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Biomedical subjects

Marina Krol

Publications and source records attributed to Marina Krol.

10 recordsLinked to original sources

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↗

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↗

Pre-donation assessment of kidneys by magnetic resonance angiography and venography: accuracy and impact on outcomes.

Reports on the accuracy of magnetic resonance angiography (MRA) and magnetic resonance venography (MRV) in evaluating living donor renovasculature employ few patients or omit the consequences of inaccurate scans. We retrospectively compared intraoperative findings to MRA/MRV scans in 146 donor-recipient pairs. For detecting accessory arteries and early branching, MRA sensitivity was 57.6%, specificity 96.5%, false positive rate 3.5%, false negative rate 42.4%, positive predictive value 82.6%, negative predictive value 88.6% and overall accuracy 87.7%. By excluding clinically inconsequential accessory arteries, MRA sensitivity rose to 73.1%, specificity to 96.7% and overall accuracy to 92.5%. For MRVs, sensitivity was 56.2%, specificity 99%, false positive rate 1%, false negative rate 43.8%, positive predictive value 90%, negative predictive value 94.8% and accuracy 94.5%. Inaccurate scans were associated with prolonged donor and recipient operations and more frequently reconstructed arteries, but did not affect clinical outcomes. Because most missed accessory arteries are inconsequential, MRA is a useful, less invasive method for defining donor renovascular anatomy.

Adult↗

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↗

Interscalene regional anesthesia for shoulder surgery.

BACKGROUND: Despite a trend toward the use of regional anesthesia for orthopaedic procedures, there has been resistance to the use of interscalene regional block for shoulder surgery because of concerns about failed blocks and potential complications. METHODS: We retrospectively reviewed the cases of 568 consecutive patients who had shoulder surgery under interscalene regional block in a tertiary-care, university-based practice with an anesthesiology residency program. The blocks were performed by a group of anesthesiologists who were dedicated to the concept of regional anesthesia in their practice. Complete anesthetic and orthopaedic records were available for 547 patients. The surgical procedure, planned type of anesthesia, occurrence of block failure, and the presence of complications were noted. RESULTS: Of the 547 patients, 295 underwent an arthroscopic procedure and 252 (including eighty who had an arthroplasty) underwent an open procedure. General anesthesia was the initial planned choice for sixty-nine patients because of the complexity or duration of the procedure, the anatomic location, or patient insistence. Thirty-four of the sixty-nine patients also received an interscalene regional block. Interscalene regional block alone was planned for 478 patients. A total of 462 patients (97%) had a successful block whereas sixteen required general anesthesia because the block was inadequate. The success of the block was independent of the type or length of the surgery. No patient had a seizure, pneumothorax, cardiac event, or other major complication. Twelve (2.3%) of the 512 patients who had a block had minor complications, which included sensory neuropathy in eleven patients and a complex regional pain syndrome that resolved at three months in one patient. For ten of the eleven patients, the neuropathy had resolved by six months. CONCLUSIONS: Interscalene regional block provides effective anesthesia for most types of shoulder surgery, including arthroplasty and fracture fixation. When administered by an anesthesiologist committed to and skilled in the technique, the block has an excellent rate of success and is associated with a relatively low complication rate.

Arthroplasty↗

Computerized case history--an effective tool for management of patients and clinical trials.

UNLABELLED: Monitoring diagnostic procedures, treatment protocols and clinical outcome are key issues in maintaining quality medical care and in evaluating clinical trials. For these purposes, a user-friendly computerized method for monitoring all available information about a patient is needed. OBJECTIVE: To develop a real-time computerized data collection system for verification, analysis and storage of clinical information on an individual patient. METHODS: Data was integrated on a single time axis with normalized graphics. Laboratory data was set according to standard protocols selected by the user and diagnostic images were integrated as needed. The system automatically detects variables that fall outside established limits and violations of protocols, and generates alarm signals.Results. The system provided an effective tool for detection of medical errors, identification of discrepancies between therapeutic and diagnostic procedures, and protocol requirements. CONCLUSIONS: The computerized case history system allows collection of medical information from multiple sources and builds an integrated presentation of clinical data for analysis of clinical trials and for patient follow-up.

Journal Article↗

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↗

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↗

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↗

Interscalene regional anesthesia for arthroscopic shoulder surgery: a safe and effective technique.

There has been resistance to the use of interscalene regional block for arthroscopic shoulder surgery because of concerns about potential complications and failed blocks with the subsequent need for general anesthesia. The purpose of this study was to assess whether interscalene regional block is safe and effective and offers many advantages over general anesthesia for outpatient arthroscopic shoulder surgery. Through a retrospective chart review of consecutive arthroscopic shoulder surgeries over a 2.5-year time period, in a tertiary university medical center with an anesthesiology residency, 277 interscalene blocks (96%) were successful; 12 (4%) required general anesthesia because of an inadequate block. There were no seizures, pneumothoraces, cardiac events, or other major complications. There was a 1% rate of minor complications, all of which were transient sensory neuropathies that resolved within 5 weeks on average. We conclude that interscalene block can provide effective anesthesia for arthroscopic shoulder surgery.

Adolescent↗