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Biomedical subjects

Brian M Parker

Publications and source records attributed to Brian M Parker.

9 recordsLinked to original sources
PubMed2007

Six sigma methodology can be used to improve adherence for antibiotic prophylaxis in patients undergoing noncardiac surgery.

BACKGROUND: Six Sigma methodology is a data management process that can be used to achieve a goal of near perfection in process performance. An audit of 615 surgeries over 2 mo revealed only 38% of noncardiac patients admitted on the day of surgery at our institution received perioperative antimicrobial prophylaxis within the target interval of < or =60 min before incision. METHODS: Six Sigma methodology was used to improve our process of timing of antimicrobial prophylaxis administration. A multidisciplinary team was assembled which identified seven process inputs by which patients receive antimicrobial prophylaxis. Interventions for improvement included reinforcement of use of preoperative antibiotic order forms, eliminating administration of antibiotics in the preoperative admission area, and sending appropriate antibiotics and IV tubing with the patient to the operating room. We concurrently developed a control plan to sustain this improvement using a recently deployed electronic anesthesia record keeping system using real-time measurement and reporting capabilities of antimicrobial prophylaxis administration. After defining the new process and undertaking a system-wide educational effort, implementation was begun with data collection and analysis occurring over the next 7 mo. RESULTS: For the 8-mo postintervention interval, there was a significant improvement with 86% of 1716 surgical patients receiving their antibiotic prophylaxis within the specified time frame (P < 0.01). The time interval for antibiotic administration before surgical incision also decreased from a preintervention mean of 88 (CI 56-119 min) to 38 min (CI 25-51 min) (P < 0.01). CONCLUSION: We conclude that Six Sigma methods were used to successfully improve our process for timing of perioperative antibiotic prophylaxis before surgical incision. An electronic anesthesia record keeping system is a useful tool to monitor this process improvement.

Antibiotic Prophylaxis↗
PubMed2006

Anesthetics and anesthesia techniques: impacts on perioperative management and postoperative outcomes.

Inhaled and intravenous anesthetic agents have diverse effects on the nervous, cardiovascular, and respiratory systems. Spinal and epidural anesthetics also produce significant physiologic changes. Some evidence points to improved immediate postoperative outcomes (in terms of cardiovascular outcomes, blood loss, and venous thromboembolism) for certain types of surgical procedures with epidural and spinal techniques relative to general anesthesia. Evidence is just beginning to emerge, however, on the relation between specific anesthetics and anesthetic techniques and long-term clinical outcomes. A proposed relationship between anesthetics, inflammation, and long-term outcomes has attracted increasing research interest but has yet to be well defined.

Anesthesia↗
PubMed2005

Dynamic left ventricular outflow tract obstruction in an orthotopic liver transplant recipient.

A 53 year-old man with Laennec's and hepatitis C-related cirrhosis was found to have dynamic left ventricular outflow tract obstruction during routine evaluation for orthotopic liver transplantation. The outflow tract obstruction gradient was quantified as being 155 to 189 mmHg maximally during dobutamine stress echocardiography. The patient subsequently underwent successful orthotopic liver transplantation at our institution. We discuss here the use of intraoperative transesophageal echocardiography to detect early signs of dynamic outflow tract obstruction and provide a rational guide for fluid and hemodynamic management. We conclude that the measured pressure across the left ventricular outflow tract during dobutamine stress testing does not necessarily predict either intraoperative hemodynamic perturbations such as obstruction or outcome in these patients.

Echocardiography, Stress↗
PubMed2004

Quality and resource utilization in managing preoperative evaluation.

The evaluation of patients before surgery is a component of anesthesia practice that must be performed to ensure the safe delivery of anesthesia for every patient. How an anesthesia group performs this evaluation differs from institution to institution as the structure of preoperative clinics in hospitals across the country can be quite variable. However, the major question that anesthesiologists must ask when approaching this area of practice is: "Can a system for preoperative evaluation that uses the expertise of anesthesiologists,surgeons, and internists to deliver high quality, cost conscious, and efficient patient preparation for surgery be developed.

Algorithms↗
PubMed2004

Leukocyte reduction during orthotopic liver transplantation and postoperative outcome: a pilot study.

STUDY OBJECTIVE: To investigate the effect of intraoperative leukocyte reduction of administered blood products on the incidence of acute cellular rejection and postoperative patient outcome. DESIGN: Prospective, nonrandomized, historical control study. SETTING: Academic tertiary medical center. PATIENTS: The study group (Group 1) consisted of 30 consecutive adult patients with end-stage liver disease scheduled to undergo orthotopic liver transplantation (OLT) between 1998 and 2000. The historical control group (Group 2) consisted of 30 adult patients with end-stage liver disease matched to study group patients as closely as possible for age, gender, and etiology of liver disease who underwent OLT between 1995 and 1999. INTERVENTIONS: Group 1 patients had all intraoperative allogeneic and cell salvaged blood products leukocyte reduced before administration. Group 2 patients underwent OLT without leukocyte filtration of any administered blood products. MEASUREMENTS: Demographic data were collected for both patient groups and included age, gender, etiology of liver disease, and both intraoperative and postoperative immunosuppression. Demographic allograft donor data for both patient groups were collected and included age, gender, use of vasopressors during procurement, and cold and warm donor organ ischemic times. Outcome variables measured included incidence of acute cellular rejection, length of intensive care unit (ICU) and length of hospital stay, incidence of both graft loss and retransplantation, and mortality. MAIN RESULTS: The incidence of acute cellular rejection was 40% in Group 1 and 66.7% in Group 2 (p = 0.037). Length of ICU stay was 3.0 (2.0, 5.0) days in Group 1 and 4.0 (3.0, 6.0) days in Group 2 (p = 0.16). Length of hospital stay was 14.0 (11.0, 18.0) days in Group 1 and 18.0 (14.0, 27.0) days in Group 2 (p = 0.035). One allograft was lost in Group 2 because of primary nonfunction requiring retransplantation (p = 0.31), and three postoperative deaths occurred in Group 1 as a result of multisystem organ failure (p = 0.08). CONCLUSIONS: Coincident with leukocyte reduction of all administered blood products during OLT, an improved outcome was observed in Group 1 patients as demonstrated by both a decreased incidence of acute cellular rejection and length of hospital stay.

Acute Disease↗
PubMed2004

Spontaneous spinal epidural hematoma in a pregnant patient.

Spontaneous spinal epidural hematoma is a rare occurrence during pregnancy with only five cases described in the literature since 1900. Even in the general population, the frequency of spontaneous spinal epidural hematoma is extremely low and the etiology unclear. Several theories exist for the cause of spontaneous spinal epidural hematoma, however, none has gained uniform acceptance. A case of spontaneous spinal epidural hematoma during pregnancy in a 27-year-old, gravida 2, para 1, female at term with 36 hours duration of both paresthesia and progressive weakness of the lower extremities is presented. In addition, all previous known cases are summarized, including outcome. We hypothesize that the cause of spontaneous spinal epidural hematoma is multifactorial, and pregnancy-induced structural changes in arterial walls and hemodynamic changes may play a role. In addition, we postulate that the origin of the bleeding is arterial, rather then venous. Lastly, the symptoms, diagnosis, and management of spontaneous spinal epidural hematoma during pregnancy are discussed.

Adult↗
PubMed2004

A comparison of postoperative pain control in patients after right lobe donor hepatectomy and major hepatic resection for tumor.

After initiating a living donor liver transplant program at our institution, we observed that donor patients experienced significant postoperative pain despite the use of thoracic patient-controlled epidural analgesia (PCEA) infusion catheters. We retrospectively compared patients who underwent right lobe donor hepatectomy (RLDH, n = 15) with patients who had undergone major hepatic resection for tumor (MHRT, n = 15) to elucidate the cause for this observation. All patients had preoperative thoracic epidural catheters placed, and both groups had similar surgical exposure. Demographic information, intraoperative variables, intensity of postoperative pain by visual analog pain score (VAPS), side effects, total number of requested and delivered PCEA doses, and the total amount of bupivacaine (mg) and volume (mL) of PCEA solution administered through 48 h postoperatively were collected and analyzed. The RLDH group had a significantly longer surgical duration than did the MHRT group. The RLDH group patients had higher postoperative pain scores (P = 0.034), and were 2.76 (1.12-6.82, 95% CI) times more likely to have pain than those patients in the MHRT group. There was no significant difference between patient groups for the amount of bupivacaine and volume of PCEA solution administered. These observations may be explained, in part, by the longer duration of surgery in the RLDH group. The possible role of preemptive analgesia via PCEA infusion and better perioperative teaching of PCEA use are discussed; these may lead to improved early postoperative pain control in RLDH patients.

Adult↗