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Biomedical subjects

A I Fields

Publications and source records attributed to A I Fields.

At least 19 recordsLinked to original sources
PubMed1992

Near-drowning in the pediatric population.

Near-drowning is a frequently preventable accident that has significant morbidity and mortality for a previously healthy population. It causes an hypoxic-ischemic insult and multisystem organ dysfunction. Effective and aggressive CPR at the scene is the most important therapy presently available. Children needing CPR in an emergency room setting have poor outcome unless the submersion incident occurred in ice-water and the patient is hypothermic upon arrival in the emergency room. Attempts at prevention through parent education, requiring of CPR certification for pool owners, and legislation of barriers around the pool are critical because treatment to improve the outcome of the neurologic insult has proved ineffective.

Adolescent↗
PubMed1991

Outcome of home care for technology-dependent children: success of an independent, community-based case management model.

Case management is important for successful home care of technology-dependent, respiratory-disabled children. Traditionally, the medical model of hospital-based home care and case management has been used for these children. The outcome may be different from when using independent, community-based home care and case management. We evaluated the results of 28 technology-dependent children [23 receiving mechanical ventilation and 5 receiving continuous positive airway pressure (CPAP)] from 8 hospitals, who utilized an independent, community-based, case management group to coordinate home care. After 26.3 +/- 20.6 months of follow-up, 13 children (46%) remained technology-dependent, 10 (36%) were technology-independent, and 5 (18%), all with neurologic dysfunction, had died. Only one death was caused by a complication of technology. All children with congenital anomalies (n = 4), primary pulmonary disease (n = 8), and neuromuscular disease (n = 4) survived, and 9 (56%) were weaned from technological support. Children with chronic respiratory failure secondary to central neurologic dysfunction (n = 12) did poorly: 5 died, 6 remained technology-dependent, and only 1 became independent of technology. Children with neuromuscular diseases tended to use less home care nursing at a lower home care cost. Parent satisfaction was high among those who responded (82%), indicating that the child, siblings, and family were better off with the child at home. These outcomes suggest that community-based home care and case management is a reasonable alternative to the hospital-based model.

Abnormalities, Multiple↗
PubMed1991

Home care cost-effectiveness for respiratory technology-dependent children.

We evaluated home care costs and the cost-effectiveness of home care vs alternative institutional care for respiratory technology-dependent children in a Medicaid Model Waiver Program. "Cost-savings" was measured as the difference between the established Medicaid reimbursable charges to enact an individualized care plan at a long-term care institution and the actual Medicaid reimbursements for home care. Ten patients--six dependent on mechanical ventilation and four with a tracheostomy who were receiving oxygen--were included in the analysis. The mean (+/- SD) annual home care costs were $109,836 +/- $20,781 for ventilator-dependent children and $63,650 +/- $12,350 for oxygen-dependent patients with a tracheostomy, representing annual savings of approximately $79,000 per patient and $83,000 per patient, respectively. The largest portion of home care reimbursements was for nursing care, accounting for 69.0% and 59.0% of the two patient groups. The full program (50 patients) has the potential for a savings of $4 million per year.

Child↗
PubMed1989

Sequential physiologic interactions in pediatric cardiogenic and septic shock.

We report that the pediatric cardiogenic shock and septic shock populations show similar hemodynamic and oxygen utilization physiologic relationships during aggressive intensive care therapy. We examined the mathematical relationships between vascular tone and flow, and oxygen utilization and oxygen delivery (DO2) in the early and middle stages of cardiogenic and septic shock. The fitted curves between cardiac index and systemic vascular resistance, and oxygen consumption (VO2) and DO2 were clinically and statistically similar in both shock populations. We found no evidence for decreased oxygen extraction in sepsis as compared to the cardiogenic shock population. In addition, it appears that the major determinant of VO2 in these populations is DO2, not oxygen extraction. We suggest that patients with cardiogenic or septic shock can be treated according to similar physiologic principles.

Child, Preschool↗
PubMed1989

Immobilization hypercalcemia: unusual presentation with seizures.

Immobilization hypercalcemia usually causes mild neurologic symptoms. Seizures are a rare complication, appearing weeks after the appearance of other symptoms of hypercalcemia. We report here the case of a 10-year-old boy who developed generalized seizures early in the course of the syndrome. In this child, early diagnosis and therapy probably prevented the more complicated course described in previous cases. We wish to draw attention to this potentially life-threatening complication of immobilization.

Child↗
PubMed1987

Invasive hemodynamic monitoring in children.

Invasive monitoring is an important aspect of the care of the infant or child with multisystem organ dysfunction or severe acute respiratory failure. The indications for these procedures in children vary little from current recommendations for adults. The size, anatomy, physiologic responses, and pathophysiologic processes in children frequently require modifications in the placement and maintenance of these lines, and in the interpretation of the data. The literature suggests that although the absolute numbers may vary, broad therapeutic goals may be identified and treated in pediatric patients as in older patients.

Catheterization, Central Venous↗
PubMed1986

Shock following generalized hypoxic-ischemic injury in previously healthy infants and children.

Eighteen previously healthy patients with hypoxic-ischemic shock were observed longitudinally by means of data measured or derived from systemic arterial and pulmonary artery catheters. Shock was characterized by low cardiac index, elevated right and left heart filling pressures, elevated systemic and pulmonary vascular resistances, decreased oxygen consumption, and elevated oxygen extraction indices. Oxygen consumption was significantly correlated with oxygen delivery (r = 0.74, P less than 0.0001). This pattern fits that of cardiogenic shock. Cardiopulmonary data were not significantly different in survivors (n = 10) and nonsurvivors (n = 8). Outcome was determined by neurologic injury.

Blood Pressure↗
PubMed1986

High-frequency ventilation versus conventional ventilation in dogs with right ventricular dysfunction.

A randomized crossover protocol was used to compare conventional mechanical ventilation (CMV) and high-frequency ventilation (HFV) in mongrel dogs experiencing right ventricular dysfunction after right ventriculotomy. When inspired oxygen, pH, PCO2, core temperature, and preload were held constant, cardiac output increased significantly (p less than .05) from 1.16 +/- 0.24 to 1.38 +/- 0.25 L/min and pulmonary vascular resistance decreased significantly (p less than .05) from 734 +/- 257 to 554 +/- 169 dyne X sec/cm5 during HFV relative to CMV. We also noted a significant (p less than .05) increase in mean arterial pressure from 116 +/- 27 to 124 +/- 23 mm Hg and a significant (p less than .05) increase in left ventricular stroke work from 10.2 +/- 3.5 to 12.3 +/- 2.6 g X m during HFV. During the inspiratory phase of CMV there were increases in CVP, pulmonary artery pressure, and systemic arterial pressure, and decreases in pulmonary artery flow which did not occur during HFV. HFV may be preferable to CMV in the presence of right ventricular dysfunction.

Animals↗
PubMed1986

Shock in infants and children.

Physiologic data obtained from infants and children in shock indicate that there is a high frequency of abnormalities that can only be discovered with pulmonary artery catheters. Cardiogenic shock is a low-output, high-resistance condition, and septic shock is a relatively high-output, low-resistance condition. The use of pulmonary artery catheter data demonstrates that optimal therapeutic goals can be estimated and basic pathophysiologic abnormalities can be discovered.

Animals↗
PubMed1985

Distributions of cardiopulmonary variables in pediatric survivors and nonsurvivors of septic shock.

The association of cardiopulmonary variables with outcome was investigated in 42 pediatric patients (18 survivors) with septic shock. All cardiopulmonary variables were obtained during active BP support. The variable distributions were separated into ranges by two empiric cutoff methods: normal ranges and the survivor median values. The proportion of survivors with normal values of wedge pressure and cardiac index was significantly (p less than .05) higher than the proportion of survivors outside the normal range. The percentage of survival also significantly (p less than .05) increased with above-normal values of oxygen consumption, arteriovenous O2 content difference, O2 extraction, pH, and core temperature. There were significantly (p less than .05) more nonsurvivors with wedge pressure, pulmonary shunt, and pH values below the survivor medians. Therapeutic goals based on the distributions of these eight variables isolated patient groups with survival rates of 59% to 75%, compared to the overall survival rate of 43%.

Adolescent↗
PubMed1984

Evaluation of pediatric intensive care.

A total of 294 Clinical Classification System (CCS) Classes III and IV patients in a pediatric ICU (PICU) were evaluated in terms of severity of illness and quantity of care. The group was comprised of patients from 3 services: medicine, cardiovascular surgery, and other surgery. Severity of illness was measured by the Physiologic Stability Index (PSI) and quantity of care was measured by the Therapeutic Intervention Scoring System (TISS). Comparisons were made between survivors and nonsurvivors and among the 3 services. Nonsurvivors had significantly higher (p less than .01) PSI and TISS scores than survivors. Medical patients had the highest PSI scores while cardiovascular surgery patients had the highest TISS scores. Analysis of 7-day regression slopes for all survivor groups and medicine and other surgery nonsurvivor groups demonstrated slopes consistent with the expected clinical course. Cardiovascular surgery nonsurvivor slopes were unique and demonstrated increasing stability with stable amounts of care. The PSI/TISS ratio was used to relate levels of physiologic instability to the amount of therapy. Medical patients had the highest ratios and cardiovascular surgery patients had the lowest ratios. Comparisons of survivors and nonsurvivors for the PSI/TISS ratios and regression slopes demonstrated differences that were not evident through comparison of PSI and TISS scores alone.

Child↗
PubMed1984

Sequential cardiopulmonary variables of infants and children in septic shock.

Sequential cardiopulmonary variables were analyzed in 32 infants and children with septic shock. Variables were staged by a system based on therapeutic efforts to control blood pressure. There were 14 survivors and 18 nonsurvivors. Systemic circulation variables (MAP, cardiac index [CI], systemic vascular resistance index [SVRI], wedge pressure [WP], left cardiac work index [LCWI]) and pulmonary circulation variables (mean pulmonary artery pressure [MPAP], pulmonary vascular resistance index [PVRI], CVP, right cardiac work index [RCWI]) were similar in survivors and nonsurvivors. Pulmonary variables (intrapulmonary shunt [Qsp/Qt], fraction of inspired oxygen [FIO2], Pao2, PaCO2) revealed significantly more dysfunction in nonsurvivors than survivors during the postresuscitation (PR) and middle (M) shock stages. Even though oxygen delivery was equivalent in survivors and nonsurvivors, nonsurvivors demonstrated decreased oxygen utilization variables (oxygen consumption [Vo2], arteriovenous oxygen content difference [C(a-v)O2], O2 extraction index, core temperature) during the resuscitation (RS) and PR stages.

Blood Circulation↗
PubMed1984

Validation of a physiologic stability index for use in critically ill infants and children.

We developed a physiology-based scoring system, the Physiologic Stability Index (PSI) to assess severity of acute illness in the total population of pediatric Intensive Care Unit (ICU) patients. Thirty-four variables from seven physiologic systems were chosen, and the degree of abnormality of each variable was assigned a score reflecting the clinical importance of the derangements. Validity was demonstrated by comparing PSI to hospital mortality and to two other methods that reflect severity of illness, the Clinical Classification System (CCS) and the Therapeutic Intervention Scoring System ( TISS ). Four hundred and twenty-three consecutive admissions to a multidisciplinary ICU were followed daily. Patients classified into higher CCS classes had significantly higher PSI scores (P less than 0.001), and there was a highly significant correlation (P less than 0.001) between PSI and TISS scores. The linear-logistic regression of observed mortality versus PSI was highly significant (P less than 0.0001) and provided an excellent fit. Highly significant differences between survivors and nonsurvivors were observed for PSI scores (P less than 0.001), as well as for composite slopes of the regression of PSI scores versus days of care (P less than 0.001). These data demonstrate validity of the PSI scoring system.

Acute Disease↗
PubMed1982

Assessment of pediatric intensive care--application of the Therapeutic Intervention Scoring System.

There are few reports analyzing the results of intensive care for children. We evaluated quantitatively the amount of care required in our multidisciplinary pediatric ICU using the Therapeutic Intervention Scoring System (TISS) and assessed qualitatively the severity of illness using the Clinical Classification System (CCS). Over a 6-month period, there were 323 patients (99 CCS Class II, 83 Class III, 141 Class IV) whose overall mortality at 1-month follow-up was 10% (Class II, 0%; Class III 2%; Class IV, 23%). A strong association was obtained between CCS and TISS admission scores (Class II-TISS, 11 +/- 0.6; Class III-TISS, 20 +/- 0.8; Class IV-TISS, 38 +/- 1.0). Class IV patients had a highly significant difference between survivors (S) and nonsurvivors (NS) for admission TISS (S = 36, NS = 47, p less than 0.001) and highest TISS (S = 38, NS = 54, p less than 0.001), as well as slopes of the regression of TISS points versus days of care (S = -4.2 vs. NS = +2.3). The mortality of our Class IV patients was lower than a comparable adult population with similar TISS scores; however, the TISS regression slopes for Class IV patients were similar. We conclude that CCS and TISS are both useful for describing the pediatric intensive care patient population. TISS is particularly helpful in assessing the amount of care received as well as providing a means of evaluating severity of illness.

Child↗
PubMed1980

Adult respiratory distress syndrome in children.

Respiratory distress syndrome is the clinical manifestation of injury to the terminal alveolar-capillary unit, and may result from a variety of nonpulmonary insults including shock, sepsis, and trauma. The clinical characteristics, pathophysiology, and treatment of respiratory distress syndrome in children are reviewed.

Biological Transport↗
PubMed1980

Cardiopulmonary parameters during high PEEP in children.

There are a few reports of the application of high PEEP (PEEP greater than or equal to 15 cm H2O) infants and children. Data concerning cardiac index (CI), pulmonary venous admixture (Qsp/Qt), and arterial mixed venous oxygen content difference (avDO2) during mechanical ventilation with high PEEP have not been reported. Fourteen infants and children were treated with high levels of PEEP; 8 of these patients were monitored with pulmonary artery catheters. Cardiopulmonary data were obtained from these 8 patients and pulmonary barotrauma data were tabulated from all 14 patients. At highest PEEP, CI = 3.6 +/- 0.6 L/min x M2, avDO2 = 4,45 +/- 0.83 ml/dl and Qsp/Qt = 16.7 +/- 2.1%. One patient experienced severe cardiac depression unresponsive to therapy; it resolved when PEEP was lowered. Pulmonary barotrauma was a frequent complication. Pneumothroax occurred in 6 patients. No patient died from pulmonary barotrauma. We conclude that PEEP greater than or equal to 15 cm H2O can be used in infants and children to decrease Qsp/Qt toward normal; CI and avDO2 can usually be maintained in an acceptable range. Patients should be frequently monitored for pulmonary barotrauma.

Adolescent↗