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Biomedical subjects

I A Fein

Publications and source records attributed to I A Fein.

At least 19 recordsLinked to original sources
PubMed1993

Mechanical ventilation for the elderly patient in intensive care. Incremental changes and benefits.

OBJECTIVE: To evaluate the cost-effectiveness of prolonged mechanical ventilation in patients 80 years of age and older in the intensive care unit (ICU). DESIGN: A retrospective review of consecutive ICU patients requiring 3 or more days of mechanical ventilation. Cost-effectiveness analysis was performed by assessing incremental hospital charges from hospital billing records; charges were then related to years of life saved. A telephone survey was used to follow up hospital survivors for a minimum of 4 years after discharge. SETTING: A 20-bed medical-surgical ICU in a 420-bed, tertiary-care community teaching hospital. PATIENTS: The study included all patients aged 80 years or older taken from a comprehensive database of all patients admitted to the ICU requiring mechanical ventilation from April 1, 1985, through October 31, 1987 (n = 512). Of 59 potential candidates, 45 were found to have complete billing records and were the subject of further analysis. RESULTS: Of the 45 patients in the group under analysis, 10 survived to leave the hospital. Of these, two were alive and one could not be located at the time of follow-up. The charge per year of life saved is estimated to between $51,854 and $75,090 in 1985-1987 dollars. Of 22 patients whose age in years plus duration of mechanical ventilation in days totaled 100 or greater, only two survived hospitalization and neither was alive at follow-up. The cost per year of life saved in this subset of patients was $1181,308 in 1985-1987 dollars. One of these patients was discharged to a nursing home and died there 4.5 years later, after multiple hospital readmissions. The other patient died at home 2 months after hospital discharge. CONCLUSION: Based on hospital charges and life expectancy, the cost-effectiveness of prolonged mechanical ventilation in ICU patients age 80 years and over was poor in our population when the combination of age and duration of mechanical ventilation exceeded 100. Further studies using this type of analysis may prove valuable in both clinical and administrative decision-making processes.

Aged↗
PubMed1993

The critical care unit. In search of management.

Given the impending crisis in health care economics, all segments of the health care industry must maintain quality while becoming more efficient and cost effective, particularly the critical care units that are disproportionately large consumers of the health care dollar. This article reviews the managerial and administrative issues, responsibilities, challenges, and demands that confront unit directors now and in the future. Also, this article provides a context and framework for all following articles in this volume.

Cost Control↗
PubMed1991

Clinical utility and cost-effectiveness of protective sleeve pulmonary artery catheters.

OBJECTIVE: To assess the clinical utility of protective sleeves in pulmonary artery (PA) balloon flotation catheters. DESIGN: Prospective, randomized trial with cost-effectiveness analysis. SETTING: A general adult ICU in a community teaching hospital. PATIENTS: All patients receiving PA balloon flotation catheters over a 1-yr period. INTERVENTIONS: Groups 1 and 2 received PA catheters with and without protective sleeves, respectively. Indications for catheter changes, other than catheter malposition, were the same for both groups. MEASUREMENTS AND MAIN RESULTS: In group 1, 54 patients received 71 catheters and four catheters were replaced due to the inability to obtain a PA occlusion pressure (PAOP) tracing. In group 2, 48 patients received 66 catheters, 11 of which were inserted due to failure to obtain a PAOP (p less than .05). PA catheters were repositioned successfully in 37/56 attempts in group 1, compared with 8/20 attempts in group 2 (p less than .05). There was no significant difference in complication rates between the two groups. Even at the increased cost of the protective sleeves and introducer ($7/kit), for 100 catheter insertions, we project a direct cost savings of $742, and personnel time savings of 10.5 hrs for physicians, 14 hrs for nurses, and 4.7 hrs for radiology technicians. CONCLUSION: Protective sleeves on PA catheters are safe, effective, cost-saving devices for ICU patients.

Aged↗
PubMed1991

Reduction of duration and cost of mechanical ventilation in an intensive care unit by use of a ventilatory management team.

OBJECTIVE: To test the hypothesis that a formal interdisciplinary team approach to managing ICU patients requiring mechanical ventilation enhances ICU efficiency. DESIGN: Retrospective review with cost-effectiveness analysis. SETTING: A 20-bed medical-surgical ICU in a 450-bed community referral teaching hospital with a critical care fellowship training program. PATIENTS: All patients requiring mechanical ventilation in the ICU were included, comparing patients admitted 1 yr before the inception of the ventilatory management team (group 1) with those patients admitted for 1 yr after the inception of the team (group 2). Group 1 included 198 patients with 206 episodes of mechanical ventilation and group 2 included 165 patients with 183 episodes of mechanical ventilation. INTERVENTION: A team consisting of an ICU attending physician, nurse, and respiratory therapist was formed to conduct rounds regularly and supervise the ventilatory management of ICU patients who were referred to the critical care service. MEASUREMENTS AND MAIN RESULTS: The two study groups were demographically comparable. However, there were significant reductions in resource use in group 2. The number of days on mechanical ventilation decreased (3.9 days per episode of mechanical ventilation [95% confidence interval 0.3 to 7.5 days]), as did days in the ICU (3.3 days per episode of mechanical ventilation [90% confidence interval 0.3 to 6.3 days]), numbers of arterial blood gases (23.2 per episode of mechanical ventilation; p less than .001), and number of indwelling arterial catheters (1 per episode of mechanical ventilation; p less than .001). The estimated cost savings from these reductions was $1,303 per episode of mechanical ventilation. CONCLUSION: We conclude that a ventilatory management team, or some component thereof, can significantly and safely expedite the process of "weaning" patients from mechanical ventilatory support in the ICU.

Aged↗
PubMed1990

Nursing perception of the availability of the intensive care unit medical director for triage and conflict resolution.

The Joint Commission on the Accreditation of Healthcare Organizations and the Society of Critical Care Medicine call on the physician medical director of the intensive care unit (ICU) to play an important role in admission and discharge decision-making. To assess nursing perception of the medical director's involvement in this decision-making, we analyzed data from a questionnaire administered at an annual ICU management conference to ICU nursing supervisors representing 101 hospitals and 137 ICUs. We asked nurses if the medical director or his or her designee (excluding residents) was available at night for triage, admission decision-making, and conflict resolution. In 21% (29) of the ICUs, nurses perceived no medical director at all. In the 54 ICUs with full-time medical directors, nurses in approximately 30% of the units said that there was no nighttime availability of the medical director or designee. The data suggest that many ICUs lack physician leadership in ICU management and resource allocation.

Conflict, Psychological↗
PubMed1988

Endotracheal tube occlusion associated with the use of heat and moisture exchangers in the intensive care unit.

A heat moisture exchanger (HME) with bacterial filtering capabilities was evaluated over an 8-month period in a total of 170 ICU patients. During this time there were 15 endotracheal tube (ETT) occlusions in 15 patients. Over the ensuing 4 months, cascade humidification was used for 81 patients and only one ETT occlusion occurred (p less than .01). The HMEs were replaced frequently with cascade humidifiers during the evaluation period because of inadequate airway humidification. The increase in ETT occlusion was associated with an increased incidence of pneumonia (p less than .001) and atelectasis (p less than .01). Most patients with ETT occlusion required minute volumes greater than 10 L and F10(2) greater than 0.4. We conclude that HMEs do not provide sufficient airway humidification for generalized ICU use. Their role outside of the operating room remains to be determined.

Adult↗
PubMed1983

Fluid resuscitation in circulatory shock: a comparison of the cardiorespiratory effects of albumin, hetastarch, and saline solutions in patients with hypovolemic and septic shock.

Twenty-six consecutive patients in hypovolemic shock were randomized to fluid challenge with 5% albumin (A), 6% hetastarch (H), or 0.9% saline (S) solutions. Fluid challenge consisted of 250 ml of test fluid every 15 min until the pulmonary artery wedge pressure (WP) reached 15 mm Hg. Thereafter, WP was maintained at 15 mm Hg for an additional 24 h with infusions of the same test fluid. Vital signs, hemodynamic and respiratory variables, as well as arterial lactate and colloid osmotic pressure (COP) were monitored according to protocol. Chest x-rays were performed by standardized technique before fluid challenge and at 12 and 24 h of maintenance fluid therapy and were evaluated for evidence of pulmonary edema. Cardiac function and hemodynamic stability were restored by fluid challenge with A, H, and S. Two to 4 times the volume of S as A or H was required to achieve similar hemodynamic endpoints. COP was increased by fluid challenge with A or H but was markedly reduced by fluid challenge with S and throughout the 24-h maintenance period. Fluid challenge resulted in reductions in COP-WP gradient of 62% in the A, 43% in the H, and 125% in the S groups. Resuscitation with S resulted in a significantly higher incidence of pulmonary edema (87.5%) than did resuscitation with A (22%) or H (22%). Urine output was not different among the groups at any time during the study. We conclude that 6% H performs as well as 5% A as a resuscitative fluid and that resuscitation with either of these colloids is associated with a lower incidence of pulmonary edema than is resuscitation with 0.9% S.

Aged↗
PubMed1982

Neurogenic pulmonary edema.

This report presents a patient who developed fulminant pulmonary edema as a complication of an acute subarachnoid hemorrhage. Hemodynamic evaluation revealed low-normal pulmonary arteriolar resistances. Endobronchial fluid was freely suctioned from the patient over a two-day period and had a colloid osmotic pressure and protein content equal to the patient's plasma throughout the entire course. These findings suggest that neurogenic pulmonary edema in this patient was related to increased capillary permeability and may occur independent of pulmonary hemodynamics.

Adult↗
PubMed1982

The relationship of the colloid osmotic-pulmonary artery wedge pressure gradient to pulmonary edema and mortality in critically ill patients.

The relationship of serum colloid osmotic pressure (COP) and pulmonary artery wedge pressure (PAWP) to pulmonary edema and mortality was investigated in 76 critically ill patients. Forty patients suffered from circulatory shock and 36 did not. The COP-PAWP gradient and radiographic evidence of pulmonary edema were measured at the time of diagnosis. The COP-PAWP gradient was markedly decreased in both shock and non-shock patients with pulmonary edema. Decrease of the COP-PAWP gradient correlated with mortality only in those patients with shock. The shock patients who died had a significantly higher incidence of pulmonary edema than those who survived, whereas there was no difference in the incidence of pulmonary edema for surviving or dying non-shock patients. We conclude that marked decreases of the COP-PAWP gradient predict pulmonary edema in the critically ill, but predict mortality only for patients with circulatory shock.

Adult↗
PubMed1982

Relation of colloid osmotic pressure to arterial hypoxemia and cerebral edema during crystalloid volume loading of patients with diabetic ketoacidosis.

The effect of crystalloid volume loading on serum colloid osmotic pressure, arterial oxygen (Po2), alveolar-arterial oxygen gradient (A-aDo2), and cerebral lateral ventricle dimensions was prospectively studied in 18 patients with diabetic ketoacidosis. Serial measurements showed concomitant decreases in colloid osmotic pressure, hematocrit, arterial Po2 (p less than 0.001), and significant increases in A-aDo2 (p less than 0.001) during treatment. Serial echoencephalograms were taken of 11 of the 18 patients; each patient served as his or her own control. Nine of these 11 patients showed significant decreases in lateral ventricle width during treatment; seven patients showed the echoencephalographic "hash" marks characteristic of cerebral edema. Follow up studies showed resolution of these abnormalities. Volume loading with large amounts of crystalloid solution seems to produce an acute hypooncotic state that may cause the development of both subclinical pulmonary and cerebral edema.

Adolescent↗
PubMed1981

Hemodynamic and metabolic effects of abdominal aortic crossclamping.

The hemodynamic and metabolic effects of aortic crossclamping and declamping were studied in 10 patients undergoing abdominal aortic reconstructive surgery. After placement of pulmonary and radial arterial catheters, measurements were obtained preoperatively, during the procedure according to protocol, and postoperatively. Pulmonary arterial wedge pressure was maintained at 10 to 15 mm Hg throughout the operation. Aortic cross clamping produced a significant increase in systemic arteriolar resistance and systolic blood pressure, with no change noted in the left ventricular stroke work index. Declamping decreased systemic resistance and produced no change in the left ventricular stroke work index. Clamping and declamping resulted in elevations of serum lactate. Central venous pressure correlated with pulmonary arterial wedge pressure in each patient and in the entire group. Cardiac function is not decreased by aortic crossclamping, and central venous pressure can usually be used for hemodynamic monitoring in these patients.

Adult↗
PubMed1981

The spectrum of pulmonary edema: differentiation of cardiogenic, intermediate, and noncardiogenic forms of pulmonary edema.

Pulmonary edema fluid and serum samples were obtained from 20 patients with cardiac and noncardiac pulmonary edema, and total protein, albumin, and globulin concentrations were measured. The mean edema fluid to serum protein ratio in patients with pure cardiogenic pulmonary edema was 0.37 +/- 0.09. In contrast, the patients with pure noncardiogenic pulmonary edema had protein ratios of 0.84 +/- 0.12 (p less than 0.001). Another group of patients with both cardiac and noncardiac causes for edema demonstrated edema fluid to serum protein ratios that were significantly higher than those found in the cardiogenic patients and lower than the protein ratios in the noncardiogenic patients (0.60 +/- 0.07) (p less than 0.01) A cardiac or noncardiac causes of pulmonary edema could be determined in all patients, using edema fluid to serum total protein ratios in conjunction with globulin ratios. Cardiogenic and noncardiogenic pulmonary edema represent the extremes in the spectrum of pulmonary edema. A combination of increased permeability and hydrostatic pressure may account for an intermediate form of pulmonary edema.

Adult↗
PubMed1980

Pulmonary edema; a complication of diabetic ketoacidosis.

Hemodynamic evaluation in two patients and analysis of pulmonary edema fluid in one patient with diabetic ketoacidosis and acute pulmonary edema were performed. Pulmonary arterial wedge pressures in both patients were low or normal (1 and 9 mm Hg). In one patient the colloid osmotic pressure of the pulmonary edema fluid was 68 percent of the value of the serum. The serum colloid osmotic pressure-pulmonary arterial wedge pressure gradient in the second patient was markedly reduced. Pulmonary edema complicating diabetic ketoacidosis may be the result of increased permeability of pulmonary capillary membranes and altered intravascular colloid-hydrostatic forces.

Adult↗
PubMed1978

Uremic pulmonary edema.

Pulmonary edema fluid analyses and hemodynamic evaluations were performed in two uremic patients with acute pulmonary edema. The colloid osmotic pressure of the pulmonary edema fluid ranged from 57 per cent to 93 per cent that of the serum. Although cardiac function was normal in both patients, the serum colloid osmotic pressure--pulmonary artery wedge pressure gradients were markedly reduced. Uremic pulmonary edema is the result of alterations of pulmonary intravascular Starling forces and increases in pulmonary capillary membrane permeability, allowing for the efflux of protein-rich fluid from the capillaries into the lung.

Adult↗