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Biomedical subjects

A J Fedullo

Publications and source records attributed to A J Fedullo.

At least 19 recordsLinked to original sources
PubMed1996

Long-term outcome when major complications follow coronary artery bypass graft surgery. Recovery after complicated coronary artery bypass graft surgery.

OBJECTIVE: To determine whether information available 1 week after surgery correlates with long-term function in patients who suffer major complications after coronary artery bypass graft (CABG) surgery. DESIGN: An inception cohort study. SETTING: A 526-bed community teaching hospital. PATIENTS: All 67 patients who required at least 7 days of CT-ICU care following 2,751 consecutive CABG operations. MAIN OUTCOMES: Hospital survival, long-term survival, and functional ability at long-term follow-up. RESULTS: Forty-three patients survived hospitalization (64%), while 24 died 37 +/- 45 days (range, 7 to 190 days) after surgery. When 42 patients were surveyed 22 +/- 9 months after surgery, 21 of the survivors enjoyed excellent, independent function, 7 were moderately impaired but living at home, 6 were institutionalized with severe limitations, and 8 had died. Patients with very severe cardiac or neurologic dysfunction 1 week after surgery had an extremely poor outcome. When mechanical ventilation was required for causes other than primary failure of the respiratory system, long-term function and hospital survival were poor. Twelve of 14 patients with pulmonary complications survived hospitalization, and all 12 were alive at long-term follow-up. CONCLUSION: More than half of patients requiring 7 days or more of ICU treatment after CABG surgery survive, and many enjoy excellent long-term function. However, those with very severe cardiac or neurologic dysfunction 1 week after surgery have little chance for independent recovery.

Activities of Daily Living↗
PubMed1994

Withdrawing care. Experience in a medical intensive care unit.

OBJECTIVE: To describe the process and outcomes of withdrawing life-sustaining interventions in a medical intensive care unit (MICU). DESIGN: Retrospective case series. SETTING: Medical intensive care unit in a community teaching hospital. PATIENTS: Consecutive series of 28 patients in whom mechanical ventilation, dialysis, and/or vasopressors were withdrawn. We distinguished physiological, neurological, and functional rationales for care withdrawal. MAIN OUTCOME MEASURES: Duration of discussions, MICU length of stay, and hospital survival. RESULTS: Mean +/- SD Acute Physiology and Chronic Health Evaluation (APACHE II) score was 27.1 +/- 7.3 on MICU admission, and average +/- SD predicted hospital mortality was 61% +/- 22%. Discussions leading to withdrawal of care occurred over an average +/- SD of 5.2 +/- 5.5 days, with decisions achieved soonest in cases with poor neurological prognosis. Average +/- SD MICU length of stay was 1.4 +/- 1.8 days following a decision to withdraw MICU care, and only four patients received more than 48 hours of additional MICU care. Four patients were discharged alive from the hospital. CONCLUSIONS: Patients and their surrogates willingly considered outcomes in addition to mortality when considering withdrawal of life-sustaining interventions. Finding an accommodation between physician judgments and patient preferences took time and effort but was an effective means of limiting ineffective life-sustaining efforts. Withdrawing futile or unwanted care was not always fatal.

Decision Making↗
PubMed1994

Effect of positive pressure ventilation on impedance plethysmography.

It has been stated that positive pressure ventilation (PPV) may cause false positive impedance plethysmography (IPG) results because PPV can decrease venous outflow. We studied 36 patients who were being weaned from mechanical ventilation to determine the effect of PPV on IPG. Patients had IPGs performed during spontaneous ventilation and while receiving mechanical ventilation in the assist/control (A/C) mode without positive end expiratory pressure (PEEP) and with 10 cm H2O PEEP. No patient developed a positive IPG with institution of PPV (mean airway pressure = 6.8 cm H2O), or with PEEP (mean airway pressure = 14.9 cm H2O). The IPG values for venous capacitance and venous outflow did not change during either mode of mechanical ventilation. There also was no tendency for positive pressure ventilation to move IPG results in the direction of a positive test. In summary, PPV does not cause IPG results to be false positive, nor does it move IPG results toward the discriminant line that separates normal from abnormal results.

Aged↗
PubMed1993

Respiratory failure in the elderly. Analysis of outcome after treatment with mechanical ventilation.

BACKGROUND: Concerns about rendering futile care, the financial costs of mechanical ventilation, and aging of the population make it important to analyze the benefit of aggressive therapy for respiratory failure in the elderly. METHODS: This study is a retrospective review of 1860 patients treated with mechanical ventilation in the medical intensive care unit for more than 3 hours between 1974 and 1985. Patients were assigned to one of nine diagnostic groups, and 10 premorbid chronic illnesses or organ system dysfunctions were recorded. Survival to discharge was determined for all patients, and the duration of survival after discharge was determined for patients aged 80 years and older. Two hundred eighty-two patients aged 80 years and older were compared with 1578 patients less than 80 years of age. RESULTS: Fifteen percent of patients treated with mechanical ventilation were 80 years of age or older. Forty-four percent of patients younger than 80 years, and 30.9% of patients aged 80 years and older survived to discharge. Patients aged 80 years or older with preexisting renal disease, liver disease, cancer, systemic illness, or chronic gastrointestinal disease with malnutrition had only a 7% survival compared with 29% for younger patients. For patients without these premorbid conditions (80% of both the younger and older groups) survival among the elderly was better, even though it was still poorer than for younger patients (38% vs 49%). Elderly patients requiring more than 15 days of mechanical ventilation had a 9% survival compared with 36% for younger patients. CONCLUSIONS: A subgroup of patients 80 years of age or older can be identified whose chance for survival from respiratory failure is so poor that withholding or withdrawing treatment with mechanical ventilation may be appropriate. For the majority of elderly patients, short-term survival is nearly as good as in younger patients. Further studies are needed that assess long-term survival and functional recovery after treatment for respiratory failure so that elderly patients and their physicians can better decide whether or not to choose treatment with mechanical ventilation.

Age Factors↗
PubMed1993

Effect of age and preoperative airway obstruction on lung function after coronary artery bypass grafting.

To determine whether age or obstructive lung disease affects pulmonary function changes caused by uncomplicated coronary artery bypass grafting, we measured pulmonary function before operation and then 3 or 4 days, 7 days, and 17 +/- 2.2 weeks after operation in elderly patients (age, 74.8 +/- 3.3 years) and patients with obstructive lung disease (ratio of forced expiratory volume in 1 second to forced vital capacity, 0.60 +/- 8.8) and compared the results with those of a "normal" group. In all three groups a severe restrictive defect developed on day 3 (vital capacity, 61% +/- 20% of the preoperative value). Vital capacity recovered to 76.4% +/- 18.5% of the preoperative value on day 7. Three months after coronary artery bypass grafting, lung function had recovered to preoperative baseline (p > 0.2). The percent change from baseline in vital capacity, forced expiratory volume in 1 second, total lung capacity, and diffusing capacity for carbon monoxide was the same in all three groups throughout the study. A severe, reversible restrictive pulmonary function change follows coronary artery bypass grafting. This change is not affected by age or preexisting moderately severe obstructive lung disease.

Age Factors↗
PubMed1992

Sonographic measurement of diaphragmatic motion after coronary artery bypass surgery.

Forty-eight patients were prospectively evaluated following coronary artery bypass grafting (CABG) in order to determine values for diaphragmatic mobility by sonography, to compare diaphragmatic motion to chest x-ray findings, to relate diaphragmatic motion to pulmonary function tests, and to determine whether use of the left internal mammary artery (LIMA), aortic cross-clamp time, or other clinical variables were predictive of diaphragmatic dysfunction. Mean left diaphragmatic motion was 2.8 +/- 1.1 cm (range, 1.0 to 5.7 cm), mean right diaphragmatic motion was 3.9 +/- 1.1 cm (range, 1.8 to 6.4 cm), and ratio of left to right motion was 0.74 +/- 0.27 (range, 0.19 to 1.4). Forty-one patients had normally positioned diaphragms on the chest x-ray film; four of these had poor mobility by ultrasonography (< 1.6 cm). Of the seven elevated left hemidiaphragms on chest x-ray films, three had an excursion of 1.6 cm or more by ultrasonography. The mean FVC for all patients was 59 +/- 13 percent of predicted. There was no relationship between diaphragmatic mobility and FVC or negative inspiratory pressure. The diaphragmatic motion in 36 patients having LIMA grafting was similar to those without (2.7 +/- 1.2 cm [n = 36] vs 2.8 +/- 0.8 cm [n = 12], respectively). Aortic cross-clamp time and respiratory symptoms also did not correlate with diaphragmatic mobility. Sonography can be used in the evaluation of diaphragmatic motion after CABG and may be more accurate in detecting a poorly mobile diaphragm than is the chest x-ray film.

Coronary Artery Bypass↗
PubMed1991

Acute cardiogenic pulmonary edema treated with mechanical ventilation. Factors determining in-hospital mortality.

We reviewed 88 episodes of cardiogenic pulmonary edema (CPE) treated with mechanical ventilation to define the clinical features that predict in-hospital mortality. Fifty-six patients survived to hospital discharge. APACHE II scores were not helpful in prediction. Multiple logistic regression models to predict outcome were developed using variables present at the time of intubation and 24 hours later. The model at the time of intubation indicated mortality was related to systolic blood pressure less than 130 mm Hg, the presence of anterior myocardial infarction, use of calcium channel blockers, age, and absence of prior hospitalization for CPE. A model using additional variables available 24 hours later showed that mortality was related only to the need for vasopressor medication at 24 hours, and systolic blood pressure at intubation less than 130 mm Hg. The predictive power of these models was confirmed by applying them to 46 additional patients. The variables contained in these models suggest that the prognosis of patients with CPE treated with mechanical ventilation depends primarily on the severity of acute left ventricular injury. Variables relating the degree of respiratory failure, however, were not predictive of mortality. These multiple logistic regression models provide a means to compare patients with CPE for quality assessment purposes and for studies of treatment regimens, and may also provide information useful to patient and family counseling regarding the value of continued aggressive intensive care.

Aged↗
PubMed1989

Chylothorax: a complication of the nephrotic syndrome.

A 50-yr-old man with the nephrotic syndrome developed a chylothorax that was shown to be due to transdiaphragmatic movement of chylous ascites. Because a significant number of patients with nephrotic syndrome have been reported to have chylous ascites, the possibility that chylothorax is due to movement of chylous ascites into the pleural space should be considered prior to surgical intervention directed toward repair of the thoracic duct.

Chylothorax↗
PubMed1988

APACHE II score and mortality in respiratory failure due to cardiogenic pulmonary edema.

We reviewed retrospectively 88 patients to assess whether the APACHE II severity of disease classification system can predict mortality in patients with respiratory failure due to cardiac pulmonary edema. Mean score for survivors was higher than for nonsurvivors (24.5 +/- 6.7 vs. 20.7 +/- 5.7, p less than .01), and increasing APACHE II scores were not associated with increasing mortality. Mortality was 54% for APACHE II scores less than or equal to 18, 43% for scores greater than 18 and less than or equal to 24, 22% for scores greater than 24 and less than or equal to 31, and 25% for scores between 32 and 40. The relationship of APACHE II scores to mortality did not improve when the 25 patients with ICU stays less than 48 h were analyzed; the mean score of survivors in this group was 24.3 +/- 5.2 vs. 18.8 +/- 4.6 for nonsurvivors, p less than .001. The presence of myocardial infarction (MI) was associated with a high mortality. Mortality in the 51 MI patients was 52.9% vs. 13.5% in the 37 patients without MI (p less than .001), but APACHE II scores were similar (22.6 +/- 6.6 and 23.7 +/- 6.4, respectively). The relationship between APACHE II scores and mortality did not improve if patients with and without MI are analyzed separately. For patients with MI, mortality was 78.6% for scores between 12 and 17, 56.2% for scores between 18 and 23, 33.3% for scores between 24 and 29, and 33.3% for scores greater than 29.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1987

Comparison of noninvasive measurements of carbon dioxide tension during withdrawal from mechanical ventilation.

End tidal CO2 tension (PetCO2) and transcutaneous CO2 tension (PtcCO2) were compared with arterial CO2 (PaCO2) before and after withdrawal of mechanical ventilation in 20 patients predisposed to hypercarbia. With stable PaCO2 during mechanical ventilation, the correlation coefficient (r) between PaCO2 and PetCO2 was .9, and between PaCO2 and PtcCO2, .87. PtcCO2 considerably overestimated PaCO2 in three patients who were receiving dopamine. After withdrawal of mechanical ventilation, changes in PaCO2 were closely paralleled by changes in PetCO2 and PtcCO2 (r = .82 and .86, respectively). Nine of 20 patients had an increased PaCO2 of 10 torr or greater. In eight of these, PetCO2 and PtcCO2 rose by at least 5 torr, and in seven, the rise in PetCO2 and PtcCO2 was within 5 torr of the rise in PaCO2. During mechanical ventilation, PetCO2 and PtcCO2 estimated stable PaCO2 with sufficient accuracy for clinical use, except in patients with cutaneous vasoconstriction. After withdrawal of mechanical ventilation, changes in PetCO2 and PtcCO2 were predictive of important PaCO2 increases, warranting continued exploration and evaluation as to their use in monitoring patients predisposed to hypercarbia.

Aged↗
PubMed1986

Hereditary telangiectasia and multiple pulmonary arteriovenous fistulas. Clinical deterioration during pregnancy.

We describe the effect of pregnancy on a woman with multiple pulmonary arteriovenous fistula. Pregnancy was terminated at 35 weeks' gestation because of severe hypoxemia. During the early postpartum period, the intrapulmonary shunt fraction enlarged, and hypoxemia worsened, necessitating emergency resection of the A-V fistula. Pregnancy may increase the intrapulmonary shunt fraction in patients with multiple pulmonary arteriovenous fistula through its effect on plasma volume and produce life-threatening hypoxemia near term or in the early postpartum period.

Adult↗
PubMed1985

Relationship of patient age to clinical features and outcome for in-hospital treatment of pneumonia.

Medical records of 166 patients hospitalized for pneumonia were analyzed to determine the relationship between patient age and the clinical features and outcome. Fifty-seven patients were older than 79 years, 55 were 60 to 79 years, and 54 were younger than 60 years. The three groups had similar heart rates, respiratory rates, arterial/alveolar oxygen tension ratios, leukocyte counts, body temperatures, frequency of multilobe pneumonias, and incidence and types of bacterial pathogens. Mortality was 0, 6, and 11% in decades 5 through 7 and rose gradually with age, being 11, 13, and 17% in decades 8 through 10. Hospital stay was 5.7 days in those less than 60 years of age, 9.8 days in those aged 60 to 79, and 11.3 days in those older than 79 years. Although elderly adults are hospitalized frequently for treatment of pneumonia, an individual episode of pneumonia requiring hospitalization in the elderly patient is of equivalent severity to that in younger patients and has similar clinical features and outcome.

Adolescent↗
PubMed1985

Hypoxemia from right to left shunting through patent foramen ovale.

We report a patient with severe hypoxemia from a large (41%) right to left shunt through a patent foramen ovale after right ventricular myocardial infarction, and review 18 previous descriptions of patients with right to left shunting through patent foramen ovale. These shunts occur when right atrial pressure is elevated above left atrial pressure, or when the anatomic relationship of the interatrial septum to the inferior vena cava is altered. Since 15-35% of the population have a potentially patent foramen ovale, interatrial right to left shunting may occur more frequently than had previously been recognized, and should be considered in a differential diagnosis of hypoxemia.

Adult↗
PubMed1985

Bronchoalveolar lavage in lymphangitic spread of adenocarcinoma to the lung.

We report the results of bronchoalveolar lavage in a patient who had pulmonary lymphangitic spread of adenocarcinoma from an unknown primary. The lavage specimen was remarkable for a large increase in the number of lymphocytes. This observation extends the differential diagnosis of a lymphocyte-predominant lavage specimen. The recovery of large numbers of lymphocytes associated with malignancy in this case suggests that bronchoalveolar lavage may also be useful to study aspects of the immune response to interstitial lymphangitic spread of malignancy to the lung.

Adenocarcinoma↗