I. Alan Fein

Reduction of duration and cost of mechanical ventilation in an intensive care unit by use of a ventilatory management team

ObjectiveTo test the hypothesis that a formal interdisciplinary team approach to managing ICU patients requiring mechanical ventilation enhances ICU efficiency. DesignRetrospective review with cost-effectiveness analysis. SettingA 20-bed medical-surgical ICU in a 450-bed community referral teaching hospital with a critical care fellowship training program. PatientsAll patients requiring mechanical ventilation in the ICU were included, comparing patients admitted 1 yr before the inception of the ventilatory management team (group 1) with those patients admitted for 1 yr after the inception of the team (group 2). Group 1 included 198 patients with 206 episodes of mechanical ventilation and group 2 included 165 patients with 183 episodes of mechanical ventilation. InterventionA team consisting of an ICU attending physician, nurse, and respiratory therapist was formed to conduct rounds regularly and supervise the ventilatory management of ICU patients who were referred to the critical care service. Measurements and Main ResultsThe two study groups were demographically comparable. However, there were significant reductions in resource use in group 2. The number of days on mechanical ventilation decreased (3.9 days per episode of mechanical ventilation [95% confidence interval 0.3 to 7.5 days]), as did days in the ICU (3.3 days per episode of mechanical ventilation [90% confidence interval 0.3 to 6.3 days]), numbers of arterial blood gases (23.2 per episode of mechanical ventilation; p < .001), and number of indwelling arterial catheters (1 per episode of mechanical ventilation; p < .001). The estimated cost savings from these reductions was

Hemodynamic and metabolic effects of abdominal aortic crossclamping

1,303 per episode of mechanical ventilation. ConclusionWe conclude that a ventilatory management team, or some component thereof, can significantly and safely expedite the process of “weaning” patients from mechanical ventilatory support in the ICU.

Uremic pulmonary edema.

The hemodynamic and metabolic effects of aortic crossclamping and declamping were studied in 10 patients undergoing abdominal aortic reconstructive surgery. After placement of pulmonary and radial arterial catheters, measurements were obtained preoperatively, during the procedure according to protocol, and postoperatively. Pulmonary arterial wedge pressure was maintained at 10 to 15 mm Hg throughout the operation. Aortic cross clamping produced a significant increase in systemic arteriolar resistance and systolic blood pressure, with no change noted in the left ventricular stroke work index. Declamping decreased systemic resistance and produced no change in the left ventricular stroke work index. Clamping and declamping resulted in elevations of serum lactate. Central venous pressure correlated with pulmonary arterial wedge pressure in each patient and in the entire group. Cardiac function is not decreased by aortic crossclamping, and central venous pressure can usually be used for hemodynamic monitoring in these patients.

Clinical practice guidelines: culture eats strategy for breakfast, lunch, and dinner.

Pulmonary edema fluid analyses and hemodynamic evaluations were performed in two uremic patients with acute pulmonary edema. The colloid osmotic pressure of the pulmonary edema fluid ranged from 57 per cent to 93 per cent that of the serum. Although cardiac function was normal in both patients, the serum colloid osmotic pressure--pulmonary artery wedge pressure gradients were markedly reduced. Uremic pulmonary edema is the result of alterations of pulmonary intravascular Starling forces and increases in pulmonary capillary membrane permeability, allowing for the efflux of protein-rich fluid from the capillaries into the lung.

The 1988 DNR Reforms: A Comparative Study of the Impact of the New York DNR Law and the Jcaho Accreditation Requirements

The first morbidity and mortality conferences in the United States were instituted by Ernest Amory Codman, a surgeon with a keen interest in improving the quality of medical care. In 1914, shortly after proposing a program for evaluating the performance of surgeons, the Massachusetts General Hospita

Rationing Americanʼs Medical Care: The Oregon Plan and Beyond

The DNR reforms of 1988, a coincident trial of both the legislative and the self-regulatory routes to reform, provide an ideal vehicle for assessing the impact of bioethical reform. They can be construed as inadvertant “natural experiment,” a comparative trial of the effects of reforming DNR practices by means of an amendment to the state’s public health law, or by means of a change in the accreditation policies of the Joint Commission on Accreditation of Health-Care Organizations (hereafter, JCAHO). In the study described below, we attempt to assess the impact of these two different routes to mandatory bioethical reform: the JCAHO’s latitudinarian professional self-regulative approach; and New York’s use of a statute enforced by the state department of health and the law courts.

Colloid Osmotic Pressure as a Prognostic Indicator of Pulmonary Edema and Mortality in the Critically Ill

As Americas struggle with the dual problem of exploding health costs and assuring access to health care for the uninsured, health care rationing has moved to the centre of the public policy debate. A prime example of this is the intense public discussion surrounding the proposal by the state of Oregon to provide universal health care but to ration which diagnoses and treatments will be covered. Focusing largely on the Oregon proposal, this volume examines a wide range of ethical, methodological, legal and political issues that must be addressed by any serious programme of health care reform.