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Biomedical subjects

P Nightingale

Publications and source records attributed to P Nightingale.

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

Computerised protocols for laboratory investigation and their effect on use of medical time and resources.

AIMS: To devise a computerised management system protocol which not only proposes the laboratory investigations to be performed on each patient but also performs related clinical functions. METHODS: The system was designed by senior members of staff. The protocols defined all laboratory investigations including haematology, biochemistry, immunology and cross-matching, and included static and dynamic rules. Patients can be changed to different or additional protocols, as required; likewise proposed tests can be deleted or added. The software is written in MUMPS and runs on a 386 PC running MSM MUMPS under MSDOS. RESULTS: The number of clinical chemistry tests requested per patient per day fell by 9.5% (p less than 0.01) for transplant recipients and by 28.8% (p less than 0.01) for non-transplant recipients. The average time spent by junior medical staff requesting laboratory investigations and enquiring about results fell from 10 minutes per patient per day to 4.1 minutes (p less than 0.001). CONCLUSIONS: The introduction of this system in no way abrogates clinicians' responsibility for the management of patients, because all proposed investigations must be confirmed or modified by the authorising doctor. The system allows for the audit of requesting patterns and subsequent improvement in protocols by recording any alterations made to the proposed investigations. Significant benefits in terms of better use of house officer time and medical resources were also achieved.

Clinical Laboratory Information Systems↗
PubMed1991

Persistence of supply dependency of oxygen uptake at high levels of delivery in adult respiratory distress syndrome.

OBJECTIVE: To identify any plateau in oxygen consumption (VO2) when oxygen delivery (DO2) is increased in patients with the adult respiratory distress syndrome (ARDS). DESIGN: Clinical prospective study; multiple regression analysis was done to assess the relationship between VO2 and DO2 for pooled data and for each individual patient. SETTING: University hospital ICU. PATIENTS: Twenty consecutive patients aged 18 to 78 yrs (mean 43.5) in whom ARDS was present during their ICU stay. INTERVENTIONS: Multiple measurements were obtained in individual patients (mean number of measurements 40, range 20 to 83) and mathematical models were fitted to both pooled and individual patient data. DO2 ranged from 212 to 1550 mL/min.m2 with a maximum of 758 to 1550 mL/min.m2 (mean 1136). Because of the large variations between patients, it was not justifiable to describe a relationship for the pooled data and each case was analyzed individually. MEASUREMENTS AND MAIN RESULTS: We found the optimal regression model to be linear in 13 patients, cubic in four, and either cubic or linear in one. Two patients demonstrated no significant relationship. The relationship for the group was determined from each patient's data and was best described by linear regression. CONCLUSIONS: In no patient was there evidence of a plateau, despite high levels of DO2 being achieved in all patients.

Adolescent↗
PubMed1991

Mechanism of shock associated with right ventricular infarction.

Various mechanisms have been proposed to explain the shock sometimes associated with right ventricular infarction, but only small numbers of patients with clinical shock have been studied. The haemodynamic profiles of seven patients with clinical cardiogenic shock after right ventricular myocardial infarction were studied prospectively. They were selected because all had a stable cardiac rhythm and none had absolute hypovolaemia during the study period. In all of them the mean right atrial pressure exceeded the pulmonary artery occlusion pressure. After treatment with varying combinations of dopamine, dobutamine, and glyceryl trinitrate (titrated to achieve the optimum haemodynamic response) the mean systemic arterial pressure increased, as did the cardiac index. There was an associated increase in the left ventricular stroke work index but the right ventricular stroke work index was unchanged. There was no significant change in heart rate, mean right atrial pressure, or pulmonary artery occlusion pressure. This suggests that the probable mechanism of the shock associated with right ventricular infarction is concomitant severe left ventricular dysfunction.

Aged↗
PubMed1990

Hemodynamic and oxygen transport variables in cardiogenic shock secondary to acute myocardial infarction, and response to treatment.

There are few data on oxygen transport in cardiogenic shock after acute myocardial infarction. This prospective study examined oxygen transport variables in 19 such patients and assessed their responses to treatment. Femoral and pulmonary arterial catheters were inserted before any therapy except correction of hypoxemia by mechanical ventilation in 8 patients, defibrillation (3 patients) or pacing (5 patients). In 3 patients mean arterial pressure was greater than 80 mm Hg and cardiac index greater than 2.1 liters/min/m2 with normal mixed venous oxygen saturation despite simultaneous clinical shock. They recovered with no further treatment. Sixteen patients were treated with varying combinations of intravenous fluids and dobutamine (37 +/- 25 mu/kg/min) and 14 survived long enough for a second set of measurements to be completed. Mean heart rate increased from 83 +/- 22 to 101 +/- 20 beats/min and mean cardiac index from 1.4 +/- 0.5 to 2.5 +/- 0.4 liters/min/m2 (p less than 0.001). Oxygen consumption (VO2) was maintained even when oxygen delivery (DO2) was less than 330 ml/min/m2. After treatment DO2 increased from 230 +/- 69 to 397 +/- 60 ml/min/m2 (p less than 0.001) and VO2 from 103 +/- 31 to 124 +/- 27 ml/min/m2 (p less than 0.05). Mean mixed venous oxygen saturation increased from 54 +/- 16 to 69 +/- 8% (p less than 0.001) and mean oxygen extraction ratio decreased from 48 +/- 16 to 31 +/- 6% (p less than 0.001). There was no correlation between cuff systolic blood pressure and mean arterial pressure before or after resuscitation. Thirteen patients survived to hospital discharge. When cardiogenic shock responds to treatment, large increases in DO2 lead to small increases in VO2 but large increases in mixed venous oxygen saturation, reflecting improved tissue oxygen availability.

Aged↗
PubMed1990

Practical points in the application of oxygen transport principles.

Application of the principles of oxygen transport in the management of critically ill patients can influence the frequency of organ failure and outcome. Adequate tissue oxygen consumption in these patients may depend on a supranormal level of oxygen delivery. The equations used for calculating oxygen delivery and consumption are provided, and it is noted that clinicians should have a clear understanding of the limitations of each of the measurements included in the equations. The methods used to perform the measurements are reviewed. Widespread acceptance and use of oxygen transport protocols in treatment is only possible if the measurements on which they are based are accurate and properly interpreted.

Critical Care↗
PubMed1990

A critical study of the APACHE II scoring system using earlier data collection.

The APACHE II severity of illness scoring system was prospectively studied on 756 patients admitted to a general intensive care unit (ICU) from January 1986 to June 1988. Admission data were used. Individual and group risk of death were calculated for 3 diagnostic categories commonly seen in the A&E department and requiring admission to an ICU. The APACHE II score on admission tended to underestimate the risk of death following operative and non-operative trauma, and self-poisoning. This may have been related to the use of an analysis not yet validated against values obtained on admission to ICU. Such validation is urgently needed on a UK population if APACHE II scoring is to be of value in the A&E department.

Adolescent↗
PubMed1989

The haemodynamic effects of sublingual nitroglycerin spray in severe left ventricular failure.

The use of sublingual nitroglycerin spray has been studied in twenty patients referred to our Intensive Care Unit for further treatment of severe left ventricular failure. Within five minutes of spray administration significant falls in pulmonary artery occlusion pressure, mean arterial pressure, heart rate, right atrial pressure and systemic vascular resistance occurred. Similarly significant increases in cardiac index, stroke volume index and left ventricular stroke work index were found. These results show a considerable improvement in the haemodynamic parameters of invasively monitored patients and we believe that its administration undoubtedly "buys time" for the critically ill patient. However, we would caution against its routine use at present in view of the potential problem of hypotension, until further information is available.

Administration, Sublingual↗
PubMed1989

Hemodynamic and oxygen transport response to modified fluid gelatin in critically ill patients.

The hemodynamic and oxygen transport effects of the rapid infusion of 500 ml of modified fluid gelatin, an artificial colloid widely used in Europe, were studied in a group of critically ill patients suffering from cardiovascular instability. Oxygen consumption tended to increase. There were no significant changes in heart rate, shunt fraction, or systemic vascular resistance index. There were significant increases in mean arterial pressure, pulmonary artery wedge pressure, stroke index, cardiac index, and oxygen delivery. There were significant decreases in Hgb concentration and arterial oxygen content. The overall circulatory effects of modified fluid gelatin are beneficial.

Adult↗
PubMed1989

Use of survivors' cardiorespiratory values as therapeutic goals in septic shock.

The responses to therapy of 29 patients in septic shock are described. Patients received controlled plasma volume expansion followed by infusions of norepinephrine, dobutamine, and dopamine to achieve appropriate therapeutic goals. Increases in oxygen delivery (Do2) from 605 +/- 40 (SEM) to 843 +/- 27 ml/min-m2 (p less than .001) were associated with increases in oxygen consumption (Vo2) from 130 +/- 6.8 to 169 +/- 6.2 ml/min.m2 (p less than .001). The overall hospital survival rate was 52%. We suggest that the rational use of adrenergic agents and the achievement of appropriate physiologic end-points for therapy not only result in the reversal of hypotension, but also maintain or increase Do2 and Vo2, and may improve survival.

Adult↗
PubMed1989

Anesthesia and gastrointestinal surgery.

Anesthesia can have various effects on the outcome of surgery, especially gastrointestinal procedures. Many anesthetic agents, for example, produce a fall in lower esophageal sphincter pressure, which can allow reflux of gastric contents into the lower esophagus. This can lead to potentially fatal aspiration of vomit. Anesthesia also alters gastrointestinal motility, secretion, and absorption; postoperative opiate analgesia in particular contributes to delayed gastric emptying. Anesthetic technique can affect the success of intestinal anastomosis; for example, intravenous induction agents and some inhalational anesthetics decrease regional blood flow, whereas regional anesthetics may act to increase colonic blood flow. Other aspects of anesthetic management are also discussed as they relate to surgical outcome; examples are the use of invasive monitoring in elderly patients, the importance of oxygen delivery to the anastomosis, and the effect of transfusion on survival after surgery for carcinoma.

Anastomosis, Surgical↗
PubMed1988

Oxygen consumption following trauma: a reappraisal in severely injured patients requiring mechanical ventilation.

Oxygen consumption (VO2) immediately following major injury in man has been said to be reduced. The evidence for this is poor. We have therefore measured VO2 soon after major injury in 16 patients. VO2 was reduced in only two patients, within the normal range in four and increased in ten. VO2 was maintained by increased oxygen extraction in six patients leading to low levels of mixed venous oxygen saturation. There is no evidence for an 'ebb phase' response in man.

Adolescent↗