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Biomedical subjects

R D Stewart

Publications and source records attributed to R D Stewart.

At least 37 records · Page 2Linked to original sources
PubMed1998

Clinical and economic impact of diabetes following coronary artery bypass.

BACKGROUND: Diabetes has been shown to have a negative impact on mortality following coronary artery bypass graft (CABG) surgery. This analysis examines the impact of diabetes on additional clinical and economic outcomes. MATERIAL AND METHODS: Between May and October of 1996, 312 consecutive patients undergoing isolated primary CABG were followed through hospital discharge. A total of 114 diabetics (37%) and 198 nondiabetics (63%) was evaluated. Among the diabetics, 62 (54%) were insulin requiring and 52 (46%) were treated with oral hypoglycemic agents or with diet alone. RESULTS: The incidences of major clinical complications including death, renal failure, stroke, reexploration for bleeding, and mediastinitis or sternal dehiscence were not significantly different among insulin-requiring diabetics, noninsulin-requiring diabetics, and nondiabetics. However, insulin-requiring diabetics had a significantly longer (P < 0.01) total length of stay compared to both noninsulin-requiring diabetics and nondiabetics (107 +/- 12.7 days vs. 5.6 +/- 1.5 days vs. 6.8 +/- 5.4 days, respectively), a significantly longer (P < 0.01) intensive care unit length of stay (5.3 +/- 12.4 days vs. 1.4 +/- 0.8 days vs. 2.0 +/- 3.9 days, respectively), and significantly greater (P, 0.01) total hospital charges (48.7 +/- 56.1 thousand dollars vs. 29.3 +/- 4.3 thousand dollar vs. 32.9 +/- 18.9 thousand dollars, respectively). There were no significant differences between the noninsulin-requiring diabetics and the nondiabetics with regard to these clinical and economic outcomes. CONCLUSIONS: Diabetics treated with oral hypoglycemic agents or with diet alone have clinical and economic outcomes similar to nondiabetics following CABG. Insulin-requiring diabetes, however, predicts significantly increased hospital resource utilization. Future outcome assessment and resource utilization analyses must stratify diabetes by treatment to be completely accurate.

Aged↗
PubMed1998

Central venous catheter use in low-risk coronary artery bypass grafting.

BACKGROUND: To assess the impact of central venous pressure catheter monitoring in low-risk coronary artery bypass grafting (CABG), we compared the hospital course of patients undergoing CABG with central venous pressure catheter monitoring with that of similar patients undergoing CABG with pulmonary artery catheter monitoring. METHODS: All isolated primary CABG procedures (n = 312) performed between April 22 and October 31, 1996, were evaluated, and 194 patients meeting six central venous pressure catheter use criteria were identified. Of these 194 patients, 133 (68%) underwent CABG with central venous pressure catheter monitoring, and 61 (32%) had pulmonary artery catheter monitoring owing to surgeon or anesthesiologist preference. RESULTS: In-hospital mortality was similar. A trend toward increased overall complications was seen in the pulmonary artery catheter group. The total volume infused in the first 12 hours, the 24-hour weight gain, and the intubation time were significantly greater in the pulmonary artery catheter group. Increases in intensive care unit length of stay and in total hospital charges trended toward statistical significance in the pulmonary artery catheter group. CONCLUSIONS: Pulmonary artery catheter use in low-risk patients undergoing CABG was associated with greater weight gain and longer intubation time and may be associated with increased morbidity and utilization of hospital resources.

Aged↗
PubMed1998

EMS agenda for the future: where we are ... where we want to be. EMS Agenda for the Future Steering Committee.

During the past 30 years, emergency medical services (EMS) in the United States have experienced explosive growth. The American health care system is now transforming, providing an opportune time to examine what we have learned over the past three decades in order to create a vision for the future of EMS. Over the course of several months, a multidisciplinary steering committee collaborated with hundreds of EMS-interested individuals, organizations, and agencies to develop the "EMS Agenda for the Future." Fourteen EMS attributes were identified as requiring continued development in order to realize the vision established within the Agenda. They are Integration of Health Services, EMS Research, Legislation and Regulation, System Finance, Human Resources, Medical Direction, Education Systems, Public Education, Prevention, Public Access, Communication Systems, Clinical Care, Information Systems, and Evaluation. Discussion of these attributes provides important guidance for achieving a vision for the future of EMS that emphasizes its critical role in American health care.

Emergency Medical Service Communication Systems↗
PubMed1997

A study of forty-nine consecutive Whipple resections for periampullary adenocarcinoma.

BACKGROUND: We designed a program to evaluate the morbidity, mortality, survival rates, and patient's quality of life after Whipple resection for pancreatic and other periampullary adneocarcinoma. PATIENTS AND METHODS: After studying 11 fresh and unembalmed cadavers to learn the regional anatomy and to practice the surgical techniques for traditional Whipple procedure by the senior author (JS), 49 patients aged 56 to 84 years old were treated with Whipple's pancreatoduocenectomy. RESULTS: There was no postoperative mortality or morbidity from anastomotic leakage. All 49 patients were discharged in an improved condition following surgery, including 5 patients with emergency resection. Eight patients are alive at the time of this writing, including 2 patients who had their pancreatic cancer resected 168 and 139 months ago. CONCLUSIONS: In the opinion of these authors, treatment of all resectable cancers with Whipple's pancreatoduodenectomy offers not only a superior palliation but also the hope of cure.

Adenocarcinoma↗
PubMed1995

Lightwand intubation: I--a new lightwand device.

Tracheal intubation under direct vision using a laryngoscope can be challenging and difficult even in experienced hands. Transillumination of the soft tissues of the neck using a lighted-stylet (lightwand) is one of many effective alternative intubating techniques developed during the past several decades. While many versions of lightwand have been available, each has its limitations. A newly developed lightwand (Trachlight) has incorporated many design modifications. It has a brighter bulb, permitting intubation under ambient light in most cases. A retractable stiff wire within the wand adds flexibility to facilitate both oral and nasal intubation. The flexible wand also allows visual (transillumination) guide to proper placement of the tip of the tracheal tube in the trachea. The Trachlight does have some limitations. It is a light-guided technique in which there is no direct visualization of the upper airway structures. It should be avoided in patients with known anatomical abnormalities of the upper airway and used with caution in patients in whom transillumination of the anterior neck may not be achieved adequately. As with any intubating technique, successful intubation using the Trachlight relies on the preparation of the patient and the operator's skill and experience.

Humans↗
PubMed1995

Lightwand intubation: II--Clinical trial of a new lightwand for tracheal intubation in patients with difficult airways.

Lightwands have been used to assist in the tracheal intubation of patients with difficult airways for many years. A new lightwand (Trachlight) with a brighter light source and a flexible stylet permits both oral and nasal intubation under ambient light. This study reports the effectiveness of the Trachlight in tracheal intubation in patients with difficult airways. Two groups of patients were studied: Group 1--patients with a documented history of difficult intubation or anticipated difficult airways; Group 2--anaesthetized patients with an unanticipated failed laryngoscopic intubation. In Group 1, the tracheas were intubated using the Trachlight with patients either awake or under general anaesthesia. In Group 2, tracheas were intubated under general anaesthesia using the Trachlight. The time-to-intubation, number of attempts, failures, and complications during intubation for all patients were recorded. Two hundred and sixty-five patients were studied with 206 patients in Group 1, and 59 in Group 2. In most patients, the tracheas were intubated orally (183 versus 23 nasal) during general anaesthesia (202 versus 4 awake) in Group 1. Intubation was successful in all but two of the patients with a mean (+/- SD) time-to-intubation of 25.7 +/- 20.1 sec (range 4 to 120 sec). The tracheas of these two patients were intubated successfully using a fibreoptic bronchoscope. Orotracheal intubation was successful in all patients in Group 2 using the Trachlight with a mean (+/- SD) time-to-intubation of 19.7 +/- 13.5 sec. Apart from minor mucosal bleeding (mostly from nasal intubation), no serious complications were observed in any of the study patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1995

Clinical trial of a new lightwand device (Trachlight) to intubate the trachea.

BACKGROUND: Transillumination of the soft tissue of the neck using a lighted stylet (lightwand) is an effective and safe intubating technique. A newly designed lightwand (Trachlight) incorporates modifications to improve the brightness of the light source as well as flexibility. The goal of this study was to determine the effectiveness and safety of this device in intubating the trachea of elective surgical patients. METHODS: Healthy surgical patients were studied. Patients with known or potential problems with intubation were excluded. During general anesthesia, the tracheas were intubated randomly using either the Trachlight or the laryngoscope. Failure to intubate was defined as lack of successful intubation after three attempts. The duration of each attempt was recorded as the time from insertion of the device into the oropharynx to the time of its removal. The total time to intubation (TTI), an overall measure of the ease of intubation, was defined as the sum of the durations of all (as many as three) intubation attempts. Complications, such as mucosal bleeding, lacerations, dental injury, and sore throat, were recorded. RESULTS: Nine hundred fifty patients (479 in the Trachlight group and 471 in the laryngoscope group) were studied. There was a 1% failure rate with the Trachlight, and 92% of intubations were successful on the first attempt, compared with a 3% failure rate and an 89% success rate on the first attempt with the laryngoscope (P not significant). All failures were followed by successful intubation using the alternate device. The TTI was significantly less with the Trachlight compared with the laryngoscope (15.7 +/- 10.8 vs. 19.6 +/- 23.7 s). For laryngoscopic intubation, the TTI was longer for patients with limited mandibular protrusion and mentohyoid distance, with a larger circumference of the neck, and with a high classification according to Mallampatti et al. However, there was no relation between the TTI and any of the airway parameters for Trachlight. There were significantly fewer traumatic events in the Trachlight group than in the laryngoscope group (10 vs. 37). More patients complained of sore throat in the laryngoscope group than in the Trachlight group (25.3% vs. 17.1%). CONCLUSIONS: In contrast to laryngoscopy, the ease of intubation using the Trachlight does not appear to be influenced by anatomic variations of the upper airway. Intubation occasionally failed with the Trachlight but in all cases was resolved with direct laryngoscopy. The failures of direct laryngoscopy were resolved with Trachlight. Thus the combined technique was 100% successful in intubating the tracheas of all patients.

Adult↗
PubMed1995

Benign cervical prevertebral soft tissue swelling in traumatic asphyxia.

Two cases of benign cervical prevertebral soft tissue swelling following traumatic asphyxia are presented. Neither were associated with neck pain, neck tenderness, or mechanism of injury associated with cervical injury, and each resolved spontaneously. Traumatic asphyxia, which results in significant craniofacial swelling, may also result in swelling of the retropharyngeal soft tissues, which may be detected on cervical radiography. Cervical prevertebral soft tissue swelling in the setting of traumatic asphyxia should not be misinterpreted as suggestive of spinal injury in the absence of other findings.

Adult↗
PubMed1993

An extended tabulation of effective dose equivalent from neutrons incident on a male anthropomorphic phantom.

The limiting quantity in radiation protection for whole body exposures in the United States is currently based on the effective dose equivalent (EDE). Because EDE is computed from the individual organ dose equivalents, it is essentially impossible to measure EDE directly. However, calculated organ dose equivalents, and the resulting EDE, can be correlated to the response of a detector located at one or more locations on the human body. Until now, calculations of the effective dose equivalent and corresponding organ dose equivalents have been tabulated for relatively few standard irradiation geometries and energies. In this work, a more extensive tabulation of EDE is compiled and compared to the works of other researchers. This tabulation includes calculations of the EDE for a total of 493 different combinations of source particle energy and angle of incidence. This extensive tabulation of the EDE should allow researchers to improve algorithms for the evaluation of neutron personnel dosimetry.

Humans↗
PubMed1991

An evaluation of cannulae and oxygen sources for pediatric jet ventilation.

The authors evaluated the cannulae and oxygen sources available for pediatric translaryngeal ventilation. Peak flow rates were measured and maximum tidal volumes (MTV) calculated for each combination of cannula and oxygen source. Standard 22, 20, 18, and 16 gauge intravenous catheters and a 14 gauge cannula designed for pediatric jet ventilation were tested. The oxygen sources evaluated included an adult bag-valve device; a continuous flow source regulated between 6 to 15 L/min; and a high pressure jet source regulated between 5 to 50 psi. Mean calculated MTV delivered to the cannula tip (22 g to 14 g) were: 26 to 235 mL with the bag-valve source; 91 to 236 mL with the continuous flow sources; and 58 to 1034 mL with the jet sources. Assuming that in normal subjects approximately 70% of the flow from the tip of a translaryngeal cannula reaches the distal respiratory tree, the authors conclude that bag-valve and continuous flow low pressure sources are unlikely to deliver sufficient tidal volumes to sustain normal ventilation in apneic children when coupled with standard cannulae. Jet oxygen sources with standard cannulae provide a wide range of tidal volumes sufficient to sustain normal ventilation in apneic pediatric patients.

Catheterization↗
PubMed1990

Nasotracheal intubation using a flexible lighted stylet.

Nasotracheal intubation is an essential skill for clinicians involved in the care of acutely ill or injured patients. Unfortunately, it has the dangers and difficulties of any blind technique. Although usually performed in the awake patient, nasotracheal intubation has also been used in the apneic patient. Transillumination of the soft tissues of the neck with a lighted stylet has been shown to be a reliable method of orotracheal intubation. The usefulness of a longer, flexible lighted stylet as an aid to nasotracheal intubation in the apneic patient has been examined. Eighty patients, who were paralyzed, apneic, and about to undergo nasotracheal intubation for elective ear, nose, and throat or maxillofacial surgery were randomized to be nasotracheally intubated blindly or with a stylet by an emergency medicine resident or anesthesiologist. Sixty-three percent intubated in the lighted-stylet group and 41% in the blind nasotracheal intubation group were successfully intubated. There were no significant differences in the time needed to intubate or the number of attempts. There were notable differences in the success rates of individual intubators with each technique. Although not statistically significant, our results suggest a useful role for the lighted stylet in nasotracheal intubation in the apneic patient.

Adolescent↗
PubMed1990

Manual translaryngeal jet ventilation and the risk of aspiration in a canine model.

STUDY OBJECTIVES: Manual translaryngeal jet ventilation (TLJV) is a safe and effective method of maintaining normal ventilation in apneic subjects. Little data exist on the amount of airway protection afforded with this technique of airway management. We sought to evaluate the risk of aspiration during manual TLJV. SETTING: Data were collected in a laboratory animal model. DESIGN: A prospective, nonrandomized, controlled trial was performed. PARTICIPANTS: Seventeen adult apneic mongrel dogs were enrolled. INTERVENTIONS: Intratracheal Gastrograffin was instilled and radiographic changes assessed during ventilation using a 0 to 3 scale (none to severe). Thirty-six trials were performed, with equal numbers at both 30 degrees and 45 degrees head elevation. The three groups studied were animals without airway protection (control), animals with a cuffed endotracheal tube (tube), and animals with a percutaneous TLJV cannula and a 50-psi oxygen source ventilated at a rate of 20 breaths per minute (jet). MEASUREMENTS AND MAIN RESULTS: Significantly less radiographic evidence of aspiration was noted in the jet and tube groups at 30 degrees and 45 degrees compared with control animals (P = .002 each). At 45 degrees head elevation a trend toward increased aspiration scores in the jet group compared with the tube group (P = .065) was observed. CONCLUSION: In our model, manual TLJV at 20 breaths per minute and an I:E ratio of 1:2 provided protection from aspiration comparable to that observed with a cuffed endotracheal tube at 30 degrees head elevation. At 45 degrees elevation, this protection was diminished.

Animals↗
PubMed1990

Correct positioning of an endotracheal tube using a flexible lighted stylet.

Endotracheal intubation is not without complications, among the most serious of these being misplacement of the endotracheal (ET) tube. Unrecognized esophageal placement is a lethal complication, but even when placed in the trachea, ET tubes can be displaced distally and enter a mainstem bronchus. Correct positioning of an ET tube is usually defined as the placement of the tube within the trachea approximately 5 cm above the carina. Chest x-ray is the most common and a reliable method of demonstrating correct positioning, particularly in ICU patients. Using transillumination by means of a flexible stylet (lightwand), we investigated whether transillumination could position an ET tube consistently within 5 +/- 2 cm of the carina. Ten human cadavers of varied weight and body habitus were intubated under direct vision and 10 ml of a radiopaque dye was injected down the tube as a marker for the carina. A premeasured flexible lighted stylet was then inserted into the inplace tube so that the bulb was positioned at the tube's distal opening. The brightest transilluminated glow produced by the bulb was then positioned at the sternal notch. A chest x-ray was taken and the distance of the tube tip from the carina was calculated. In each case the tube tip could be placed consistently at a level 5 +/- 1 cm from the carina by observing the maximal transilluminated glow at the sternal notch. We conclude that transillumination of the neck using a flexible lighted stylet can accurately and consistently position an ET tube at an appropriate distance above the carina.(ABSTRACT TRUNCATED AT 250 WORDS)

Female↗
PubMed1990

Facilities and regionalization--emergency medical services systems.

Advanced life support and the modern EMS system were born out of the hope that by extending hospital emergency facilities outside the bounds of the hospital, earlier and more intensive care could be provided to those patients requiring it. EMS systems have since left the nest and only recently, following a turbulent adolescence, is prehospital care returning as a partner with the medical facilities and physicians that presided over their modern origins. The next decade will see the continuing trend toward hospitals and practitioners regaining some influence in the design and direction of prehospital care.

Emergency Medical Services↗