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Biomedical subjects

David L Reich

Publications and source records attributed to David L Reich.

18 recordsLinked to original sources
PubMed2006

Development of a module for point-of-care charge capture and submission using an anesthesia information management system.

BACKGROUND: The use of electronic charge vouchers in anesthesia practice is limited, and the effects on practice management are unreported. The authors hypothesized that the new billing technology would improve the effectiveness of the billing interface and enhance financial practice management measures. METHODS: A custom application was created to extract billing elements from the anesthesia information management system. The application incorporates business rules to determine whether individual cases have all required elements for a complete and compliant bill. The metrics of charge lag and days in accounts receivable were assessed before and after the implementation of the electronic charge voucher system. RESULTS: The average charge lag decreased by 7.3 days after full implementation. The total days in accounts receivable, controlling for fee schedule changes and credit balances, decreased by 10.1 days after implementation, representing a one-time revenue gain equivalent to 3.0% of total annual receipts. There are additional ongoing cost savings related to reduction of personnel and expenses related to paper charge voucher handling. CONCLUSIONS: Anesthesia information management systems yield financial and operational benefits by speeding up the revenue cycle and by reducing direct costs and compliance risks related to the billing and collection processes. The observed reductions in charge lag and days in accounts receivable may be of benefit in calculating the return on investment that is attributable to the adoption of anesthesia information management systems and electronic charge transmission.

Anesthesia↗
PubMed2006

Future directions in cardiac and vascular anesthesia: unanswered questions regarding variables controllable by anesthetic management.

The influence of anesthetic choices and techniques upon outcomes in cardiac surgery is difficult to ascertain because of the low incidence of morbid and fatal outcomes that are attributable to anesthetic management. This discussion summarizes several areas that have been addressed in clinical trials, including temperature management, intraoperative hemodynamics, and glucose control.

Anesthesia↗
PubMed2005

Multi-platforms medical computer systems integration.

Presently, software architects face the challenge of integrating and linking different application software packages built on different computer platforms. Often they inherit various systems, ranging from mainframe to PDA-based applications. The first stage before programming different interfaces is to identify the means of communications most suitable for particular systems. The experience of the Mount Sinai Medical Center in New York, which combines a hospital, a healthcare network, a research center and a medical school, illustrates common problems faced by a number of medical institutions. This paper will discuss the various options, including the Internet, software architects have, and how they can use them during the development of an infrastructure for health care systems.

Academic Medical Centers↗
PubMed2005

Antifibrinolytic use and bleeding during surgery on the descending thoracic aorta: a multivariate analysis.

OBJECTIVES: The purpose of this study was to determine the potential benefit of antifibrinolytic (AF) therapy in improving hemostasis in descending aortic surgery in which extracorporeal distal perfusion is used. DESIGN: Retrospective database study. SETTING: University hospital. PARTICIPANTS: Seventy-two patients who underwent descending thoracic or thoracoabdominal aortic replacement during the period from January 1993 through December 1996 when the use of AF therapy was emerging. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Seventy-two records met criteria for inclusion. The use of AF therapy had no significant effect on any bleeding or transfusion outcome in any model. Excessive chest tube drainage postoperatively was independently associated with repeat surgery and intraoperative hypothermia. The risk of receiving a red blood cell (RBC) transfusion was independently predicted by low preoperative hemoglobin and age > or =65 years. Cross-clamp was an independent predictor of receiving a transfusion of non-RBC products (p = 0.03). CONCLUSIONS: The authors could not show a beneficial effect of AF therapy on bleeding and transfusion, although current practice shows that this therapy continues to be used. Because heterogeneity of patient population exists and bias cannot be completely excluded, a prospective investigation evaluating efficacy and safety in this population is warranted.

Aged↗
PubMed2005

Predictors of hypotension after induction of general anesthesia.

Hypotension after induction of general anesthesia is a common event. In the current investigation, we sought to identify the predictors of clinically significant hypotension after the induction of general anesthesia. Computerized anesthesia records of 4096 patients undergoing general anesthesia were queried for arterial blood pressure (BP), demographic information, preoperative drug history, and anesthetic induction regimen. The median BP was determined preinduction and for 0-5 and 5-10 min postinduction of anesthesia. Hypotension was defined as either: mean arterial blood pressure (MAP) decrease of >40% and MAP <70 mm Hg or MAP <60 mm Hg. Overall, 9% of patients experienced severe hypotension 0-10 min postinduction of general anesthesia. Hypotension was more prevalent in the second half of the 0-10 min interval after anesthetic induction (P < 0.001). In 2406 patients with retrievable outcome data, prolonged postoperative stay and/or death was more common in patients with versus those without postinduction hypotension (13.3% and 8.6%, respectively, multivariate P < 0.02). Statistically significant multivariate predictors of hypotension 0-10 min after anesthetic induction included: ASA III-V, baseline MAP <70 mm Hg, age > or =50 yr, the use of propofol for induction of anesthesia, and increasing induction dosage of fentanyl. Smaller doses of propofol, etomidate, and thiopental were not associated with less hypotension. To avoid severe hypotension, alternatives to propofol anesthetic induction (e.g., etomidate) should be considered in patients older than 50 yr of age with ASA physical status > or =3. We conclude that it is advisable to avoid propofol induction in patients who present with baseline MAP <70 mm Hg.

Adult↗
PubMed2004

Using jugular bulb oxyhemoglobin saturation to guide onset of deep hypothermic circulatory arrest does not affect post-operative neuropsychological function.

OBJECTIVES: Deep hypothermic circulatory arrest (DHCA) is commonly used during thoracic aortic surgery, and is initiated only after a sufficient degree of cerebral hypothermia is induced. The criteria for initiating DHCA vary among institutions: most centers use temperature criteria, some use electroencephalography, and a minority use jugular bulb oxyhemoglobin saturation SjO(2) criteria. The purpose of this study was to determine whether the use of SjO(2) monitoring to guide the onset of DHCA was associated with better post-operative neuropsychological outcome. METHODS: Sixty-one thoracic aortic surgical patients underwent both pre- and post-operative neuropsychological testing. Patients were divided into three groups: (1) those with SjO(2)> or =95% at DHCA onset; (2) those with SjO(2)<95% at DHCA onset; and (3) those without SjO(2) monitoring. RESULTS: There were no statistically significant differences in the incidence of post-operative decline in neuropsychological function among the three groups of patients. Patients in whom SjO(2) data were used to guide onset of DHCA had lower esophageal and bladder temperatures at that time compared with patients without SjO(2) monitoring. CONCLUSIONS: Monitoring of SjO(2) had no apparent effect upon post-operative neuropsychological outcome, and there were no trends in our small patient cohort suggesting differences that our study was not adequately powered to detect. Use of SjO(2) monitoring was associated with more profound hypothermia prior to DHCA due to more prolonged cooling in attempts to bring the SjO(2) above the 95% threshold. Using our institutional cooling protocol, SjO(2) monitoring does not appear to increase neuroprotection in patients undergoing DHCA for thoracic aortic repairs.

Adult↗
PubMed2004

Comparison of cisatracurium and vecuronium by infusion in neonates and small infants after congenital heart surgery.

BACKGROUND: Neonates and infants often require extended periods of mechanical ventilation facilitated by sedation and neuromuscular blockade. METHODS: Twenty-three patients aged younger than 2 yr were randomly assigned to receive either cisatracurium or vecuronium infusions postoperatively in a double-blinded fashion after undergoing congenital heart surgery. The infusion was titrated to maintain one twitch of a train-of-four. The times to full spontaneous recovery of train-of-four without fade, extubation, intensive care unit discharge, and hospital discharge were documented after drug discontinuation. Sparse sampling after termination of the infusion and a one-compartment model were used for pharmacokinetic analysis. The Mann-Whitney U test and Student t test were used to compare data between groups. RESULTS: There were no significant differences between groups with respect to demographic data or duration of postoperative neuromuscular blockade infusion. The median recovery time for train-of-four for cisatracurium (30 min) was less than that for vecuronium (180 min) (P < 0.05). Three patients in the vecuronium group had prolonged train-of-four recovery: Two had long elimination half-lives for vecuronium, and one had a high concentration of 3-OH vecuronium. There were no differences in extubation times, intensive care unit stays, or hospital stays between groups. CONCLUSIONS: Our results parallel data from adults demonstrating a markedly shorter recovery of neuromuscular transmission after cisatracurium compared with vecuronium. Decreased clearance of vecuronium and the accumulation of 3-OH vecuronium may contribute to prolonged spontaneous recovery times. Cisatracurium is associated with faster spontaneous recovery of neuromuscular function compared with vecuronium but not with any differences in intermediate outcome measures in neonates and infants.

Atracurium↗
PubMed2003

Emergency and elective coronary artery bypass grafting: comparisons of risk profiles, postoperative outcomes, and resource requirements.

OBJECTIVE: To investigate the association between preoperative risk factors and postoperative outcomes in emergency and elective coronary artery bypass graft (CABG) patients and to quantify resource requirements. DESIGN: Retrospective database review. SETTING: New York State SPARCS database. PARTICIPANTS: Data from 4,001 emergency and 7,489 elective CABG patients were evaluated retrospectively. INTERVENTIONS: Data were compared between groups using chi-squares, t tests, and logistic regression analysis. MEASUREMENTS AND MAIN RESULTS: Preoperatively, 47.1% of patients in the emergency group had unstable angina and 34.1% had acute myocardial infarction compared with 33.9% and 15.2% in the elective group, respectively (p < 0.0001). There were no marked differences in the preoperative noncardiac risk factors between groups. The mortality rate was 4.7% in the emergency group and 2.6% in the elective group (p < 0.0001). The emergency group had more postoperative cardiac complications (18.3% v 8.3%, p < 0.0001). The length of hospital stay in the emergency group was 17.5 +/- 15.8 days (median 14 days) compared with 12.9 +/- 15.1 days (median 9 days) in the elective group (p < 0.00001). Total hospital charges in the emergency and elective groups were 46,700 US dollars +/- 42,400 US dollars (median 35,600 US dollars ) and 34,800 US dollars +/- 36,400 US dollars (median 26,500 US dollars) (p < 0.00001), respectively. The median total cost was 26,300 US dollars for emergency and 19,600 US dollars for elective group (p < 0.00001). CONCLUSION: Patients undergoing emergency CABG had greater postoperative morbidity and mortality, longer LOS, and higher total costs than patients undergoing elective surgery. This difference is predictable on the basis of preoperative cardiac risk factors. Emergency operations have a major impact on the rates of morbidity, mortality, and use of resources.

Age Factors↗
PubMed2003

Association of intraoperative hypotension and pulmonary hypertension with adverse outcomes after orthotopic liver transplantation.

BACKGROUND: Various preoperative, surgical, and postoperative markers of impaired outcome after orthotopic liver transplantation have been reported, but the influence of intraoperative hemodynamic aberrations has not been thoroughly investigated. SETTING: University Hospital.Study design Retrospective cohort analysis. METHODS: The authors retrospectively reviewed computerized anesthesia records to determine associations between occurrences of abnormally low or high mean pulmonary artery pressure (MPAP), cardiac output, heart rate, systolic arterial pressure, diastolic arterial pressure, and mean arterial pressure (MAP) with negative surgical outcome. Negative surgical outcome was defined as poor early graft function, primary graft nonfunction, or death attributable to hemodynamic causes. RESULTS: Of 789 patients, 142 (18.0%) had negative surgical outcome. Controlling for the influence of United Network for Organ Sharing (UNOS) status > 1, long operation time, cold donor organ ischemia time, and donor age, the only hemodynamic parameters that were independently associated with negative surgical outcome were MAP < 40 mmHg at least once during the procedure (odds ratio [OR] 2.39, p = 0.0016) and MPAP > 40 mmHg at least 3 times during the procedure (OR 2.2, p = 0.035). The occurrence of MAP < 40 mmHg was temporally associated with donor graft reperfusion. Hepatic artery thromboses were not associated with hemodynamic aberrations. CONCLUSIONS: Hemodynamic events are independently associated with adverse outcomes after orthotopic liver transplantation.

Blood Pressure↗
PubMed2002

Validation of a preoperative risk index as a predictor of perioperative morbidity and hospital costs in coronary artery bypass graft surgery.

OBJECTIVE: To validate a previously developed model (CABDEAL) for predicting postoperative morbidity for coronary artery bypass graft (CABG) surgery patients using the New York State Statewide Planning and Research Cooperative System (SPARCS) database and to examine the effects of preoperative risk factors, postoperative complications, and death on costs of care for CABG surgery. DESIGN: Retrospective database review. SETTING: Governmental agency database of cardiac surgery. PARTICIPANTS: CABG surgery patients (n = 15,388). INTERVENTIONS: A previously developed preoperative risk model (CABDEAL) was applied to all patients. Predicted length of hospital stay and costs were compared with actual length of stay and costs, using a charge-to-cost conversion formula. MEASUREMENTS AND MAIN RESULTS: The CABDEAL model was moderately predictive of outcomes. The specificity was 64%, the sensitivity was 73.8%, and the receiver operating characteristic curve area was 0.728. Morbidity in the form of postoperative complications was recorded in 24.5% (3,770 patients), and the mortality rate was 3.4% (527 patients). The mean (+/- SD) total hospital cost was 28,408 US dollars +/-28,982, and the median cost was 21,644 US dollars. Based on the linear regression model, an equation was developed for predicting total costs: Cost (in US dollars) = 22,952 + (3,277. [CABDEAL score]). CONCLUSION: The previously developed CABDEAL model was predictive of increased morbidity in the SPARCS database. Total hospital costs increased nearly linearly with increasing CABDEAL score. These results encourage the development of models for preoperative estimation of costs related to perioperative morbidity.

Aged↗
PubMed2002

The anesthetic considerations in patients with ventricular assist devices presenting for noncardiac surgery: a review of eight cases.

IMPLICATIONS: The number of patients supported by ventricular assist devices (VADs) that present for noncardiac surgery is increasing in our institution. Our recent experience with eight such patients is reported, along with a review of the most commonly implanted VADs and the anesthetic implications and considerations for VAD-supported patients undergoing noncardiac surgery.

Adult↗
PubMed2002

Intraoperative tachycardia and hypertension are independently associated with adverse outcome in noncardiac surgery of long duration.

UNLABELLED: Relatively little is known about the influence of intraoperative hemodynamic variables on surgical outcomes. We drew subjects (n = 797) from a study of patients undergoing major noncardiac surgery. The physiological component of the POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality) operative risk stratification index was determined, and intraoperative measurements of heart rate (HR), mean arterial blood pressure, and systolic arterial blood pressure (SAP) were retrieved from computerized anesthesia records. For every 5-min epoch during the surgery, HR, mean arterial blood pressure, and SAP were each classified as low, normal, or high. Negative surgical outcome (NSO) was defined as a hospital stay of >10 days with a morbid condition or death during the hospital stay. Statistical analyses included Mantel-Haenszel tests and multiple logistic regression. There was no significant association between hemodynamic variables and NSO with short operations. In 388 patients with operations longer than the median time of 220 min, NSO occurred in 15.6%. Controlling for POSSUM score and operation time beyond 220 min, both high HR (odds ratio, 2.704; P = 0.01) and high SAP (odds ratio, 2.095; P = 0.009) were associated with NSO in longer operations. Thus, intraoperative tachycardia and hypertension were associated independently with adverse outcomes after major noncardiac surgery of long duration, over and above the risk imparted by underlying medical conditions. IMPLICATIONS: Intraoperative tachycardia and hypertension were associated with negative postoperative outcomes after major noncardiac surgery of long duration. These results imply that intraoperative tachycardia and hypertension may have independent effects on outcome over and above the risk imparted by underlying medical conditions.

Adult↗
PubMed2002

A retrospective analysis of the costs and benefits related to alterations in cardiac surgery from routine intraoperative transesophageal echocardiography.

UNLABELLED: We sought to determine how frequently intraoperative transesophageal echocardiography (TEE) altered the planned surgical procedure and to assess the potential cost implications associated with these changes. A retrospective chart review was conducted at one university hospital. Cardiac surgical operative notes from July 1999 through June 2000 were reviewed. We interrogated all adult cardiac surgical records for patients scheduled for repair of coronary artery disease or valvular disease requiring the use of cardiopulmonary bypass. Cancellations based on TEE findings were included in the analysis. Of the 430 patient records reviewed, 24 procedures were ether canceled or changed on the basis of the intraoperative TEE examination (5.6%; 95% confidence interval, 3.6%-8.2%). Six of these cases involved valvular heart disease, and the remaining 18 involved the intraoperative diagnosis and repair of a patent foramen ovale. A cost-benefit analysis based on the 6 valvular diagnoses revealed a saving of $230 per patient. Assuming that unnecessary present or future operations may be avoided by altering the surgical plan on the basis of TEE findings, these preliminary data suggest that routine intraoperative TEE in cardiac surgery is beneficial and cost-effective. IMPLICATIONS: A review of 430 adult cardiac surgical records indicates that routine transesophageal echocardiography during cardiac surgery, including coronary artery surgery, is beneficial and cost-effective.

Cardiac Surgical Procedures↗
PubMedDate not supplied

Preemptive epidural analgesia for thoracic surgery.

The purpose of this study was to determine if preemptive epidural analgesia performed before thoracotomy incision and during the operation reduces postoperative pain. Patients in the treatment group received 8 mL of 0.25% bupivacaine and 2 mL of fentanyl (50 microg/mL) via the epidural route prior to skin incision, followed by an infusion of bupivacaine 0.1% and fentanyl 10 microg/mL at 6 mL/hr. The control group received saline in the epidural. All patients in both groups were dosed with 8 mL of 0.25% bupivacaine and 2 mL of fentanyl 50 microg/mL via the epidural route at the time of the chest closure. The patients in the treatment group required less isoflurane intraoperatively and had lower maximum pain scores in the first 6 hours postoperatively. No significant differences were noted after the first 6 hours.

Analgesia, Epidural↗