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Biomedical subjects

F W Clevenger

Publications and source records attributed to F W Clevenger.

At least 19 recordsLinked to original sources
PubMed1997

Preoperative management of patients with major trauma injuries.

Traumatic injuries require rapid, efficient, and precise diagnose and immediate treatment. Patients with major trauma injuries place special demands on emergency department, OR, and intensive care unit health care providers. Cost-effective and time-efficient management of these patients results in improved patient care and optimal outcomes in this era of shrinking health care dollars. Perioperative nurses need to be aware of the many evolving changes in the preoperative management of patients with major trauma injuries to provide quality care to these patients.

Acute Disease↗
PubMed1997

The metabolic response to spinal cord injury.

The metabolic response to trauma, including neurotrauma in general, has been studied extensively, but the acute metabolic response to spinal cord injury (SCI) has not. Therefore, 12 patients with SCI are presented in whom intensive nutrition assessment and management were instituted immediately after injury. Nitrogen balance (NB), predicted energy expenditure (PEE), and actual energy expenditure (MEE) were calculated or measured in each patient. A persistent negative NB was observed in all but one of the 12 patients. The single patient who did not exhibit persistent negative NB (no positive NB from week 2 to week 4 in the face of appropriate feeding) had an incomplete myelopathy, thus implying that the degree of motor dysfunction correlates with the obligatory nature of the negative NB. The negative NB observed in several of the patients did not occur until the second or third post-injury week. In addition, calculations of PEE by successively multiplying the Harris-Benedict equation by an activity factor of 1.2 and then by a stress factor of 1.6, resulted in excessive feeding (as assessed by metabolic cart measurements; ie indirect calorimetry) in the majority of the patients. In all of the 11 patients with persistent negative NBs, protein administration in the amount of 2 g/k of ideal body weight and aggressive caloric delivery did not alter the negative pattern of the NBs. Therefore, it is concluded that the negative NB following SCI is obligatory. Furthermore, the extent of SCI (extent of myelopathy or of neurological injury) correlates with the obligatory nature of the negative NB. In addition, the results from using the above method for estimating caloric requirements and the delayed manifestation of the negative NB may cause an additional tendency to acutely overfeed SCI patients. Therefore, eliminating the activity factor of 1.2 (due to the diminished activity arising from paralysis) and a diminution of the stress factor is recommended for initial PEE calculations. Serial metabolic cart (indirect calorimetry) measurements are recommended to accurately assess the patient's subsequent metabolic requirements.

Adult↗
PubMed1997

Throughput analysis of trauma resuscitations with financial impact.

OBJECTIVES: In an era of diminishing reimbursement, efficient resource utilization is paramount. The effects of three parallel factors were tracked: (a) coordinated physician-hospital patient care, (b) increasing physician awareness of resources, and (c) in-house trauma attendings. DESIGN: Observational study. METHODS: A Windows-based database application was made to track all resuscitations at a Level I adult/pediatric trauma center. Time data were immediately entered upon discharge from the resuscitation bay, and further data (Injury Severity Score, length of stay, and mortality) were obtained by linking to a concurrent trauma registry. Group I was a 6-month control. Group II reflects factors a and b, and group III adds factor c, each contributing 3 months of additional data. Statistical comparisons were made using analysis of variance and Fisher's exact test. RESULTS: There were 2,546 resuscitations with 1,201, 636, and 709 in groups I, II, and III, respectively. The five most frequent dispositions, resuscitation times, and hospital costs were analyzed. CONCLUSIONS: Given similar patient groups, factors a and b together and factor c improved throughput in the resuscitation bay by approximately 35% (5-133 min) each. Hospital costs concurrently decreased with no rise in mortality.

Adult↗
PubMed1996

The impact of selective laboratory evaluation on utilization of laboratory resources and patient care in a level-I trauma center.

BACKGROUND: Routine laboratory evaluation of preoperative patients has not been shown to be cost effective when a detailed history and physical examination are performed. However, since such a detailed history is not possible in trauma patients, the time-honored approach has been for laboratory evaluation to be protocol driven. The cost-benefit ratio of this practice has never been evaluated. METHODS: Trauma patients who underwent routine laboratory evaluation (n = 552; group I) were compared with patients who had laboratory evaluation based on clinical need (n = 603; group II). A concurrent review of each case in group II was conducted every day while a retrospective review of charts was conducted for patients in group I to determine patient care issues and identify abnormal trauma center test results. RESULTS: The number of patients with laboratory tests decreased from 97% in group I to 27% in group II (P < 0.0001). Positive chemistry profiles increased (55% versus 92%; P < 0.0001) as did coagulation profiles (8% versus 33%; P < 0.0001). There were no differences in the percentage of patients receiving intervention based on laboratory data (7% in group I versus 8% in group II). No adverse effect on patient care was identified as a result of absent laboratory information in group II. Mortality, length of stay, and intensive care unit days were statistically unchanged. There was an annualized savings of $1.5 million in billed trauma center laboratory charges in group II. CONCLUSION: Selective laboratory evaluation of trauma patients can greatly reduce medical cost and does not adversely affect care.

Adult↗
PubMed1996

The effects of positive end-expiratory pressure of intrapulmonary shunt and ventilatory deadspace in nonhypoxic trauma patients.

Controversy exists regarding the routine use of positive end-expiratory pressure (PEEP) in mechanically ventilated patients. We hypothesized that nonhypoxic patients receiving 5-cm H2O PEEP would have improved shunt and PaO2/F10(2) ratios (P/F), without an increased dead space to tidal volume ratio (VD/VT) versus patients receiving no PEEP. Forty-four trauma patients were randomized to receive 5-cm H2O PEEP (PEEP) or 0-cm H2O PEEP (ZEEP). Shunt VD/VT and P/F were measured at 0, 12, 24, 36, and 48 hours after intubation and after extubation. PEEP and ZEEP comparisons used Student's t test and the General Linear Models procedure. Shunt was significantly increased at t = 0 and at extubation in the PEEP group. At extubation, the PEEP group demonstrated significantly higher VD/VT and poorer P/F ratios. After correction for baseline values, no statistically significant differences were noted in spite of a trend toward worsening pulmonary function in all measured parameters. These results suggest that routine use of 5-cm H2O PEEP in mechanical ventilated trauma patients is not necessary.

Adult↗
PubMed1996

Information retrieval patterns and needs among practicing general surgeons: a statewide experience.

Information retrieval has progressed from a reliance on traditional print sources to the modern era of computer databases and online networks. Surgeons, many from remote areas not served by professional medical libraries, must develop and maintain skills in information retrieval and management in both electronic and standard formats. One hundred thirty-three New Mexico general surgeons were surveyed to identify their information-seeking patterns in five areas: retrieval purposes, retrieval sources, barriers to access, techniques used, and continuing education needs. Ninety-nine (74.4%) surgeons responded to the survey. Ninety-five percent utilize professional meetings, the medical literature, and physician colleagues as information sources. Only 17% utilize the outreach services of the state's only medical school library. Common retrieval barriers were practice demands (71%), isolation from medical schools (30%), computer illiteracy (28%), and rural environment (25%). Continuing education topics related to information management would be valuable to 61% of the surgeons. Sixty-nine percent believe their current ability to access biomedical information is adequate, despite most frequently accessing their personal libraries for information related to decision-making or patient management. These data suggest that, despite significant information needs, surgeons have not embraced newer forms of information retrieval. It is imperative that surgeons acquire and maintain modern information retrieval skills as a means of remaining up-to-date in their profession. Professional surgical organizations and medical librarians should collaborate on these continuing education ventures.

Chi-Square Distribution↗
PubMed1995

Is measured energy expenditure correlated to injury severity score in major trauma patients?.

A common method for calculating energy needs (PEE) in acute trauma patients is multiplying the Harris-Benedict equation (BEE) by activity factors (AF) and variable stress factors (SF) depending on the injury severity. Selection of the SF can be an arbitrary and potentially inaccurate decision. The purposes of this study were: (1) to investigate the relationship between injury severity score (ISS) to postinjury energy expenditure (MEE), and (2) to compare the MEE to PEE when using the SF of 1.75. Thirty-five severely injured patients (mean ISS = 27.5 +/- 10.7 SD) admitted to our Level I Trauma Center of the University of New Mexico were prospectively assessed for energy needs [PEE = BEE x 1.2(AF) x 1.75(SF)] and ISS. Total nutritional support delivered estimated needs. Indirect calorimetry measurements were obtained on all of the patients within the first 7-10 days following injury. No correlation (r = -0.042) existed between the MEE and ISS. There was a significant correlation (r = 0.772, P < 0.05) between PEE and MEE when using the SF of 1.75 for all of the patients. These results suggest that there is not a correlation between ISS and subsequent MEE in major trauma patients. In addition, using the SF of 1.75 will closely estimate energy needs in acute trauma patients.

Calorimetry↗
PubMed1995

Acute spinal cord injury and neurogenic shock in pregnancy.

A case of a pregnant woman with a subluxation of C-6 on C-7 with acute quadriplegia and sensory loss to the T-10 dermatome is described. Hemodynamic and fetal monitoring during the 3-week period of neurogenic shock resulted in good maternal and fetal outcomes. Pulmonary complications and anesthetic issues are important aspects of the care of these critically ill patients. Major trauma is a common cause of death and disability in young adults and may contribute to as much as 15 percent of nonobstetric maternal deaths. Spinal cord injuries involve young women in 15 percent of cases. The literature is replete with information on the obstetric management of patients with preexisting spinal cord injury (1-4) but there is little on the management and special problems of the pregnant patient with acute spinal cord trauma. We report here the management of a case of acute cord transection accompanied by spinal shock and discuss the specific maternal as well as fetal considerations in this syndrome.

Acute Disease↗
PubMed1995

Decision-making for enteral feeding administration: the why behind where and how.

Enteral nutrition has become the preferred route of nutrient administration. Because of vigorous attempts to deliver nutrient enterally in expanded patient groups, many different locations for enteral access have been advocated along with a variety of methods related to rate and pattern of delivery. Because all modes of delivery are not compatible with all sites of access and both need to be tailored to specific subsets of patients, confusion can develop regarding where and how enteral nutrients are best delivered and why. In an era when such a high priority has been placed on feeding through the enteral route, a review of the methods and rationale behind the ever-expanding choices of enteral access is timely.

Decision Making↗
PubMed1994

On-line search strategies of third year medical students: perception vs fact.

The curriculum at the University of New Mexico School of Medicine has evolved with a high priority on problem-based and life-long learning. As the information pool enlarges, a greater emphasis must be placed on the ability of physicians to access the biomedical literature following residency training. To foster information retrieval skills, our medical school has included on the ability of physicians to access the biomedical literature following residency training. To foster information retrieval skills, our medical school has included on-line searching instruction since 1987. On-line classes are taught by experienced medical librarians during the second month of the first year curriculum. After receiving training, students are assigned a code via Grateful Med software. The purpose of the study was to measure the long-term effectiveness of this training approach and to determine the students' ability to formulate a search strategy and run a search to answer clinical questions at the third year level. During the 1990-1991 school year, all third year students were asked to use Grateful Med to answer two questions related to surgical patient care and to complete a questionnaire showing how they use Grateful Med and how they view their training. The students' searches were compared to "gold standard" searches run by an experienced medical librarian. Nineteen percent of all searches resulted in zero retrieval, and the remainder missed 74-100% of the gold standard available citations. Additional instruction shortly after on-line training could identify problem areas (poor search behavior) and information retrieval skills should be integrated and encouraged in all levels of the curriculum.

Evaluation Studies as Topic↗
PubMed1994

Mangled extremity severity score: an accurate guide to treatment of the severely injured upper extremity.

The mangled extremity severity score (MESS) is a scoring system that can be applied to mangled extremities and help one determine which mangled limbs will eventually come to amputation. The MESS is a graduated grading system based on skeletal and soft tissue injury, shock, ischemia, and age. The records of 37 patients having sustained 43 open fractures or mangled upper extremity injuries, seen and treated at the University of New Mexico's Regional Trauma Center between April 1987 and September 1990, have been reviewed. All nine extremity injuries with a MESS of greater than or equal to seven were amputated, and 34 of 34 with a MESS of less than seven were salvaged. Nine Grade IIIC and six mangled extremities were identified in our study. Five of these Grade IIIC and four of the mangled extremities with a MESS of greater than or equal to seven were amputated. All Grade IIIC or mangled extremities with a MESS of less than seven were salvaged. In conclusion, the MESS is an early and accurate predictor for identifying the extremities that may be best treated by amputation.

Adult↗
PubMed1994

Evaluation of pulmonary infections in patients with extremity fractures and blunt chest trauma.

The use of preventive antibiotics has become the standard of care in the management of patients with multiple trauma who have injuries at risk for infection. In many areas of surgical practice, preventive antibiotic utilization has been restricted to the perioperative period only. In this study we reviewed a series of trauma patients with combined blunt chest injuries and extremity fractures to determine whether the duration of postoperative antibiotic administration would have adverse effects upon nosocomial pneumonia rates and severity.

Adolescent↗
PubMed1993

Effectiveness and tolerance to highly concentrated vs conventional TPN formulas.

Conventional total parenteral nutrition regimens (TPN-C) involve concentrations of dextrose/protein which necessitate administration of 2.5-4 liters/day to meet target nutritional needs. Although this is frequently acceptable, certain clinical settings mandate a volume-restricted (VR) approach. This study compares a VR TPN regimen (TPN-VR) involving the use of 25% dextrose and 9.5% amino acid with D17.5 AA 5.0 (TPN-C). The two groups were compared for adequacy of nutritional delivery, balance, and tolerance. Twenty patients received the TPN-VR (Group 1) and 20 patients received TPN-C (Group 2). The groups were comparable in age, sex, injury severity, and APACHE 2 scores. Harris-Benedict (BEE) x 2 and 2 g/protein/kg of ideal body weight were delivered by the second day of TPN. A 27% reduction in administered fluid was achieved in Group 1 (P < 0.001). Metabolic cart data in both groups demonstrated that delivered calories exceeded REE. The average RQ in Group 1 was 0.84 and in Group 2 was 0.90 (P > 0.1). There was no significant difference between the two groups in nitrogen balance, mean serum bilirubin levels, PT and PTT, serum albumin levels, and triglycerides (P > 0.20). SGPT and alkaline phosphatase levels were significantly higher in Group 2 (P < 0.001). Group 2 received an average of 22% more carbohydrate than Group 1 and 45% required insulin compared to 25% in Group 1 (P < 0.01). In summary, TPN-VR is comparable to TPN-C in terms of effectiveness of delivery, nutritional balance, and tolerance.

Adult↗
PubMed1993

Nutritional support in the patient with the systemic inflammatory response syndrome.

The syndrome previously known as "sepsis" is now recognized as a generalized response to a number of stimuli that cause systemic activation of inflammatory mediators. The so-called "systemic inflammatory response syndrome" (SIRS) represents a final common endpoint to overwhelming persistent infection, massive tissue injury, prolonged tissue oxygen debt, or any other insult precipitating global inflammation. The metabolic consequences of SIRS are profound but in the past were not fully appreciated because patients died from more immediate causes (e.g., renal failure, pulmonary failure, gastrointestinal hemorrhage). As modern critical care has maintained patients in prolonged phases of recovery, the need for appreciation of the nutritional impact of the hypermetabolic response is taking center stage. The systemic activation of counterregulatory hormones, cytokines, and other mediators of inflammation has complex metabolic effects that are discussed in this review. A rational approach to assessing nutritional needs in patients with SIRS will be presented along with a discussion of how the needs are best met. Finally, the pitfalls encountered in nutritional support of patients with sepsis will be outlined along with a protocol for monitoring tolerance to and effectiveness of metabolic support in SIRS.

Humans↗
PubMed1993

Oropharyngeal impalement on a wrought iron fence.

Oropharyngeal impalement is a potentially life-threatening injury with protean manifestations. Attention to airway obstruction and active hemorrhage take initial priority. Foreign bodies are not removed outside the operating room unless they are causing immediately life-threatening compromise. The majority of injuries that cause thrombosis of the internal carotid artery are in the peritonsillar region of the lateral palate. These patients typically have a delayed onset of symptoms, sometimes more than 24 hours, so close observation is warranted.

Adult↗
PubMed1992

Protein and energy tolerance by stressed geriatric patients.

Nutritional support of stressed geriatric patients remains empiric and has classically been limited by tolerance. Although the hypermetabolic response is known to increase protein and calorie demands, tolerance to increased loads of delivered nutrients in older patients has been questioned. We compared tolerance to nutrient delivery and nitrogen metabolism in 38 stressed surgical patients over age 65 to 38 Injury Severity Score or disease matched younger controls. Twenty-seven of the 31 geriatric patients (87%) who maintained normal renal function (serum creatinine less than 2.0 mg/dl) became azotemic (BUN greater than 30) while receiving 1.5 to 2.0 g of protein per kilogram of ideal body weight compared to only 21% of controls. This phenomenon led to inaccuracies in 17% of geriatric nitrogen balance studies because of unaccounted for serum accumulation of urea nitrogen (compared to only 6% in the control group). When calculated protein requirements were administered to the geriatric group, the mean nitrogen balance was -1.6. Resting energy expenditure as measured by indirect calorimetry demonstrated a strong correlation between actual calorie expenditures and calculated needs based on the Harris-Benedict basal energy expenditure (BEE) multiplied by an activity factor of 1.2 and a stress factor of 1.75 for trauma (r = 0.86, P less than 0.05) or 1.5 for general surgery patients (r = 0.72, P less than 0.05). In summary, energy requirements by stressed geriatric patients can be closely defined by calculation of the Harris-Benedict BEE in conjunction with appropriate activity and stress factors. However, attempts to deliver traditional levels of protein lead to azotemia and are frequently unsuccessful in achieving positive nitrogen balance.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗