and the use of a polyurethane catheter, in preference to Teflon, to maximise catheter life after insertion.

Adolescent↗
PubMed1994

Paralytic ileus as a complication of atropine therapy following severe organophosphate poisoning.

A 32-year-old man presented with symptoms of severe organophosphate poisoning and required an atropine infusion for 5 weeks. We believe the development of a paralytic ileus occurred as a rare feature of atropine toxicity when other signs were masked by the underlying condition. The onset of a paralytic ileus coincided with a spontaneous increase in red cell cholinesterase levels and may be an early sign of recovery from organophosphate poisoning.

Adult↗
PubMed1994

Malignant astrocytoma of the cervico-medullary junction masquerading as Guillain-Barré syndrome.

Brainstem gliomas are rare primary brain tumours which most commonly occur in the midbrain and pons. Malignant gliomas and tumours at the cervico-medullary junction are particularly unusual. The diagnosis of tumours at this site is particularly difficult using computed tomographic (CT) scanning owing to artifacts around the base of the skull. Intrinsic tumours of the cervico-medullary junction may lead to a dissociated motor deficit and the onset of symptoms can be rapid. We describe a patient in whom an isolated ascending motor deficit in association with a raised cerebrospinal fluid protein and a normal CT scan led to an erroneous diagnosis of Guillain-Barré syndrome. The patient was treated on the intensive care unit for an 8-week period before further investigation demonstrated a malignant glioma of the cervico-medullary junction. We recommend confirmation of the diagnosis of polyradiculopathy by nerve conduction studies wherever possible.

Adult↗
PubMed1994

Haemodynamic and oxygen transport response during exchange transfusion for severe falciparum malaria.

We describe the haemodynamic and oxygen transport response in a patient undergoing exchange transfusion for severe falciparum malaria. We found that exchange transfusion produced a significant increase in left ventricular stroke work index, systemic oxygen delivery and oxygen consumption. This potentially beneficial effect of exchange transfusion has not been reported previously.

Adult↗
PubMed1994

A double-blind comparison of vecuronium administered by the Springfusor infusion device to vecuronium by intermittent bolus injection in critically ill adult patients.

To evaluate the Springfusor infusion device for clinical use in an Intensive Care Unit and to compare the technique of intermittent bolus and constant infusion of muscle relaxants, we undertook a prospective double-blind randomized placebo-controlled study. Twenty critically ill ventilated patients requiring muscle paralysis were investigated. Although we could show no clinical advantage in infusing vecuronium, the Springfusor provided a more constant level of paralysis compared with hourly bolus doses. The device is robust, easy to use and reduces nursing workload. This may translate into cost-saving improvement in patient care if the Springfusor is used to provide muscle relaxation, sedation and analgesia.

Adult↗
PubMed1994

Humidification in intensive care.

The normal physiological function of the upper respiratory tract is to filter and humidify inspired air. In intensive care units the upper respiratory tract is frequently bypassed. The importance of humidifying and warming the dry, cold, piped gas is well documented. The results of lack of adequate humidification include endotracheal tube obstruction, impairment of the mucociliary elevator and altered pulmonary function. Optimal levels of humidification are as yet undefined and useful clinical markers of adequate humidification are not available. As a result there is a bewildering array of humidification devices available at present, the most recent of which are heat and moisture exchangers with or without specific filtration properties. This article reviews available data on these humidification devices, and recommends an approach to their appropriate use, based on the probable physiological needs of individual patients.

Adult↗
PubMed1994

Tension pneumoperitoneum aggravating respiratory failure. A case report.

A case of tension pneumoperitoneum secondary to barotrauma is reported. Any patient needing high pressures for ventilation and oxygenation is prone to this complication. The important respiratory and haemodynamic implications are discussed. It is suggested that drainage of a tension pneumoperitoneum is easy and safe and has major beneficial effects on the respiratory and cardiovascular systems.

Adult↗
PubMed1994

Esmolol in a case of severe tetanus. Adequate haemodynamic control achieved despite markedly elevated catecholamine levels.

A patient with severe tetanus, who had a sympathetic crisis while sedated with 30 mg/h diazepam and 30 mg/h morphine, is described. Satisfactory control of the haemodynamic crisis was achieved with bolus doses of esmolol to a total of 180 mg. A disturbing finding was that although there was adequate control of the tachycardia and hypertension, arterial catecholamine levels remained markedly elevated. Adrenaline levels of 531 pg/ml (normal 10-110 pg/ml) and noradrenaline levels of 1,036 pg/ml (normal 100-500 pg/ml) were recorded when the patient had a systolic arterial pressure of 110 mmHg and a heart rate of 97/min. The implications of this finding are discussed.

Adrenergic beta-Antagonists↗