Respiratory insufficiency after abdominal surgery.

The objective of this study was to define the relationship between respiratory insufficiency (RI) and various putative risk factors for patients undergoing abdominal surgery. A review of 1332 adults undergoing abdominal surgery was undertaken. Information was collected in a unbiased, prospective and uniform manner with regard to baseline characteristics, perioperative events and adverse outcomes after surgery. Respiratory Insufficiency was defined as either: a PO2 < 60 mm Hg, the performance of a tracheotomy, or endotracheal intubation for more than 24 h. The incidence of RI was 3% (40/1332). A logistic regression analysis only identified an American Society of Anesthesia (ASA) classification > 2 (P < 0.001) and the presence of chronic bronchitis (P (P < 0.05) as significant risk factors. In addition, 33% (8/24) of the patients who developed postoperative intraperitoneal sepsis and 30% (14/47) of the patients who underwent a reoperation developed RI. It was concluded that patients with a significant systemic disease (ASA > 2), as well as patients with chronic bronchitis, should be the recipients of intense efforts to prevent pulmonary complications after abdominal surgery.

A case-control study of postoperative pulmonary complications after laparoscopic and open cholecystectomy.

Postoperative pulmonary complications (PPC) are common after upper abdominal surgery. The objective of this case-control study was to compare the incidence of PPC after laparoscopic cholecystectomy (LC) and open cholecystectomy (OC) within a tertiary care center. Patients were accrued from two sequential clinical trials that evaluated the role of incentive spirometry in the prevention of PPC after abdominal surgery. Included for study were patients with gallstones undergoing elective surgery who had an American Society of Anesthesiologists (ASA) classification < 3. All patients included in the study were encouraged to use an incentive spirometer at least 10 times each hour while awake. Patients with chronic bronchitis were excluded from study, as were patients who received other forms of physical therapy. OC was performed through either a transverse or an oblique incision. There was an equitable dispersion of putative risk factors for PPC between the groups at baseline. PPC were defined as clinical features consistent with collapse/consolidation, an otherwise unexplained temperature above 38 degrees C, plus either confirmatory chest radiology or positive sputum microbiology. The incidence of PPC was 2.7% (1/37) after LC and 17.2% (10/58) after OC (p < 0.05). It is concluded that PPC are less common after laparoscopic cholecystectomy than after open cholecystectomy.

Prevention of respiratory complications after abdominal surgery: a randomised clinical trial.

OBJECTIVE: To evaluate the prevention of respiratory complications after abdominal surgery by a comparison of a global policy of incentive spirometry with a regimen consisting of deep breathing exercises for low risk patients and incentive spirometry plus physiotherapy for high risk patients. DESIGN: Stratified randomised trial. SETTING: General surgical service of an urban teaching hospital. PATIENTS: 456 patients undergoing abdominal surgery. Patients less than 60 years of age with an American Society of Anesthesia classification of 1 were considered to be at low risk. OUTCOME MEASURES: Respiratory complications were defined as clinical features consistent with collapse or consolidation, a temperature above 38 degrees C, plus either confirmatory chest radiology or positive results on sputum microbiology. We also recorded the time that staff devoted to prophylactic respiratory therapy. RESULTS: There was good baseline equivalence between the groups. The incidence of respiratory complications was 15% (35/231) for patients in the incentive spirometry group and 12% (28/225) for patients in the mixed therapy group (P = 0.40; 95% confidence interval -3.6% to 9.0%). It required similar amounts of staff time to provide incentive spirometry and deep breathing exercises for low risk patients. The inclusion of physiotherapy for high risk patients, however, resulted in the utilisation of an extra 30 minutes of staff time per patient. CONCLUSIONS: When the use of resources is taken into account, the most efficient regimen of prophylaxis against respiratory complications after abdominal surgery is deep breathing exercises for low risk patients and incentive spirometry for high risk patients.

Pulmonary alveolar proteinosis in association with Fanconi's anemia and psoriasis. A possible common pathogenetic mechanism.

We report a case of PAP which proved to be fatal despite whole lung lavage. The need for early BAL and transbronchial biopsies in diffuse infiltrative lung disorders of unknown etiology is highlighted. The occurrence of PAP in association with Fanconi's anemia and psoriasis raises the possibility of a common pathogenetic defect which may be related to abnormal cytokine metabolism. Investigation of cytokine metabolism in PAP is warranted.

A multivariate analysis of the risk of pulmonary complications after laparotomy.

We evaluated the relationship between PPC and various putative risk factors in a prospective longitudinal study of 1,000 patients undergoing abdominal surgery. Transient subclinical events were excluded by defining PPC as positive clinical findings in combination with either positive sputum microbiology, unexplained pyrexia, or positive chest roentgenographic findings. The overall incidence of PPC was 23.2 percent (232/1,000). Multivariate analysis identified seven factors which were associated with PPC: ASA classification greater than 2, upper abdominal surgery, residual intraperitoneal sepsis, age greater than 59 years, BMI greater than 25, preoperative hospital stay greater than 4 days, and colorectal or gastroduodenal surgery (overall F score = 33.5, p less than 0.0001). The ASA classification was the most powerful indicator of risk in both the univariate and the multivariate analyses. The combination of ASA classification greater than 1 and age greater than 59 years identified 88 percent (205 of 232) of the patients who developed PPC. These findings provide clinicians and clinical investigators with a simple means of identifying patients who are at high risk of PPC after abdominal surgery.

Multiple pneumatocoeles and bilateral tension pneumothoraces complicating pneumocystis pneumonia in AIDS.

Pneumatocoele and pneumothorax are uncommon complications of Pneumocystis carinii pneumonia. We report a patient with the Acquired Immune Deficiency Syndrome who developed multiple bilateral pneumatocoeles which we demonstrate to have ruptured leading to the subsequent bilateral tension pneumothoraces and to death. The computerised tomographic appearances, and histopathology of these unusual complications are presented. The literature on these manifestations is reviewed and management discussed.

Nebulized ipratropium in the treatment of acute asthma.

The efficacy of ipratropium and salbutamol was determined in 117 patients with acute asthma who presented to an emergency department to determine whether the order of administration of the two agents affects the improvement in peak flow rates. Patients were given two nebulized treatments at an interval of one hour in a randomized, double-blind design. They received either 5 mg nebulized salbutamol followed by 0.5 mg ipratropium, ipratropium followed by salbutamol, or both drugs administered together followed by nebulized saline. Ipratropium was an effective bronchodilator when given as the first agent. Simultaneous administration with salbutamol was as effective as sequential administration. At one hour after treatment, there was no difference in peak flow between the combination of drugs and either drug given alone. Ipratropium given after salbutamol was not superior to saline solution given after the combination of drugs. Our data do not suggest a substantial therapeutic effect from addition of ipratropium to salbutamol in the immediate treatment of acute asthma.

Evaluation of ketotifen (HC20-511) in bronchial asthma.

Ketotifen 1 mg b.d. (oral) and sodium cromoglycate 20 mg q.i.d. (inhalation) were compared in a double-blind crossover trial in 43 asthmatic outpatients. Comparison of diary card scores and pulmonary function tests showed significant improvement over a 12 week period on each drug. Comparison of the diary card scores and pulmonary function tests showed no significant difference between the drugs after 12 weeks of treatment. Twenty-six patients experienced sedation and/or lethargy whilst on ketotifen and 11 patients had similar side effects whilst on cromoglycate. Physician preferences based on diary card and pulmonary function data showed an approximately equal number of preferences for each medication and also a small group of patients in which no preference could be made. The present trial suggests that both ketotifen and cromoglycate are effective in the management of outpatient asthma. When all the patients are considered as a group no distinction can be made between the two drugs; on the basis of physician assessment of each patient, it appears that some patients may do better on ketotifen and others on cromoglycate.

Effect of intravenous injection of rimiterol in asthma.

1 The effect of i.v. rimiterol was compared with aerosol rimiterol in twelve asthmatic patients. 2 A cumulative dose of rimiterol (1050 microgram) given in six separate injections over 90 min resulted in a mean increase in peak expiratory flow rate (PEFR) of 50.6% and FEV1 of 53.7%. 3 Comparison of the degree of bronchodilation to the same dose of rimiterol administered intravenously or by aerosol, suggested that on average the potency ratio was 10:1, i.e. ten times the aerosol dose was required to produce the equivalent bronchodilator effect. 4 Palpitations, tremor and postural hypotension were common during the first minute after the drug was injected intravenously, but did not occur after aerosol administration. 5 It is suggested that rimiterol by intravenous injection is a useful addition to the treatment of acute asthma.

Comparative efficacy of salbutamol by pressurized aerosol and wet nebulizer in acute asthma.

1 Cumulative dose-response curves (FEV1) to pressurized aerosol salbutamol were established in 17 patients admitted to hospital with acute severe asthma. After the maximal pressurized aerosol effect had been achieved, a further dose (5 mg) of salbutamol was given by wet nebulizer and any further increment recorded. 2 Baseline FEV1 was 1.16 +/- 0.55 (mean +/- s.d.), an average of 36% of predicted, and the maximal aerosol induced change in FEV1 was 0.435 +/- 0.330 1 (t = 5.72, P < 0.01). There was an additional, small increment in FEV1 after nebulizer of 0.043 +/- 0.085 1 (t = 2.26, P < 0.05). 3 Detailed analysis of the data according to a theoretical dose-response relationship showed that the nebulizer-aerosol increment was unrelated to asthma severity.

A hand-held calculator program for individualized dosage adjustment of intravenous theophylline in acute asthma.

Despite general development of drug assay services and increasing interest in pharmacokinetics, proper dosage regimen calculations are not often made in routine clinical practice. This could be due, in part, to unfamiliarity with pharmacokinetic theory, the consequent difficulty of collaboration and the inevitable delay while data are processed on a computer. The present program for a hand-held calculator (TI-59) was written to minimize these problems, and was designed for the use of intravenous theophylline in the management of acute asthma, where there is a need for individualisation of dosage. Calculations are based on the one compartment open model. With 3--4 plasma drug concentrations taken early in the treatment, the program gives a measure of goodness of fit, the elimination rate constant (kel), the volume of distribution (Vd) and the suggested infusion rate to achieve a given steady-state level. Data from 10 severe acute asthmatic patients were used to test the model and the estimated parameters were: Vd = 0.26 +/- 0.029l/kg (mean +/- SEM) and Kel = 0.20 +/- 0.045 h(-1). The average standard deviation (s) for differences between the model and observations was 0.96 +/- 0.21 mg/l, of which at least 0.5 mg/l was due to assay error. In seven patients where the infusion period was extended, the predicted steady state plasma concentration agreed reasonably with that observed (r = 0.83, df = 5, 0.01 < p < 0.05).

Abuse of drugs "for kicks": a review of 252 admissions.

Abuse of drugs "for kicks" is becoming more common in Great Britain. This article reviews 252 consecutive cases of drug abuse admitted to the Regional Poisoning Treatment Centre, Royal Infirmary, Edinburgh, during 1971 and 1972. Of the 189 patients (146 males and 43 females; mean age 20 years) 72% of admissions occurred between 6 p.m. and 8 a.m., and Saturday was the most common day for admissions. The commonest source of referral was via the police or ambulance service. Barbiturates were the drugs most often abused, followed by LSD (lysergide) and Mandrax (methaqualone and diphenhydramine). Sixty-five per cent. of patients had previously abused drugs. Medical care was required in 45% of the admissions. Sixty per cent. were in social class 4 or 5 and psychiatric and social support was required in only a small minority of patients.