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Biomedical subjects

P R Kenney

Publications and source records attributed to P R Kenney.

12 recordsLinked to original sources
PubMed1992

Could the oxygen cost of breathing be used to optimize the application of pressure support ventilation?

Pressure support ventilation (PSV) is a new ventilator modality that augments spontaneous inspiratory pressure with selected levels of positive airway pressure. There is presently considerable interest in its use in the management of critically ill, ventilator-dependent patients. The optimal method for application has not yet been established. This study investigated the effects of PSV on the oxygen cost of breathing (OCOB), a clinically applicable technique for quantitating the work of breathing. The OCOB and other bedside variables of pulmonary function were measured during PSV in ventilator-dependent patients where weaning was limited by an inability to sustain respiratory work. Nine studies were performed in 8 patients in the surgical intensive care unit. The OCOB, tidal volume (VT), respiratory rate (RR), and minute ventilation (VE) were measured at various levels of pressure support. The OCOB was calculated from the difference in oxygen consumption (VO2) during mechanical and spontaneous ventilation both at CPAP and with PSV. With increasing levels of PSV, the OCOB was observed to steadily decrease from 22% to 8% (p < 0.001). There were also statistically significant increases in VT and decreases in RR. VE appeared not to be influenced. The results of this study suggest that the bedside measurement of the OCOB may be an accurate, simple, and reproducible method of titrating the level of applied pressure support in order to optimize respiratory work.

Aged↗
PubMed1991

Elective intrahospital admissions versus acute interhospital transfers to a surgical intensive care unit: cost and outcome prediction.

After a decade of intense fiscal scrutiny, appropriate utilization of intensive care resources remains controversial. In particular, the financial impact of patients transferred to a tertiary surgical intensive care unit (SICU) from a community hospital (interhospital) is unknown, especially when compared with elective (intrahospital) SICU admissions admitted from the tertiary center itself. We prospectively studied outcome and costs in 82 consecutive tertiary SICU admissions. Half were transferred acutely from community hospitals and half were transferred from within the hospital or postoperatively. Severity of illness (APACHE II) was scored on day 1, at the same time of the day (9:00-10:00 AM) and by one attending surgeon (BCB). Acute transfer patients had a significantly elevated mortality (36%) when compared with elective admissions (12%) (p less than 0.05). When stratified by APACHE II score, acute transfers had twice the mortality for equivalent APACHE II scores (p less than 0.05). Acute transfer patients with APACHE II scores greater than 19 had an 89% mortality; those nonsurvivors cost $128,652 each. From these results we conclude the following: (1) Acute transfer patients have a significantly elevated mortality when compared with elective intrahospital admissions with equivalent APACHE II day-1 scores; (2) patients transferred acutely to tertiary SICUs are significantly more costly, irrespective of outcome; (3) admission source (elective vs. acute transfer) should be seriously considered when evaluating patient outcome and cost in a SICU.

Acute Disease↗
PubMed1991

Trauma care for the elderly?

The enormous consumption of health-care resources by bluntly injured elderly patients can be justified if their outcome after trauma is good. In this series, 89% of injured elderly patients ultimately returned to their homes, either independent of (57%) or dependent on (32%) outside help. Factors contributing to increased mortality in such patients included age, injury severity, and the presence or absence of cardiac and septic complications. A Geriatric Trauma Survival Score (GTSS) was devised that predicted the likelihood of mortality in these patients. Finally, study of reimbursement indicated that Medicare does not adequately reimburse hospitals for the enormous cost of providing elderly trauma care.

Aged↗
PubMed1988

Do DRG payments adequately reimburse the costs of trauma care in geriatric patients?

The records of 82 consecutive trauma patients over age 65 years were reviewed to determine the costs of trauma care as well as the projected DRG reimbursement in the seriously injured elderly. During the period of study, 636 additional trauma patients under the age of 65 were admitted. For all trauma victims, hospital costs exceeded projected reimbursement by $2.55 million ($98,000 per month). In the elderly population, mean hospital costs dramatically exceeded mean projected reimbursement in patients over the age of 80 ($18,197 +/- 3,682 vs. $7,069 +/- 700; p less than 0.001), in patients with severe overall injury ($18,992 +/- 3,540 vs. $8,508 +/- 643; p less than 0.001), and in patients with more than one complication ($25,504 +/- 3,959 vs. $7,247 +/- 626; p less than 0.001). Hospital costs were also increased in elderly patients discharged to a nursing home ($22,811 +/- 3,664) primarily as a result of prolonged hospital stay in older patients with more severe injury and with more frequent complications. The daily cost for trauma care in elderly patients who died was a staggering $1,735 +/- 366, reflecting the aggressive care given these patients. In the elderly trauma population, the number of complications was the only factor that correlated with hospital costs (r = 0.63; p less than 0.001). There was no significant correlation between hospital costs and projected DRG reimbursement, suggesting that the current DRG system is a very poor predictor of actual costs for trauma care in this population. The data suggest that the present DRG system grossly underestimates hospital costs in patients more than 65 years old with severe injury and with complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1987

Survival after trauma in geriatric patients.

In contrast to other studies, a recent report from the authors' institution has shown a good prognosis for functional recovery in geriatric patients that survive trauma. Because most survivors regained their pre-injury function, the authors examined factors related to nonsurvival in this population of 82 consecutive blunt trauma victims older than the age of 65. Seventeen patients died (21%). Compared with survivors, nonsurvivors were older, had more severe overall injury, and had more severe head and neck trauma but did not differ in severity of trauma that did not involve the head and neck, number of body regions injured, mechanism of injury, or incidence of surgery after injury. Nonsurvivors experienced more frequent complications (82% vs. 33%, p less than 0.05), including a higher incidence of cardiac complications (53% vs. 15%, p less than 0.05) and ventilator dependence for 5 or more days (41% vs. 14%, p less than 0.05). Mortality rates were increased in patients who were 80 years of age or older compared with those ages 65-79 (46% vs. 10%, p less than 0.01), despite injury of similar severity. More frequent complications may contribute to an increased mortality rate in the older group, including an increased incidence of prolonged mechanical ventilation (36% vs. 12%, p less than 0.025), cardiac complications (54% vs. 10%, p less than 0.01), and pneumonia (36% vs. 16%, p less than 0.06). Severely injured patients (Injury Severity Score [ISS] greater than or equal to 25) older than 80 years old had a mortality rate of 80%, and the survivors required permanent nursing home care. Discriminant analysis yielded a reliable method of differentiating survivors from nonsurvivors based on age, ISS, and the presence of cardiac and septic complications. To assess the accuracy of the discriminant function, 61 consecutive patients admitted during 1985 were reviewed prospectively. Discriminant scoring predicted outcome correctly in 92% of these patients. A Geriatric Trauma Survival Score (GTSS) based on the discriminant function was calculated for each of the 143 patients studied and was highly correlated with mortality rate (r = 0.99, p less than 0.001). Thus, the GTSS may serve as a valuable tool for evaluating death in geriatric trauma victims. Furthermore, because complications are potentially avoidable and contribute to increased mortality rates, routine aggressive care for geriatric patients with moderate overall injury is indicated.

Aged↗
PubMed1987

Aggressive trauma care benefits the elderly.

Few past studies have examined the long-term functional outcome of geriatric patients who survive trauma. To evaluate factors that determine the long-term potential for recovery in this population, we studied 63 survivors of blunt trauma over age 65 years between 9 and 38 months after hospital discharge. The overall level of injury was moderate, with a mean Injury Severity Score of 15.8 +/- 1.1. Thirty-nine patients (62%) had two or more body regions injured. Forty-five patients (71%) had pre-existing cardiopulmonary disease. Surgery was required in half of the patients, one third experienced complications, and nine (14%) required ventilatory support for 5 or more days. Only two patients did not live independently before trauma. Immediately after discharge, 21 patients (33%) were independent, 23 (37%) were dependent but living at home, and 19 (30%) required nursing-home care (NH). NH patients were older, more severely injured, had more severe head and neck trauma, and required surgery more frequently after trauma than patients discharged directly home. Twelve of the 19 NH patients (63%) returned home 3.1 +/- 0.9 months after discharge, and 13 of the 23 dependent patients (57%) became independent. Ultimately, 56 patients (89%) returned home after trauma. These patients were younger, had a shorter hospital stay, and experienced fewer complications than patients who required permanent NH care. Among 12 patients 80 years old and over, eight patients eventually returned home. Overall, 38 patients (57%) returned to independent living after trauma. Aggressive support of the elderly trauma victim appears justified, since few patients require permanent NH care and the majority return to independent living after trauma.

Activities of Daily Living↗
PubMed1985

Enterococcal bacteremia in surgical patients.

In 73 surgical patients enterococcal bacteremia was preceded by antibiotic administration (n = 58), central venous catheters (n = 52), other-organism bacteremia (n = 44), and gastrointestinal tract operations (n = 41). Surgical wounds and urinary tract infections were the most frequent portal of entry. The overall mortality was 42%. The mortality risk was significantly greater in patients with preceding or concomitant gram-positive bacteremia and four or more days of cephalosporin administration prior to enterococcemia. In 21 patients who had been given cephalosporins and who had gram-positive bacteremia, specific antienterococcal therapy resulted in survival in five of nine patients, compared with three of 12 who survived without therapy. Enterococcal bacteremia in surgical patients follows antibiotic administration, central venous catheter use, other-organism bacteremia, and intra-abdominal operations. Preceding or concomitant gram-positive bacteremia defines a subgroup of patients with high mortality who seem to respond to antienterococcal therapy.

Adult↗
PubMed1985

Septic complications of corticosteroid administration after central nervous system trauma.

The records of 197 consecutive multiple trauma patients were reviewed to define the infectious complications of corticosteroids used to treat brain and spinal cord injury. An injury severity score (ISS) and a central nervous system (CNS) injury score were determined for each patient. Patients with an ISS less than 20 did well with or without steroids and were excluded from further study. All deaths that occurred 5 or more days after injury were caused by sepsis, and all occurred in steroid recipients. Twenty-nine of 61 steroid-treated early survivors developed infectious complications, compared to eight of 55 patients who did not receive steroids (47.5% vs. 14.5%, p less than 0.001). There was no correlation between severity of CNS trauma and infectious complication rate. Steroid-treated patients frequently developed multiple pathogen primary infections and multiple, simultaneous septic foci. Patients treated with steroids more often developed infections caused by Staphylococcus aureus, assorted gram negative rods, anerobic bacteria, or fungi. The study strongly suggests a significant increase in both the incidence and severity of infectious complications occurring in patients treated with corticosteroids for CNS trauma.

Adolescent↗
PubMed1985

Percutaneous inferior vena cava cannulation for long-term parenteral nutrition.

Thrombosis of the superior vena cava and its contributory veins from previous parenteral nutrition catheters precluded this approach for a new Hickman catheter in a patient with short-gut syndrome. Percutaneous puncture of the inferior vena cava with subcutaneous tunneling of the catheter to the anterior chest wall provided good access to the central venous circulation for long-term parenteral nutrition.

Catheterization↗
PubMed1983

Glucose and osmolality as predictors of injury severity.

Elevation in osmolality occurs after both injury and experimental hemorrhage. Similar elevations in glucose and cortisol have been found to correlate with both injury severity and survival. In this study, we have investigated the relationship between the severity of trauma and changes in glucose, osmolality, and cortisol in injured patients. Trauma severity was estimated using the Injury Severity Score, and correlation coefficients were computed for the three measured variables. Elevations in both osmolality and glucose correlated positively with severity of injury, whereas cortisol did not correlate. Although glucose and alcohol contributed to the rise in osmolality, they did not account for the entire increase. The results indicate that measured increases in osmolality and glucose following trauma may be useful in the prospective evaluation of its severity, especially in those patients with occult major injury. The lack of correlation of increased cortisol with injury severity suggests an interaction of multiple hormones resulting in the increase in osmolality and glucose.

Adolescent↗