Thiamine deficiency in the critically ill.

There have been recent reports of hospitalised patients developing clinical thiamine deficiency, combined with much debate on the optimal supplementation of thiamine for the parenterally fed patient, particularly in the intensive therapy environment. We performed a retrospective study on 158 patients admitted to the Intensive Care Unit who required nutritional support. Patients who survived had significantly higher body thiamine status than those who died (p less than 0.01). There was no difference between serum albumin concentrations of the two groups. Twenty percent of the patients had biochemical evidence of thiamine deficiency and the mortality rate in these patients was 72% as compared with 50% mortality overall. Follow-up results suggest that current levels of thiamine supplementation are insufficient for critically ill intravenously fed patients. We suggest that patients be given a loading dose of 50-250 mg thiamine on admission to the Intensive Care Unit.

Rapid diagnosis of an outbreak of Legionnaires' disease at Glasgow Royal Infirmary.

In the last three months of 1985 there was an outbreak of legionnaires' disease at Glasgow Royal Infirmary affecting 15 patients and one surgeon; five patients died. Legionnaires' disease was first suspected when a second case of severe nosocomial pneumonia occurred in a high dependency unit. The application of the direct fluorescent antibody test to specimens obtained at bronchoscopy was responsible for the rapid diagnosis of legionnaires' disease, which led to the prescription of appropriate antibiotic treatment and the shutting down of the contaminated cooling tower, thereby containing the outbreak. It also led to a search for further cases. It is suggested that these diagnostic techniques should be included in the investigation of affected patients in an outbreak of pneumonia.

Improving the prognosis in acute renal and respiratory failure.

We have achieved smooth homeostasis in patients with acute renal and respiratory failure by means of machine-controlled, continuous ultrafiltration and simultaneous bicarbonate hemodialysis with a polysulfone, biocompatible membrane (CUPID). No adverse effects were seen, even after 22 days of continued treatment. Mortality was reduced (7/14) when compared to that of a similar group given short conventional daily acetate hemodialysis and ultrafiltration with a cuprophane membrane (12/18).

Absorption of 1.5% glycine after percutaneous ultrasonic lithotripsy for renal stone disease.

An elderly normotensive man underwent percutaneous ultrasonic lithotripsy for renal stone disease, the procedure lasting three hours and the fragments being washed out with 20 l 1.5% glycine. After two hours the inflation pressure had risen to 25 cm H2O and his blood pressure to 150 mm Hg. Inflation pressure continued to rise until drainage tubes were inserted into the retroperitoneal space, releasing a large volume of fluid, some of which appeared to be from the peritoneal cavity. Shortly after transfer to the recovery area the patient showed signs of the transurethral resection syndrome, with hyponatraemia, hyperkalaemia, and hypertension. He was treated appropriately and survived. Low infusion pressures should be used for irrigation during lithotripsy and 0.9% saline instead of 1.5% glycine. In patients given a general anaesthetic any rise in inflation pressure suggests extravasation of fluid and warrants emergency estimation of the plasma sodium concentration.

Tourniquets for surgery: safety aspects.

There are a variety of different types of pneumatic tourniquets in constant use within the UK Health Service. These range from simple manually operated units to more complex gas-powered devices. Fatalities have occurred following the failure of pneumatic tourniquets during surgery when the local anaesthetic agent administered to the patient entered the circulation. Investigation has revealed that certain tourniquet systems have design defects, for example deterioration of rubber tubing, inadequate securing of pressure tubing, excessive wear in a pressure regulator. With any tourniquet system, routine maintenance coupled with regular user checks are essential to ensure reliability.

Respiratory injury in the burned patient. The role of flexible bronchoscopy.

The purpose of the study was to investigate the role of flexible bronchoscopy in the management of patients admitted to a busy Regional burns unit, with particular reference to possible smoke inhalation injury. The basic procedure employed was that used in routine bronchoscopy for the diagnosis of bronchial carcinoma, with modification of the premedication required in view of the shorter duration of the technique and the lack of a requirement for bronchial biopsy. We have found the procedure easy to perform, well tolerated by the patients and not associated with any complications. It provides additional information not otherwise available, which can influence the subsequent management of the patient. An experienced bronchoscopist and additional personnel skilled in resuscitation techniques are required. It should be performed in patients with clear evidence of smoke inhalation injury and in particular with facial burns in order to visualise the extent of airway injury, remove debris and give some indication of the likelihood of subsequent complications such as acute upper airways obstruction.

A survey of infection in an intensive care unit. "Forewarned is forearmed".

The infection (36%) and mortality rates (28%) were investigated in 433 patients admitted to a Respiratory Intensive Care Unit. It was found that the mortality rate was higher (45%) in the infected group than in the non-infected group (19%) and particularly so in patients who had had intra-abdominal surgery or who remained in the unit for longer than a week.

Respiratory intensive care: a 10-year survey.

The work of the respiratory intensive care unit at the Glasgow Royal Infirmary covering a period of 10 years and involving more than 2,000 patients has been analysed. The rate of admission of patients with acute respiratory or metabolic disturbances remained surprisingly constant over the years, allowing for the increase in available beds after 1965. A disturbing feature was the notable increase in the incidence of severe self-poisonings. The continued importance of infection as a life-threatening complication is also emphasized. The reduction in mortality observed in some of the most gravely ill patients appears to justify this approach to patient care.