Adverse events in a surgical intensive care unit--a cause of increased mortality.

The incidence and nature of and the outcome following adverse events were studied prospectively in a surgical intensive care unit over a period of 1 year. From a total of 657 patients, 229 (34.8%) suffered 369 adverse events. The number of adverse events per patient ranged from 1 (58.1%) to a maximum of 4 (6.1%). The overall mortality rate was 23.4%. Eighty-seven deaths (20.3%) occurred in patients not suffering an adverse event and 67 (29.3%) in those whose treatment was complicated by an adverse event (P < 0.02). There was no significant difference in mortality between patients with single or multiple events. Twenty-two patients died as a direct result of the event, the commonest reason being loss of airway control. Adverse events contribute significantly to mortality in critically ill patients.

Direct intracompartmental pressure measurement in the management of snakebites in children.

Snakebite remains a source of considerable morbidity in Natal. Despite the availability of specific and polyvalent antivenins, the regional effects of envenomation and inappropriate first-aid result in significant, potentially avoidable, disability--particularly in children. Direct measurement of intracompartmental pressure has been used as an adjunct to clinical assessment of the child with a swollen limb following snakebite in order to diagnose compartment syndrome. Initial encouraging results in 9 patients suggest that, in this difficult clinical situation, such measurements may have an important role in patient assessment.

Boomslang bite--diagnosis and management. A report of 2 cases.

Bites by boomslang are uncommon and usually occur in adult snake handlers who are aware of the potentially fatal consequences, i.e. disseminated intravascular coagulation with delayed onset of spontaneous haemorrhage. Accidental bites in children are rare. Aids to diagnosis include the description of the bite, identification of the snake, and the recognition of an abnormal bleeding tendency before the onset of spontaneous haemorrhage. Specific boomslang antivenin arrests established bleeding but may not be immediately available, in which case the administration of heparin should be considered. Thrombo-elastography is a useful aid to diagnosis and management.

Evaluation of the efficacy and tolerance of intravenously administered imipenem/cilastatin in the treatment of septicaemia.

In an open study to determine the efficacy, safety and tolerance of intravenously administered imipenem/cilastatin (Tienam 500; Logos) in the treatment of septicaemia, 34 patients were given this thienamycin antibiotic in doses ranging from 1.5 g to 2 g daily for an average of 8.6 days (range 3-44 days). Based on clinical assessment, the study drug appeared to be effective in treating the septicaemia in 28 out of 34 patients and bacteriologically assessed eradication of the isolated pathogen was proven in 24 out of 34 patients. The drug appeared to be well tolerated in all but 4 patients, 3 of whom developed mild phlebitis and 1 a skin rash.

Thyroid function in hospitalized patients: effect of illness and serum albumin concentrations.

We assessed the clinical utility of measuring thyrotropin (TSH) in serum by immunoradiometry and of measuring total thyroxin (TT4), total triiodothyronine (TT3), free thyroxin (FT4), and free triiodothyronine (FT3). We used a group of 110 healthy volunteers, 45 ill hypoalbuminemic patients, and 42 ill normoalbuminemic patients. In addition, the free thyroxin index (FTI) and TT4:thyroxin-binding globulin (TBG) ratio were also calculated. The hypoalbuminemic group had significantly lower FT4, FT3, TT4, TT3, and FTI concentrations, but only FT3 and TT3 were significantly lower in the ill normoalbuminemic group as compared with controls. We found significant correlation between FT4 and albumin (r = 0.372, P less than 0.001) and FT3 and albumin (r = 0.465, P less than 0.001). TSH concentrations were undetectable in two of 45 hypoalbuminemic patients, significantly higher in the rest. The TT4/TBG ratio was the only parameter of thyroid function that remained unchanged in the ill patients.

Anti-endotoxin in the treatment of severe surgical septic shock. Results of a randomized double-blind trial.

A randomized double-blind trial of human antilipopolysaccharide (anti-LPS)-specific globulin (LG-1) versus placebo (albumin) in the treatment of severe septic shock of surgical origin was carried out over a 6-month period from June to December 1983. Hospital mortality was 10 patients (59%) out of 17 in the control group and 9 out of 17 (53%) in the treated group. Irreversible shock was the cause of death in 4 patients (23,5%) in the control group and 5 (29,4%) in the treated group. Duration of hospital stay of the survivors averaged 44 days for the control group and 62 for the treated group. Measurement of serum endotoxin and anti-LPS levels at the time of admission to the study and 24 hours later revealed no significant difference between controls and treated patients. Significantly higher mortality rates were observed in patients who were endotoxemic after 24 hours of treatment compared with those who were not (chi 2 = 4,80; P less than 0,025).

Fatal air embolism following penetrating lung trauma: an autopsy study.

During a 3-month period an autopsy study was performed on cases of penetration lung trauma to assess the frequency and significance of air embolism. The technique of detecting air in the chambers of the heart and the coronary vessels was, in the early part of the study, to flood the pericardium with water and observe for air while stabbing the heart chambers. Later it was found preferable to manipulate the removed heart in a basin under water. Twelve cases demonstrated injury to the pulmonary parenchyma alone with no other injury, either intra- or extra-thoracic, to account for death. In nine of these cases significant amounts of air were demonstrated in the heart and coronary vessels using our autopsy techniques. Case reports are summarized to emphasize the clinical picture (unexplained hypovolemic shock, cerebral symptoms) and autopsy findings (evidence of air embolism). Successful management requires an awareness of the condition, correction of those factors exacerbating air embolism, and prompt thoracotomy in order to clamp the injured lung pedicle in patients failing to respond to therapy.

Rectal administration of metronidazole in severely ill patients.

Ten severely ill patients with life threatening sepsis received metronidazole as suppositories and blood concentrations of the drug were measured twice daily over five days. Therapeutic blood concentrations of metronidazole were maintained at all times in all patients. Rectal administration of metronidazole is accepted as effective prophylaxis against infection associated with surgery and as treatment of established infection. This study shows that in gravely ill patients metronidazole administered as suppositories gives perfectly adequate therapeutic serum concentrations of the drug, but that to achieve these concentrations rapidly the first suppository should be given with an intravenous loading dose.

Percutaneous infraclavicular subclavian vein catheterization in shocked patients: a prospective study in 172 patients.

To assess the safety and efficacy of percutaneous infraclavicular subclavian venipuncture in shocked patients 172 consecutive cases were prospectively studied. Catheterization was successful in 163 patients (94.7%); in 119 (69.2%) of these only one attempt was required. Failure was encountered in nine cases (5.2%). There were nine (5.2%) serious complications, four requiring active treatment. Procedure-related mortality was nil. Extrathoracic placement of the catheter tip was detected on routine check chest X-ray in 24 cases (14.8%). Staff relatively inexperienced in the technique contributed eight of the nine complications and six of the nine failures. This study supports the concept that percutaneous infraclavicular subclavian catheterization in shocked patients is a relatively safe technique providing rapid access to a central vein.

Chronic intestinal ischaemia: A report of 3 cases.

Chronic intestinal ischaemia should always be considered in the differential diagnosis of dyspepsia. Three cases are described to illustrate the variable presentation of the condition, its diagnosis and the satisfactory result of surgical reconstruction which may avert the potentially fatal complication of acute mesenteric thrombosis.

Influence of sampling on fatty acid composition of human milk.

To study effects of sampling on the fat and fatty acid composition of human milk, three subjects each obtained four complete expressions of milk in sequential fractions from each breast. Two subjects collected partial expressions of about 5 ml of milk from each breast frequently over a 2-mont period. Milk samples were analyzed gravimetrically for fat and by gas chromatography for the fatty acids 10:0, 12:0, 14:0, 14:1, 16:0, 16:1, 18:0, 18:1, and 18:2. While hindmilk contained a higher percentage of fat than foremilk, fatty acid composition of the milk fat did not vary throughout a nursing. Fatty acid composition from pairs of left and right breast samples collected at the same nursing did not differ. Therefore, fatty acid analyses of human milk will be representative of the entire nursing if the sample is taken from either breast at any time during the nursing.

Pancreatic ascites: report of two cases.

Two cases of pancreatic ascites are reported in which endoscopic retrograde and operative pancreatography were used to demonstrate the source of leakage from the duct system. Both patients were successfully treated by surgery. The management of patients with pancreatic ascites is discussed.

Influence of diet on trans fatty acids in human milk.

In two experiments on relations between diet and milk lipids, subjects recorded food intake for 1 week and saved duplicate portions of foods consumed on 3 days. Diet collections were analyzed for selected nutrients and percent fatty acids. In the first experiment, for 1 week five subjects took morning and evening milk samples for fatty acid analysis. Significant differences were found in percentages of trans- 18:1 and total trans fatty acids between subjects' milks but not between morning and evening samples. In the second experiment six additional subjects collected milk samples in the morning only. Subjects were significantly different in the percentages of trans- 18:1 and total trans acids in their milks. In nine of the 11 subjects the fluctuation of percent total trans acids in the milk appeared to follow dietary trans changes after a 12 to 36 hr lag period. A significant correlation was found for diet and evening milk of the same day. Polyunsaturated/saturated ratios of the fatty acids in the diet lipids were related to those for milk lipids from the same evening and the next morning. Although other factors are involved, diet lipids influence trans fatty acids and polyunsaturated/saturated ratios of the fatty acids in human milk.

Synthesis and loss of activity of glucose-6-phosphate dehydrogenase in dividing plant cells.

1. Using the technique of density-labelling with deuterium oxide, evidence has been obtained for the de novo synthesis of glucose-6-phosphate dehydrogenase (D-glucose-6-phosphate:NADPH+ 1-oxidoreductase, EC 1.1.1.49), during the culture of synchronously growing plant cells. 2. The entire increase in enzyme activity during the early cell cycles in this material can be accounted for by the appearance of an enzyme species with increased buoyand density. 3. A method is described for resolving overlapping distribution profiles after density centrifugation, which allows estimation of the amount of each species present at different times, and calculation of the loss of activity of the light species present from the start of culture. 4. Loss of activity of glucose-6-phosphate dehydrogenase in normal growing conditions in the presence of 2,4-dichlorophenoxyacetic acid is very much faster than in conditions which do not lead to cell division: in the absence of 2,4-dichlorophenoxyacetic acid, or in the presence of the inhibitor of RNA synthesis, 6-methylpurine.