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Biomedical subjects

J A Savino

Publications and source records attributed to J A Savino.

At least 19 recordsLinked to original sources
PubMed2001

Preparation and achievement of American College of Surgeons level I trauma verification raises hospital performance and improves patient outcome.

OBJECTIVE: The purpose of this study was to assess the impact on patient outcome and hospital performance of preparing for and achieving American College of Surgeons (ACS) Level I trauma verification. METHODS: The center was a previously designated state regional trauma center located adjacent to a major metropolitan area. Preparation for ACS verification began in early 1996 and was completed in early 1998. Final verification took place in April 1999. Data were analyzed before (1994) and after (1998) the process. There was a marked increase in administrative support with trauma named one of the hospital's six centers of excellence. Two full-time board-certified trauma/critical care surgeons were added to the current six trauma surgeons. Their major focus was trauma care. Trauma support staff was also increased with case managers, a trauma nurse practitioner, additional trauma registrars, and administrative support staff. Education and continuous quality improvement were markedly expanded starting in 1996. RESULTS: There were 1,098 trauma patients admitted in 1994, and 1,658 in 1998. Overall mortality decreased (1994, 7.38%; 1998, 5.37%; p < 0.05). There was a marked decrease in mortality for severely injured (Injury Severity Score > 30) patients (1994, 44% mortality [38 of 86]; 1998, 27% [22 of 80]; p < 0.04). Average length of stay also decreased (1994, 12.22 days; 1998, 9.87 days; p < 0.02). This yielded an estimated cost savings for 1998 of greater than $4,000 per patient (total saving estimate of $7.4 million). CONCLUSION: Trauma system improvement as related to achieving ACS Level I verification appeared to have a positive impact on survival and patient care. There were cost savings realized that helped alleviate the added expense of this system improvement. The process of achieving ACS Level I verification is worthwhile and can be cost effective.

Adolescent↗
PubMed1996

Open versus closed treatment of necrotizing pancreatitis.

The records of 30 consecutive patients who underwent operative procedures for infected (25 patients) and sterile (5 patients) necrotizing pancreatitis were reviewed. 17 patients were managed by an open procedure and 13 patients by a closed procedure. Overall mortality was six patients (20%). All the mortalities were among the 25 infected patients and among the 16 patients managed open. Open management was associated with higher Apache II scores at admission (13.5 vs. 8.5) (p < .05). Nonsurvivors had a higher Ranson prognostic criteria score, first CT severity index, and Apache II score versus survivors (16.8 vs. 10) (p < .05). Open management was associated with more operations, more transfusions of blood, and longer length of intensive care unit and hospital stays. All mortalities were secondary to multiple organ failure. There were more local complications in the open group (fistulas and colon necrosis). At the initial operation, infected patients demonstrated predominantly emerging resistant flora. Open management is associated with a higher morbidity and mortality; however, due to the progressive nature of the pathology, repeated explorations are necessary in the more severely ill patients with necrotizing pancreatitis.

APACHE↗
PubMed1995

Surgical management of the patient with a thyroid disorder.

In this article, fundamental thyroid physiology and diagnostic procedures in the elderly patient are described. Emphasis is placed on performing nonthyroid surgery in elderly patients with hypo- or hyperthyroidism. The management of the thyroid nodule in the elderly patient is also described with a detailed algorithmic approach. Preoperative and intraoperative cardiac risk assessment and monitoring in elderly patients undergoing nonthyroid as well as thyroid surgery are also described.

Aged↗
PubMed1995

Reduced frequency of percutaneous injuries in surgeons: 1993 versus 1988.

OBJECTIVE: To compare the frequency of occupational injuries reported by surgeons in 1993 with similar data obtained in 1988. DESIGN AND SETTING: Two point-prevalence studies of percutaneous injuries of surgeons practicing in tertiary and non-tertiary-care hospitals in the New York metropolitan area. PARTICIPANTS: A total of 202 surgeons and surgical residents surveyed in 1988 and 347 surveyed in 1993 (67 and 65% of the eligible groups, respectively), including 85 surgeons in 1993 (71% of the eligible group) who had participated in the 1988 survey. OUTCOME MEASURES: Yearly frequency of percutaneous injuries, and injury frequency per 1000 operative hours. RESULTS: There was a significant decrease in the frequency of reported percutaneous injuries over the 5-year period. For all surgeons, the mean number of yearly injuries decreased from 5.5 +/- 14.4 SD to 2.1 +/- 6.0 SD (P < or = 0.001). Paired analysis of the subgroup of 85 surgeons who participated in both surveys showed a nearly identical decrease (P = 0.001). Significant decreases were observed in general surgeons, specialists and residents. CONCLUSIONS: During the 5 years studied, surgeons practicing in the greater New York metropolitan area reported a significant reduction in the frequency of occupationally associated percutaneous injuries. The reduced risk of percutaneous injuries should substantially lower the rate of acquired infections from blood-borne pathogens.

Adult↗
PubMed1994

Laparoscopic cholecystectomy. The early experience of surgical attendings compared with that of residents trained by apprenticeship.

During our first year of laparoscopic surgery, all cases were performed by attending surgeons; resident involvement was confined to camera work and occasionally to acting as first assistant. These residents were PGY3 or -4. During our second year, these same residents, who had learned the craft in the traditional apprenticeship method, on promotion to senior resident functioned as the primary surgeon in laparoscopic cholecystectomy cases, but under very close guidance by the credentialed attending. Ninety-two cases were attempted in the first year and 100 in the second. There were no differences in age, gender, or preoperative symptoms. More than half the patients had at least one co-morbidity in addition to their gallbladder disease. More women had laparoscopic cholecystectomy soon after pregnancy in the second year, but the percent of the patients with previous surgery declined from 21.4% to 5%. There was a threefold increase in the percent of cases performed in less than two hours and there was a significant reduction in hospital length of stay in the second year. Complication rates were similar in the first and second years. Training residents to do laparoscopic cholecystectomy can be done in a traditional residency program provided the attendings are adequately trained. However, the residents need a higher level of skill at this time than was necessary for open cholecystectomy and have to be further advanced in their training in order to perform this operation laparoscopically.

Adult↗
PubMed1994

Routine prophylactic antifungal agents (clotrimazole, ketoconazole, and nystatin) in nontransplant/nonburned critically ill surgical and trauma patients.

A prospective, randomized study was conducted to determine if prophylactic antifungal agents prevented yeast colonization (YC) or yeast sepsis (YS), or if they diminished mortality in 292 critically ill adult (nontransplant/nonburned) surgical and trauma patients admitted to the SICU for 48 hours or longer. Patients were randomized to receive (group I) no therapy, (group II) clotrimazole 10 mg three times a day, (group III) ketoconazole 200 mg per day, or (group IV) nystatin 2 million units every 6 hours. For comparison patients were stratified by the criteria of Slotman and Burchard into high risk (> or = 3 risk factors) and low risk (< 3 risk factors). Fifty patients (17%) had yeast colonization, nine (3.1%) had yeast sepsis, and 41 (14%) died. Stepwise logistic regression analysis of yeast colonization and sepsis using the variables APACHE II scores > 10, need for ventilator support > 48 hours, and 14 risk factors (Slotman and Burchard) showed that treatment with three or more antibiotics, APACHE II > 10, and ventilatory support > 48 hours were the only three variables that were significant predictors of yeast colonization and sepsis. There was no significant difference between the four groups with regard to YC (23%, 18%, 12%, and 15%, respectively), YS (3%, 1%, 2%, and 7%, respectively), or mortality (15%, 14%, 6%, and 20%, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1988

Overinflation of pneumatic antishock garments in the elderly.

The hemodynamic effects of pneumatic antishock garment application in high-risk elderly patients were examined in 10 preoperative patients (mean age 66.5 +/- 6.4 years) with the pneumatic antishock garments uninflated, after 15 minutes of inflation to 50 mm Hg, and after 15 minutes of inflation to 75 mm Hg. After inflation, significant increases in right atrial pressure (89 percent), pulmonary capillary wedge pressure (34 percent), and mean pulmonary artery pressure (21 percent) were noted. Mean peripheral arterial pressure increased 11.2 percent. Depression of the cardiac index (18 percent), left ventricular stroke work (20 percent), and right ventricular stroke work (16.4 percent) with associated increases in total peripheral resistance (26 percent) and pulmonary vascular resistance (18 percent) occurred in 5 of 10 patients. Left ventricular function curves revealed a progressive decrease in ventricular function at 50 mm Hg and 75 mm Hg. We have concluded that the effect of the pneumatic antishock garment on myocardial function is variable and unpredictably dangerous in the elderly patient with diminished myocardial reserve. As no significant benefit was derived from inflation pressures greater than 50 mm Hg in these patients, the lowest combination of pressures producing the most efficacious results should be used.

Aged↗
PubMed1988

Manipulation of ascitic fluid pressure in cirrhotics to optimize hemodynamic and renal function.

Intra-abdominal pressure (IAP), measured via a transurethral catheter, hemodynamic, and renal functions were evaluated in 25 cirrhotic patients admitted to ICU with variceal bleeding, tense ascites, and peripheral edema. In patients with an IAP greater than 25 cm H2O, a paracentesis was performed to decrease the IAP by 10 cm H2O. After paracentesis, a decrease in the IAP from 33.47 to 19.06 cm H2O (p less than 0.001) resulted in a decrease in total peripheral resistance (TPR) (p less than 0.01) and a significant increase in cardiac index (CI) (p less than 0.001), stroke index (p less than 0.001), left ventricular stroke work (LVSW) (p less than 0.01), and right ventricular stroke work (p less than 0.01). The therapeutic effects of paracentesis on renal function were: a decrease in BUN and serum creatinine (p less than 0.001) and an increase in the creatinine clearance (Ccr) (p less than 0.001), urine volume (p less than 0.001), osmolar clearance (Cosm) (p less than 0.001), and urine creatinine (p less than 0.001) values. The IAP correlated directly with the TPR (r = +0.35, p less than 0.01) and inversely with the CI (r = -0.39, p less than 0.001) and LVSW (r = -0.37, p less than 0.001) in the 126 studies of IAP performed with the 25 patients. IAP also correlated directly with BUN (r = 0.40, p less than 0.001), serum creatinine (r = 0.28, p less than 0.01), and free water clearance (CH2O) (r = 0.3, p less than 0.001); IAP correlated negatively with Ccr (r = -0.54, p less than 0.001) and Cosm (r = -0.43, p less than 0.001). In critically ill cirrhotic patients, IAP, when measured noninvasively via a bladder catheter, is an accurate and useful method to follow manipulation of ascitic fluid pressure quantitatively in order to optimize hemodynamic and renal function.

Abdomen↗
PubMed1988

Minimally invasive devascularization for variceal bleeding that could not be controlled with sclerotherapy.

The appropriate therapy for continued bleeding despite sclerotherapy remains controversial. This study evaluates a devascularization procedure performed without the risks of major surgery and general anesthesia. Fifty consecutive patients, each with an endoscopically proven variceal hemorrhage that was uncontrollable with sclerotherapy, were treated with minimally invasive devascularization. The procedure was performed in three stages. First, the portal pressure was sharply reduced by angiographic embolization of the midsplenic artery. Then the esophagogastric variceal network was thrombosed by means of a catheter introduced during laparotomy, which created a portoazygos disconnection. Finally, the left gastric and left gastroepiploic arteries were embolized, which completed devascularization of the proximal stomach. According to the Child classification, 16 patients were in class B and 34 were in class C. All Child's class B patients (16/16) and 71% (24/34) of Child's class C patients survived hospitalization. One-year survival was 94% (15/16) for Child's class B and 62% (21/34) for Child's class C patients. Rebleeding occurred in 63% (25/40) of the discharged patients but caused the death of only seven. In conclusion, the 20% initial hospital mortality for these difficult patients was significantly better than that reported for emergency surgery, and the rate of rebleeding was comparable to that seen with other nonshunting therapies.

Arteries↗
PubMed1985

Preoperative assessment of high-risk surgical patients.

From the foregoing accounts of preoperative assessment of myocardial performance, as well as preload and afterload status it is clear that the proper anesthesia techniques and agents can be selected. Physiologically optimal adjustments of preload, afterload, and myocardial function can be attained by the appropriate, harmonious selection of anesthesia technique and vasoactive drugs made on the basis of close hemodynamic monitoring preoperatively, intraoperatively, and in the immediate postoperative period.

Anesthesia↗
PubMed1985

Physiologic assessment of surgical diagnosis-related groups.

Although (diagnostic related groups) DRGs were originally devised as a research instrument for the evaluation of medical resource allocation, no studies have been reported that compare the actual physiologic status of patients with DRG classification. At the Westchester Medical Center, a University tertiary referral center, 100 consecutive high-risk elective surgical patients entered a preoperative intensive care unit for a prospective analysis of physiologic assessment, resource utilization, DRG classification, and outcome. Swan-Ganz catheters inserted 1 or 2 days before surgery were used to compute physiologic profiles and stage according to previously published criteria. Risk was determined by age, associated conditions, and magnitude of the proposed operation. There were no patients in stage 1; 55% in stage 2; 41% in stage 3; and 4% in stage 4, which accounted for three of the four total deaths. The 41% of patients over age 70 all had DRG comorbidity factors, but none died. All in stages 3 and 4 had comorbidity factors, as did 87% in stage 2. In 53% of the patients, the physiologic profile provided data necessary for preoperative "fine tuning"; in 37%, for volume expansion; in 23%, for inotropic therapy; and in 17%, for pulmonary therapy. Reoperation was required in 17% and contributed to the long average length of stay (LOS) of 24.5 days. In spite of case severity and comorbidity factors, LOS in the postoperative ICU was only 3 days. There were no significant differences in patients with cancer DRGs. Significant differences between stages 2 and 3 were found for pulmonary wedge pressure, right ventricular stroke work, pulmonary vascular resistance, and pulmonary shunt fraction. The 4% who died all had advanced liver disease. Although the DRG system as set up by the Health Care Financing Administration (HCFA) correctly predicts that age and comorbidity factors lead to increased utilization of resources, the extent to which they underestimate the increased needs of these patients will lead to financial disaster. Compensation for comorbidity factors and advanced age are not cumulative, but patients over 70 had an average of 2.5 comorbidity factors and required an average 26.5 days hospitalization. DRGs allowed only 15% extra reimbursement for these complex cases. High-risk, referred surgical patients are much sicker than they appear to the DRG system, and in all 100 cases compensation was grossly inadequate.

Age Factors↗
PubMed1985

Factors encouraging laparotomy in acalculous cholecystitis.

Because it is difficult to diagnose, acalculous cholecystitis in critically ill patients is treated frequently in an advanced stage. Three of 1600 cardiac surgery ICU admission cases and five of 500 general surgical ICU admission cases were analyzed retrospectively to determine which variables expedited diagnosis and might have encouraged earlier surgery. Vague right upper quadrant physical findings and nonspecific changes in liver function chemistries led frequently to radiologic evaluations. Noninvasive diagnostic procedures such as ultrasound and hepatobiliary scans were helpful but frequently inconclusive. Of the eight patients, the five survivors were diagnosed while still in the hyperdynamic hemodynamic state of early sepsis. Cholecystostomy performed early under local anesthesia was the safest procedure in this group of critically ill patients. After other sources of sepsis such as suppurative phlebitis, yeast septicemia, catheter sepsis, and other extra-abdominal sources such as soft-tissue, urinary, and pulmonary infections have been ruled out, hemodynamic data obtained from pulmonary artery catheters inserted during the early phase of sepsis increase diagnostic accuracy and should expedite surgical exploration.

Bacterial Infections↗
PubMed1985

The metabolic cost of breathing in critical surgical patients.

Twenty ventilator-dependent patients, 14 male and six female, age 47.9 +/- 14, status post polytrauma (14), emergency surgery (three), and coronary artery bypass (three) were evaluated to compare measured energy expenditure (MEE) between the intermittent mandatory ventilation mode (IMV) and assist mode ventilation (AMV) utilizing indirect calorimetry. The MEE was then compared to the predicted basal energy expenditure (PEE) utilizing the Harris-Benedict equation (HBE) and appropriate correction factors dependent on disease and injury status (mean 1.65 +/- 0.24). The mean oxygen consumption (VO2) (IMV) was 347.5 +/- 54.6 ml/min; (VO2) (AMV) was 307.1 +/- 51.4 ml/min (p less than 0.001). The mean MEE (IMV) was 2,380 +/- 369 kcal/day; MEE (AMV) was 2,128 +/- 342 kcal/day (p less than 0.05). The mean predicted energy expenditure (PEE) was 2,731 +/- 416 kcal/day. The IMV mode required 11.6% more pulmonary work when compared to AMV (VO2 IMV - VO2 AMV). The PEE overestimated caloric needs in ventilator-dependent patients by 12.8% on IMV and 22.1% on AMV. The MEE (IMV) required 10.7% more energy than MEE (AMV). Assist mode ventilation resulted in decreased work of breathing and decreased energy expenditure, and the (HBE) inaccurately predicted caloric needs in ventilator dependent patients.

Adult↗
PubMed1983

The automated metabolic profile.

The automated metabolic profile provides the physician with a comprehensive review and graphic display of the patient's nutritional status, energy expenditure, substrate utilization, and nutritional requirements. A paramedical assistant performs all data acquisition, anthropometric and indirect calorimetric measurements. Data reduction is performed on a standard microcomputer system utilizing off-the-shelf peripherals. A standardized graphic sheet is used for the printout. The automated metabolic profile is utilized before initiation of nutritional therapy and subsequently to record the progress. Its use optimizes the clinical management of patients needing both ventilatory and nutritional support. By its use, total parenteral nutrition can be tailored to the requirements of the critically ill patient.

Anthropometry↗
PubMed1982

Malabsorption secondary to Meckel's diverticulum.

This case report of a patient with a large Meckel's diverticulum with associated stagnation and bacterial proliferation demonstrates the resultant metabolic and nutritional alterations that have classically been described with the blind loop syndrome. A lesion as large as the one presented herein has rarely been reported with iron, vitamin B12, and folic acid deficiency anemias secondary to the contaminated small bowel (ileum) syndrome. A discussion of the pathophysiology, diagnosis, and treatment of this disorder and the multiple disease entities incorporated in the contaminated small bowel syndrome are included.

Adult↗
PubMedDate not supplied

Transmesenteric-transfemoral method of intrahepatic portosystemic shunt placement with minilaparotomy.

PURPOSE: To determine whether the transmesenteric-transfemoral method of intrahepatic portosystemic shunt (IPS) placement is safer and more efficient than the transjugular method. PATIENTS AND METHODS: Sixty-six consecutive patients with cirrhosis and bleeding varices underwent 67 IPS procedures. Sixty-one of these procedures were performed using a combination of transfemoral access to the hepatic vein with transmesenteric access to the portal system provided by means of minilaparotomy. Follow-up days were collected periodically by means of clinical evaluation and duplex sonography of the shunt. Angiographic evaluation was performed when necessary. RESULTS: No technical failures or periprocedural deaths occurred. The radiologic and surgical portions of the procedure were accomplished within 45 and 55 minutes, respectively. In cases without portal thrombosis, maximum fluoroscopy time was 12 minutes. During follow-up (mean, 16 months), eight shunt revisions including one additional shunt placement were necessary. CONCLUSION: Transmesenteric-transfemoral IPS placement requires surgical participation but may offer improved efficiency and safety compared with regular transjugular IPS placement.

Angiography↗
PubMedDate not supplied

Central catheter-related infections: comparison of pulmonary artery catheters and triple lumen catheters for the delivery of hyperalimentation in a critical care setting.

We prospectively studied the risk of catheter-related sepsis (CRS) in 75 critically ill patients who received total parenteral nutrition (TPN) through 158 pulmonary artery catheters (PACs) and 214 triple-lumen catheters (TLCs). We relied on semiquantitative cultures of the catheter tips, peripheral blood cultures in febrile patients and clinical response to catheter removal to diagnose catheter-related sepsis. The infection rate was 2.5% (4/158) of PACs and 6.5% (14/214) of TLCs (p = 0.124). Colonization rates were 29.1% for PACs and 32% for TLCs. PACs were left in place a significantly shorter length of time than TLCs, 3.1 vs 5.1 days (p less than 0.005). Guidewire exchanges and subclavian vein insertions were associated with a decreased rate of CRS when compared to new insertions and internal jugular vein insertions, respectively. We conclude that pulmonary artery catheters can be used safely for the delivery of hyperalimentation in critically ill patients with no increased risk for catheter-related sepsis compared to triple-lumen catheters. The use of the PAC in this manner allows for the use of a single central venous catheter for the delivery of hyperalimentation and hemodynamic monitoring.

Adult↗