Ann Acad Med Singap
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Ann Acad Med Singap · Jul 2000
Case Reports Comparative StudyPerioperative deaths: a further comparative review of coroner's autopsies with particular reference to the occurrence of fatal iatrogenic injury.
In previous triennial reviews of Coroner's perioperative autopsies conducted during the periods 1989 to 1991 and 1992 to 1994, it was observed that the necropsy incidence of such deaths rose from 2% to 2.6% (P < 0.05). Concurrently, the rate of iatrogenic deaths had nearly doubled from 15.2% to 28.8% (P < 0.02). These findings spurred a review of the subsequent triennium (1995 to 1997), in order to monitor the apparent rise in these trends and to study the frequency and occurrence of iatrogenic deaths in relation to the number of invasive procedures performed, as well as during emergency and elective procedures. ⋯ There appears to have been a steady increase in the number of perioperative deaths reported to the Coroner over the previous triennia (1989 to 1997) for which autopsies were conducted. While this observation may not denote an increase in perioperative morality rates per se, it may be indicative of an increasingly "aggressive" or defensive approach to the clinical management of seriously ill patients, particularly over the past decade. Although the rate of iatrogenic deaths appears to have stabilised, it is too early to say whether this apparent trend will persist in the future. It is perhaps not surprising that the risk of iatrogenic injury appears to increase with the number of interventions performed; however, it is not clear why initial, supposedly elective, interventions should be associated with an apparently greater risk of iatrogenic injury than those classified as emergency procedures. The substantial divergence between the autopsy finding of an iatrogenic death and the corresponding Coroner's verdict of misadventure may be comforting to clinicians, but certainly warrants further examination.
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Ann Acad Med Singap · Jul 2000
Randomized Controlled Trial Clinical TrialProphylactic esmolol infusion for the control of cardiovascular responses to extubation after intracranial surgery.
Emergence from general anaesthesia and extubation are often accompanied by significant surges in heart rate and blood pressure. To document these changes and the efficacy of low-dose beta-blocker infusions in ameliorating these rises, we undertook a descriptive dose-ranging study comparing the use of esmolol to placebo in patients emerging from neuro-anaesthesia. ⋯ Severe hypertension or tachycardia occurs in 92% of patients during extubation following neuro-anaesthesia and warrants the consideration of routine prophylaxis. Prophylactic esmolol infusion for the control of haemodynamic disturbances during extubation is feasible and safe. A modest level of obtundation is evident at 100 micrograms/kg/min but a rate of 200 micrograms/kg/min may prove to be more effective.
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Ann Acad Med Singap · Jul 2000
Cardiac marker point-of-care testing: evaluation of rapid on-site biochemical marker analysis for diagnosis of acute myocardial infarction.
Up to 40% of patients with acute myocardial infarction (AMI) present with non-diagnostic electrocardiograms (ECGs). The diagnosis in such cases is usually made with the aid of biochemical markers. Newer and more rapid assays for such markers have now enabled testing to be done on-site instead of in the laboratory. This potentially enables the clinician to rapidly diagnose and triage patients. We evaluated the diagnostic precision of this point-of-care testing strategy using one such analyser, the Stratus CS (Dade Behring) in a prospective study. ⋯ Point-of-care testing utilising a panel of 2 or 3 cardiac markers has comparable diagnostic precision to the presently utilised testing strategy for AMI, with earlier availability of results.
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Ann Acad Med Singap · Mar 2000
Comparative StudyPerioperative and rehabilitative outcomes after amputation for ischaemic leg gangrene.
Amputation of the severely ischaemic leg is often done when limb salvage is not possible or the patient is not fit enough for it. It is therefore important to determine the natural history of these amputees as our understanding of this will have significant impact on decision making. The aim of this study was to determine the early and late morbidity and mortality rates and rehabilitative outcome of these patients with lower limb amputation for end-stage arterial occlusive disease. ⋯ Early and late rehabilitation after amputation for critical limb ischaemia remain poor and efforts should be made to salvage critically ischaemic limbs wherever possible in patients who are fit enough.
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We report an unusual case of a patient with clinical and histological features of cutaneous vasculitis. CASE PICTURE: A middle-aged Chinese male presented with livedo reticularis and digital gangrene without visceral involvement. Skin biopsy showed features suggestive of cutaneous vasculitis. Repeated testing for anticardiolipin antibody was negative. ⋯ This is an interesting case of cutaneous vasculitis, which has features of polyarteritis nodosa and the antiphospholipid syndrome, who responded well to intravenous prostacyclin, steroids, pentoxifylline, aspirin, nifedipine and colchicine.