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Biomedical subjects

H M Horst

Publications and source records attributed to H M Horst.

51 records · Page 3Linked to original sources
PubMed1986

Endotracheal aminoglycosides in gram negative pneumonia. A preliminary report.

Five postoperative patients with respiratory failure and gram negative pneumonia unresponsive to systemic antimicrobials were treated with endotracheally instilled aminoglycosides. Sputum cultures in four patients grew Pseudomonas aeruginosa and, in the fifth, Enterobacter cloacae. The five patients had been treated systemically for an average of 13 days (range 9 to 19 days) without improvement prior to endotracheal antibiotic administration. The gram negative organisms disappeared from the sputum cultures in all patients within an average of 4 days (range 2 to 8 days) following initiation of endotracheal antibiotics. All five patients had continued clinical improvement manifest by improved chest radiographs, improved oxygenation, and absence of the offending organisms from sputum cultures. None of the patients died from their gram negative pneumonia. This success coupled with data from other investigators suggests that endotracheal antibiotics should be considered in life-threatening gram negative pneumonias that are unresponsive to conventional systemic antimicrobials.

Adult↗
PubMed1985

Catheter aspiration for simple pneumothorax (CASP) in the outpatient management of simple traumatic pneumothorax.

Catheter aspiration for simple pneumothorax (CASP) was evaluated prospectively in the outpatient management of simple traumatic pneumothorax in 17 patients and compared to conventional tube thoracostomy (CTT) in 17 matched control patients. In 16 of the 17 consecutive study patients CASP maintained lung reexpansion without complications. Pneumothorax was due to needle puncture for drug abuse in 11 patients, stab wounds in five patients, and blunt trauma in one patient. The CASP patients were not hospitalized, whereas the control CTT patients averaged 4.9 days' hospitalization. CTT was associated with complications in two patients versus none for CASP. Parenteral analgesics were utilized for greater than 48 hours in CTT patients but were not needed for CASP patients. Costs averaged +310 for CASP compared to +3,030 for CTT. This ongoing pilot study data indicates that CASP is a reasonable alternative to CTT in selected patients with simple traumatic pneumothorax.

Adolescent↗
PubMed1985

Acute penetrating arterial injuries of the forearm. Ligation or repair?

The management of forearm arterial trauma is controversial and follow-up data on such injuries is scant. A survey was made of 249 patients with penetrating forearm trauma to determine the incidence and outcome of arterial injury. Sixty-six patients (26.5%) sustained 69 arterial injuries documented at operation or with angiography. The clinical manifestations of arterial injury were often subtle; 42.4 per cent of the patients had normal pulses and only 7.6 per cent presented with distal ischemia. In 9.1 per cent of the patients there was no clinical evidence of vascular injury. The most frequent types of arterial injury were transection (72.5%) and partial laceration (14.5%). Arterial repair was performed in 84.8 per cent of the cases, and resection with end-to-end anastomosis was usually possible. Volar compartment fasciotomies were necessary in 18.2 per cent of the cases. The early postoperative complications seen were wound-related, and these were six times more frequent in the group undergoing arterial ligation (36% vs 6%). In 49 patients evaluated an average of 6 months after repair, the patency rate determined by clinical examination was 85.7 per cent. Because of a high incidence of associated nerve (56.1%) and tendon (54.5%) injuries, the functional status of the injured extremity was less satisfactory, with only 49.2 per cent of the patients having normal hand function. Since the forearm vessels can be repaired with minimal morbidity and acceptable results, arterial ligation is recommended only when repair is not readily accomplished, or when treatment of a more pressing associated injury demands priority.

Acute Disease↗
PubMed1985

A critical reappraisal of a mandatory exploration policy for penetrating wounds of the neck.

Over-all, the results of this review suggest that mandatory exploration for penetrating wounds of the neck may be safely supplanted by selective management. The basis for this conclusion includes: 1, most neck wounds were not associated with significant injury; 2, routine exploration did not obviate the possibility of missed injuries; 3, negative findings at exploration were associated with a number of complications; 4, hospital stay for patients with negative neck exploration results was similar to those with positive exploration findings, and 5, it appears that selective management should not increase the need for special diagnostic studies. Patients with clearly positive clinical findings indicating visceral neck injury should undergo operative exploration. Those with a negative clinical examination should be closely observed. Contrast roentgenographic and other special studies should be reserved for those with equivocal clinical findings or who have a change in clinical status under observation.

Adolescent↗
PubMed1984

The risks of pulmonary arterial catheterization.

Pulmonary arterial catheters have been widely accepted as useful for monitoring the critically ill patient. New modifications allowing transvenous cardiac pacing, Hiss bundle electrocardiography and continuous monitoring of mixed venous saturation promise to increase the acceptance and use of these catheters. The 52 per cent combined major and minor complication rate documented in this study suggest that enthusiasm for pulmonary arterial catheterization should be tempered with caution. Serious complications and death do occur with these devices and may be more frequent than previously recognized. Use of a pulmonary arterial catheter should be undertaken for defined indications, with a reasonable expectation of benefit from the data obtained and with a clear understanding of the risks involved.

Cardiac Catheterization↗
PubMed1983

Resuscitative thoracotomy for patients with traumatic injury.

The clinical course and final outcome were determined for 63 trauma victims who underwent resuscitative thoracotomy (RT) for hypovolemic cardiac arrest in the Department of Emergency Medicine during a 24-month period. The objectives of the study were to determine the efficacy of and indications for RT and to define the prognostic signs for survival. Of 63 patients, six were successfully resuscitated (9.5%), and five of these were discharged from the hospital (7.9%). The presence of pupillary reactions was an extremely reliable indicator of successful outcome (P = 0.0009), as was the presence of some respiratory effort (P = 0.025). None of the victims of blunt trauma (n = 6) or severe head injury (n = 13) survived. Three of 17 patients (17.6%) with stab wounds and two of 36 (5.6%) with gunshot wounds survived the procedure. RT was beneficial in 13.6% of patients who had isolated organ system injuries, but no patient with injuries to more than two organ systems survived. Victims of isolated penetrating thoracic trauma had an 11.8% survival rate, as opposed to a 0% survival rate for those with abdominal trauma. The best prognosis was in victims with penetrating cardiac injuries, who had a 22.7% survival rate. The cost of RT averaged $1660 per patient, exclusive of physician charges. In our experience, RT is most beneficial for victims of penetrating thoracic trauma, especially those with cardiac injuries. However, routine use of this high cost/low benefit procedure cannot be recommended for patients who have cardiac arrest secondary to blunt trauma or severe head injuries. Also, it is not recommended for patients whose pupillary reflexes and respiratory movements are absent.

Adolescent↗
PubMedDate not supplied

Antibiotics for penetrating abdominal trauma: a prospective comparative trial of single agent cephalosporin therapy versus combination therapy.

In this prospective, comparative study, 129 patients who sustained penetrating abdominal trauma were randomized to receive preoperatively, and for 3-5 days postoperatively, one of three antibiotic regimens: Group I--cefotaxime (CTX) (2 Gm Q8H), Group II--cefoxitin (2 Gm Q6H), or Group III--clindamycin (900 mg Q8H) and gentamicin (3-5 mg/kg/day in divided doses Q8H). The three groups were similar in terms of the following: age, sex, severity of injury, number of organs injured, colon injuries, shock, blood transfusions, or positive intraoperative cultures. Septic complications occurred as follows: Group I--6.9%, Group II--2.3%, and Group III--6.9%. The three regimens ranked as follows in terms of therapy costs: CTX less than cefoxitin less than clindamycin and gentamicin. It is concluded that single agent therapy with a cephalosporin is preferable to combination therapy on the basis of equivalent effectiveness, lower toxicity, and lower costs.

Adult↗
PubMedDate not supplied

Twice-daily moxalactam versus gentamicin and clindamycin in patients with penetrating abdominal trauma.

The effectiveness and total costs of moxalactam administered every 12 hours versus a combination of gentamicin and clindamycin for prophylactic use in patients with penetrating abdominal trauma were compared. Fifty patients scheduled for laparotomy after penetrating abdominal wounds were randomly assigned to receive either clindamycin phosphate 600 mg every six hours with gentamicin (as the sulfate salt) 3-5 mg/kg/day in three divided doses or moxalactam disodium 2 g every 12 hours. Therapy was begun preoperatively and continued for a minimum of three days in patients without hollow-organ injury and five days in patients with hollow-organ injury; total duration of therapy could not exceed four weeks. Patients receiving moxalactam also received phytonadione 10 mg intramuscularly once a week. Although wound cultures from several patients were positive for Staphylococcus epidermidis, Pseudomonas aeruginosa, and enterococci, no symptomatic infections developed. No direct toxic effects of moxalactam or gentamicin-clindamycin were seen; transient abnormalities in blood-coagulation tests or serum creatinine concentration occurred in several patients. Although mean drug costs per patient for moxalactam and gentamicin-clindamycin were similar, the mean cost of therapy per patient was $125.23 higher for the combination regimen than for moxalactam when laboratory, personnel-time, and supply costs were added to drug costs. Moxalactam given every 12 hours was a safe and effective alternative to the combination of gentamicin and clindamycin for preventive use in the study patients with penetrating abdominal trauma.

Abdominal Injuries↗
PubMedDate not supplied

Accuracy of two-hour urine urea nitrogen determinations in critically ill patients.

The accuracy of two-hour versus 24-hour urine urea nitrogen (UUN) determinations in critically ill patients was compared. A 24-hour urine collection for UUN determinations was obtained each day for five days in 20 patients who had been receiving parenteral nutrition at a constant rate for at least 36 hours. For each patient, the UUN value obtained from a two-hour sample was projected using the actual 24-hour urine output to determine an estimated daily UUN excretion. Creatinine clearance determinations were performed to evaluate the effects of impaired renal function on the correlation of two-hour and 24-hour UUN excretion. A significant correlation (r = 0.889) was found between the two-hour and 24-hour UUN excretions. However, in three patients with creatinine clearances less than 30 ml/min and two patients with gram-negative sepsis, correlations between two-hour and 24-hour UUN excretion were poor. Total urine volumes in the 20 patients varied considerably but did not affect the correlation between UUN determinations. A two-hour UUN determination may be a valuable tool for monitoring the nutritional status of critically ill patients. The rate of intravenous nutrition must be kept constant, however, to minimize diurnal variations in nitrogen excretion. Conditions such a shock, sepsis, or acute renal failure may limit the use of a shorter urine collection period for urea nitrogen determination.

Adult↗
PubMedDate not supplied

Bar code documentation of pharmacotherapy services in intensive care units.

Bar code technology has been used for 5 years to improve the efficiency of identifying and documenting clinical pharmacy services at our institution. Data for an entire year (1993) were analyzed to quantify the nature and magnitude of pharmacy services provided for critically ill patients in intensive care units (ICU). Patients in the medical (MICU), respiratory (RICU), intermediate (IMU), and surgical (SICU) units (3234/3743 patients, 86%) were reviewed. Clinical interventions and expected outcomes were documented by pharmacists using an automated bar code system. There were 11,628 pharmacotherapy interventions, 3.6/patient; 12/pharmacist work day. Of patients whose drug therapy was reviewed at least once, 50% (1610/3234) received at least one intervention. The mean number of interventions/patient was 7.2 in the MICU, 6.1 in RICU, 3.4 in IMU, and 2.4 in the SICU, corresponding to APACHE III scores of 71.2, 66.2, 42.8, and 43.3, respectively. The majority of interventions were to modify dosages of antimicrobial agents, and were performed to achieve optimum efficacy (42%) and to minimize toxicity (46.2%). These data support the necessity for pharmacists to provide individualized care to critically ill patients.

Drug Therapy, Computer-Assisted↗