Biomedical subjects
D M Nierman
Publications and source records attributed to D M Nierman.
Pneumocephalus following nasotracheal intubation.
A 75-year-old woman with a previous repair of a cribiform plate fracture was nasotracheally intubated following a suicide attempt. Twenty-one days later she was readmitted to the hospital with a massive pneumocephalus, followed by a terminal intracranial hemorrhage. Nasotracheal intubation as a contributing factor in the development of pneumocephalus is previously unreported.
Core temperature measurement in the intensive care unit.
OBJECTIVE: To compare three devices that measure core body temperature at the bedside in ICU patients. DESIGN: Prospective, consecutive sample. SETTING: Voluntary community teaching hospital. PATIENTS: Fifteen patients, 78 +/- 6 (SD) yrs of age, admitted to the medical ICU over a 5-month period who had pulmonary artery catheters inserted as part of their routine care were studied. Thirteen patients were studied once, one patient twice, and one patient six times for a total of 21 sets of measurements. INTERVENTIONS: All patients had urinary bladder thermistor catheters inserted just before pulmonary artery catheterization. Simultaneous core temperatures were measured for the duration of pulmonary artery catheterization every 4 hrs by the pulmonary artery thermistor catheter, the bladder thermistor catheter, and by a tympanic membrane infrared probe set on its core temperature setting. The three devices were then compared with each other in vitro using a specialized constant water bath setup. Finally, two of the tympanic membrane infrared probes were compared with each other in 20 ambulatory emergency department patients. MEASUREMENTS AND MAIN RESULTS: Over 32 hrs of pulmonary artery catheterization, the pulmonary artery thermistor catheters and bladder thermistor catheters showed excellent agreement, with a bias of only -0.04 degrees C between the two. However, the bias comparing the tympanic membrane infrared probe with the pulmonary artery thermistor catheter was -0.38 degrees C, and the bias was -0.34 degrees C comparing the tympanic membrane infrared probe with the bladder thermistor catheter. The tympanic membrane infrared probe readings remained significantly higher than the pulmonary artery thermistor catheter or bladder thermistor catheter readings over the entire 32-hr period. The two tympanic membrane infrared probes compared with each other in emergency room patients showed excellent agreement (p less than .001). In the in vivo water bath setup, the tympanic membrane infrared probe on most of its settings again registered significantly (p less than .01) higher than both the pulmonary artery thermistor catheter and the bladder thermistor catheter. CONCLUSIONS: Pulmonary artery thermistor catheters and bladder thermistor catheters appear to give consistent, highly reliable bedside measurements of core body temperature in ICU patients. The currently available device that measures core body temperature from the tympanic membrane appears to give erroneously high readings, and should be used with caution.
Permeability of the bronchial mucosa to 99mTc-DTPA in asthma.
Previous investigators, using 99mTc-DTPA aerosol as a marker to assess epithelial permeability in asthma, did not find an increased permeability in this group. However, they either failed to deliver the aerosol to the optimal site (bronchial mucosa, not alveoli) or failed to account for mucociliary clearance in analyzing their results. We studied 10 asthmatics and eight age-matched control subjects using a dosimeter (Spira-Elektra 2) and a carefully controlled breathing pattern to deliver aerosol to the subjects' airways. Two aerosols were delivered on separate days in each patient; 99mTc-DTPA aerosol, and 99mTc-HSA (human serum albumin), using similar breathing patterns to ensure reproducibility of the deposition pattern with the two aerosols. From measurements of retention versus time over a 1-h period, rate constants Ktot and Km were determined for the clearance of 99mTc-DTPA and 99mTc-HSA, respectively. By modelling the airways as a single compartment with two possible routes of clearance, we determined the permeability rate constant, Kp, as Ktot minus Km. There was no significant difference between Ktot in normal subjects and asthmatics; however, because of the slower mucociliary clearance in the asthmatic group, and the relative importance of mucociliary clearance in determining the washout of 99mTc-DTPA aerosol, there was a significant difference in airway permeability between the normal subjects and the asthmatics (t1/2 = 296 min +/- 141 SD and 126 min +/- 58, p less than 0.01, in normal subjects and asthmatics, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)
Bilateral upper lobe Pneumocystis carinii pneumonia in a patient receiving inhaled pentamidine prophylaxis.
A 46-year-old man with AIDS, receiving inhaled pentamidine for Pneumocystis carinii pneumonia (PCP) prophylaxis, developed bilateral upper lobe infiltrates. Bronchoalveolar lavage confirmed the diagnosis of PCP. Therapy with intravenous trimethoprim-sulfamethoxazole (TMP-SMX) was begun, with gradual resolution of these infiltrates noted. An explanation for the development of upper lobe PCP, despite aerosol chemoprophylaxis, is presented and emphasizes the importance of aerosol particle size (and therefore of nebulizer type) on the distribution of inhaled pentamidine.