PubMed Health⌕ Search

Biomedical subjects

I A Fein

Publications and source records attributed to I A Fein.

15 recordsLinked to original sources
PubMed1991

Clinical utility and cost-effectiveness of protective sleeve pulmonary artery catheters.

OBJECTIVE: To assess the clinical utility of protective sleeves in pulmonary artery (PA) balloon flotation catheters. DESIGN: Prospective, randomized trial with cost-effectiveness analysis. SETTING: A general adult ICU in a community teaching hospital. PATIENTS: All patients receiving PA balloon flotation catheters over a 1-yr period. INTERVENTIONS: Groups 1 and 2 received PA catheters with and without protective sleeves, respectively. Indications for catheter changes, other than catheter malposition, were the same for both groups. MEASUREMENTS AND MAIN RESULTS: In group 1, 54 patients received 71 catheters and four catheters were replaced due to the inability to obtain a PA occlusion pressure (PAOP) tracing. In group 2, 48 patients received 66 catheters, 11 of which were inserted due to failure to obtain a PAOP (p less than .05). PA catheters were repositioned successfully in 37/56 attempts in group 1, compared with 8/20 attempts in group 2 (p less than .05). There was no significant difference in complication rates between the two groups. Even at the increased cost of the protective sleeves and introducer ($7/kit), for 100 catheter insertions, we project a direct cost savings of $742, and personnel time savings of 10.5 hrs for physicians, 14 hrs for nurses, and 4.7 hrs for radiology technicians. CONCLUSION: Protective sleeves on PA catheters are safe, effective, cost-saving devices for ICU patients.

Aged↗
PubMed1991

Reduction of duration and cost of mechanical ventilation in an intensive care unit by use of a ventilatory management team.

OBJECTIVE: To test the hypothesis that a formal interdisciplinary team approach to managing ICU patients requiring mechanical ventilation enhances ICU efficiency. DESIGN: Retrospective review with cost-effectiveness analysis. SETTING: A 20-bed medical-surgical ICU in a 450-bed community referral teaching hospital with a critical care fellowship training program. PATIENTS: All patients requiring mechanical ventilation in the ICU were included, comparing patients admitted 1 yr before the inception of the ventilatory management team (group 1) with those patients admitted for 1 yr after the inception of the team (group 2). Group 1 included 198 patients with 206 episodes of mechanical ventilation and group 2 included 165 patients with 183 episodes of mechanical ventilation. INTERVENTION: A team consisting of an ICU attending physician, nurse, and respiratory therapist was formed to conduct rounds regularly and supervise the ventilatory management of ICU patients who were referred to the critical care service. MEASUREMENTS AND MAIN RESULTS: The two study groups were demographically comparable. However, there were significant reductions in resource use in group 2. The number of days on mechanical ventilation decreased (3.9 days per episode of mechanical ventilation [95% confidence interval 0.3 to 7.5 days]), as did days in the ICU (3.3 days per episode of mechanical ventilation [90% confidence interval 0.3 to 6.3 days]), numbers of arterial blood gases (23.2 per episode of mechanical ventilation; p less than .001), and number of indwelling arterial catheters (1 per episode of mechanical ventilation; p less than .001). The estimated cost savings from these reductions was $1,303 per episode of mechanical ventilation. CONCLUSION: We conclude that a ventilatory management team, or some component thereof, can significantly and safely expedite the process of "weaning" patients from mechanical ventilatory support in the ICU.

Aged↗
PubMed1990

Nursing perception of the availability of the intensive care unit medical director for triage and conflict resolution.

The Joint Commission on the Accreditation of Healthcare Organizations and the Society of Critical Care Medicine call on the physician medical director of the intensive care unit (ICU) to play an important role in admission and discharge decision-making. To assess nursing perception of the medical director's involvement in this decision-making, we analyzed data from a questionnaire administered at an annual ICU management conference to ICU nursing supervisors representing 101 hospitals and 137 ICUs. We asked nurses if the medical director or his or her designee (excluding residents) was available at night for triage, admission decision-making, and conflict resolution. In 21% (29) of the ICUs, nurses perceived no medical director at all. In the 54 ICUs with full-time medical directors, nurses in approximately 30% of the units said that there was no nighttime availability of the medical director or designee. The data suggest that many ICUs lack physician leadership in ICU management and resource allocation.

Conflict, Psychological↗
PubMed1988

Endotracheal tube occlusion associated with the use of heat and moisture exchangers in the intensive care unit.

A heat moisture exchanger (HME) with bacterial filtering capabilities was evaluated over an 8-month period in a total of 170 ICU patients. During this time there were 15 endotracheal tube (ETT) occlusions in 15 patients. Over the ensuing 4 months, cascade humidification was used for 81 patients and only one ETT occlusion occurred (p less than .01). The HMEs were replaced frequently with cascade humidifiers during the evaluation period because of inadequate airway humidification. The increase in ETT occlusion was associated with an increased incidence of pneumonia (p less than .001) and atelectasis (p less than .01). Most patients with ETT occlusion required minute volumes greater than 10 L and F10(2) greater than 0.4. We conclude that HMEs do not provide sufficient airway humidification for generalized ICU use. Their role outside of the operating room remains to be determined.

Adult↗
PubMed1983

Fluid resuscitation in circulatory shock: a comparison of the cardiorespiratory effects of albumin, hetastarch, and saline solutions in patients with hypovolemic and septic shock.

Twenty-six consecutive patients in hypovolemic shock were randomized to fluid challenge with 5% albumin (A), 6% hetastarch (H), or 0.9% saline (S) solutions. Fluid challenge consisted of 250 ml of test fluid every 15 min until the pulmonary artery wedge pressure (WP) reached 15 mm Hg. Thereafter, WP was maintained at 15 mm Hg for an additional 24 h with infusions of the same test fluid. Vital signs, hemodynamic and respiratory variables, as well as arterial lactate and colloid osmotic pressure (COP) were monitored according to protocol. Chest x-rays were performed by standardized technique before fluid challenge and at 12 and 24 h of maintenance fluid therapy and were evaluated for evidence of pulmonary edema. Cardiac function and hemodynamic stability were restored by fluid challenge with A, H, and S. Two to 4 times the volume of S as A or H was required to achieve similar hemodynamic endpoints. COP was increased by fluid challenge with A or H but was markedly reduced by fluid challenge with S and throughout the 24-h maintenance period. Fluid challenge resulted in reductions in COP-WP gradient of 62% in the A, 43% in the H, and 125% in the S groups. Resuscitation with S resulted in a significantly higher incidence of pulmonary edema (87.5%) than did resuscitation with A (22%) or H (22%). Urine output was not different among the groups at any time during the study. We conclude that 6% H performs as well as 5% A as a resuscitative fluid and that resuscitation with either of these colloids is associated with a lower incidence of pulmonary edema than is resuscitation with 0.9% S.

Aged↗
PubMed1982

Relation of colloid osmotic pressure to arterial hypoxemia and cerebral edema during crystalloid volume loading of patients with diabetic ketoacidosis.

The effect of crystalloid volume loading on serum colloid osmotic pressure, arterial oxygen (Po2), alveolar-arterial oxygen gradient (A-aDo2), and cerebral lateral ventricle dimensions was prospectively studied in 18 patients with diabetic ketoacidosis. Serial measurements showed concomitant decreases in colloid osmotic pressure, hematocrit, arterial Po2 (p less than 0.001), and significant increases in A-aDo2 (p less than 0.001) during treatment. Serial echoencephalograms were taken of 11 of the 18 patients; each patient served as his or her own control. Nine of these 11 patients showed significant decreases in lateral ventricle width during treatment; seven patients showed the echoencephalographic "hash" marks characteristic of cerebral edema. Follow up studies showed resolution of these abnormalities. Volume loading with large amounts of crystalloid solution seems to produce an acute hypooncotic state that may cause the development of both subclinical pulmonary and cerebral edema.

Adolescent↗
PubMed1980

Pulmonary edema; a complication of diabetic ketoacidosis.

Hemodynamic evaluation in two patients and analysis of pulmonary edema fluid in one patient with diabetic ketoacidosis and acute pulmonary edema were performed. Pulmonary arterial wedge pressures in both patients were low or normal (1 and 9 mm Hg). In one patient the colloid osmotic pressure of the pulmonary edema fluid was 68 percent of the value of the serum. The serum colloid osmotic pressure-pulmonary arterial wedge pressure gradient in the second patient was markedly reduced. Pulmonary edema complicating diabetic ketoacidosis may be the result of increased permeability of pulmonary capillary membranes and altered intravascular colloid-hydrostatic forces.

Adult↗
PubMed1978

Uremic pulmonary edema.

Pulmonary edema fluid analyses and hemodynamic evaluations were performed in two uremic patients with acute pulmonary edema. The colloid osmotic pressure of the pulmonary edema fluid ranged from 57 per cent to 93 per cent that of the serum. Although cardiac function was normal in both patients, the serum colloid osmotic pressure--pulmonary artery wedge pressure gradients were markedly reduced. Uremic pulmonary edema is the result of alterations of pulmonary intravascular Starling forces and increases in pulmonary capillary membrane permeability, allowing for the efflux of protein-rich fluid from the capillaries into the lung.

Adult↗
PubMed1978

Acute pulmonary edema in Plasmodium falciparum malaria.

This report describes a patient who developed acute pulmonary edema as a complication of Plasmodium falciparum malaria. Hemodynamic evaluation revealed a pulmonary artery wedge pressure of 3 mm Hg and a cardiac index of 4.6 liter per min per m2. The patient exhibited an acute decrease in serum colloid osmotic pressure from 25.1 mm Hg to 16.8 mm Hg. These findings suggest that pulmonary edema in this patient was the result of altered capillary membrane permeability.

Acute Disease↗
PubMed1978

Hyperchloremic acidosis during the recovery phase of diabetic ketosis.

We have studied 35 patients to find the occurrence of hyperchloremic acidosis during the recovery phase of diabetic ketoacidosis. At admission the patients had typical normochloremic acidosis, with increased anion gap exactly balancing decreased serum bicarbonate. In contrast, in 18 patients with phenformin-induced lactic acidosis, the increase in anion gap at admission was much greater than the decrease in bicarbonate. The difference between lactic acidosis and ketoacidosis may be explained by a slower rate of excretion of lactate than of ketone anions. After the patients with ketoacidosis were treated, the acidosis became predominantly hyperchloremic with normal anion gap. Failure to normalize serum bicarbonate is attributed to excretion of ketone anions in the urine.

Adolescent↗
PubMed1977

Colloid osmotic pressure as a prognostic indicator of pulmonary edema and mortality in the critically ill.

The relationship of colloid osmotic pressure (COP) to pulmonary edema and mortality in 128 critically ill patients was investigated in our critical care unit, and confirms previously reported observations. The COP in the 86 survivors was 22.0 (+/- 0.4 SEM) mm Hg versus 17.2 (+/- 0.6 SEM) mm Hg in the 42 who died (P less than 0.001). The patients were divided into three groups: 71 with no pulmonary edema, COP of 21.5 (+/- 0.5 SEM) mm Hg; 40 with cardiogenic pulmonary edema, COP of 21.4 (+/- 0.4 SEM) mm Hg; and 17 with noncardiogenic pulmonary edema, COP OF 13.6 (+/- 0.8 SEM) mm Hg. Colloid osmotic pressure was significantly lower in patients with noncardiogenic pulmonary edema (P less than 0.001). In 36 patients in whom pulmonary artery wedge pressures (PWP) were available, a COP-PWP gradient of 4.0 mm Hg or less was always associated with pulmonary edema, while a COP-PWP gradient greater than 4.0 mm Hg was never associated with pulmonary edema. Colloid osmotic pressure is a useful prognostic indicator of pulmonary edema and mortality in the critically ill.

Adolescent↗
PubMedDate not supplied

Fulminant noncardiogenic pulmonary edema in the critically ill.

The relationship between the serum colloid osmotic pressure (COPs), pulmonary artery wedge pressure (PWP), and pulmonary edema fluid colloid osmotic pressure was studied in six critically ill patients with fulminant noncardiogenic pulmonary edema. The relationship between COPs and PWP was also studied in 36 critically ill patients without pulmonary edema. The COPs-PWP gradient was normal in those patients without pulmonary edema. Three patients with noncardiogenic pulmonary edema had markedly reduced COPs-PWP gradients secondary to decreases in COPs. Their pulmonary edema fluid colloid osmotic pressure averaged 61% that of their serum colloid osmotic pressure. Three patients with noncardiogenic pulmonary edema had normal COPs-PWP gradients. Their pulmonary edema fluid colloid osmotic pressure averaged 92% that of their COPs. Noncardiogenic pulmonary edema in the critically ill patient may be caused by either a decrease of COPs-PWP gradient or an increase in capillary membrane permeability.

Adult↗