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Biomedical subjects

J Lipman

Publications and source records attributed to J Lipman.

At least 91 records · Page 5Linked to original sources
PubMed1994

Continuous venovenous haemodiafiltration--an audit demonstrating control of electrolytes with haemodynamic stability in the critically ill.

OBJECTIVE: Renal replacement therapy has evolved significantly in the last 15 years, resulting in a large diversity of techniques with differing attributes. Theoretical advantages of the continuous over intermittent techniques in critically ill patients include haemodynamic stability and a reduction in disequilibrium syndrome. Limited clinical evidence supports this, but a clear reduction in mortality or morbidity has yet to be shown. The technique of renal replacement therapy in the Intensive Care Unit at Baragwanath Hospital was recently revised and a retrospective study of the haemodynamic and electrolyte changes associated with implementing continuous venovenous haemodiafiltration (CVVHD) was carried out. METHOD: A retrospective analysis of demographic data, haemodynamic and physiological parameters in 10 consecutive patients receiving CVVHD during a 10-week period was conducted. Patients' systolic (SBP), and mean (MAP) arterial blood pressures, heart rates (HR), and central venous pressures (CVP) during the first 36 hours after the implementation of CVVHD were reviewed. Serum creatinine, urea and potassium values were also collated. Other organ system failures and outcomes were noted. RESULTS: HR decreased by 6.1% (SD 1.5) and average MAP rose (12.1%; SD 7.8) as did SBP (12.4%; SD 6.3), compared with the values immediately before CVVHD: CVP was unchanged. Control of hyperkalaemia was effected in all cases. Serum urea and creatinine levels were well controlled, and clearances were closely related to the dialysate flow. Although the mortality rate was high, it was lower than predicted. No deaths were directly attributable to acute renal failure or complications of CVVHD: CONCLUSION: In the critically ill, CVVHD provides excellent serum urea and creatinine clearance and control of electrolytes without further compromise of haemodynamics. The low associated morbidity, the ease of implementation and the efficacy of the technique may make CVVHD the technique of choice for ARF in the intensive care unit.

Acute Kidney Injury↗
PubMed1994

Invasive candidiasis in the ICU--pathogenesis and management strategy.

How should new and old antifungals be used in the management of invasive candidiasis in ICU patients? A pathogenesis-based management strategy for invasive candidiasis is outlined. Colonisation of the catheterised bladder by Candida species should be eliminated to prevent invasion from the urinary tract. Invasion from the peritoneum (in the patient with a perforated bowel) should be treated promptly to prevent local vascular invasion. Empirical therapy is recommended for treatment of suspected disseminated candidiasis, 'pulmonary' candidiasis and vascular-access candidiasis. Dose and duration of therapy are decided according to clinically determined patient/disease categories and modified according to information from laboratory results. Short-term low-dose regimens are suitable for peritoneal candidiasis that is recognised early, and for vascular-access candidiasis, provided the source-catheter can be removed.

Antifungal Agents↗
PubMed1993

Successful use of continuous veno-venous haemofiltration to treat profound fluid retention in severe peripartum cardiomyopathy.

The use of continuous veno-venous haemofiltration after failure of conventional treatment in a patient with severe peripartum cardiomyopathy is described. Treatment with inotropes and diuretics failed to produce a diuresis despite the presence of severe fluid overload. Haemofiltration over a 9-day period allowed removal of 171 of fluid with a concomitant improvement in haemodynamic function and a spontaneous diuresis.

Adult↗
PubMed1993

High-dose adrenaline in adult in-hospital asystolic cardiopulmonary resuscitation: a double-blind randomised trial.

Forty intensive care unit patients requiring cardiopulmonary resuscitation were randomised to receive either the standard dose of adrenaline (1 mg every five minutes) or high-dose adrenaline (10 mg every five minutes). In the majority of patients, overwhelming sepsis was the major contributing factor leading to cardiac arrest. In this group of patients no difference could be detected in response to high-dose adrenaline compared with the standard dose. Although no side-effects were noted with this high dose of adrenaline, more investigation is required prior to its routine use in cardiopulmonary resuscitation.

Adult↗
PubMed1993

Intensive care utilisation: the Baragwanath experience.

Intensive care medicine is an expensive service whose impact on health care has been questioned. South Africa is a country undergoing rapid social and political change and the role of intensive care medicine in the health care system of this country needs to be assessed. In this paper we evaluated the quality, cost-effectiveness and utilisation of technology in the intensive care unit of Baragwanath Hospital, a hospital serving the black community of Soweto.

Adult↗
PubMed1993

Acute lung injury at Baragwanath ICU. An eight-month audit and call for consensus for other organ failure in the adult respiratory distress syndrome.

To test the expanded definition of acute lung injury (ALI), we prospectively, over a period of 8 months, studied all adult ICU admissions who fitted the definition. Our study consisted of 83 patients with the adult respiratory distress syndrome (ARDS) and 60 with mild to moderate ALI. Sepsis and trauma were the most common diagnoses on admission. The overall mortality rate was 45 percent for ARDS and 38 percent in the other group. Mortality rose significantly with associated other organ failure, the incidence of which was as follows: hepatic, 39 percent; cardiac, 38 percent; hematologic, 22 percent; renal, 21 percent; neurologic, 5 percent. Sepsis syndrome eventually occurred in 73 percent and septic shock in 38 percent of all cases of ALI. We found the expanded definition a useful grading system and consider this definition of ARDS to be currently the best. There are, however, problems with the determination of lung compliance, the effect of inverse ratio ventilation, and the lack of consensus in defining other organ failure.

Adult↗
PubMed1993

Hydrocortisone and tumor necrosis factor in severe community-acquired pneumonia. A randomized controlled study.

BACKGROUND: Community-acquired pneumonia is a major cause of death in third world countries. Antimicrobial therapy may have little impact on the natural history of patients with severe pneumonia. We hypothesized that the intrapulmonary production of tumor necrosis factor-alpha (TNF-alpha) may be responsible for the progressive lung injury and shock commonly seen in patients with severe pneumonia after commencing antibiotic therapy. AIM: To investigate the effects of a single bolus of hydrocortisone on the clinical course and serum TNF-alpha levels of patients with severe community-acquired pneumonia. DESIGN: Randomized placebo-controlled study. SETTING: Multidisciplinary ICU of a tertiary care teaching hospital. PATIENTS AND METHODS: Patients with three or more British Thoracic Society criteria of severe pneumonia were studied. Patients were randomized to receive either a single dose of hydrocortisone (10 mg/kg) or placebo 30 min prior to commencing antibiotic therapy. Patients were treated with cefotaxime and other antibiotics as clinically indicated. Blood for TNF-alpha was taken at the time of hospital admission and repeated 2, 6, and 12 h after starting antibiotic therapy. RESULTS: Thirty patients were studied: 16 received placebo and 14 received hydrocortisone. The patients who received placebo tended to be sicker than the patients who received hydrocortisone. The baseline TNF-alpha value was 989 +/- 374 pg/ml in the placebo group and 827 +/- 394 pg/ml in the hydrocortisone group. In both groups of patients, the TNF-alpha levels did not change significantly with time. There was no correlation between the TNF-alpha levels and the APACHE II score, lung injury score, or outcome. The only variable that predicted outcome was the APACHE II score. CONCLUSION: Bactericidal antibiotics do not increase serum TNF-alpha levels in patients with severe pneumonia. Hydrocortisone given prior to antibiotic treatment had no effect on the serum TNF-alpha levels or the clinical course of patients with severe community-acquired pneumonia.

Adult↗
PubMed1993

Renal replacement therapy for the critically ill--precarious progress. Part II. Technical aspects and clinical application.

Renal replacement therapy has evolved significantly in the last 15 years. Evolution has produced diversity in both techniques and terminology. Theoretical advantages of the continuous over intermittent techniques in critically ill patients exist. Limited clinical evidence supports this, but a clear reduction in mortality or morbidity has yet to be shown. In Part I of this review the terms and techniques used were defined and the physiological aspects of renal replacement therapy discussed. In this part the technical aspects and associated problems are discussed and a prescription for an effective application of the technique in critically ill patients is provided.

Humans↗
PubMed1993

Renal replacement therapy for the critically ill--precarious progress. Part I. Definitions and physiological aspects.

Renal replacement therapy has evolved significantly in the last 15 years. Evolution has produced diversity in both techniques and terminology, leading to considerable ambiguity and confusion. Theoretical advantages of the continuous over intermittent techniques in critically ill patients exist. These include haemodynamic stability, expedient correction of metabolic derangement, accurate fluid control, cytokine clearance, and improved respiratory function. Limited clinical evidence supports this, but a clear reduction in mortality or morbidity has yet to be shown. In Part I of this review the terms and techniques used are defined and the physiological aspects of renal replacement therapy are discussed. In Part II the technical aspects will be discussed and a prescription for an effective technique in critically ill patients will be provided.

Critical Illness↗
PubMed1992

Erythropoietin in a patient following multiple trauma.

We report on a Jehovah's Witness who had severe blood loss following major trauma. The problems of her management without blood transfusion, and with the use of recombinant human erythropoietin therapy for severe anaemia, are described.

Anemia↗
PubMed1992

Septic shock: does adrenaline have a role as a first-line inotropic agent?

Fifteen adult patients, admitted to Baragwanath Hospital ICU with septic shock after adequate fluid loading and on no other inotropic agents, were given adrenaline in incremental doses. Oxygen transport and haemodynamic variables were monitored with each dose increment until a systolic blood pressure of 120 mmHg was obtained. This was reached on an average dose of adrenaline of 0.16 +/- 0.02 micrograms/kg/min. Mean arterial blood pressure increased by 22 +/- 2 mmHg mainly due to an increase in cardiac index (1 +/- 0.2 l/min/m2) and systemic vascular resistance index (130 +/- 41 dyn.s.cm.-5m-2) with a small increase in heart rate of 8 +/- 3 beats per minute. Oxygen delivery was increased with no significant increase in oxygen consumption and lactate levels increased. Adrenaline is therefore an effective initial inotropic agent. Patients may respond to lower doses than when used concurrently with other inotropic agents but there was still a significant dose variation in response. We cannot, however, exclude a deleterious effect on oxygen utilization.

Adult↗
PubMed1991

The pharmacokinetic of amikacin in critically ill adult and paediatric patients: comparison of once- versus twice-daily dosing regimens.

The pharmacokinetic profile of amikacin was analysed by a two-compartment model in 100 critically-ill adult and paediatric patients with normal renal function. In addition the serum amikacin levels in 200 patients randomized to receive a once- or twice-daily dosing regimen are reported. The mean volume of distribution (Vdt) was 0.33 l/kg in the adult patients, 0.50 l/kg in patients 6 to 12 months of age and 0.58 l/kg in patients less than 6 months old. The elimination half-life was prolonged, being 3.45, 2.86 and 5.02 h for the respective age groups (normal 2 h). The clearances dose/AUC) were 0.051, 0.068 and 0.063 l/h/kg respectively. Within each group of patients there was a large variation in the pharmacokinetic parameters, with the Vdt varying by a factor of 6 and the elimination half-life by a factor of 10. All patients receiving a once-daily dose of amikacin had therapeutic peak concentrations. In comparison, therapeutic concentrations were achieved in only 48% of adult and 44% of the paediatric patients receiving the twice-daily dosing regimen. Furthermore the amikacin trough concentrations were significantly higher in the patients who received a divided daily dose. As a consequence of the pharmacokinetic profile of amikacin in critically ill patients a once-daily dosing regimen may be more effective and less toxic than the conventional twice-daily dosing regimen.

Adolescent↗
PubMed1991

A prospective randomized study comparing once- versus twice-daily amikacin dosing in critically ill adult and paediatric patients.

Three hundred and forty eight critically-ill patients with a documented Gram-negative infection were randomized to receive amikacin once- (od) or twice-daily (bd). The amikacin was given by slow intravenous injection in a daily dose of 20 mg/kg in patients under the age of one year (paediatric group) and 15 mg/kg in patients over the age of one year (adult group). Paediatric and adult patients on the od regimen received a loading dose of 25 and 20 mg/kg respectively. The dosages were subsequently adjusted to achieve desirable blood levels. Patients received other antibiotics as clinically indicated. Forty-eight patients were withdrawn from the study due to death or azotaemia occurring in the first 72 h. One hundred and fifty five patients (76 paediatric) received an od dose and 145 (65 paediatric) received a bd dose. The clinical cure rate was 83% in the od group compared to 66% in the bd group (P = 0.001). The bacteriological cure rate was 81% in the od group compared to 58% in the bd group (P = 0.005). In the paediatric sub-group the cure rate was higher with the od regimen (P = 0.002) but this difference was not statistically significant in the adult patients (P = 0.1). The serum creatinine rose in 35% of patients in the bd group compared to 21% in the od group (P = 0.05). Although audiometry was not performed there was no clinical evidence of ototoxicity in any of the patients. In conclusion od amikacin dosing resulted in a higher cure and less nephrotoxicity than conventional bd dosing.

Adolescent↗
PubMed1991

Comparison of disease severity scoring systems in septic shock.

OBJECTIVE: To compare six disease severity scoring systems as predictors of mortality in septic shock when used in the first 24 hrs of diagnosis. The six scoring systems tested were: Multiorgan Failure; the Acute Organ System Failure; the Acute Physiology and Chronic Health Evaluation (APACHE II); the Multisystem Organ Failure scoring system; the Mortality Prediction Model; and the grading of sepsis. DESIGN: Retrospective, case series, consecutive sample. SETTING: Adult ICUs of three teaching hospitals. PATIENTS: Seventy-one patients from 12 to 84 yrs, fulfilling specific criteria for the diagnosis of septic shock, who were admitted to the ICU during 15 consecutive months. MEASUREMENTS AND MAIN RESULTS: The Multiorgan Failure scoring system, Acute Physiology and Chronic Health Evaluation (APACHE II), and Acute Organ System Failure scoring system were found, with our modifications, to be statistically significant predictors of mortality. Predictive data for these three scoring systems were as follows: Multiorgan Failure scoring system p = .008, mean number of points of survivors 5.2 +/- 1.5 (SD), mean number of points of nonsurvivors 6.3 +/- 1.5; APACHE II p = .013, mean number of points of survivors 21.1 +/- 5.9, mean number of points of nonsurvivors 24.6 +/- 6.0; and Acute Organ System Failure scoring system p = .011. None of the other three scoring systems showed significant predictive ability: Multisystem Organ Failure scoring system p = .072, Mortality Prediction Model p = 0.091, and the grading of sepsis p = .27. There was a significant (p = .004) difference in the survival rate of the three hospitals. CONCLUSION: The Multiorgan Failure scoring system, APACHE II, and the Acute Organ System Failure scoring system, with minor modifications, were found to be useful prognostic tools for patients with septic shock and allowed us to compare the performance and treatment programs of different ICUs.

Adult↗
PubMed1991

Vasoconstrictor effects of adrenaline in human septic shock.

In an open prospective study, adrenaline administration in ten patients with eleven episodes of septic shock was studied. Appropriate supportive therapy (antibiotics, laparotomies, parenteral alimentation, ventilation) was given as needed. Haemoglobin was kept at or about 12 g%, pulmonary capillary wedge pressure kept at approximately 15 mmHg, and cardiac index at greater than 4.5 l/min/m2. Only when systemic vascular resistance (SVR) dropped below 600 dyn. s. cm-5 was adrenaline given to raise the latter to no higher than 800 dyn. s. cm-5 and the adrenaline was titrated to this end point. Adrenaline was used at doses up to 0.47 microgram/kg/min for up to nineteen days. There was no reliable dose response curve for adrenaline: each septic insult needed different dosages. However, if high enough doses were given, SVR eventually increased. There was no deterioration in cardiac index nor further increase in pulse rate and no renal damage was demonstrated. Only one patient died in septic shock. Two others died from causes not directly related to sepsis and another two while still in hospital, but again not septic. Five patients were eventually discharged from hospital. Adrenaline can thus be used as a vasoconstrictor in septic shock without adverse effects, but initial doses have to be high and the effects measured and titrated carefully. Used this way, adrenaline provides time for the eradication of sepsis.

Adult↗
PubMed1991

Acetazolamide in the treatment of metabolic alkalosis in critically ill patients.

Metabolic alkalosis is a common acid-base disturbance in critically ill patients. In many patients correction of fluid and electrolyte status does not fully correct the metabolic derangement. In this study we examined the effect of 500 mg of intravenous acetazolamide, after correcting for fluid and electrolyte abnormalities, on the acid-base status of 30 ventilated patients. In all patients studied there was a fall of total serum bicarbonate; the mean reduction at 24 hours was 6.4 mmol/L, with a normalization of the base excess and pH. The onset of action was rapid (within 2 hours), and the maximal effect occurred at a mean of 15.5 hours, although there was wide variation. The effect of acetazolamide was still apparent at 48 hours. No adverse effects were noted. We conclude that in patients with metabolic alkalosis, once fluid and electrolyte abnormalities have been corrected, acetazolamide is an effective and safe form of therapy with a quick onset and long duration of action.

Acetazolamide↗