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Biomedical subjects

M M Shabot

Publications and source records attributed to M M Shabot.

At least 37 records · Page 2Linked to original sources
PubMed1995

Outcome from critical care in the "oldest old" trauma patients.

This study evaluated the "oldest old" Intensive Care Unit (ICU) trauma patients, defined as patients of age 75 and over, to determine the relationships between age, injury magnitude, physiologic severity of illness, and outcome in this group, compared with younger trauma patients. Of 1,039 consecutive Surgical ICU (SICU) patients with complete data, 45 were in the Oldest group, 54 were in the Elderly group (ages 65 to 74), and 940 were in the Younger group (age < 65). Age, sex, and type of trauma (penetrating versus blunt) did not predict outcome. The Injury Severity Score (ISS) was significantly higher in the Oldest group than in the other groups (p = 0.0005), but the Trauma Score was the same for all groups. The proportion of Oldest group patients with ISS > or = 20 was significantly higher than for Elderly and Younger group patients (p = 0.0002 and p < 0.00005, respectively). The Simplified Acute Physiology Score (SAPS) on the first SICU day was the best outcome predictor for all age groups, along with maximum SAPS during the SICU stay (p < 0.00005 for both). When patients were stratified by ISS, there was a statistically significant difference in day 1 SAPS among age groups for most ISS categories, with higher SAPS associated with advancing age. The oldest old fare worse with trauma because their injury is more severe (higher ISS) and because their physiologic response to a given level of injury is exaggerated (higher SAPS). However, once the oldest old are stratified by SAPS, their outcome parallels that of their younger trauma cohorts.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1995

Pulmonary artery rupture associated with the Swan-Ganz catheter.

OBJECTIVES: This study was designed to determine the incidence rate, define risk factors, and suggest proper management protocols for pulmonary artery (PA) rupture associated with Swan-Ganz catheters. DESIGN: This is a retrospective chart-review study. SETTING: This study involved 32,442 inpatients requiring hemodynamic monitoring with Swan-Ganz catheters in the operating rooms and ICUs at a large, private teaching hospital over a 17-year period (1975 to 1991). RESULTS: Ten patients sustained PA rupture, yielding an observed rupture rate of 0.031% of catheter insertions. All ten patients had hemoptysis and five (50%) had pulmonary hypertension. Two patients (20%) had undergone anticoagulation at the time of rupture. Four of the six surgical patients were still in surgery at the first sign of rupture. A thoracotomy was performed in five patients. We noted a trend toward survival with thoracotomy, but it was not statistically significant. The overall mortality rate was 70%. When data from our 10 patients were combined with 65 patients from the literature, we found that thoracotomy was essential for survival in patients with hemothorax. There were no survivors among seven patients with hemothorax simply observed, compared with eight (50%) survivors in 16 patients undergoing thoracotomy (p = 0.026). Thirty-nine (75%) of 52 patients without hemothorax survived, whether or not a thoracotomy was performed. CONCLUSIONS: Our study suggested that the incidence of Swan-Ganz catheter-associated PA rupture is 0.031% and that an urgent thoracotomy should be performed if hemothorax is present at any point.

Aged↗
PubMed1995

ICU care after infra-inguinal arterial surgery: an analysis of indications and outcomes.

The authors analyzed 632 consecutive, nontrauma Surgical Intensive Care Unit (SICU) admissions after infra-inguinal arterial surgery over a 3-year period (4/89-3/92) for the need for postoperative SICU care. Group I consisted of 122 patients (58 males, 64 females) with at least one absolute indication for SICU care, including mechanical ventilation, pulmonary artery, catheter monitoring, or intravenous infusion of vasoactive or antiarrythmic drugs. Group II comprised 510 patients (275 males, 235 females) without an absolute indication for SICU care. Data collected included age, first day ICU severity of illness scores (Simplified Acute Physiology Score [SAPS] and Quantitative Therapeutic Intervention Scoring System [QTISS]), preoperative length of stay (LOS), SICU LOS, hospital LOS, and mortality. Ten patients (8.2%) in Group I and ten patients (2.0%) in Group II died in the SICU (P = 0.0004). There was no significant difference in the age of Group I and Group II patients, but Group I patients had a significantly longer preoperative LOS (6.1 +/- 0.7 vs 3.2 +/- 0.3 days, P < 0.0005). In Group II patients there were significant correlations between patient age and postoperative death, as well as between preoperative LOS and SICU LOS > 1 day. Patient age > or = 80 years and preoperative LOS > 3 days are significant preoperative correlates of the need for SICU care following infra-inguinal arterial surgery in patients who do not have an absolute indication for such care.

Aged↗
PubMed1995

Real-time wireless decision support alerts on a Palmtop PDA.

The authors devised a system which continuously analyzes data exported from a Clinical Information System for the occurrence of exceptional or life-threatening clinical events. A configurable rule-based system was created to detect and act on such events. When detected, the system formats an alerting message, dials a modem and transmits the message to a commercial satellite relay system. Ennunciated by an alerting beep and blinking LED on a PCMCIA receiver card, the alert message appears on the screen of a Palmtop Personal Digital Assistants (PDA) carried by designated clinicians.

Algorithms↗
PubMed1994

Future shock: trauma in the managed care era.

This study examines the effects of managed care on the treatment of 1724 trauma patients seen over a 2-year period at an urban Level I trauma center. Fifty-one per cent of all trauma patients were insured. Managed care plans represented 42 per cent of the insurance coverage overall, increasing from 39 per cent in the first year to 45 per cent in the second. All treatment was provided by the receiving general surgery trauma team and was rendered independent of insurance status. Eighty per cent of patients completed their hospitalization at the trauma center. Clinical outcome, transfer rates, and mortality were similar regardless of insurance type. We conclude that managed care plans represent a significant and increasing portion of the insurance coverage of trauma patients, and propose that national guidelines should be developed to guarantee quality and continuity of trauma care.

Forecasting↗
PubMed1994

Trauma in the elderly: an analysis of outcomes based on age.

This study evaluated the comparative outcomes of elderly trauma patients admitted to a tertiary Surgical Intensive Care Unit (SICU) over a 5-year period (4/1/87-3/31/92). A total of 289 trauma patients 65 or older (mean age 76.3 +/- 0.4 years) were compared with 1,877 trauma patients under age 65 (mean age 31.4 +/- 0.3). The Simplified Acute Physiology Score (SAPS) severity of illness on admission for elderly trauma patients was 12.2 +/- 0.3, significantly higher than the SAPS of the younger patient group, 7.9 +/- 0.1 (P < 0.0005). Elderly survivors had higher than the SAPS of admission than their younger cohorts, 11.0 +/- 0.3 versus 7.3 +/- 0.1 (P < 0.0005), but there was no significant difference in SAPS for non-survivors. The Injury Severity Score (ISS) of elderly patients, 14.2 +/- 1.0, was not significantly higher than the ISS of younger patients, 12.3 +/- 0.3 (P = 0.06). Thirty-three elderly trauma patients (11.4%) died in the SICU, compared with 90 (4.8%) deaths in younger patients (P < 0.00005). However, when patients were stratified by admission SAPS, SICU mortality was nearly equivalent between the older and younger patient groups. An additional 14 elderly patients (4.8%) died in the hospital after SICU discharge, compared with 9 additional deaths (0.5%) in the younger patient group (P < 0.00005).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1994

Relationship of hyperglycemia and severity of illness to neurologic outcome in head injury patients.

Hyperglycemia upon hospital admission has been associated with poorer neurologic outcomes in patients with brain injury, but this relationship has not been well defined. To evaluate the relationship of hyperglycemia and severity of illness to neurologic outcome, the authors examined Surgical Intensive Care Unit (SICU) records for a 6 month period at a Level I trauma center. Of 276 trauma admissions, 97 patients had intracranial injuries. The peak glucose determination on the first day of admission was correlated with the Glasgow Coma Scale (GCS) score upon admission and discharge from the SICU and with severity of illness as measured by the Simplified Acute Physiology Score (SAPS). The mean admission GCS was 10.6 (+/- 0.49 S.E.M.), the mean glucose on the first SICU day was 146 (+/- 7.7 S.E.M.), and the mean peak glucose was 176 (+/- 8.2 S.E.M.). The peak glucose was inversely related to both GCS on admission and GCS at discharge (P < 0.001). However, stepwise multiple regression analysis revealed that the best single predictor of GCS at discharge was the GCS on admission. The next best predictor was the SAPS on the first SICU day. Peak glucose did not add to the power of admission GCS and SAPS to predict neurologic outcome. Peak glucose levels in brain-injured patients may simply reflect severity of illness and injury that is better represented by SAPS.

Adult↗
PubMed1994

Automated severity scoring in level I trauma patients.

The authors evaluated the sensitivity and specificity of a computerized Simplified Acute Physiology Score (SAPS) for outcome prediction in Level I trauma patients admitted to a Surgical ICU (SICU). SAPS was compared with the combined Trauma Score (TS) and Injury Severity Score (ISS). 1434 consecutive trauma patients admitted to the SICU over a 3-year period were studied. All patients had the SAPS automatically calculated on the first SICU day. Patient data was extracted from an electronic flowsheet, and the most abnormal values for the previous 24 hours were used to calculate the SAPS. TS and ISS were calculated by a trained nurse. The relationship among the severity scores, ICU length of stay (LOS), and survival was evaluated. A logistic regression equation was calculated for SAPS alone and for TS combined with ISS. The predictive power of the severity methods was compared using Receiver Operating Characteristic (ROC) curve analysis. Scores for survivors and non-survivors were compared with Student's t-tests. 1085 patients had complete data available. There were 995 survivors and 90 non-survivors. The mean (+/- standard error of the mean) ISS was 12.7 (+/- 3.2) with 36 per cent of the patients having an ISS > or = 15. The mean SAPS was 8.1 (+/- 2.5). Survivors had a significantly lower SAPS than non-survivors, 7.0 versus 20.2 (P < 0.0005) and a shorter LOS, 2.5 versus 4.9 days (P < 0.002). ROC curve analysis revealed no statistically significant difference in the areas under the two curves, indicating that the SAPS was equivalent to TS combined with ISS in outcome prediction (P > 0.70).(ABSTRACT TRUNCATED AT 250 WORDS)

Critical Care↗
PubMed1993

Surgical intensive care in the nonagenarian. No basis for age discrimination.

OBJECTIVE: To investigate the effect of extreme age on outcome from surgical intensive care. DESIGN: Prospective data collection. SETTING: A 20-bed noncardiac surgical intensive care unit (SICU) that admits 2200 patients per year from a 1201-bed tertiary medical center. PATIENTS: Nonagenarians were compared with patients under 90 years of age over a 33-month period. Seven patients over age 100 years and 77 nonsurgical patients were excluded. MAIN OUTCOME MEASURES: Mortality and length of stay were determined for both the SICU and the entire hospitalization. The nonagenarian and younger groups were stratified by severity of illness using the first-day Simplified Acute Physiology Score (SAPS). RESULTS: One hundred forty nonagenarian patients (mean +/- SE age, 92.1 +/- 0.2 years) were compared with 5652 younger patients (mean age, 60.1 +/- 0.3 years). The mean SAPS of 11.1 for nonagenarian patients was significantly higher than the SAPS of 8.6 for younger patients (P < .001). Mortality in the SICU was 4.3% for nonagenarian patients vs 2.3% for younger patients (P = .13). SICU mortality rose with increasing SAPS in both groups, but there was no significant difference between nonagenarian and younger patients for any SAPS group. Hospital mortality differed significantly, with 17.1% for nonagenarian patients and 5.3% for younger patients (P < .001). Hospital and SICU length of stay did not differ significantly between the groups. CONCLUSIONS: Nonagenarians do not differ from younger SICU patients in survival from SICU care, although hospital mortality is greater in nonagenarians. Age alone should not be used to make decisions about the utility of SICU care for the elderly. Outcome correlates better with severity of illness, and the measure is valid in young and old alike.

Age Factors↗
PubMed1993

Mature fibrous cyst formation after Marlex mesh ventral herniorrhaphy: a newly described pathologic entity.

UNLABELLED: Two patients developed seromas overlying Marlex mesh repairs of ventral hernias. After repeated unsuccessful attempts at aspiration of the fluid, each patient underwent formal exploration and excision of the cystic mass to the level of the mesh. Histology showed thick, fibrous, trabeculated cysts. Postoperatively, one patient had prolonged closed suction drainage. In the other, suction drains had scant output, but she developed a recurrence of serous fluid, which resolved with two aspirations. CONCLUSIONS: 1) Mature fibrous cyst is a rare complication of Marlex mesh herniorrhaphy; 2) Chronic seroma collections may be etiologic; 3) Surgical excision and closed suction drainage, rather than simple aspiration, are required for treatment; 4) Prolonged postoperative drainage may be needed to prevent recurrence.

Aged↗
PubMed1993

Bradycardia following carotid endarterectomy.

This study was performed to determine whether bradycardia complicates the postoperative course of patients undergoing carotid endarterectomy (CEA). The records of 216 patients undergoing 233 CEAs over a 2-year period were reviewed. Patients were divided into two groups based on their lowest Surgical Intensive Care Unit (SICU) heart rate (HR). Those with HR < 60 were in the Bradycardic (BRADY) group and those with HR > or = 60 were in the Non-Bradycardic (NON-BRADY) group. One hundred and sixteen patients developed bradycardia, with a mean (+/- SEM) HR of 51.1 +/- 0.5, compared with 117 NON-BRADY patients with a mean HR of 70.6 +/- 0.9 (P < 0.0005). There were no significant differences between the groups in age, use of cardioactive drugs, SICU severity of illness, or length of SICU stay. The systolic blood pressure for BRADY patients averaged 144 +/- 2.2 on admission and 144 +/- 2.2 (P = NS) in the SICU, while that of NON-BRADY patients rose from 143 +/- 2.3 on admission to 156 +/- 2.5 (P = 0.001). Fifty-four patients receiving a second CEA had a SICU HR not significantly different from those patients undergoing a first CEA. Of 17 patients who underwent bilateral CEAs during the study period, SICU HRs averaged 65.1 +/- 3.7 after the first procedure and 64.7 +/- 3.6 after the second (P = NS). The authors conclude that bradycardia following CEA is a frequent but benign postoperative finding that does not affect outcome, cause significant hypotension, or prolong the SICU stay.

Adult↗
PubMed1992

Coagulopathy and catecholamines in severe head injury.

The prospective study reported here evaluated the relationship between coagulopathy, catecholamines, and outcome in severe head trauma. Thirty-six trauma patients (10 with penetrating injuries, 26 with blunt injuries, 50% overall mortality) were evaluated. These patients had severe head trauma (Glasgow Coma Scale score less than 9). Blood was analyzed for platelet count, prothrombin time (PT), partial thromboplastin time (PTT), and fibrinogen, D-dimer, antithrombin III, protein C, and protein S levels. A 24-hour urine sample was collected for vanillylmandelic acid (VMA), normetanephrine, and metanephrine determinations. A control group of five patients undergoing elective neurosurgery was also studied. Statistically significant differences between head injury survivors and nonsurvivors were present for platelet count, PT, and fibrinogen activity. There were no differences in the results of the other coagulation tests or in urinary catecholamine levels. The trauma patients differed from the elective neurosurgery patients with regard to D-dimer levels, PT, PTT, protein C levels, and urinary normetanephrine concentrations. Head trauma patients have a coagulopathy that is absent in patients following elective neurosurgical procedures. The coagulopathy may correlate with poor survival in head trauma and may be related to a catecholamine surge.

Blood Coagulation Tests↗
PubMed1992

Glucose intolerance in critically ill surgical patients: relationship to total parenteral nutrition and severity of illness.

The authors evaluated the relative influence of severity of illness and total parenteral nutrition (TPN) on glucose intolerance in critically ill surgical patients. Records of TPN administration, serum glucose measurements, and the simplified acute physiology score (SAPS) were extracted from the surgical intensive care unit (SICU) and hospital clinical information systems (CIS) for all patients admitted to the SICU from October 1, 1989 through March 31, 1990. Critical hyperglycemia was defined as glucose > 400 mg/dL and critical hypoglycemia as < 40 mg/dL. During the study period, 1,129 patients received 3,054 days of care, including 88 patients who received 705 days of TPN. Of 4,985 glucose determinations performed during the study period, 48 (0.96%) were critically abnormal. Critical hyperglycemia occurred in 1.7 per cent of blood samples from TPN patients, compared to 0.7 per cent in non-TPN patients (P < 0.005). However, the mean admission and daily and maximum severity of illness scores were significantly higher in TPN patients compared to non-TPN patients (all P < 0.0005). Mean glucose levels rose with increasing SAPS in both TPN and non-TPN patients. When stratified by severity of illness, TPN patients did not have significantly higher glucose levels than non-TPN patients except for the SAPS = 15 category. The authors conclude that the glucose intolerance noted in critically ill TPN patients reflects their underlying severity of illness rather than TPN administration per se.

Aged↗
PubMed1992

Continuous intra-arterial oxygen monitoring: accuracy and reliability in the surgical intensive care unit.

The accuracy and reliability of an invasive intra-arterial oxygen sensor catheter was evaluated in 20 critically ill surgical intensive care unit (SICU) patients. All patients required continuous arterial blood pressure monitoring, at least 72 hours of ventilator support, and intermittent arterial blood gas sampling for clinical management. The intra-arterial sensor provided continuous PO2 (PsO2) values on a bedside electronic monitor. PsO2 values were sampled every 60 seconds and automatically stored on a bedside personal computer. Arterial blood gas (ABG) PaO2 values were collected and matched by collection time with corresponding PsO2 values. During 1,238 hours of continuous intra-arterial monitoring, 74,280 PsO2 values and 246 ABG PaO2 values were collected. Of the 246 PaO2 results, 175 (71.3%) had a matching PsO2. Regression of matched PsO2 and PaO2 values yielded a correlation coefficient of 0.58 and standard error of the estimate (SEE) of 33.1 (P < 0.0005). Even though matched PsO2 and PaO2 measurements demonstrated a linear relationship, only 34 per cent of the variation in PsO2 could be attributed to changes in PaO2. Technical sensor or instrument problems affected PsO2 monitoring in 17 of 20 patients and 28 of the 33 sensors tested. The authors conclude that continuous intra-arterial monitoring of PsO2 is a novel idea, but technical issues limit its use in acutely ill, conscious SICU patients.

Adolescent↗
PubMed1991

New method for monitoring pulmonary artery catheter location.

OBJECTIVE: To test the ability of a modified pulmonary artery (PA) monitoring catheter to detect distal catheter migration. DESIGN: Prospective nonrandomized trial. PATIENTS: Surgical ICU patients requiring invasive hemodynamic monitoring. INTERVENTIONS: Eight patients received PA catheters modified to include a right ventricular (RV) pressure monitoring port located 7 cm from the tip. Fifteen patients received catheters with an RV port located 10 cm from the tip. Guided by the RV port pressure waveform, catheters were initially positioned so that the RV port was located just proximal to the pulmonic valve. MEASUREMENTS AND MAIN RESULTS: Pulmonary capillary occlusion pressure (PAOP) could not be obtained in six of the eight patients receiving the 7-cm RV port catheter unless the RV port was advanced into the PA. PAOP was consistently obtained in all 15 patients receiving the 10-cm RV port catheter, with the RV port positioned in the RV. Chest radiographs confirmed a central PA catheter position. In this group, distal migration of the catheter occurred 14 times in eight patients, as detected by appearance of a PA pressure waveform at the RV port. Distal migration was corrected by withdrawal of the catheter until an RV waveform reappeared at the RV port. CONCLUSIONS: We conclude that distal catheter migration occurs frequently with PA monitoring catheters, but can be detected at the bedside with a catheter modified to include an RV port 10 cm from the tip. This new catheter may add a margin of safety to PA monitoring and lower its overall cost by eliminating the need for chest radiographs ordered solely to confirm catheter tip location.

Aged↗