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Biomedical subjects

J V Snyder

Publications and source records attributed to J V Snyder.

At least 19 recordsLinked to original sources
PubMed1995

Acute care nurse practitioner curriculum: content and development process.

Curriculum development for preparation of acute care nurse practitioners requires a comprehensive process. To develop a program for their preparation at a large university, the faculty examined needs of the target patient population and care delivery system; scope of acute care nurse practitioner practice; current guidelines for the education of primary care nurse practitioners; evolving guidelines for the didactic and clinical education of acute care nurse practitioners; educational requirements of governing or licensing and certifying bodies; and placement of this new role within the existing healthcare team structure. A curriculum was then developed using a collaborative, multidisciplinary approach.

Acute Disease↗
PubMed1994

Trial of nurse practitioners in intensive care.

As public concern for quality control of medical care at the beginning of this century forced regulations on medical licensing of physicians, the forces of change in health care are again substantial, this time driven by concerns for cost and access. Our experience at the University of Pittsburgh Medical Center leads us to believe that well-trained physician extenders will play a valuable role in improving efficiency and effectiveness in the care of critically ill patients. We have developed a method for training and supervision. Graded practice supervision, with physician-led professional review, is considered a reasonable goal. We propose that the appropriate degree of supervision in any given area can be determined by: a) careful development of training programs; b) careful assessment of the individual's practice with the target patient population; and c) application of a review process that is sensitive in that population. Issues surrounding the independent practice and reimbursement of acute care nurse practitioners (ACNPs) are not resolved. These issues should be addressed by joint position statements that are based on objective documentation of the safe, effective performance of ACNPs, and on the incorporation of routine performance measurements with continued medical or joint evaluation of the quality review system. Guidelines regarding the evolving roles of ACNPs should be established by professional associations and state or national boards of both nursing and medical practice. Critical care physician and nursing leaders should lead such initiatives.

Clinical Protocols↗
PubMed1994

Outcome from central nervous system injury.

In general, coma portends a very poor outcome in ICU patients except when a drug overdose is the cause. Interactions with concurrent diseases and the cause of the comatose state are important variables that modify mortality rates. Recent studies have made it possible to predict irreversibility with a high degree of specificity in many cases. Three approaches show promise for early prediction of poor outcome--multivariate analysis, neurologic findings, and technologic innovations. Multivariate analysis of combinations of clinical conditions common in ICUs appears to have defined some patients whose prognosis is nearly hopeless, empirically. It would seem reasonable to consider withholding or withdrawing life support from these patients so that mere prolongation of death is avoided. Additional studies are needed and are relatively easy to perform with computerized statistical analyses of a readily available database derived from large patient populations in multicenter studies. A second useful approach for predicting irreversibility has arisen from studies using neurologic findings at defined time points after brain injury. The studies of Levy and colleagues exemplify this approach; their data suggest that coma can be declared irreversible with a high degree of confidence in a large subset of patients, delineated by simple sequential neurologic observations. Finally, technologies are evolving that may lead to noninvasive measurements to provide quantitative evidence of irreversible brain damage. Additional clinical studies are needed to validate the predictive value of these approaches to identifying patients who are certain to have a poor ultimate outcome. It then may be possible to predict function and irreversibility of central nervous system injury in individual cases with a high degree of certainty early in the clinical course.

Brain Injuries↗
PubMed1992

Pulse oximetry in the postoperative care of cardiac surgical patients. A randomized controlled trail.

STUDY OBJECTIVE: To demonstrate the utility of pulse oximetry in detecting clinically unapparent episodes of arterial desaturation in postoperative cardiac surgical patients and to evaluate the effect of pulse oximetry on ordering arterial blood gas analyses. DESIGN: Prospective, randomized, partially blinded comparison. SETTING: Cardiothoracic surgical intensive care unit. PATIENTS: 35 patients following elective cardiac surgical procedures. INTERVENTIONS: All patients were monitored continuously with pulse oximetry throughout their ICU course. In group 1 patients, the SpO2 data were available at the bedside. In group 2 patients, the SpO2 data were masked at the bedside and monitored at a remote location. MEASUREMENTS AND RESULTS: Utilization of pulse oximetry allowed a significant reduction in arterial blood gas utilization in group 1 (group 1: 12.4 +/- 7.5 blood gas analyses per ICU admission vs group 2: 23.1 +/- 8.8; p = 0.0007) without adverse events. Clinically unapparent desaturations were detected in 7 of 15 patients in group 2. CONCLUSIONS: Pulse oximetry improves patient safety through the detection of clinically unapparent episodes of desaturation and can allow a reduction in the number of blood gas analyses utilized without adverse effects to the patient. This may allow a potential cost savings to the patient.

Cardiac Surgical Procedures↗
PubMed1991

Risk monitoring of randomized trials in emergency medicine: experience of the Brain Resuscitation Clinical Trial II.

Risk monitoring for the Brain Resuscitation Clinical Trial II, a multicenter, placebo-controlled trial to evaluate the efficacy of the calcium-entry blocker lidoflazine in the amelioration of brain damage in comatose cardiac-arrest survivors, posed unexpected challenges. Concern arose when monitoring of adverse reactions showed an excess of dangerous cardiac arrhythmias, including rearrest, in the lidoflazine group. To ascertain the cause of this problem and determine whether it was ethical for the trial to continue, an in-depth review of data was conducted, outside experts were consulted, and additional data were collected. These efforts suggested possible causes for the problem. Existing drug administration protocols for blood pressure control were reinforced, resulting in lower subsequent arrhythmia rates. Thus, through an efficient monitoring system, an important problem was uncovered and resolved, allowing the trial to be completed without major changes.

Arrhythmias, Cardiac↗
PubMed1988

Flow resistance of expiratory positive-pressure systems.

We measured the flow-resistance of five commercially available 10 cm H2O expiratory positive-pressure (EPP) valves (n = five per valve type) at bias flows of between 0 and 2,000 ml/s. We found that individual valves of each type and manufacturer functioned similarly. Different valve types, however, functioned differently: with one type, system pressure was higher than rated (p less than 0.05), and with another type, system pressure was significantly flow-dependent (p less than 0.01). The remaining types of valves had no flow-resistive properties and maintained a system pressure of 10 cmH2O. We conclude that system pressure is not similar in all continuous positive airway pressure (CPAP) systems using bias flow and EPP valves. The work of breathing imposed by CPAP circuits will be increased in systems whose EPP valves have flow-dependent properties.

Airway Resistance↗
PubMed1987

Do periodic hyperinflations improve gas exchange in patients with hypoxemic respiratory failure?

Prolonged artificial ventilation may result in worsening gas exchange and pulmonary compliance in patients with otherwise normal lungs. Prolonged hyperinflations to 40 cm H2O can completely reverse deterioration of gas exchange and compliance in such patients. Similar efforts have effectively recruited atelectatic lung regions in critically ill patients. Less aggressive hyperinflations have not improved lung function in patients with abnormal lungs with hypoxemia. However, sustained exaggerated hyperinflations may successfully open collapsed lung units in these patients when standard recruitment techniques fail. We compared periodic hyperinflations of 40 cm H2O lasting 15 to 30 sec associated with body positioning (directed recruitment [DR]) to standard bag-sigh-suctioning (BSS) for their effects on gas exchange and pulmonary compliance in 16 stable surgical ICU patients with hypoxemic respiratory failure of 24-h duration or longer. Patients were sequentially alternated between DR and BSS (group 1, BSS followed by DR; group 2, DR followed by BSS). Neither technique, alone or in sequence, resulted in a sustained (greater than or equal to 5 min) improvement or deterioration in either gas exchange or pulmonary compliance. We conclude that neither BSS nor DR reliably affects gas exchange or compliance in patients with established hypoxemic respiratory failure.

Blood Gas Analysis↗
PubMed1986

Hospital guidelines for deciding about life-sustaining treatment: dealing with health "limbo".

The decision to withhold life-sustaining treatment from hopelessly ill patients is fraught with ethical dilemmas and legal uncertainties. Although there are extensive published commentaries on the subject and the law is gradually becoming clearer, care-givers often need concrete guidance when confronted with actual cases. Hospital ethics committees can assist care-givers, patients, and families in resolving these dilemmas, but the committees also need some specific guidance to be relatively consistent. Therefore, the Ethics and Human Rights Committee of Presbyterian-University Hospital, one of the University Health Center Hospitals in Pittsburgh, has developed guidelines for deciding about life-sustaining treatment.

Decision Theory↗
PubMed1985

LV filling pressure during PEEP measured by nadir wedge pressure after airway disconnection.

Pulmonary arterial occlusion pressure (Ppao) may not accurately reflect left ventricular filling pressure (LVFP) during ventilation with positive end-expiratory pressure (PEEP) because increases in pleural pressure (Ppl) increase measured intrathoracic vascular and cardiac chamber pressures relative to atmospheric while decreasing LVFP by decreasing venous return. Steady-state values of Ppao off PEEP are not useful in understanding the hemodynamics on PEEP because of changes in blood volume distribution and ventricular afterload associated with the removal of PEEP. We hypothesized that changes in Ppao immediately after abrupt airway disconnection from PEEP selectively reflect removal of PEEP-associated Ppl changes prior to other physiological changes. In pentobarbital-anesthetized closed-chest dogs, we compared absolute left atrial pressure and left atrial pressure relative to Ppl (Platm) prior to abrupt disconnection from 15 cmH2O PEEP (on-PEEP), with Ppao at its nadir (nadir Ppao) following airway disconnection in three sequential conditions: control (normal), after propranolol-induced acute ventricular failure, and after oleic acid-induced lung injury. For all conditions at low LVFP (less than 9 Torr), nadir Ppao reflects Platm better than on-PEEP Ppao, while at higher LVFP (greater than 9 Torr), on-PEEP Ppao better reflects Platm than nadir Ppao (P less than 0.05). Accurate predictions of on-PEEP Platm can be made using both on-PEEP and nadir Ppao values in a multiple regression equation.

Animals↗
PubMed1985

Subjective and objective measurement of tidal volume in critically ill patients.

Subjective assessment of the respiratory rate and the adequacy of tidal ventilation are the oldest and most widely practiced forms of respiratory monitoring in critically ill patients. Surprisingly, this method of assessment has itself never been evaluated in patients. The estimation of tidal volume in nine patients was performed by full-time intensive care unit (ICU) personnel and compared to the objective measurement of using a calibrated and validated respiratory inductive plethysmograph (RIP). Linear correlation analysis was performed. Poor correlation between clinical estimation by ICU personnel and actual measurement by RIP was revealed in all cases. A widespread and potentially dangerous tendency to overestimate tidal volume was noted. These data suggest that subjective assessment of tidal volume is inaccurate in critically ill patients and that the development of techniques of continuous, nonobtrusive and objective monitoring are to be encouraged.

Acute Disease↗
PubMed1985

Barotrauma and hypotension resulting from jet ventilation in critically ill patients.

We present the first reports of pneumoperitoneum secondary to jet ventilation, barotrauma secondary to jet ventilation through the suction port of a fiberoptic laryngoscope, and hypotension due to jet ventilation via nasotracheal and orotracheal catheters. We suggest that minimizing airway pressure and using jet catheters with side holes may help decrease the risk of such complications. We cannot, at present, recommend the use of hand-held jet ventilators unless both adequate exhalation space is guaranteed and direct impingement of the catheter's tip on the mucosal surface is avoided.

Aged↗