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Biomedical subjects

D J Cullen

Publications and source records attributed to D J Cullen.

At least 55 records · Page 3Linked to original sources
PubMed1992

Consistency between peer reviewers for a clinical specialty journal.

To analyze the consistency between independent peer reviewers in evaluating and ranking unsolicited articles, the authors used paired reviews of 422 unsolicited submissions to the Journal of Clinical Anesthesia from the end of 1988 through 1991. (The editors of this journal base their publication decisions, to a substantial degree, on congruence of their reviewers' recommendations). The reviewers were chosen for their interest in reviewing and areas of expertise. Their recommendations were ranged along a continuum of four categories: (1) accept outright, (2) accept with revision, (3) reject in present form (article could be revised and submitted again as a new submission), and (4) reject outright. The pairs of peer reviewers were consonant for 169 papers (40%), differed by one category for 168 papers (40%), differed by two categories for 73 papers (17%), and differed by three categories for 12 papers (3%). Thus, most articles' reviews were in consonance or close to it; articles reviewed by two members of the editorial board, however, were significantly less likely to be consonant (32%) than were those reviewed by two nonmembers (44%, chi-square, p = .027).

Anesthesiology↗
PubMed1992

Effect of pulse oximetry, age, and ASA physical status on the frequency of patients admitted unexpectedly to a postoperative intensive care unit and the severity of their anesthesia-related complications.

Unanticipated intensive care unit admission (UIA) associated with anesthesia served as an outcome measure to assess the quality of anesthesia care in a large teaching hospital. We characterized the patient population and types of problems associated with UIAs, attempted to identify patterns of care that could have led to specific adverse outcomes, and determined if a specific intervention, pulse oximetry, reduced UIAs. During a consecutive 65-wk period (July 1985-September 1986), 17,093 surgical patients were expected to enter the recovery room and then return to floor care. Seventy-one patients (0.42%) experienced a UIA from either the recovery room or operating room, and the circumstances of their admissions were analyzed in detail. After introduction of pulse oximetry in all anesthetizing locations (not including the recovery room) in the 29th week, the overall rate of UIAs and, specifically, the rate of UIA to rule out myocardial infarction, decreased significantly. Increasing ASA physical status (ASA-PS) and age significantly increased the probability of UIA. UIA patients with ASA-PS III/IV had a significantly higher acuity in the intensive care unit and were far more likely to die during their hospitalization than ASA-PS I/II patients. Retrospective review of UIAs alone did not identify patterns of care requiring remediation, which leads us to question the utility of UIAs as a generic screen for quality assurance.

Adult↗
PubMed1989

Effect of labetalol or lidocaine on the hemodynamic response to intubation: a controlled randomized double-blind study.

Labetalol, a combined alpha 1- and nonselective beta-adrenergic blocking drug, was compared to lidocaine or saline to minimize the hypertensive and tachycardic response to intubation in a controlled randomized double-blind study in patients undergoing surgical procedures under general anesthesia. Forty adult patients were divided into four groups of 10 each: placebo (saline), lidocaine 100 mg, labetalol 5 mg, or labetalol 10 mg. The double-blind preparation was administered as an IV bolus just prior to induction and 2 min before the stimulus of laryngoscopy and intubation. Heart rate and blood pressure were measured at 1-min intervals for 2 min prior to induction of anesthesia and through 6 min following induction of anesthesia. Labetalol 10 mg prevented a rise in heart rate after intubation compared to patients who received placebo, lidocaine 100 mg, or labetalol 5 mg. The hypertensive response to intubation was similar in all four groups. Labetalol 10 mg IV just prior to induction of anesthesia is a safe and cost-effective means of preventing tachycardia but not hypertension in response to laryngoscopy and intubation.

Adult↗
PubMed1989

Cardiovascular, pulmonary, and renal effects of massively increased intra-abdominal pressure in critically ill patients.

Massive elevation of intra-abdominal pressure (IAP) causes cardiovascular, respiratory, and renal dysfunction. We managed eight patients with high IAP (mean 51 +/- 7 cm H2O), six of whom had hemodynamic measurements; a clinical syndrome, characterized by hemodynamic, respiratory, and renal dysfunction, then became apparent. We report a) a baseline cardiopulmonary profile and response to an acute vascular volume challenge in six patients and b) surgical decompression of the abdomen in four patients. The clinical impression of hypovolemia was confused by small to normal left ventricular end-diastolic volume (64 +/- 14 ml) and normal ejection fraction (55 +/- 6%) despite very high right and left atrial filling pressures. Complete ventilatory support was necessary to maintain oxygenation and ventilation; oliguria (urine output less than 10 ml/h) was present. Pericardial effusion was absent. After fluid challenge (10 ml/kg of colloid or crystalloid infused iv over 10 min), filling pressures, cardiac output, and stroke volume all increased significantly (p less than .025) while heart rate decreased. Surgical decompression of the abdomen improved oxygenation, ventilation, cardiac output, atrial filling pressures, and urine output within 15 min. The cardiovascular effects of massively elevated IAP compounded by the requisite supportive care may require surgical relief.

Abdomen↗
PubMed1989

Risk modification in the postanesthesia care unit.

By taking an organized approach to problem-solving in the PACU, as part of an overall hospital-mandated quality assurance program, PACU staff can increase patient safety, reduce risk, and improve the quality of care.

Anesthesia Recovery Period↗
PubMed1989

Postanesthesia care unit standards for anesthesiologists. Board of Directors of the American Society of Post Anesthesia Nurses.

The following article describes postanesthesia care unit standards for anesthesiologists as developed by the Harvard Anesthesia Department's Risk Management Committee, Harvard Medical School. The standards were endorsed by the ASPAN Board of Directors, April 10, 1988. It is hoped that publication of these standards will assist PACU nurses in evaluating the anesthesia support they receive in their respective settings.

Anesthesiology↗
PubMed1987

Effects of information feedback and pulse oximetry on the incidence of anesthesia complications.

No standard outcome measures exist to evaluate the effect of interventions intended to improve the quality of anesthesia care. The authors established a clinically practical definition of outcome, and used it to assess the effect of feedback of information about complications and the effect of pulse oximetry on the rate and severity of important anesthesia-related problems encountered in the operating room (OR) and recovery room (RR). On admission to the RR, the patient's anesthetist documented Recovery-Room-Impact Events (RRIE), defined as an "unanticipated, undesirable, possibly anesthesia-related effect that required intervention, was pertinent to recovery-room care, and did or could cause at least moderate morbidity." Following a control period with no feedback of data, intense feedback of grouped (anonymous) RRIE rates was provided. Later, pulse oximeters were introduced to all anesthetizing locations. Among 12,088 patients (71% of all RR admissions), 18% had at least one RRIE in the OR or RR. The most common RRIEs were hypotension (4.4%), arrhythmia (3.9%), hypertension (1.5%), intubation difficulties (0.8%), hypoventilation (0.8%), and hypovolemia (0.6%). Feedback of information produced no demonstrable change in the rate of RRIEs. Although significantly fewer patients experienced RRIEs (15.6% vs. 12.4%, P less than 0.0001), hypotensive RRIEs (5.2% vs. 3.8%, P = 0.0003), and hypovolemic RRIEs (0.88% vs. 0.42%, P = 0.0017) following the introduction of pulse oximetry in the OR, confounding factors prevent establishment of a cause-and-effect relationship. Quality assurance may require more direct intervention and individual feedback to be effective. Still, the RRIE measure requires minimal effort at low cost and encourages improved transmission of information at the time of admission to recovery-room care.

Anesthesia↗
PubMed1986

The autopsy incidence of acute pulmonary embolism in critically ill surgical patients.

Critically ill patients should be susceptible to pulmonary thromboembolism (PTE). To determine the incidence of acute PTE in this patient population, we reviewed hospital charts and autopsy findings of all Class IV critically ill patients admitted to our hospital's Recovery Room-Acute Care Unit, between 1972 and 1982. Massive PTE either contributed to or was the sole cause of death in only two of the 152 patients studied (1.3%). Small single or scattered PTE were an incidental finding not contributing to morbidity or mortality in 13 patients. No gross evidence of PTE was found in the remaining 137 patients. There was no relationship between the occurrence of PTE and obesity, polycythemia, platelet count, PT or PTT, ventilatory support, level of PEEP, fluid balance, intravascular catheter days, pulmonary artery pressure, or pulmonary vascular resistance. Twelve patients did not have PTE at autopsy though it was seriously considered during ICU management. Unlike many other types of hospitalized patients, Class IV critically ill surgical patients are highly unlikely to suffer from PTE. When acute cardiorespiratory decompensation occurs, other more common causes should be given primary consideration.

Autopsy↗
PubMed1984

Results, charges, and benefits of intensive care for critically ill patients: update 1983.

Objective and quantitative methods were used to measure severity of illness and outcome of intensive care in critically ill patients, in terms of success or failure of therapy within the ICU, survival or death at 1 yr, quality of life in survivors, and utilization of resources. One hundred ninety-nine consecutive Class IV critically ill surgical patients hospitalized between 1977 and 1978 at the Massachusetts General Hospital comprised the study population. Although the mortality rate of 69% was close to the 73% rate we recorded for 1972-1973, the survivors' quality of life was significantly better. Hospitalization costs increased from $15,000 to $22,000 per patient, almost consistent with the inflation rate between 1973 and 1978. Survival rates and quality of life in survivors did not vary with age. The disease process for which the patient was hospitalized was an important determinant of outcome. Intensive care medicine for critically ill surgical patients does prolong life and enable some patients to return to a productive lifestyle; however, the costs of these benefits are extremely high.

Adult↗
PubMed1984

Objective, quantitative measurement of severity of illness in critically ill patients.

Severity of illness must be quantitated in critically ill patients if studies of outcome and therapeutic efficacy are to be meaningful. Objective physiologic indicators of critical illness, such as pertinent laboratory values, can be quantitated using the Therapeutic Intervention Scoring System--TISS. TISS data were obtained for 199 consecutive Class IV critically ill surgical ICU patients and compared to the same data obtained in less critically ill Class II and III ICU patients who served as the control group. For the physiologic indicators of critical illness, a wide range of normal values was established prospectively. The actual values generated by Class IV patients were compared to values of the same indicators as measured in Class II and III ICU patients. Of all objective indicators of critical illness, 55% were either outside the normal range or more than 2 SD away from the mean value of objective indicators for Class II and III ICU patients; 49% were beyond the normal range or more than 3 SD away. Of all TISS indicators, 73% were abnormal, and 36% of all physiologic indicators were still abnormal despite massive therapeutic support when compared to Class II or III ICU patients. Those patients who had more than 40% of their physiologic indicators abnormal were more likely to die. However, the percentage of abnormal TISS indicators did not discriminate between patients who died and those who lived, because almost all patients received massive support.(ABSTRACT TRUNCATED AT 250 WORDS)

Critical Care↗
PubMed1983

Therapeutic Intervention Scoring System: update 1983.

The Therapeutic Intervention Scoring System (TISS) introduced in 1974 has become a widely accepted method of classifying critically ill patients. In response to requests to update the system because of recent innovations in critical care, some items have been deleted, some have been added, and certain point scores have been adjusted. Explanations of items within the system and guidelines for the user are included. A comparison of the new 1983 system to the old 1974 system in 100 consecutive patients reveals no difference in total point scores. We hope this updated explanation will ease the task of assessing use of intensive care services.

Critical Care↗