Anaesthesia
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Comparative Study
Recombinant activated protein C usage in Scotland: a comparison with published guidelines and a survey of attitudes.
Severe sepsis is a common cause of admission to the intensive care unit and is associated with a high hospital mortality. This audit explored the current use of, and attitudes towards, recombinant activated protein C therapy across Scotland, and compared these with current guidance. Patients with severe sepsis were followed for three days. ⋯ Thirty-nine respondents (38%) stated that two-organ failures alone would be an adequate trigger for therapy. We conclude that recombinant activated protein C is potentially under-used to treat severe sepsis. Many consultants seem to reserve the drug for the most severely ill sub group of patients.
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The prevalence and severity of aortic stenosis in unselected patients admitted with a hip fracture is unknown. Derriford Hospital operates a routine weekday, pre-operative, targeted bedside echocardiography examination on all patients admitted with a hip fracture. We carried out a prospective service evaluation for 13 months from October 2007 on all 501 admissions, of which 374 (75%) underwent pre-operative echocardiography. ⋯ Detection of a murmur does not necessarily reflect the presence of underling aortic valve disease. However, if a murmur is heard then the likelihood of the lesion's being moderate or severe aortic stenosis is increased (OR 8.5; 95% CI 3.8-19.5). Forty-four (12%) of our unselected patients with fractured femur had either moderate or severe aortic stenosis (with or without moderate or severe left ventricular failure), or mild stenosis with moderately or severely impaired left ventricular function.
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Target controlled infusion (TCI) devices can be associated with significant safety concerns when used during magnetic resonance imaging (MRI). We tested the safety and compatibility of newer TCI systems in a 3-Tesla MRI environment. Two Asena PK and two Agilia TCI pumps were used to administer TCI propofol (at target blood concentrations of 0.5 and 6.0 μg.ml⁻¹) using the Marsh model under magnetic fields of up to 50 G with a T2-weighted sequence. ⋯ Both devices did not demonstrate any significant deflection at the tested field strengths, and performed within acceptable limits (cumulative error in total delivered volume < 3%; maximum 10-min interval error < 10%). The Asena pump caused minor artefacts on MR images. The TCI pumps tested perform well and safely implement pharmacokinetic software in a high magnetic field.
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The 2003-2005 Confidential Enquiry into Maternal and Child Health report recommended the introduction of the modified early obstetric warning system (MEOWS) in all obstetric inpatients to track maternal physiological parameters, and to aid early recognition and treatment of the acutely unwell parturient. We prospectively reviewed 676 consecutive obstetric admissions, looking at their completed MEOWS charts for triggers and their notes for evidence of morbidity. Two hundred patients (30%) triggered and 86 patients (13%) had morbidity according to our criteria, including haemorrhage (43%), hypertensive disease of pregnancy (31%) and suspected infection (20%). ⋯ There were no admissions to the intensive care unit, cardio respiratory arrests or deaths during the study period. This study suggests that MEOWS is a useful bedside tool for predicting morbidity. Adjustment of the trigger parameters may improve positive predictive value.
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To provide further evidence for the lipid sink theory, we have developed an in vitro model to assess the effect of Intralipid® 20% on methaemoglobin formation by drugs of varying lipid solubility. Progressively increasing Intralipid concentrations from 4 to 24 mg.ml⁻¹ suppressed methaemoglobin formation by the lipid soluble drug glyceryl trinitrate in a dose-dependent manner (p < 0.001). ⋯ Intralipid did not significantly suppress methaemoglobin formation induced by 2-amino-5-hydroxytoluene (partially lipid soluble) or sodium nitrite (lipid insoluble; both p > 0.5). This work may assist determination of the suitability of drugs taken in overdose for which Intralipid might be deployed.