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Biomedical subjects

E J Will

Publications and source records attributed to E J Will.

At least 73 records · Page 4Linked to original sources
PubMed1990

Adverse effects of prostacyclin administered directly into patients with combined renal and respiratory failure prior to dialysis.

We infused prostacyclin into 11 critically ill patients for 30 min at a rate of 5 ng/kg.min, prior to commencing prostacyclin haemodialysis. All patients had combined respiratory and renal failure and required intropic support. Despite the previous correction of hypovolaemia, prostacyclin produced a decrease in mean arterial pressure, pulmonary and systemic vascular resistances and cardiac filling pressures. There was no compensatory increase in cardiac output and due to an increase in pulmonary ventilation/perfusion mismatch an overall decrease in tissue oxygen delivery from a median of 560 ml/min.m2 to 370 ml/min.m2 was noted p less than 0.05, with a corresponding reduction in tissue oxygen uptake from 140 ml/min.m2 to 125 ml/min.m2. This was associated with an increase in both arterial hydrogen ion and lactate concentrations in 8 of the 11 patients studied, suggesting a deterioration in tissue oxygen supply/oxygen requirement. Prostacyclin should not be infused directly into patients unless monitored to assess the therapeutic/adverse effects on an individual patient basis.

Acute Kidney Injury↗
PubMed1990

Early changes in intracranial pressure during haemofiltration treatment in patients with grade 4 hepatic encephalopathy and acute oliguric renal failure.

We measured the intracranial pressure (ICP), using a subdural catheter in nine patients admitted with grade 4 hepatic encephalopathy due to fulminant hepatic failure complicated by oliguric renal failure. Six patients received daily machine haemofiltration and four patients were treated with continuous arteriovenous haemofiltration (CAVHF). The mean ICP increased during the first hour of machine haemofiltration from 9 +/- 1.4 mmHg to 13 +/- 1.8 mmHg (P less than 0.05), and there was a reduction in the mean arterial pressure from 92.4 +/- 2.7 mmHg to 81 +/- 3.2 mmHg (P less than 0.05) resulting in a reduction in cerebral perfusion pressure of up to 30%. The group treated by CAVHF, although having a greater mean ICP prior to treatment (19 +/- 4.8 mmHg) and a lower mean arterial pressure (66 +/- 3.6 mmHg) and consequently a lower cerebral perfusion pressure, did not show any increase in ICP or reduction in mean arterial or cerebral perfusion pressure. There was a significant reduction in serum osmolality during the first hour of treatment in the machine haemofiltration group (314 +/- 4 mOsm/kg to 309 +/- 4 mOsm/kg, P less than 0.05), whereas there was no corresponding change in the CAVHF group. This suggests that CAVHF is to be preferred for the treatment of acute renal failure in such patients who are at considerable risk of developing cerebral oedema.

Acute Kidney Injury↗
PubMed1990

Paradoxical increase in arterial hydrogen ion concentration in patients with hepatorenal failure given lactate-based fluids.

We have investigated lactate intolerance in nine patients with acute hepatorenal failure during 21 machine haemofiltration treatments using a lactate based replacement solution. In all cases hyperlactataemia occurred, the mean arterial lactate increased from 1 +/- 0.2 mmol/l (mean +/- SEM) prior to treatment to 3.2 +/- 0.3 mmol/l at 1 h (P less than 0.01), 4.2 +/- 0.4 mmol/l at 2 h (P less than 0.01), 4.2 +/- 0.4 mmol/l at 3 h (P less than 0.01) and 3.9 +/- 0.4 mmol/l (P less than 0.01) post-treatment. There were correlations between the maximum increase in blood lactate and both the change in arterial hydrogen ion concentration (r = 0.71, P = 0.001) and the mean arterial blood pressure prior to starting treatment (r = -0.57, P = 0.007). During eight of the treatments (38%), the arterial hydrogen ion concentration increased. This group showed increased lactate intolerance in association with a lesser pretreatment mean arterial pressure. The administration of exogenous lactate to patients with hepatorenal failure who are at, or near to, the threshold of their own endogenous lactate metabolism can result in an increase in hydrogen ion concentration rather than the expected decrease, and therefore lactate-based dialysate solutions are best avoided.

Acid-Base Equilibrium↗
PubMed1990

Effect of posture on intracranial pressure and cerebral perfusion pressure in patients with fulminant hepatic and renal failure after acetaminophen self-poisoning.

We measured the effect of posture on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in eight patients admitted with grade 4 hepatic coma due to fulminant hepatic failure complicated by renal failure. Upward head elevation greater than 20 degrees did not consistently reduce ICP; instead, ICP increased in three patients who later died of cerebral edema. CPP was reduced significantly by elevation greater than 20 degrees, falling to less than 50 mm Hg in those patients who subsequently died of cerebral edema. Our study does not support the current practice of nursing patients with hepatic coma, who are at risk of dying from cerebral edema, in head-upright postures greater than 20 degrees.

Acetaminophen↗
PubMed1990

Effect of the direction of dialysate flow on the efficiency of continuous arteriovenous haemodialysis.

We have investigated the effect of the direction of the dialysate flow during continuous arteriovenous haemodialysis. Under similar conditions countercurrent flow was more efficient than concurrent flow in terms of both urea clearance (mean +/- SEM), 23.5 +/- 0.5 compared to 18.4 +/- 0.4 ml/min (p less than 0.001) and creatinine clearance, 21.1 +/- 0.5 compared to 15.6 +/- 0.4 ml/min (p less than 0.001). There was a greater drop in pressure along the blood compartment of the haemodiafilter during countercurrent flow, 16 +/- 0.8 compared to 13 +/- 0.3 mm Hg (p less than 0.05) during concurrent flow, and this was associated with a greater ultrafiltration rate, 7.2 +/- 0.6 compared to 6.0 +/- 0.5 ml/min. The differences in diffusion, back diffusion and convection between the two systems resulted in a net gain of lactate/bicarbonate and a net loss of chloride during countercurrent dialysate flow, and a net loss of lactate/bicarbonate with a gain of chloride during concurrent flow. These losses would have to be corrected in the clinical setting of patients who had been continuously treated by these systems for several days.

Adult↗
PubMed1990

Urinary aluminium excretion following renal transplantation and the effect of pulse steroid therapy.

Urinary aluminium was measured in 48 patients with primary graft function for 14 days following renal transplantation. The plasma aluminium prior to transplantation was greater in those prescribed aluminium-containing phosphate binders (1.7 +/- 0.2 vs 0.6 +/- 0.2 mumol/L, P less than 0.05) and correlated with the duration of dialysis therapy (r = 0.42, P less than 0.008). After an initial reduction the plasma aluminium returned to pre-transplant values by the fifth day. The 24 h urinary aluminium excretion, aluminium clearance and fractional aluminium excretion all increased during the first week to a maximum around the sixth postoperative day, thereafter returning to values obtained during the first postoperative days, suggesting an early 'wash-out' of a readily accessible aluminium pool followed by a lower steady state determined by the rate of release of aluminium from tissue stores. For the whole group, aluminium excretion, at this steady state, was five times that of urinary aluminium excretion in normal subjects. Acute allograft rejection was diagnosed in 25 patients, who were treated with pulsed methyl prednisolone. Apart from improving graft function, no additional effect was observed on aluminium excretion, suggesting that the readily accessible aluminium pool does not come from lysosomal release, but probably from aluminium bound to small molecular weight protein.

Adolescent↗
PubMed1990

Hyperlactatemia and increasing metabolic acidosis in hepatorenal failure treated by hemofiltration.

We report a case of increasing hyperlactatemia in the course of repeated treatment by machine hemofiltration (MHF) using a lactate-buffered replacement solution. The hyperlactatemia was associated with a reduction in mean arterial pressure, and in the majority of treatments a metabolic acidosis developed. Hyperlactatemia due to exogenous lactate may not be as benign as previously discussed.

Acidosis, Lactic↗
PubMed1989

Late renal failure due to prostatic outflow obstruction: a preventable disease.

Nineteen patients presenting with late renal failure due to prostatic outflow obstruction (mean age 68.7 years; mean serum creatinine concentration 1158 mumol/l) were identified from the admission records of two renal units. As late renal failure secondary to prostatic enlargement is preventable case records were analysed retrospectively in an attempt to identify aspects of management in which preventive efforts might be of value. Delays in referral were common, with a mean of 2.8 years between the onset of prostatic symptoms and time of referral, six patients being referred who had had symptoms for more than three years. Four of five patients who had had a prostatectomy were known to be in renal failure at the time of operation but were not referred until 2-13 years later, when prostatic symptoms had recurred and there was evidence of progressive nephropathy with dilatation of the upper urinary tract. Two patients died on admission and eight (47% of survivors) required long term dialysis, most patients (80%) requiring some dialysis support during the initial period. These findings suggest that progressive nephropathy caused by prostatic outflow obstruction might, in part, be averted by more adequate screening of renal function in men with untreated prostatism and closer follow up of patients with uraemia at the time of prostatectomy.

Aged↗
PubMed1989

Rebound surges of intracranial pressure as a consequence of forced ultrafiltration used to control intracranial pressure in patients with severe hepatorenal failure.

Cerebral edema remains the most common immediate cause of death in patients with fulminant hepatic failure. We have used ultrafiltration as a method of controlling intracranial pressure (ICP) when other measures have failed. Two cases in which an initial decrease in ICP was followed by a marked rebound increase resulting in death are reported.

Acetaminophen↗
PubMed1989

Quantitative bone scanning in the diagnosis of aluminium osteomalacia.

Skeletal uptake of diphosphonate was measured by emission tomography in 30 patients on chronic dialysis treatment. In 19 patients mean plasma aluminium concentrations, measured over the preceding 12 months, were 'high' (greater than 1.0 mumol/l, and in the other 11 were 'low' (less than 1.0 mumol/l). There was a strong correlation between serum alkaline phosphatase and skeletal uptake of diphosphonate in each group, but no difference in diphosphonate uptake between the groups. Additionally, when six patients with positive desferrioxamine tests were matched for serum alkaline phosphatase with six patients from the 'low' aluminium group there was no significant difference in uptake of diphosphonate (median and range 7.2; 5.2-16.5 and 5.9; 2.7-10.8 respectively). We conclude that skeletal uptake of diphosphonate is not suppressed in patients with moderate aluminium loading, but reflects bone turnover as indicated by serum alkaline phosphatase. Quantitative bone scintigraphy is not a useful discriminator for early aluminium osteomalacia.

Adult↗
PubMed1989

Changes in intracranial pressure during haemofiltration in oliguric patients with grade IV hepatic encephalopathy.

Seven consecutive patients with grade IV hepatic encephalopathy, due to fulminant hepatic failure complicated by oliguric renal failure were allocated at random to treatment with daily machine haemofiltration (MHF) or continuous arteriovenous haemofiltration (CAVHF). Intracranial pressure (ICP) was continuously monitored using a subdural catheter. Four patients received 17 treatments by MHF, and ICP increased from 8.4 +/- 1.5 mm Hg (mean + SEM) prior to treatment to 12.6 +/- 1.8 mm Hg on completion (p less than 0.05). Active intervention was required on twenty occasions to treat sustained increases in ICP (greater than 25 mm Hg maintained for 5 min or longer). A total of 12 haemofilters were used in the treatment of 3 patients by CAVHF. The ICP showed greater stability during CAVHF therapy, the mean pressure prior to treatment was 15.6 +/- 5.2 mm Hg and fell to 11.7 +/- 2.3 mm Hg at 4 h. Sustained increases in ICP occurred in only 1 patient as a preterminal event. These findings suggest that CAVHF is the preferred method of treatment in patients with fulminant hepatic failure complicated by oliguric renal failure who are at risk of developing cerebral oedema.

Acute Kidney Injury↗
PubMed1989

The effect of lactate-buffered solutions on the acid-base status of patients with renal failure.

We investigated the effect of an exogenous lactate load given during intermittent machine haemofiltration to three groups of patients with renal failure: those with dialysis-dependent end-stage renal failure (6 patients) and those with either acute renal (8 patients) and/or acute hepatorenal failure (6 patients). As expected, the hepatorenal group exhibited the greatest degree of hyperlactataemia, and this was associated with the development of a metabolic acidosis. There were correlations between the maximum blood lactate measured during treatment and the increase in arterial hydrogen ion concentration (r = 0.76, P less than 0.001), and between the decrease in serum bicarbonate (r = 0.89, P less than 0.001) and the mean arterial blood pressure prior to treatment (r = -0.57, P = 0.003). This suggests that hyperlactataemia is not as benign as previously thought and that lactate-buffered fluids should be used with care in patients with hepatorenal failure and cardiovascular instability.

Acid-Base Imbalance↗
PubMed1989

Are changes in intracranial pressure during intermittent machine haemofiltration dependent upon membrane biocompatibility?

We measured the intracranial pressure, using a subdural catheter in three patients admitted with grade 4 hepatic encephalopathy following paracetamol (aminocetaphen) self poisoning. Acute oliguric renal failure was present in all cases and was treated with daily intermittent machine haemofiltration. Hypovolaemia prior to treatment was corrected and a total of 14 isovolaemic 17 litre exchanges carried out using either a Gambro FH77 (8) or Hospal 3600 (6) haemofilter. Intracranial pressure (ICP) increased during treatment with both types of filter, but the increase was greater in the Gambro FH77 treated group, mean ICP increased from 7.6 +/- 2 mmHg to 12 +/- 3 mmHg at 3 hours (p less than 0.05), this was associated with a greater fall in the percentage change from the pretreatment value of both arterial oxygen tension and total peripheral white blood cell count during the first hour of treatment compared to the Hospal 3600 treated group, 8 +/- 2% vs 1 +/- 2% (p less than 0.05) and 5 +/- 2% vs 3 +/- 2% (p less than 0.05). This suggests that membrane biocompatibility may also play a role in the development of increased intracranial pressure during intermittent machine haemofiltration.

Acetaminophen↗
PubMed1989

Changes in intracranial pressure during machine and continuous haemofiltration.

Nine consecutive patients with both fulminant hepatic failure and acute oliguric renal failure were treated either by daily machine haemofiltration (MHF), or by continuous arterio-venous haemofiltration (CAVHF). Six patients received a total of twenty treatments by MHF and four CAVHF, mean duration of treatment 56 hours, range 24-160. Intracranial pressure (ICP) was measured using a subdural catheter. During treatment with MHF, the mean ICP increased from 8.9 +/- 1.4 mmHg at the start of filtration to 14.8 +/- 2.1 mmHg at the end of treatment (p less than 0.05), whereas there was no corresponding increase during the same period of time with CAVHF treatment, the mean ICP fell, but not significantly from 19.4 +/- 4.8 mmHg to 11.2 +/- 2.3 mmHg. The mean ICP increased to greater than 25 mmHg on eleven occasions during treatment with MHF, requiring treatment with bolus mannitol or propofol, during the same period of treatment with CAVHF no such surges in ICP were recorded. This suggests that continuous haemofiltration is to be preferred to intermittent machine haemofiltration in the management of patients with acute hepatorenal failure.

Adult↗