Biomedical subjects
Publications and source records attributed to S M Mostafa.
A patient undergoing pharyngo-oesphagectomy with gastric transposition sustained a large tracheal tear during the blind oesophageal dissection. High frequency jet ventilation was successfully employed in the acute airway management and continued postoperatively.
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Peribulbar anaesthesia is a form of regional anaesthesia which has been used with increasing popularity in cataract surgery. Recently indications for its use have been extended to include surgery for vitreo-retinal disease and strabismus. This study shows that in nine of 11 patients in whom the oculocardiac reflex was stimulated by traction on an extra-ocular muscle, peribulbar anaesthesia failed to abolish the reflex. In each of these patients, the reflex manifested as a bradycardia. In one subject, the bradycardia was profound, showing no QRS complex for five seconds. We recommend that cardiac rhythm be monitored throughout procedures performed under peribulbar anaesthesia, and that a vagolytic agent be available for immediate use.
Thirty patients received topical application of either timolol ophthalmic solution 0.25%, or normal saline, 2 h before elective ophthalmic surgery in a double-blind study. The responses to suxamethonium and tracheal intubation were compared by measuring intra-ocular pressure before induction of anaesthesia, 1 min after administration of thiopentone 2-4 mg.kg-1, 1 min after administration of suxamethonium 1 mg.kg-1, and 1, 2.5 and 5 min after tracheal intubation. There was no significant difference between the groups.
Between 1984 and 1986 six patients with acute respiratory failure (requiring ventilation for at least 3 days) complicating acute pancreatitis were managed on the intensive care unit (median ventilation period 6 days; range 3-41 days). Between 1987 and 1989 nine similar patients were managed (median ventilation period 35 days, range 4-69 days), and a regimen of enteral tobramycin, polymyxin and amphotericin to selectively decontaminate the digestive tract (SDD) was introduced. Five of six patients treated before 1987 had serious infections (three Gram-negative, one fungal), compared with only one of nine patients treated with SDD (P < 0.05). Clinical signs of sepsis were evident for 62% of the pre-SDD period, compared with 39% of the period during SDD therapy (P < 0.001). Systemic antibiotic prescribing was reduced in the SDD group; however, mortality remained unaffected with only two patients surviving pre-SDD and three during SDD treatment. SDD reduces infection rates and sepsis in patients with acute pancreatitis and may help to improve the prognosis of this life-threatening condition.
The cost of intensive care for patients admitted to the ICU were estimated. Patients suffering from severe combined acute respiratory and renal failure who required mechanical ventilation and renal replacement therapy (SCARRF-D) cost per day significantly more than non-renal patients (pounds 938 compared to pounds 653 per patient respectively) and their average length of stay in hospital is nearly 4 times as long (28.8 compared to 7.6 days respectively). Approximately 44% of the total cost was staff related (28% for the provision of nurses and 16% for the rest). Retrieving information related to cost was difficult, time consuming and labour intensive.
We analysed the nitrous oxide composition of the intraocular gas bubble following vitrectomy and fluid-air exchange in 12 patients. Samples were taken under standardised conditions at 20 minutes after completion of the fluid-air exchange. Analysis was conducted by a Medishield MS2 mass spectrometer. The percentage composition of nitrous oxide in the samples varied between 4 and 21% (mean 9%). This influx of nitrous oxide was associated with an increase of intraocular pressure. Pressure rises of greater than 20 mm Hg were not seen owing to venting of gas through the sclerostomies. An inverse relationship was noted between the extent of retinal detachment preoperatively and the amount of nitrous oxide entering the eye. A possible explanation for this relationship is proposed. The importance of nitrous oxide movement is stressed.
Two patients with multiple organ failure, septicaemia and a deteriorating clinical course were treated by plasma exchange in addition to standard supportive measures. Dramatic improvements were seen in cardio-respiratory (patient 1), neurological and renal parameters (patient 2) which were attributable to the exchanges. Plasma exchange might be of value as adjunctive therapy where overwhelming septicaemia occurs with multiple organ failure.
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We have examined the effect of preoperative administration of nebulized lignocaine or saline on the intraocular pressure (IOP) response to tracheal intubation in 20 adults. In the saline group, tracheal intubation was associated with a significant increase in IOP above control and preintubation values (P less than 0.01); in the lignocaine group there was no change in IOP following intubation. After intubation, IOP was significantly less in the lignocaine group than in the saline group (P less than 0.05).
Fifteen patients with severe combined acute renal and respiratory failure (SCARRF), who required mechanical ventilation and renal replacement therapy for at least 5 days, were treated with a regimen to selectively decontaminate the digestive tract (SDD). In these patients the incidence of significant infection was compared with the infection rate in 12 similar patients with SCARRF who had not received SDD, treated over the preceding 12 months. Both groups were comparable for age, study period, sepsis score, and therapeutic intervention scoring system on admission, although the Acute Physiology and Chronic Health Evaluation score was higher (p less than .05) in the SDD-treated group. Ten (83%) of 12 control patients developed definable infections compared with five (33%) of 15 in the SDD group (p less than .05). Gram-negative bacteria and fungi were responsible for 14 of the 17 infections affecting ten control patients, compared with six of the seven infections in only four SDD patients (p less than .05). The most notable site to benefit was the respiratory tract, with only one patient in the SDD group developing a pulmonary infection compared with five in the control patients (p less than .05). Urine infections may have been reduced from six (50%) of the 12 control patients to two (13%) of the 15 SDD patients, but this difference was not significant. Although survival in the control and SDD group was comparable (42% vs. 40%), mortality overall seemed related to infection. Eleven (73%) of 15 patients with definite infection died, in contrast with five (42%) of 12 who had no infections, although this was not significant.(ABSTRACT TRUNCATED AT 250 WORDS)
The Keeler Pulsair is a noncontact tonometer which can be used by those without specialist ophthalmic training. The instrument was compared, in a series of 30 patients in whom a total of 150 readings were taken, in respect of accuracy, ease and speed of use, and acceptability to patients, with the Perkins hand-held applanation tonometer. There was good correlation between measurements obtained with the two instruments: r = 0.92, (p less than 0.001); the Pulsair was described as easy to use in 87% of subjects, and no patient found the procedure unpleasant. The median times taken for Pulsair measurements were 7 (range 4-14) seconds for a single reading in conscious patients, and 11 (range 4-29) seconds for four readings in anaesthetised patients. These times were significantly quicker than those recorded with the Perkins tonometer which were 83 (range 66-138) seconds and 20 (range 8-45) seconds respectively (p less than 0.001). We conclude that the Pulsair is suitable for use by those who are not ophthalmologists for the rapid measurement of intra-ocular pressure changes during anaesthesia.
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Severe hypotension and bradycardia occurred in two patients after superior laryngeal nerve block for awake tracheal intubation. Both patients required treatment with anticholinergic drugs and i.v. infusions and made a good recovery.
A 75-year-old woman underwent panendoscopy and excision of a neck "lump". After antagonism of residual neuromuscular block and extubation of the trachea, she developed recurrent upper airway obstruction and stridor, necessitating a permanent tracheostomy. The possibility of vagal nerve involvement or injury should always be considered during excision of neck lumps. Preoperative indirect, atraumatic laryngoscopy by experienced surgeons is essential, as are tracheal intubation and vigilant postoperative observation.