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Biomedical subjects

M B Farnell

Publications and source records attributed to M B Farnell.

At least 55 records · Page 3Linked to original sources
PubMed1992

Prevention of infection in critically ill patients by selective decontamination of the digestive tract.

OBJECTIVE: To determine whether selective decontamination of the digestive tract using oral and nonabsorbable antimicrobial agents and parenteral cefotaxime prevents infection in critically ill patients. DESIGN: Randomized, controlled trial without blinding. SETTING: Surgical trauma and medical intensive care units in a tertiary referral hospital. PATIENTS: One hundred fifty patients admitted to surgical trauma and medical intensive care units during a 3-year interval, whose condition suggested a prolonged stay (greater than 3 days). INTERVENTION: Patients were randomly allocated to an experimental group (n = 75) that received cefotaxime, 1 g intravenously every 8 hours for the first 3 days only, and oral, nonabsorbable antibiotics (gentamicin, polymyxin, and nystatin by oral paste and oral liquid) for the entire stay in the intensive care unit. Control patients (n = 75) received usual care. MEASUREMENTS: The number of infections, total hospital days, and deaths, as well as the number of days in intensive care unit, were recorded. RESULTS: Control patients experienced more infections (36 compared with 12, P = 0.04), including bacteremias (14 compared with 4, P = 0.05) and pulmonary infections (14 compared with 4, P = 0.03). Although total hospital days, days in intensive care, and the overall death rate all were lower in the treatment group, these differences were not statistically significant. Clinically important complications of selective decontamination of the digestive tract were not encountered. CONCLUSIONS: Selective decontamination of the digestive tract decreases subsequent infection rates, especially by gram-negative bacilli, in selected patients during long-term stays in the intensive care unit.

Administration, Oral↗
PubMed1992

Laparoscopic cholecystectomy: operative technique.

Laparoscopic cholecystectomy has become the routine procedure for most patients with symptomatic cholelithiasis. At our institution, a two-surgeon, four-cannula technique is used. In almost all patients, a pneumoperitoneum can be established with use of a closed technique. Adherence to standard operative principles and careful attention to details in the laparoscopic technique will routinely result in the safe completion of laparoscopic cholecystectomy. Cautery provides excellent hemostasis during dissection of the gallbladder from its attachments. Cholangiography through the gallbladder or the cystic duct is easily performed in selected patients. Minimal perioperative care is necessary for patients who undergo laparoscopic cholecystectomy, and the hospitalization time is usually less than 24 hours.

Cautery↗
PubMed1992

Laparoscopic cholecystectomy: early Mayo Clinic experience.

Prospective data and follow-up information were collected on the initial 200 patients who underwent laparoscopic cholecystectomy at the Mayo Clinic. The operation was completed laparoscopically in all but five patients, who required conversion to laparotomy because of dense scarring or stones in the common bile duct. The median surgical time was 85 minutes. The major postoperative complications were retained stones in the common bile duct (in seven patients), intraperitoneal hemorrhage that necessitated transfusion (in two patients), and intra-abdominal abscess and pulmonary infection (in one patient each). The median hospital stay was 1 day (range, 0 to 8 days), and the median times to full activity and normal employment were 8 days and 12 days, respectively. Laparoscopic cholecystectomy is associated with a low frequency of complications in most patients with symptomatic gallstones and allows a rapid return to normal activity. Currently, laparoscopic cholecystectomy is the treatment of choice for most patients with symptomatic cholelithiasis.

Academic Medical Centers↗
PubMed1992

Spontaneous rupture of the spleen due to infectious mononucleosis.

Spontaneous splenic rupture is an extremely rare but life-threatening complication of infectious mononucleosis in young adults. Although splenectomy remains effective treatment, reports of successful nonoperative management have challenged the time-honored approach of emergent laparotomy. On retrospective analysis of our institutional experience with 8,116 patients who had this disease during a 40-year period, we found 5 substantiated cases of atraumatic splenic rupture due to infectious mononucleosis. Four additional cases of suspected splenic rupture were noted. All nine patients were hospitalized and treated (seven underwent splenectomy and two were treated with supportive measures only), and they remain alive and well. In patients with infectious mononucleosis suspected of having rupture of the spleen, a rapid but thorough assessment and prompt implementation of appropriate management should minimize the associated morbidity and mortality. On the basis of review of the medical literature and careful scrutiny of our own experience, we advocate emergent splenectomy for spontaneous splenic rupture in patients with infectious mononucleosis.

Adolescent↗
PubMed1992

Ruptured abdominal aortic aneurysms: repair should not be denied.

The records of 231 patients (189 men, 42 women) treated during the last decade for ruptured infrarenal abdominal aortic aneurysm were reviewed to evaluate complications and mortality rates and to determine if preoperative factors would preclude attempt at surgical repair. Mean age was 73.7 years (range, 50 to 95 years). Fifty-seven patients (24.7%) were greater than or equal to 80 years of age. Sixty-eight patients (29.4%) had known abdominal aortic aneurysm before rupture. Preoperative systolic blood pressure was less than or equal to 90 mm Hg in 155 patients (67.1%). Fifty-six patients (24.2%) had cardiac arrest before operation. The overall mortality rate from admission until the end of the hospital stay was 49.4% (114 of 231). Seventeen patients (7.4%) died in the emergency department, 40 (17.3%) in the operating room, 27 (11.7%) during the first 48 postoperative hours, and 30 (13.0%) died later but during the same hospitalization. The 30-day operative mortality rate was 41.6%. Mean age of those who died was higher (75.3 years) than of those who survived (72.2 years) (p less than 0.02). Of patients greater than or equal to 80 years, 43.9% survived. Survival was lower among women (35.7%) than men (54.0%; p less than 0.04). A high APACHE II score, a low initial hematocrit, preoperative hypotension, and chronic obstructive pulmonary disease were associated multivariately with increased mortality rates (p less than 0.02). However, 59 of the 155 patients (38.1%) with preoperative hypotension survived. Deaths were high (80.4%) among patients with cardiac arrest (45 of 56); still, 28.2% of patients (11 of 39) survived repair after cardiac arrest.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1991

Total gastrectomy for advanced cancer. A worthwhile palliative procedure.

Subtotal gastric resection usually provides the best palliation in advanced gastric cancer; however, if total gastrectomy (TG) is required there is doubt about its benefit. The authors reviewed 53 consecutive patients undergoing TG for advanced gastric adenocarcinoma between 1980 and 1989. Indications for TG were tumor location in 30% and extent of tumor in 70%, including nine patients (17%) with linitis plastica. Four patients (8%) died postoperatively, and six patients required reoperation for postoperative complications. The median postoperative hospital stay was 13 days. The median survival was 19 months, and 13 patients (24%) lived for more than 2 years. The quality of life was graded in survivors as good in 59%, satisfactory in 28%, and poor in 13% of patients. It was concluded that TG is a worthwhile procedure for selected patients, even in the presence of advanced disease, providing prolongation of good quality of life with low morbidity and mortality.

Adenocarcinoma↗
PubMed1991

Acute necrotizing pancreatitis: management by planned, staged pancreatic necrosectomy/debridement and delayed primary wound closure over drains.

We reviewed our recent experience with management of 23 consecutive patients with acute necrotizing pancreatitis. All patients had documented necrotizing pancreatitis with parenchymal or peripancreatic necrosis. Our method of treatment has evolved from our previous approach of controlled open lesser sac drainage (marsupialization) to staged necrosectomy/debridement with delayed primary closure over drains. With this latter approach, hospital mortality was 4 of 23 patients (17 per cent), but significant morbidity still occurred in 12 of 23 patients (52 per cent). However, recurrent intra-abdominal abscess before discharge occurred in only one patient. We believe that this operative approach toward the severely ill patient with acute necrotizing pancreatitis who requires operative intervention will minimize the occurrence of intra-abdominal sepsis.

Acute Disease↗
PubMed1991

Proximal gastric vagotomy in the emergency treatment of bleeding duodenal ulcer.

Proximal gastric vagotomy for bleeding duodenal ulcer was performed in 52 low-risk patients between 1973 and 1986. Duodenotomy without violation of the pylorus was done in all patients to allow inspection and control of the bleeding site. The median duration of operation was 3 hours and 20 minutes, although 25% of the procedures required 4 or more hours. There was no postoperative mortality and no early reoperations. Among the six patients with postoperative complications, one rebled from the ulcer and two developed prolonged gastric atony. At the time of follow-up (median, 2.9 years), 48 of the patients were alive and 4 had died of non-ulcer causes. No patient had significant postvagotomy sequelae. Ulcer recurrence was documented in six patients, and three required reoperation. Proximal gastric vagotomy is a safe, effective therapy for bleeding duodenal ulcer. Because of the length of the operation, it should be restricted to low-risk patients who are hemodynamically stable at the time of operation.

Adult↗
PubMed1989

Mayo Clinic's hospital-based emergency air medical transport service.

Mayo Clinic's hospital-based helicopter transport service, which is staffed by a medical flight crew consisting of two critical-care nurses, was initiated in October 1984. To date, more than 2,500 patients with a wide range of life-threatening conditions have been transported. As a quality-assurance tool, a computerized data collection system was initiated in 1986, and this report details a 3-year experience in air transport garnered prospectively. From 1986 through 1988, 1,701 flights were completed in response to 2,329 requests for transport. Overall, 10% of requests were declined because of weather. Of 1,727 patients transported, 94% were brought to the Mayo Medical Center for care. The categories of the patients were medical-surgical in 1,071 (62%), trauma in 553 (32%), and neonates in 103 (6%). Most transports (93%) originated from referral inpatient facilities or emergency rooms; the rest were scene flights or transports from Mayo to other facilities. The mortality rate among the 1,632 patients brought to the Mayo Medical Center was 16.3%. The mean distance transported was 77 miles for interhospital and 23 miles for scene flights. For both trauma and medical-surgical patients, the severity of illness was evaluated with use of recognized quantitative scoring systems. Prospective collection of data has proved useful in program administration, quality assurance, and clinical research. Mayo Clinic's hospital-based helicopter transport program has served as a logical extension of the institution's emergency-care capabilities in an effort to enhance the prehospital and interhospital care of the critically ill within the institution's referral area.

Adolescent↗
PubMed1989

Prospective, randomized trial of rapid venous access for patients in hypovolemic shock.

The placement of central venous catheters was studied prospectively in 138 selected adult patients with hypovolemic shock or in whom rapid volume replacement was needed. The patients were randomized into two groups to receive a central vein catheter: one by basilic vein cutdown and the other by percutaneous subclavian vein placement. The groups were analyzed for success rate, time required for insertion, and complications. The techniques were equally successful (87% in the basilic vein group compared with 91% in the subclavian vein group), and their complication rates were similar (10% compared with 12%). The subclavian vein catheter was inserted more quickly (8.3 minutes compared with 14.4 minutes [P = .0001] for the basilic vein group). Percutaneous subclavian vein catheters can be used successfully in patients with hypovolemic shock and can be place quickly with low complication rates.

Catheterization, Central Venous↗
PubMed1989

Limited usefulness of quantitative culture of blood drawn through the device for diagnosis of intravascular-device-related bacteremia.

The use of a differential quantitative blood culture technique (Isolator) to diagnose intravascular-device-related bacteremia (IDRB) was studied prospectively. During septic episodes in 44 patients, blood was obtained simultaneously through the suspected infected device and from a peripheral venipuncture. The blood samples were processed by the Isolator technique, which enables easy quantification of microorganisms. The cannula was removed, and its tip was cultured semiquantitatively. Of the 52 cannulas studied, 15 were the cause of IDRB, but only 7 of these showed a significantly higher bacterial count in blood obtained through the device compared with peripheral blood. The bacterial count was higher in blood drawn through the device than in peripheral blood in four of six cases that did not fulfill the definition of IDRB. Some blood cultures obtained through the device were positive despite negative cultures of peripheral blood and cannula tips (six cannulas). Quantitative blood cultures were not useful in diagnosing IDRB in this study.

Adult↗
PubMed1989

The complementary roles of diagnostic peritoneal lavage and computed tomography in the evaluation of blunt abdominal trauma.

To determine the roles of diagnostic peritoneal lavage (DPL) and abdominal computed tomography (CT) in the evaluation of blunt abdominal trauma, we compared our results in the eras before and after the advent of abdominal CT. In the pre-CT era 1977 to 1980 (group 1; 365 patients), DPL was the diagnostic procedure of choice. In the CT era 1983 to 1986 (group 2; 282 patients), DPL was used for unstable, polytraumatized patients, and CT was reserved for stable patients. The rate of delayed recognition of documented visceral injury (7%) was similar for groups 1 and 2. Celiotomy was nontherapeutic in 21 (14%) patients in group 1 and in 5 (5%) in group 2 (p less than 0.02). Despite immediate availability of abdominal CT, clinical examination alone or in combination with DPL was the diagnostic procedure of choice in 41% of those with blunt abdominal trauma in group 2. The complementary use of abdominal CT and DPL in those with blunt abdominal trauma decreased the rate of nontherapeutic celiotomy, did not result in a significant increase in missed injuries, and allowed identification of candidates for nonoperative management of solid organ injury.

Abdomen↗
PubMed1988

A new bowel preparation for elective colon and rectal surgery. A prospective, randomized clinical trial.

A two-day cathartic/enema preparation with oral administration of erythromycin and neomycin was compared with an orthograde lavage preparation with oral administration of metronidazole and neomycin in a prospective randomized trial in 300 and 293 eligible patients, respectively, who were undergoing elective colon and rectal surgery. Patients were assessed for infections at six weeks after discharge from the hospital. The major infection rate was less than 1% and the minor infection rate was less than 4%. The overall infection rate was 4.2%. The type of bowel preparation used, the type of operation, and the addition of systemic antibiotic therapy did not affect infection rates significantly. We conclude that this one-day lavage technique, as described, is a safe, effective, economical, and preferred method of colonic preparation for elective colon and rectal surgery.

Adolescent↗
PubMed1988

Volvulus of the small intestine.

At the Mayo Clinic, six patients with primary volvulus and 51 with secondary volvulus were treated during a 10-year period. Volvulus of the small intestine must be considered when a patient presents with small-bowel obstruction, and early operative intervention should be undertaken to prevent vascular compromise.

Acute Disease↗
PubMed1988

Nonoperative management of blunt hepatic trauma in adults.

Although well accepted in pediatric patients, nonoperative management of blunt hepatic trauma in adults remains controversial. From January 1981 through May 1987, 66 adults were identified with blunt hepatic trauma that had been confirmed by abdominal exploration or abdominal computed tomography (CT): 46 underwent immediate operation, and 20 were initially managed nonoperatively. Patients were considered for nonoperative management only if they were hemodynamically stable and had no significant peritoneal irritation. CT criteria for nonoperative management included contained subcapsular or intrahepatic hematoma, unilobar fracture, absence of devitalized liver, minimal intraperitoneal blood, and absence of other significant intra-abdominal organ injuries. The predominant CT pattern in the 17 patients successfully managed nonoperatively included unilobar right-lobe fracture or intrahepatic hematoma. A small amount of blood in either gutter or in the pelvis did not portend failure of nonoperative management. No delayed complications were noted during an average follow-up of 27 months. Nonoperative management of blunt hepatic injury based on abdominal CT findings is a useful alternative in a select group of hemodynamically stable patients.

Accidents, Traffic↗
PubMed1986

Closure of abdominal incisions with subcutaneous catheters. A prospective randomized trial.

A preliminary report from our institution suggested that closure of abdominal incisions with subcutaneous, closed-suction catheters intermittently irrigated with antibiotic resulted in decreased wound infection rates. To test this hypothesis, a prospective, randomized, controlled trial was undertaken to compare the results of primary closure, subcutaneous catheter irrigated with saline or antibiotic, and subcutaneous catheter alone. During the two-year trial, 3,282 incisions (type II, III, or IV) were analyzed. Subcutaneous catheter placement alone or with antibiotic or saline irrigation was not superior to primary closure for type II or III incisions. A trend favoring subcutaneous catheter and antibiotic irrigation was observed for type IV incisions. This finding suggests that further clinical trials designed to assess the role of subcutaneous catheter placement and antibiotic irrigation in decreasing wound infection rates are warranted in type IV incisions.

Abdominal Muscles↗