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Biomedical subjects

A D Slonim

Publications and source records attributed to A D Slonim.

At least 19 recordsLinked to original sources
PubMed2003

Assessing patient safety risk before the injury occurs: an introduction to sociotechnical probabilistic risk modelling in health care.

Since 1 July 2001 the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has required each accredited hospital to conduct at least one proactive risk assessment annually. Failure modes and effects analysis (FMEA) was recommended as one tool for conducting this task. This paper examines the limitations of FMEA and introduces a second tool used by the aviation and nuclear industries to examine low frequency, high impact events in complex systems. The adapted tool, known as sociotechnical probabilistic risk assessment (ST-PRA), provides an alternative for proactively identifying, prioritizing, and mitigating patient safety risk. The uniqueness of ST-PRA is its ability to model combinations of equipment failures, human error, at risk behavioral norms, and recovery opportunities through the use of fault trees. While ST-PRA is a complex, high end risk modelling tool, it provides an opportunity to visualize system risk in a manner that is not possible through FMEA.

Hospital Administration↗
PubMed2001

Long-stay patients in the pediatric intensive care unit.

OBJECTIVE: Length of stay in the pediatric intensive care unit (PICU) is a reflection of patient severity of illness and health status, as well as PICU quality and performance. We determined the clinical profiles and relative resource use of long-stay patients (LSPs) and developed a prediction model to identify LSPs for early quality and cost saving interventions. DESIGN: Nonconcurrent cohort study. SETTING: A total of 16 randomly selected PICUs and 16 volunteer PICUs. PATIENTS: A total of 11,165 consecutive admissions to the 32 PICUs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: LSPs were defined as patients having a length of stay greater than the 95th percentile (>12 days). Logistic regression analysis was used to determine which clinical characteristics, available within the first 24 hrs after admission, were associated with LSPs and to create a predictive algorithm. Overall, LSPs were 4.7% of the population but represented 36.1% of the days of care. Multivariate analysis indicated that the following factors are predictive of long stays: age <12 months, previous ICU admission, emergency admission, no CPR before admission, admission from another ICU or intermediate care unit, chronic care requirements (total parenteral nutrition and tracheostomy), specific diagnoses including acquired cardiac disease, pneumonia, and other respiratory disorders, having never been discharged from the hospital, need for ventilatory support or an intracranial catheter, and a Pediatric Risk of Mortality III score between 10 and 33. The performance of the prediction algorithm in both the training and validation samples for identifying LSPs was good for both discrimination (area under the receiver operating characteristics curve of 0.83 and 0.85, respectively), and calibration (goodness of fit, p = .33 and p = .16, respectively). LSPs comprised from 2.1% to 8.1% of individual ICU patients and occupied from 15.2% to 57.8% of individual ICU bed days. CONCLUSIONS: LSPs have less favorable outcomes and use more resources than non-LSPs. The clinical profile of LSPs includes those who are younger and those that require chronic care devices. A predictive algorithm could help identify patients at high risk of prolonged stays appropriate for specific interventions.

Age Distribution↗
PubMed2000

The impact of prematurity: a perspective of pediatric intensive care units.

OBJECTIVE: To evaluate the relative resource use of pediatric intensive care unit (PICU) patients who had been born prematurely. DESIGN: Nonconcurrent cohort study. SETTING: Consecutive admissions to 16 voluntary PICUs. PATIENTS: A total of 431 formerly premature patients (FPP) and 5,319 nonpremature patients. INTERVENTIONS: None METHODS: Patients with a history of prematurity and a prematurity-related complication or an anatomical deformity were compared for demographic and resource requirements to a group of non-premature patients by a bivariable logistic regression analysis that controlled for age as a co-morbid factor. RESULTS: Compared with other patients, FPP were younger (34.9 +/- 2.2 months vs. 72.4 +/- 1.0 months; p < .001), readmitted to the PICU more often during the same hospitalization (11.1% vs. 5.5%; p < .001), used more chronic technologies (ventilators, gastrostomy tubes, tracheostomy tubes, and parenteral nutrition; 30.3% vs. 5.6%; p < .001), and had longer lengths of stay (5.98 +/-0.59 days vs. 3.56 +/- 0.12 days; p = .004). FPP had significantly higher use of ventilators (45.5% vs. 35.0%; p < .007) and lower use of arterial catheters (27.8% vs. 35.9%, p = .006) and central venous catheters (16.9% vs. 20.9%, p = .026) than nonprematures. The need for other PICU resources, including vasopressors, were similar. CONCLUSIONS: FPP used more chronic and acute care resources than patients who were not prematurely born. Continued improvements in neonatal care will influence change in many aspects of the health care system. This will also affect the delivery of care to the current patient base of the PICU.

Case-Control Studies↗
PubMed1999

Amnestic agents in pediatric bronchoscopy.

STUDY OBJECTIVE: To assess the risk for complications with the use of sedation and analgesia techniques in pediatric fiberoptic bronchoscopy. DESIGN: A retrospective case series. SETTING: The ICU of a 325-bed tertiary care research hospital. PATIENTS: Patients from 1 to 18 years of age who underwent fiberoptic bronchoscopy with BAL or transbronchial biopsy between June 1991 and December 1995 and received IV sedation and analgesia. INTERVENTIONS: None. METHODS: A retrospective chart review was performed. Extracted data included anesthetics and sedatives used and their per kilogram dosages, procedure durations, and complications including oxygen desaturations < 90%, vital sign alterations that required intervention, and emergence reactions to ketamine. RESULTS: A total of 103 bronchoscopies were performed on 64 patients. Ketamine was used as the primary anesthetic in 60 procedures (58%). A combination of fentanyl and midazolam was used in 38 of the 43 remaining procedures. A variety of combinations were used in the five remaining procedures. Complications occurred in 13 procedures and included oxygen desaturations, stridor, cough, apnea, and nasal bleeding. Twelve of the 13 complications occurred in patients with a diagnosis of HIV infection. Eight of the13 complications involved children < or = 3 years of age. CONCLUSIONS: Pediatric bronchoscopy is a safe and valuable procedure. However, in this study, anesthetic selection was shown to adversely affect the complication rate in the subsets of children < or = 3 years of age and with an underlying diagnosis of HIV infection.

Analgesics↗
PubMed1998

Sedation for pediatric procedures, using ketamine and midazolam, in a primarily adult intensive care unit: a retrospective evaluation.

OBJECTIVE: To evaluate the effectiveness and safety of pediatric procedures performed by adult critical care practitioners, using the combination of ketamine and midazolam for anesthesia and sedation. DESIGN: A retrospective case series. SETTING: The intensive care unit (ICU) of a 325-bed tertiary research hospital. PATIENTS: Individuals from 1 to 18 yrs of age who had intravenous midazolam sedation and ketamine anesthesia administered while undergoing lumbar puncture, bone biopsy, central venous catheter placement, liver biopsy, thoracentesis, or bone marrow aspirate/biopsy. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A retrospective chart review was performed. The dosages of medications used were tabulated, and milligram per kilogram dosages were calculated. The procedures performed, their durations, and any complications of the anesthesia and sedation were noted. These complications included: oxygen desaturations <90%, vital sign alterations requiring intervention, rashes, subjective complaints of dizziness by the patient, and emergence reactions to ketamine. A total of 127 pediatric patients were admitted to the ICU sedation area for a total of 295 procedures. All patients received ketamine and midazolam intravenously in divided doses and titrated to effect. A total of nine complications were observed. These complications included oxygen desaturation <90% (n = 1), vital sign alterations requiring treatment (n = 3), rash (n = 2), dizziness (n = 1), wheezing (n = 1), and emergence reaction (n = 1). No patient required admission to the ICU because of a complication. There were no episodes of bradycardia or other cardiopulmonary compromise. CONCLUSIONS: Pediatric anesthesia and sedation, using ketamine and midazolam, can be performed in a designated monitored setting, outside of the operating room, by experienced personnel, including nonpediatricians. This therapeutic combination allows painful procedures to be performed with less anxiety and discomfort. In experienced hands, a limited number of side effects occur.

Adolescent↗
PubMed1997

Cardiopulmonary resuscitation in pediatric intensive care units.

OBJECTIVE: To determine the effectiveness of cardiopulmonary resuscitation (CPR) in the pediatric intensive care unit (ICU). DESIGN: A nonconcurrent cohort study of consecutive admissions. SETTING: Thirty-two pediatric ICUs. PATIENTS: Consecutive admissions to 32 pediatric ICUs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Pediatric ICU patients were followed for the occurrence of a cardiopulmonary arrest (external cardiac massage for at least 2 mins). Patients who were in a state of continuous cardiopulmonary arrest on admission, or who never achieved stable vital signs, were excluded from the study. A total of 205 patients, from a sample of 11,165 (1.8%) pediatric admissions, experienced a cardiopulmonary arrest. Overall, 28 (13.7%) patients survived to hospital discharge. Neither mean ages nor age distribution affected survival. Only two diagnostic categories, traumatic illness, and other etiologies, were associated with survival. None of the patients fitting this category survived (p = .0028). The durations of CPR for survivors and nonsurvivors were 22.5 +/- 10.1 and 24.8 +/- 1.9 mins, respectively (p = .015). For CPR durations of <15 mins, 15 to 30 mins, and >30 mins, the survival rates were 18.6%, 12.2%, and 5.6%, respectively (linear trend p = .022). Thirty-five (17.1%) patients had a cardiopulmonary arrest before pediatric ICU admission and another arrest in the pediatric ICU. Only two (5.7%) of these 35 patients survived to discharge. Pediatric ICU survival decreased as the number of pediatric ICU arrests increased. Patients with one arrest (n = 155), two arrests (n = 29), and more than three arrests (n = 21) experienced survival rates of 14%, 14%, and 9.5%, respectively. Severity of illness, as measured by the Pediatric Risk of Mortality III score, was a significant predictor of survival (p < .001). CONCLUSIONS: Pediatric ICU cardiac arrest is an uncommon event. When it does occur, prehospital CPR, duration of resuscitation, traumatic etiology, and severity of illness are important factors associated with survival.

Adolescent↗
PubMed1985

[Effect of short-term hypoxia on body temperature and lactic acid in the blood of the mouse].

In mice, changes of body temperature and concentration of lactic acid in the blood were studied after three modes of barochamber hypoxia (altitude 8000 m) at the temperatures +10, +20 and +36 degrees C. The greatest drop of body temperature occurred at +10 degrees C, the least one at +36 degrees C. The lactic acid concentration was the greatest (up to 3.6 mM/l) at 2-min ascend and 2-min descend as well as at 2-min ascend, 15-min "altitude", 2-min descend, the temperatures being +20 and +36 degrees C. At 15-time 2-min ascend-descend, the concentration was the least (no more than 2 mM/l). Mechanisms of accelerated adaptation to hypoxia are considered from the standpoint of occurrence of repeated hyperventilation as the result of conditioning to repeated effects of hypoxia.

Adaptation, Physiological↗
PubMed1982

[Trace reactions and ambient temperatures].

Experimental data obtained on thermoregulatory trace reaction at the organismic, organic and tissue levels divided the trace reactions into 3 groups: continuous or discontinuous influences of ambient temperatures leading to high organism tolerance--adaptations; combination of thermal stimuli with indifferent ones and the formation of conditioned thermoregulatory reflex; habituation--following either single or repeated thermal stimuli. Changes in temperature relations of tissue and organ metabolism (Q 10) on ambient temperature shifts both in experiment and in natural diurnal cycle are discussed as well as the patterns of trace reactions following different regimens of temperature stimulation of the organism.

Acclimatization↗