Howard S. Nearman

Apnea of Prematurity: Comparative Therapeutic Effects of Cutaneous Stimulation and Nasal Continuous Positive Airway Pressure.

It has been suggested that idiopathic apnea of prematurity is related to hypoxia from pulmonary instability or an immaturity of central respiratory control mechanisms. To explore these hypotheses, 18 preterm infants were studied to examine the therapeutic effects of prophylactic cutaneous stimulation (6) and continuous positive airway pressure(12). The frequency of apnea using each procedure was reduced by 35 and 69 percent, respectively. These findings constitute the basis for new therapeutic measures for treatment of idiopathic neonatal apnea.

Clinical characteristics and resource utilization of ICU patients: implications for organization of intensive care.

We reviewed the clinical characteristics and resource utilization of 391 medical (M) and 315 surgical (S) ICU patients. In general, MICU patients had more physiologic derangement, as determined by the admission, maximal, and average acute physiology scores (APS). SICU patients had more frequent therapeutic interventions as measured by admission, maximal, and average therapeutic intervention scoring system values. Notably, 40% of MICU and 30% of SICU patients never received any active interventions and were admitted strictly for monitoring purposes.Patients on admission with APS ≤ 10 had markedly shorter ICU stays, with almost 50% less treatment than patients with APS over 10. Fifty-six percent of patients with APS ≤ 10 did not require any active intervention. In contrast, 83% of patients with APS greater than 10 had considerable intensive interventions. These patients required mechanical ventilation, invasive monitoring, and vasoactive drugs more than twice as often as patients with lower APS scores. Consideration should be given, therefore, to the organization of ICUs according to the patients severity of illness.

Therapeutic considerations in the management of agitated or delirious critically ill patients

Agitation and delirium in the critical care unit are common problems that at times are difficult to treat. The difficulty stems from few placebo‐controlled or even blinded trials evaluating various therapies. In addition, the literature in these areas is scattered through various journals in a variety of disciplines. Pharmacologic and nonpharmacologic techniques may achieve the therapeutic objective for these patients. Since no one drug will achieve the goals in every patient, therapy must be tailored to the characteristics and needs of each individual.

Postoperative management of a severely anemic Jehovah's witness

Preoperative preparation and intraoperative techniques to minimize blood loss comprise standard therapy for the patient who refuses blood products on religious grounds. The severely anemic postoperative patient presents a particular problem in dealing with oxygen transport and consumption. The management of a Jehovahs Witness with a hematocrit of 6.6% is presented. Oxygen consumption (VO2) was decreased 30-50% by the use of body surface cooling, neuromuscular blocking agents, and narcotic-barbiturate administration.

Perioperative Complications of Cardiac Surgery and Postoperative Care

The care of the cardiac surgical patient postoperatively is fraught with several complications because of the nature of the surgical procedure itself and the common comorbidities of this patient population. Most complications occurring in the immediate postoperative period are categorized by organ system, and their pathophysiology is presented. Current diagnostic approaches and treatment options are offered. Preventive measures, where appropriate, are also included in the discussion.

APNEA OF PREMATURITY: EFFECTS OF CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP), CUTANEOUS STIMULATION, AND LEVELS OF URINARY BIOGENIC AMINES

Etiological theories of neonatal apnea include hypoxia from pulmonary instability, neurologic immaturity, and autonomic imbalance. To explore these hypotheses, 29 infants were studied to examine the effects of increased lung volume via low-pressure nasal CPAP, increased afferent input via cutaneous stimulation and levels of urinary biogenic amines in preterm infants with apnea(>15 sec). Apnea significantly decreased with CPAP and with stimulation; dopamine and epinephrine (epi) levels were lower in infants having apnea.The catecholamine differences compel further study of sleep states and are possible support for an abnormality of autonomic integrity. The clinical data suggest that by increasing lung volume with CPAP or increasing afferent traffic via cutaneous stimulation, respiratory efferents become more active, thus decreasing apneic spells.