325

blood-pressure or proteinuria and their clinical indices lay in the normal range. The coagu-

crease

in diastolic

lation indices for these women range for normal pregnancy.

were

also within the

Requests for reprints should be addressed to P. W. H., University Department of Obstetrics and Gynaecology, Royal Maternity Hospital, Rottenrow, Glasgow G4 ONA. REFERENCES

Sequential Data eclampsia (fig. 3)

in Two Patients with Severe Pre-

with severe pre-eclampsia who had perinatal loss had the clinical and coagulation indices measured sequentially. The first patient did not show rapid deterioration on the clinical index but the coagulation index increased sharply before intrauterine fetal death. In the second patient, the indices showed parallel deterioration during the course of the illness. The severity of the clinical condition necessitated delivery in the mother’s interest and the baby died soon after birth. Two

women

Discussion

The present classification of pre-eclampsia is based on the increase in blood-pressure and on the presence of proteinuria, and there is a continuous spectrum of abnormality ranging from the normal pregnant to the severely pre-eclamptic patient. These clinical criteria, because of their variability, do not provide a reliable guide (fig. 2) to the optimum timing of delivery in a preeclamptic patient to achieve the best chance of a viable fetus. The main purpose of the present investigation was to see whether the blood-coagulation changes could be used to provide a more sensitive index of the progress of preeclampsia. The three haemostatic tests were chosen because they had been previously shown to give the best separation between normal and pre-eclamptic patients12 and because they can be easily and rapidly performed. Discriminant analysis was used to combine the coagulation data into a single variable which is clearly superior to the individual tests at separating pre-eclamptic and normal patients as shown in figs. 1 and 2. Our results also show (fig. 2), a strong correlation between clinical and coagulation indices and that fetal death was common amongst those with the most severe haemostatic disturbance. This strongly suggests that increasing intravascular coagulation was a clinically important fac-

I

tor,

G

i

The normal results in essential hypertension show that the coagulation abnormalities are a feature of preeclampsia and not just a manifestation of hypertension. It has been reported that a reduced platelet-count correlates with intrauterine growth retardation 18 but in the present series none of the individual tests was able to identify reliably the patients in whom perinatal loss occurred. In contrast, all of the patients whose babies died had high scores on the coagulation index. Furthermore, the sequential data in fig. 3 suggests that the coagulation index may deteriorate before fetal death and be of more value in predicting fetal death than clinical criteria used alone. Full evaluation will come from further sequential studies, but the coagulation index has potential value as an indicator of those patients at greatest nsk and in need of prompt delivery. Wethank Prof. E. M. McGirr, Prof. M. C. Macnaughton, and Prof. : Atchison for their interest in this work; and Mrs K. Whigham for technical assistance. This study was financially supported by the Medi:1: ? tlearch Council.

D. G., Merrill, S. J., Weiner, A. E., Hertig, A. T., Reid, D. E. Am. J. Obstet. Gynec. 1953, 66, 507. 2. Govan, A. D. T. J. Path. Bact. 1954, 67, 311. 3. Vassalli, P., Morris, R. H., McCluskey, R. T. J. exp. Med. 1963, 118, 467. 4. McKay, D. G., Goldenberg, V., Kaunitz, H., Csavossy, L. Archs Path. 1967, 84, 557. 5. Arhelger, R. B., Douglas, B. H., Langford, H. G. ibid. p. 393. 6. Wardle, E. N., Wright, N. A. Am. J. Obstet. Gynec. 1973, 115, 17. 7. McKillop, C., Howie, P. W., Forbes, C. D., Prentice, C. R. M. Lancet, 1976, 1.

McKay,

1, 56.

McKay, D. G., Corey, A. E. Obst. Gynec. N.Y. 1964, 23, 508. 9. Wardle, E. N., Menon, I. S. Br. med. J. 1969, ii, 625. 10. Henderson, A. H., Pugsley, D. J., Thomas, D. P. ibid. 1970, iii, 545. 11. Bonnar, J., McNicol, G. P., Douglas, A. S. ibid. 1971, ii, 12. 12. Howie, P. W., Prentice, C. R. M., McNicol, G. P. J. Obstet. Gynœc. Br. Commonw. 1971, 78, 992. 13. Birmingham Eclampsia Study Group. Lancet, 1971, ii, 889. 14. Butler, N. R., Bonham, D. G. (editors) Perinatal Mortality Study; p. 86. Edinburgh, 1963. 15. Breckenridge, R. T., Ratnoff, O. D. Blood, 1962, 20, 137. 16. Merskey, C., Kluner, G. J., Johnson, A. J. ibid. 1966, 28, 1. 17. Dacie, J. V., Lewis, S. M. Practical Hæmatology; p. 61. London, 1963. 18. Trudinger, B. J. Br. J. Obst. Gynœc. 1976, 83, 284. 8.

SINGLE-DOSE PEROPERATIVE ANTIBIOTIC PROPHYLAXIS IN GASTROINTESTINAL SURGERY B. A. SHOREY D. A. GRIFFITHS R. A. SIMPSON D. C. E. SPELLER N. B. WILLIAMS

Royal Infirmary, Bristol BS2 8HW A single intravenous dose of tobramycin and lincomycin, given at the start of gastrointestinal operations, significantly reduced the in-

Summary

cidence of postoperative wound infection from 34% to 5%. The occurrence of both anaerobic and aerobic bacteria was reduced. Therapeutic concentrations of the antibiotics were maintained throughout the operative period in most cases. No toxic effects of the antibiotics were detected, no anæsthetic complication occurred, and resistant strains of bacteria normally sensitive to the antibiotics were not isolated from wounds. Introduction SURGICAL operations which involve the opening of colonised viscera are frequently followed by wound infection,l usually produced endogenously by bacteria from the viscera themselves.2 Attempts have been made to prevent this by the prophylactic use of antibiotics, in a variety of doses and routes, over different periods of time. Long courses of systemic antibiotics have often proved ineffective, and they expose the patient to the toxic effects of the drugs and may encourage the emer4 gence of resistant strains.3 Recently shorter courses have been tried with success,4 as little as two doses of broad-spectrum antibiotics being successful in reducing significantly the wound-infection rate in general surgery.5 The present investigation continues this tendency by using one dose only of tobramycin and lincomycin at the time of operation.

326

(II) Mild wound infection: erythema, scanty pus, cultures positive. (III) Colonised wound: not clinically infected, cultures posi-

Methods Patients The study was conducted as a double-blind trial. Consecutive patients for elective or emergency gastrointestinal surgery,

who were not pregnant, and who had normal renal and auditory function, were randomly allocated to "treated" and "control" groups. This allocation was unknown to the surgeon operating and to all the investigators during the study. Patients already receiving antibiotics, or requiring antibiotics in the immediate postoperative period, were excluded from the trial, as were patients with perforated viscera or established peritoneal infection; these latter were given routine antibiotic treatment. The ages of the patients ranged from 16 to 80 years, and the age distribution was similar in the treated and the control groups. Clinical Management and Assessment

Preoperative gut preparation

was

mechanical, by simple

washouts only. Each patient in the treated group received one dose of antibiotics : tobramycin 1.5mg/kg and lincomycin 600 mg administered together in 500 ml of physiological saline by intravenous infusion over 30 minutes, beginning at the time of skin incision. Control patients received 500 ml of physiological saline. At the end of the operation careful observation was kept for any difficulties in reversal of muscular paralysis or prolonged neuromuscular blockade. Wounds were assessed for signs of infection, daily during the patient’s hospital stay and at the first outpatient attendance at one month, by a surgeon who had not performed the operation, and features such as erythema and discharge were charted. At the same time the patient was assessed for signs of infection at other sites, which was treated accordingly, and for evidence of auditory, vestibular, renal, or colonic malfunction.

tive.

(IV) Healed wound: cultures negative. Results

patients undergoing gastrointestinal surgery completed the trial. 43 received tobramycin and lincomycin, 90

and there were 47 controls. The incidence of wound infection in the two groups is shown in table i. There was a significant reduction in postoperative wound infection from 34% in the control series to 5% in the treated group (r

Single-dose peroperative antibiotic prophylaxis in gastrointestinal surgery.

325 blood-pressure or proteinuria and their clinical indices lay in the normal range. The coagu- crease in diastolic lation indices for these wome...
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