Laws, guidelines and professional choice.
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Decision Making↗
Biomedical subjects
Joel Dunning
Publications and source records attributed to Joel Dunning.
Coronary bypass grafting using crossclamp fibrillation does not result in reliable reperfusion of the myocardium when the crossclamp is intermittently released: a prospective cohort study.
BACKGROUND: Cross-clamp fibrillation is a well established method of performing coronary grafting, but its clinical effect on the myocardium is unknown. We sought to measure these effects clinically using the Khuri Intramyocardial pH monitor. METHODS: 50 episodes of cross-clamping were recorded in 16 patients who underwent CABG with crossclamp-fibrillation. An Intramyocardial pH probe measured the level of acidosis in the anterior and posterior myocardium in real-time. The pH at the start and end of each period of cross-clamping was recorded. RESULTS: It became very apparent that the pH of some patients recovered quickly while others entirely failed to recover. Thus the patients were split into 2 groups according to whether the pH recovered to above 6.8 after the first crossclamp-release (N = 8 in each group). Initial pH was 7.133 (range 6.974-7.239). After the first period of crossclamping the pH dropped to 6.381 (range 6.034-6.684). The pH in recoverers prior to the second XC application was 6.990 (range 6.808-7.222) compared to only 6.455 (range 6.200-6.737) in patient's whose myocardium did not recover (P < 0.0005). This finding was repeated after the second XC release (mean pH 7.005 vs 6.537) and the third (mean pH 6.736 vs 6.376). However prior to separation from bypass the pH was close to the initial pH in both groups (7.062 vs 7.038). CONCLUSION: Crossclamp fibrillation does not result in reliable reperfusion of the myocardium between periods of crossclamping.
Aged↗
Guidelines on the prevention and management of de novo atrial fibrillation after cardiac and thoracic surgery.
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Adrenergic beta-Antagonists↗
A clinical tool for assessing risk after self-harm.
STUDY OBJECTIVE: Our aim is to develop a risk-stratification model for use by emergency department (ED) clinical staff in the assessment of patients attending with self-harm. METHODS: Participants were patients who attended 5 EDs in Manchester and Salford, England, after self-harm between September 1, 1997, and February 28, 2001. Social, demographic, and clinical information was collected for each patient at each attendance. With data from the Manchester and Salford Self-Harm Project, a clinical decision rule was derived by using recursive partitioning to discriminate between patients at higher and lower risk of repetition or subsequent suicide occurring within 6 months. Data from 3 EDs were used for the derivation set. The model was validated with data from the remaining 2 EDs. RESULTS: Data for 9,086 patients who presented with self-harm were collected during this study period, including 17% that reattended within 6 months and 22 patients who died by suicide within 6 months. A 4-question rule, with a sensitivity of 94% (92.1-95.0% [95% confidence interval]) and specificity of 25% (24.2-26.5% [95% confidence interval]), was derived to identify patients at higher risk of repetition or suicide. CONCLUSION: Application of this simple, highly sensitive rule may facilitate assessment in the ED and help to focus psychiatric resources on patients at higher risk.
Adolescent↗
The Cardiac Surgery Advanced Life Support Course (CALS): delivering significant improvements in emergency cardiothoracic care.
BACKGROUND: A 3-day cardiac surgery advanced life support course was designed with a series of protocols to manage critically ill cardiac surgical patients and patients who suffer a cardiac arrest. We sought to determine the effect of this course on the management of simulated critically ill and cardiac arrest patients. METHODS: Twenty-four candidates participated in the course. Critically ill patients were simulated using intubated mannikins, with lines and drains in situ, and a laptop with an intensive care unit monitor simulation program. Candidates were tested before and after the course with rigidly predesigned clinical situations. Candidates were split into groups of 6, and cardiac arrests were simulated in the same fashion, with all required surgical equipment immediately available. All scenarios were videotaped, and after blinding, an independent surgeon assessed the times to achieve predetermined clinical endpoints. RESULTS: The time to successful definitive treatment was significantly faster postcourse for the critically ill patient scenarios: (565 secs [SD 27 secs] precourse, compared with 303 secs [SD 24 secs] postcourse; p < 0.0005). In addition, the times taken to achieve a wide range of predetermined objectives, including airway check, assessing breathing, circulation assessment, treating with oxygen, appropriate treatment of the circulation, and requesting blood gases, chest radiographs, and electrocardiograms, were also significantly faster in the postcourse scenarios. Times to successful chest reopening and internal cardiac massage were also significantly improved in cardiac arrest patients: (451 secs [SD 39 secs] precourse and 228 secs [SD 17 secs] postcourse; p = 0.011). CONCLUSIONS: Structured training and practice in the management of critically ill cardiac surgical patients and patients suffering a cardiac arrest leads to significant improvements in the speed and quality of care for these patients.
Cardiopulmonary Resuscitation↗
Are the American College of Chest Physicians guidelines for the prevention and management of atrial fibrillation after cardiac surgery already obsolete?
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Atrial Fibrillation↗
Best evidence topic report. S-100b protein levels as a predictor for long-term disability after head injury.
A short cut review was carried out to establish whether levels of S-100b were predictive of long-term disability after head injury. 200 papers were found using the reported searches, of which 12 presented the best evidence to answer the clinical question. The author, date, and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is concluded that a raised level of S-100b is a marker of poorer long-term outcome after both major and minor head injury.
Biomarkers↗
A meta-analysis of clinical correlates that predict significant intracranial injury in adults with minor head trauma.
Previous studies have resulted in conflicting results regarding the predictive effect of various clinical symptoms, signs, and plain imaging for intracranial pathology in adults with minor head injury. We sought to perform a meta-analysis of the literature to assess the significance of these factors for the prediction of intracranial hemorrhage (ICH). The literature was searched using Medline, Embase, Experts, and the Grey literature. Reference lists of major guidelines were crosschecked. Included were control or nested case control studies of patients attending hospital with head injury that recorded clinical correlates relating to the outcome variable of presence or absence of ICH. The common relative risk ratio was calculated using the Mantel-Haenszel test with a pooled estimate. Thirty-five papers containing 83,636 patients were included in the meta-analysis after systematic review of the literature. Relative risk ratios were calculated for 23 clinical correlates from the history, the mechanism of injury, and the examination. In addition, adjusted relative risks were presented for those variables that showed significant heterogeneity across studies. Reasons for the heterogeneity are discussed. This study has determined the relative risks of 23 clinical variables that may predict the presence of an ICH in patients after minor head injury. These risks should prove invaluable to clinicians for the assessment of individual patients as well as the assessment of guidelines presented for the management of minor head injuries.
Adult↗
Best evidence topic report. Cardiopulmonary bypass and the survival of patients in cardiac arrest.
A short cut review was carried out to establish whether cardiopulmonary bypass improves survival and function after cardiac arrest resistant to ACLS. Altogether 387 papers were found using the reported search, of which nine presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.
Advanced Cardiac Life Support↗
Best evidence topic report. Antibiotics in acute exacerbations of chronic obstructive pulmonary disease.
A short cut review was carried out to establish whether antibiotics improve recovery in patients with acute exacerbations of COPD. Altogether 200 papers were found using the reported search, of which four presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.
Acute Disease↗
The frequency of pleural effusions after Bellovac drainage following coronary bypass grafting.
BACKGROUND: A common postoperative complication after CABG with internal mammary artery (IMA) harvest is the evolution of a pleural effusion. Our aim was to see if the intra-operative insertion of a Bellovac drain to the pleural cavity, with drainage continuing for 4-days post operation, eliminates the complication of pleural effusion. METHODS: Using our computerised audit database, 500 consecutive patients were identified who had undergone CABG including at least one internal mammary graft by a single consultant at Blackpool Victoria Hospital. All these patients received Bellovac drainage for 4 days on the side of the harvested IMA. The chest X-ray reports were retrospectively collected from the hospital computer databases. The 4-day post-operative, and the 6-week post-operative films were found. In the cases where no consultant radiologist report was found J.D. reviewed the film, and any abnormalities were also reviewed by R.W.J.M. RESULTS: Out of 500 radiographs, six patients (1.2%) died, 25 patients had no traceable record of a chest X-ray, 434 patients had an entirely normal chest X-ray and 461 patients had no effusion at 6 weeks. Six patients had a small effusion at 6 weeks, two had a moderate effusion successfully treated conservatively, and no patients had a pleural effusion that required drainage. CONCLUSION: In patients undergoing coronary arterial bypass grafting with internal mammary artery harvest, the intra-operative insertion of a Bellovac drain on the side of the harvested IMA reduces the risk of postoperative pleural effusions
Adult↗
A validated rule for predicting patients who require prolonged ventilation post cardiac surgery.
OBJECTIVE: Prolonged ventilation post surgery causes logistic problems on cardiac surgical intensive care units (CSU). We thus sought to derive and validate a clinical decision rule to predict patients at high risk of prolonged ventilation, so that the timing of operations on high risk patients can be optimised in the context of the workload of the CSU. METHODS: The North Staffordshire Royal Infirmary (NSRI) Open Heart Registry was analysed from April 1998 to May 2002. Prolonged ventilation was defined as that which was longer than 24 h. The Parsonnet score was assessed for its ability to predict these patients. Univariate analysis was first performed to identify predictive variables. Recursive partitioning and logistic regression was then performed to identify the optimal decision rule. This rule was then validated on the Blackpool Victoria Hospital (BVH) Open Heart Registry. RESULTS: A total of 3,070 patients were analysed of whom 201 were ventilated for more than 24 h. A Parsonnet score of 10 predicted 49% of high risk patients but 618 low risk patients are misclassified. Our rule that uses Parsonnet score over 7, ejection fraction, operation status, PA pressure and age, to identify high risk patients identifies 50% of those needing prolonged ventilation and only incorrectly identifies 282 of the 2869 patients with normal ventilation times giving a specificity of over 90%. Validation in the BVH database demonstrated similar findings. CONCLUSION: Our rule identifies 14% of all our patients as high risk and 50% of these required prolonged ventilation. Such a rule allows more efficient use of scarce CSU resources by appropriate surgical scheduling.
Aged↗
Ultrasonic guidance and the complications of central line placement in the emergency department.
A short cut review was carried out to establish whether ultrasonic guidance reduces the complication rate during central line placement in the emergency department. Altogether 349 papers were found using the reported search, of which two presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.
Catheterization, Central Venous↗
The utility of the tongue blade test for the diagnosis of mandibular fracture.
A short cut review was carried out to establish whether the tongue blade test is useful in the clinical assessment of patients with mandibular trauma. Altogether 269 papers were found using the reported search, of which two presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.
Disposable Equipment↗
Evaluation of a cardiac surgery advanced life support course.
The most critical emergency situation seen in cardiac surgical units is the need for chest reopening. While senior nurses often manage cardiac arrest they currently are not trained to open chests, which can be a life-saving action if performed efficiently. This article evaluates a three-day cardiac surgery advanced life support course with protocols to manage critically ill cardiac surgical patients who suffer a cardiac arrest and who need their chest reopening.
Advanced Cardiac Life Support↗