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Biomedical subjects

M A Fox

Publications and source records attributed to M A Fox.

At least 55 records · Page 3Linked to original sources
PubMed1991

Selective decontamination of the digestive tract in cardiac surgical patients.

OBJECTIVE: To test the hypothesis that selective decontamination of the digestive tract improves outcome in cardiac surgical patients. DESIGN: Prospective, consecutive, controlled trial over two 4-month periods. SETTING: Eight-bed, open-plan postcardiac surgery ICU. PATIENTS: All patients undergoing cardiac bypass surgery were eligible. Patients requiring endotracheal intubation for greater than 4 days were included in the analysis. In the initial 4 months, 12 (8.5%) of 141 patients required greater than 4 days of intubation. These 12 patients were not treated with selective decontamination of the digestive tract. We therefore used these patients as the control group. In the second 4-month period, 12 (6.6%) of 180 patients were treated with selective decontamination of the digestive tract and formed the study group. MAIN OUTCOME MEASURES: The primary measure was mortality. Secondary measures included oropharyngeal decontamination and the presence of lower airway infection. INTERVENTIONS: Cephradine prophylaxis. The study group received every 6 hrs 4 mL orally and 20 mL intragastrically a suspension of antimicrobial agents (tobramycin 80 mg, polymyxin E 100 mg, amphotericin B 500 mg), starting on postoperative day 1. The control group did not receive any oral antimicrobial agents. RESULTS: Mortality rate was significantly (p less than .05) reduced from eight (66%) of 12 patients in the control group to two (16.7%) of 12 patients in the selective decontamination of the digestive tract group. No differences in oropharyngeal decontamination or lower airway infection rates between the two groups were found. CONCLUSIONS: There is a reduced mortality rate in patients receiving selective decontamination of the digestive tract. However, the reader should recognize the small sample size studied. A simple suspension of the antimicrobial agents failed to rid the oropharynx of bacteria.

Administration, Oral↗
PubMed1991

Anatomy of the accident scene: a prospective study of injury and mortality.

This study of the accident scene focuses on the effects of vehicular deformity and restraint devices on occupant injury. In 500 patients evaluated in a Level I trauma center, seatbelts significantly reduced the likelihood of individuals' requiring the trauma center (P less than 0.0001). Seatbelts also significantly reduced the mortality rate of those who were transported to the trauma center (P less than 0.04). Dashboard intrusion correlated with pelvic (P less than 0.001) and femur (P less than 0.03) fractures, closed head injuries (P less than 0.001), and intraabdominal injuries (P less than 0.02). Steering wheel deformity correlated with pelvic fractures (P less than 0.001) and closed head injuries (P less than 0.005). Windshield violation correlated with closed head injuries (P less than 0.014) and spinal fractures (P less than 0.03). Irreparable vehicles correlated with pelvic (P less than 0.0001) and femur fractures (P less than 0.01), closed head injuries (P less than 0.0001) and intra-abdominal injuries (P less than 0.0001). The authors conclude that a careful examination of the accident scene for specific mechanisms of injury can lead to better prehospital care, more rapid and consistent diagnosis of injury, and improved patient outcome. Further prospective studies should accumulate data that will improve prehospital care, alert physicians to possible injury, increase community awareness of injury prevention, and improve vehicle construction.

Accidents, Traffic↗
PubMed1990

Management of complex perineal soft-tissue injuries.

Debridement, fecal diversion, and rectal washout have been proposed as the primary therapy for complex perineal lacerations, but, in most series, survivors have a pelvic sepsis rate of 40-80%. In a retrospective study, six of 18 patients sustaining severe perineal lacerations died within the first few hours of injury due to exsanguination from pelvic injuries. The remaining 12 patients underwent sigmoidoscopy, diversion of the fecal stream with irrigation of the distal rectal stump, and radical initial debridement of necrotic soft tissue. Enteral access was obtained in two patients. In the patients with mandatory daily debridement and pulsatile irrigation, no pelvic sepsis occurred. In three patients without daily debridement, pelvic sepsis complicated recovery. The ability of patients to resume oral nutrition was significantly delayed, necessitating total parenteral nutrition in three patients. We conclude that sigmoidoscopy, total diversion of the fecal stream with irrigation of the distal rectal stump, enteral access for feeding, radical initial debridement of necrotic soft tissue, and mandatory daily debridement with pulsatile irrigation optimize recovery from this devastating injury.

Adult↗
PubMed1990

Pelvic fractures: an analysis of factors affecting prehospital triage and patient outcome.

Using an established prehospital regional triage protocol, 175 patients sustaining fractures of the pelvis were managed in a level one trauma center during a 38-month interval. The majority of injuries (51.7%) were caused by motor vehicle accidents and involved an average trauma score (TS) of 13 and an average injury severity score (ISS) of 24. The overall mortality was 16%; 43.5% had open fractures, 13.2% had closed fractures, and 30.6% had been in pedestrian accidents. Significant risk factors for mortality were age, blood pressure on admission, associated injuries, and the presence of an open pelvic fracture. It appears that TS alone is not reliable in prehospital triage of patients with pelvic fractures. Age and mechanism of injury may better identify the patient at risk for morbidity and mortality.

Accidental Falls↗
PubMed1989

Hard-shell cardiotomy reservoir for reinfusion of shed mediastinal blood.

We conducted a prospective, randomized, controlled trial comparing homologous blood consumption between groups of patients receiving conventional mediastinal drainage (group 1) or reinfusion of shed mediastinal blood (group 2) using hard-shell cardiotomy reservoir. One hundred consecutive patients who had elective coronary artery or valvular operations were studied. The two groups were comparable with regard to age, sex, weight, preoperative and postoperative hemoglobin levels, and surgical procedure. Group 2 patients had their shed mediastinal blood reinfused for up to 18 hours postoperatively; otherwise, the two groups were treated identically. For groups 1 and 2, average mediastinal blood losses were 705 +/- 522 and 822 +/- 445 mL and homologous blood consumption was 3.83 +/- 2.58 and 3.15 +/- 2.05 U, respectively (neither measure was significantly different). However, if blood losses exceeded 500 mL, there was a statistically significant reduction in homologous blood requirements in group 2 as compared with matched controls in group 1. This difference was most significant in patients with the greatest mediastinal losses.

Blood Transfusion, Autologous↗
PubMed1989

Propofol-fentanyl anaesthesia for coronary artery surgery and cardiopulmonary bypass.

A two-stage propofol infusion combined with fentanyl was used to maintain anaesthesia during coronary artery surgery in patients with good ventricular function. Whole blood propofol concentrations were measured at frequent intervals; plasma protein binding was measured before, during and after cardiopulmonary bypass. An initial infusion rate of 10 mg/kg/hour provided good protection from the pressor response to sternotomy. A predictable steady state concentration was achieved in the prebypass period with a maintenance infusion rate of 3 mg/kg/hour. The onset of bypass resulted in a small decrease in propofol concentration as a result of haemodilution. Induced hypothermia resulted in an increase in propofol concentration which returned rapidly to the prebypass steady state value during rewarming. The free propofol fraction increased during cardiopulmonary bypass. No patient had any recall of operative events or required inotropic support during weaning from bypass.

Adult↗
PubMed1988

Homologous blood use and conservation techniques for cardiac surgery in the United Kingdom.

The transfusion laboratories of 32 cardiothoracic surgical centres for adults were surveyed to determine the donor blood requirement for open heart surgery in the United Kingdom. Details of the transfusion practice and the use of blood conservation techniques were sought from a representative senior cardiac anaesthetist at each centre. Suitable data were received from 24 transfusion laboratories (75%) and 29 anaesthetists (90%). The mean (SD) blood use was 5.07 (1.53) units per operation. Seven centres routinely transfused fresh frozen plasma to all patients postoperatively. Experience with autologous deposit (three centres), "cell separators" (four centres), and the reinfusion of shed mediastinal blood (four centres) was limited. Prebypass phlebotomy for postbypass reinfusion (14 centres) and the infusion of residual oxygenator blood (27 centres) were the conservation techniques most commonly applied. In only nine centres was a postoperative normovolaemic anaemia to a haemoglobin concentration of less than 100 g/l accepted. Applying blood conservation techniques more widely would help to maintain blood supplies and reduce morbidity and mortality related to transfusion.

Anemia↗
PubMed1988

Local anesthesia for radial artery cannulation: a comparison of a lidocaine-prilocaine emulsion and lidocaine infiltration.

A topical anesthetic emulsion consisting of a mixture of lidocaine and prilocaine (EMLA) was used in an attempt to reduce the pain associated with radial artery cannulation. Three groups were compared: (1) EMLA applied at least 90 minutes prior to cannulation (EMLA 90); (2) EMLA applied 60 minutes prior to cannulation (EMLA 60); and (3) lidocaine 2% infiltration performed immediately prior to the procedure (infiltration). Pain was registered using visual analog and verbal ranking scales by both the patient and an independent observer. The EMLA 90 group experienced significantly less pain (P < .001) than either the EMLA 60 or lidocaine infiltration groups. There was no statistically significant difference in pain scores between the EMLA 60 and infiltration groups. Local side-effects of EMLA were negligible.

Anesthesia, Local↗
PubMed1988

Left vocal cord paralysis after mobilisation of the internal mammary artery.

A case of vocal cord paralysis following mobilisation of the internal mammary artery is described. Of the various possible mechanisms, the most likely in this case is damage to the vagus nerve in the root of the neck, where it passes close to the origin of the internal mammary artery. Diathermy may have caused the damage, and this may be avoided by using a disposable automatic clip applier on any branches of the mammary artery in the area.

Humans↗
PubMed1987

Neostigmine in the antagonism of the action of atracurium.

Antagonism of atracurium-induced neuromuscular blockade with neostigmine (one or two doses of 2.5 mg) was compared, using electromyography, with spontaneous recovery. Two levels of blockade were studied, one in which the initial response of the train-of-four has reached 10% of control and the other 50% of control. Adequate recovery was considered to be present when the ratio of the fourth response to the first (train-of-four ratio) had reached 70%. Neostigmine always accelerated recovery and "neostigmine block" was not detected. This acceleration of recovery after neostigmine was most marked with the greater degree of blockade, but two doses of neostigmine were no more effective than one. Spontaneous recovery to the train-of-four ratio of 70% was slow, in the order of 1 h after an initial dose of 0.5 mg kg-1 and 45 min after incremental doses of 0.2 mg kg-1. It is concluded that antagonism of atracurium with one dose of neostigmine is usually desirable, that two doses are unnecessary, and that spontaneous recovery is slower than is generally realized.

Atracurium↗