Anesthesia Progress Blog - Part 5

Prospective Trial of Supranormal Values of Survivors as Therapeutic Goals in High-Risk Surgical Patients: ResultsStatistical Methods
Comparisons of mortality and morbidity figures were done using chi square analysis with Yates’ correction for small cell size where applicable. Hemodynamic data comparisons within groups and between groups were analyzed using either paired or unpaired Student’s t test and ANO\A with Newman-Keuls’ test for significance of individual comparisons. All p values were obtained using two-tailed tests. Read the rest of this entry »

Physiologic Methods
Flow-directed, balloon-tipped PA catheters were placed percutaneously in study patients via an internal jugular or subclavian vein, and radial arterial catheters were put in place in the ICU before preoperative medication. Pulmonary arterial pressures, HE, MAE CV£ and pulmonary capillary WP were measured. Cardiac output then was measured by thermodilution using a cardiac output computer (Model 9520, American Edwards Laboratories, Santa Ana, CA). Immediately after cardiac output was measured, arterial and mixed venous blood were sampled; pH, blood gas tensions, hemoglobin, hemoglobin saturation, and hematocrit were promptly measured. The LVSWI, SVRI, and PVRI, Qsp/Qt, Do2 defined as the product of Cl and arterial oxygen content, (Vo2), and oxygen extraction were calculated using standard formulas. All flow and volume measurements were indexed to body surface area. Read the rest of this entry »

Prospective Trial of Supranormal Values of Survivors as Therapeutic Goals in High-Risk Surgical Patients: Experimental DesignExperimental Design
In series 1, patients were prospectively allocated to either a protocol or control service. One or two of the three adult general surgical services were prospectively designated as control services and the other one or two services as the protocol service according to a prearranged schedule developed prior to the beginning of each academic year; the protocol service was rotated to each of the three services and the principal investigator was also rotated between protocol and control services. The protocol group used supranormal therapeutic goals and was comprised of patients who were admitted when residents on the protocol services were on duty; the control group was comprised of patients treated by residents on the control services using normal values as goals (Table 2). Previous studies have documented comparable severity of illness and mortality among the three services. Read the rest of this entry »

Clinical Series: Entrance Criteria
This study was approved by the hospitals Institutional Review Board and informed consent was obtained from each patient; no proxy consents were used. Entrance criteria for selection of high-risk patients were previously defined as one or more of the high-risk criteria listed in Table 1. Over the past seven years, patients who met one or more of these criteria had been found to have a mortality rate close to 30 percent. Series 1 consisted of 276 operations on 252 high-risk general surgical patients; PA-monitoring in 96 (35 percent) of these was not started until the postoperative period. Patients were stratified into those whose hemodynamic monitoring was started preoperatively and those whose monitoring was started postoperatively. We also compared groups who preoperatively had relatively normal cardiac output values with those who had grossly abnormal preoperative cardiac output values. Read the rest of this entry »

Prospective Trial of Supranormal Values of Survivors as Therapeutic Goals in High-Risk Surgical PatientsThe development of the balloon-tipped flow-directed pulmonary artery (PA) catheter by Swan and colleagues has led to the widespread application of invasive hemodynamic monitoring in critically ill patients. Although criteria for therapy have been tacitly assumed to be normal values, increased hemodynamic and oxygen transport variables observed in survivors raise questions regarding therapeutic goals. Therapeutic goals for cardiac patients whose other vital organs are unimpaired may be different from those of the postoperative general surgical patient whose cardiac function is normal but whose metabolic demands are increased. The problems of the noncardiac general surgical patient may be of interest to the medical consultant and to the internist who inserts PA catheters to monitor these patients. in detail Read the rest of this entry »

In the present study, there were no significant changes found in any cardiorespiratory parameters after the initiation of PC-IRV at an I:E ratio of 2:1. In particular, Cl, Do2, and Vo2 remained unaltered by the use of PC-IRV These results demonstrate that the improvement in oxygenation which accompanies use of PC-IRV at this I:E ratio is not associated with any deleterious effects on cardiac function or tissue oxygen delivery. Because higher I:E ratios were not utilized in this study, it is not possible to be sure that cardiorespiratory parameters would remain unchanged as the I:E ratio is further increased. Read the rest of this entry »

In the present study, increases in Pa02 and decreases in PIP were found after the initiation of PC-IRV These results are similar to those found in previous investigations* of PC-IRV The changes found in PaC02 and pH were minimal and probably could have been eliminated had the end-expiratory pressure been decreased, as was made possible by the improvement in oxygenation accompanying the use of PC-IRV. Because PC-IRV has been demonstrated to result in improved Pa02 and decreased PIP in patients with ARDS, it has been proposed as a useful ventilatory modality for severe respiratory failure. Although no clear improvement in patient outcome has yet been shown with the use of PC-IRV, several theoretic benefits are associated with its physiologic effects. Improved oxygenation as a result of PC-IRV in patients with ARDS will permit use of lower inspired concentrations of oxygen, minimizing pulmonary toxicity associated with high FIo2. High PIP is thought to contribute to barotrauma and pulmonary injury through the generation of elevated alveolar shear forces. Maintenance or improvement of oxygenation with PC-IRV at lower levels of PIP may decrease the incidence of these complications of mechanical ventilation. fully Read the rest of this entry »

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