Biomedical subjects

Carolyn M Smith

Publications and source records attributed to Carolyn M Smith.

3 recordsLinked to original sources

PubMed2003

Noninvasive interventions to decrease hospitalization and associated costs for pediatric patients receiving hemodialysis.

Minimal pediatric data describe hospitalization causes and associated costs for children who receive maintenance hemodialysis, and no data exist to evaluate methods to decrease hospitalization. In 1999, two common causes of hemodialysis patient hospitalization at Texas Children's Hospital were fluid overload/hypertension (FO/HTN) and vascular access thrombosis (VAT). Evaluated is the effect of two noninvasive monitoring programs, monitoring of hematocrit-guided ultrafiltration algorithm and vascular access flow using ultrasound dilution vascular access flow technology, on FO/HTN and VAT in the pediatric maintenance hemodialysis population. This prospective observational study reviewed all hospitalization data for all 51 patients who received maintenance hemodialysis from January 1999 through December 2001 obtained from unit monthly performance improvement meeting records. Hospitalization rates and related costs for FO/HTN and VAT were tracked before and after institution of the noninvasive monitoring programs. Application of the noninvasive monitoring of hematocrit-guided ultrafiltration algorithm since January 2000 significantly decreased hospitalization for FO/HTN (64 total days in 1999, 4 total days in 2000 and 2001 combined) while maintaining acceptable patient BP control and minimizing antihypertensive medication requirements. The vascular access monitoring program using ultrasound dilution vascular access flow technology to direct referral for angioplasty instituted in January 2001 led to a significant decrease in hospitalization for VAT (45 d in 2000 and 21 d in 2001). It is suggested that application of noninvasive technologies to assess patient target dry weight and access flow can significantly decrease pediatric maintenance dialysis patient morbidity and health care cost.

Adolescent↗

PubMed2002

Proactive monitoring of pediatric hemodialysis vascular access: effects of ultrasound dilution on thrombosis rates.

BACKGROUND: Hemodialysis vascular access thrombosis (VAT) is a significant cause of morbidity for hemodialysis patients and results, in part, from decreased access flow potentially caused by venous outflow stenosis. We have previously shown ultrasound dilution (UD) to be a practical and reliable predictor of venous outflow in children receiving hemodialysis. METHODS: The current study is the first to our knowledge to assess the impact of a proactive UD monitoring program upon VAT in pediatric patients. Nine patients experienced 18 VAT over the two-year study. Mean values for variables potentially associated with VAT were compared to values from a size-matched seven patient group without VAT during the study period. VAT rates were compared between the year-before (pre-UD era) and year-after (UD era) UD was initiated. During the latter half of the UD era (rapid referral period), patients with VA flow rate (QAcorr) <650 mL/min/1.73 m2 were referred for balloon angioplasty within 48 hours. RESULTS: Mean QAcorr was lower for patients with subsequent VAT (562 +/- 290 mL/min/1.73 m2) versus patients without VAT (1005 +/- 372 mL/min/1.73 m2; P = 0.02). The VAT rate was significantly lower in the UD era (4.1 VAT/100 patient-months) versus the pre-UD era (11.0 VAT/100 patient-months; P = 0.03). The decrease in VAT rates was caused predominantly in the rapid referral period, where the VAT rate dropped to 0.96 VAT/100 patient-months (P < 0.001). Cost of vascular access management was 65% higher ($1264 vs. $765/patient-month) in the pre-UD era, reflecting the increased cost for treatment of VAT. CONCLUSIONS: Monthly QAcorr <650 mL/min/1.73 m2 is predictive of imminent VAT in children receiving hemodialysis. Prompt referral for angioplasty of VA with QAcorr <650 mL/min/1.73 m2 leads to decreased VAT rates in children.

Angioplasty, Balloon↗

PubMed2002

Early and late outcome of bedside percutaneous tracheostomy in the intensive care unit.

To simplify long-term airway management in critically ill patients the feasibility of performing percutaneous tracheostomy (PT) in the intensive care unit (ICU) was investigated from August of 1997 to March of 2000. Bedside PT was considered for patients with positive end-expiratory pressure <10 cm H20, no previous tracheostomy, no anatomic distortion of the tracheal region, and no other indication to go to the operating room. Indication for tracheostomy, duration of endotracheal intubation, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, morbidity, and mortality were determined. Patients were prospectively followed until decannulation or for a minimum of 3 months. PT was performed in the ICU in 71 patients. Indications for PT were: acute respiratory failure (41), airway protection (26), and maxillofacial trauma (four). Mean duration of intubation before PT was 14 days (range 5-35 days). Average APACHE II score was 14 (range 3-28). Morbidity from PT included: early (two) and late (one) bleeding from the tracheostomy, early cuff leak (one), and self-decannulation (one). Sixteen patients died of causes unrelated to PT. Forty-five patients were decannulated after an average of 57 days (range 9-170 days); two noted a minor voice change. PT can be performed in the ICU with minimal morbidity eliminating the need for an operating room, the risks of patient transport, and the costs associated with each.

Adolescent↗