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Biomedical subjects

S K Kennedy

Publications and source records attributed to S K Kennedy.

9 recordsLinked to original sources
PubMed2000

Anesthesiologist direction and patient outcomes.

BACKGROUND: Anesthesia services for surgical procedures may or may not be personally performed or medically directed by anesthesiologists. This study compares the outcomes of surgical patients whose anesthesia care was personally performed or medically directed by an anesthesiologist with the outcomes of patients whose anesthesia care was not personally performed or medically directed by an anesthesiologist. METHODS: Cases were defined as being either "directed" or "undirected," depending on the type of involvement of the anesthesiologist, as determined by Health Care Financing Administration billing records. Outcome rates were adjusted to account for severity of disease and other provider characteristics using logistic regression models that included 64 patient and 42 procedure covariates, plus an additional 11 hospital characteristics often associated with quality of care. Medicare claims records were analyzed for all elderly patients in Pennsylvania who underwent general surgical or orthopedic procedures between 1991-1994. The study involved 194,430 directed and 23,010 undirected patients among 245 hospitals. Outcomes studied included death rate within 30 days of admission, in-hospital complication rate, and the failure-to-rescue rate (defined as the rate of death after complications). RESULTS: Adjusted odds ratios for death and failure-to-rescue were greater when care was not directed by anesthesiologists (odds ratio for death = 1.08, P < 0.04; odds ratio for failure-to-rescue = 1.10, P < 0.01), whereas complications were not increased (odds ratio for complication = 1.00, P < 0.79). This corresponds to 2.5 excess deaths/1,000 patients and 6.9 excess failures-to-rescue (deaths) per 1,000 patients with complications. CONCLUSIONS: Both 30-day mortality rate and mortality rate after complications (failure-to-rescue) were lower when anesthesiologists directed anesthesia care. These results suggest that surgical outcomes in Medicare patients are associated with anesthesiologist direction, and may provide insight regarding potential approaches for improving surgical outcomes. (Key words: Anesthesiologists; anesthesia care team; quality of care; mortality; failure-to-rescue; complication; Medicare; general surgery; orthopedics.)

Aged↗
PubMed1998

Preemptive epidural analgesia and recovery from radical prostatectomy: a randomized controlled trial.

CONTEXT: Preemptive analgesia can decrease the sensitization of the central nervous system that would ordinarily amplify subsequent nociceptive input, but a clear demonstration of its clinical efficacy is necessary for it to become a routine component of acute pain therapy. OBJECTIVE: To determine the impact of preemptive epidural analgesia on postoperative pain and other clinically important outcome variables after radical retropubic prostatectomy. DESIGN AND SETTING: A block randomized double-blind clinical trial lasting 20 months at a single academic medical center. PATIENTS: A total of 100 generally healthy and neurologically intact patients scheduled for radical retropubic prostatectomy for the treatment of prostate cancer in whom an epidural catheter for treating postoperative pain was to be placed prior to the induction of general anesthesia. INTERVENTIONS: Epidural bupivacaine, epidural fentanyl, or no epidural drug was administered prior to induction of anesthesia and throughout the entire operation, followed by aggressive postoperative epidural analgesia for all patients. MAIN OUTCOME MEASURES: Daily pain scores during hospitalization and pain scores obtained 3.5, 5.5, and 9.5 weeks after hospital discharge. RESULTS: The patients who received epidural fentanyl or bupivacaine prior to surgical incision (preemptive analgesia) experienced 33% less pain while hospitalized (P=.007). Pain scores in those receiving preemptive analgesia were significantly lower at 9.5 weeks (P=.02), but were not significantly different at 3.5 or 5.5 weeks. At 9.5 weeks, 32 (86%) of 37 patients receiving preemptive analgesia were pain-free compared with 9 (47%) of 19 control patients (P=.004). Patients receiving preemptive analgesia were more active 3.5 weeks after surgery (P=.01), but not at 5.5 or 9.5 weeks. CONCLUSIONS: Even in the presence of aggressive postoperative pain management, preemptive epidural analgesia significantly decreases postoperative pain during hospitalization and long after discharge, and is associated with increased activity levels after discharge.

Aged↗
PubMed1982

Head position, intracranial pressure, and compliance.

The effect of head position on intracranial pressure (ICP) and intracranial compliance was determined in 19 consecutive ICU patients. Ten had lower ICPs with the head raised 60 degrees, two were lower at 0 degrees, and seven were unchanged. Compliance improved with head elevation in five patients, improved with head lowering in four, and was unchanged in 10. The use of subarachnoid screw devices for compliance measurements was validated by simultaneously recording intraventricular and subarachnoid pressures in four patients. Optimal head positioning for patients with raised ICP should be established individually rather than routinely caring for patients with the head elevated.

Adolescent↗
PubMed1981

Apnea testing in the diagnosis of brain death. Clinical and physiological observations.

The absence of spontaneous respiration is a crucial determinant in the diagnosis of brain death, but standardized criteria for apnea testing have not been established. Guidelines are proposed based on the results of 51 apnea tests and associated physiological measurements. In patients who fulfilled all other conventional criteria for brain death, three exhibited non-repetitive back arching and shoulder shrugging when CO2 pressures reached 41 to 51 mm Hg during apnea testing. These respiratory-like movements were ineffective for ventilation and were not reproducible on the following day at the same of higher pCO2. The nature of these movements, evoked potential testing, and autopsy results suggest that they were not triggered by normal medullary centers, and that these patients were, in fact, brain-dead. In four other patients with severe brain damage sparing only the medulla, normal spontaneous ventilation resumed at CO2 pressures of 30 to 39 mm Hg (mean 34 mm Hg). High arterial oxygen tension raised this apnea point slightly, but spontaneous breathing always began at CO2 pressures lower than 40 mm Hg. This level is therefore adequate to stimulate medullary respiration in patients with severe brain damage who are not brain-dead. In brain-dead patients, pCO2 rises slowly during apnea (2.58 +/- 0.85 mm Hg/min), in part because CO2 production is diminished (1.8 +/- 0.23 ml/min/kg). These data allow estimation of a desired length of an apnea test and standardized interpretation of results.

Adolescent↗
PubMed1977

Cardiorespiratory and sympathoadrenal responses during weaning from controlled ventilation.

Weaning from controlled ventilation was attempted in 20 patients who were ventilated with volume constant ventilators for at least 24 hours before study. Measurement of alveolar to arterial oxygen tension differences on 100% oxygen (Aa DO2 1.0) in patients who failed to wean (nonweaners, n = 10), showed a mean AaDO21.0 at 5 minutes after beginning to wean of 388 +/- 56 mm Hg (SEM), and right-to-left shunt (QS/Qt) of 21% values which were significantly different from control (p less than 0.025) and significantly different from ten patients who weaned (p less than 0.005). Since rises in QS/Qt were not accompanied by increased pulmonary capillary wedge pressure, the increased QS/Qt was most likely due to acute atelectasis and not left ventricular failure. These data suggest that patients who fail an initial period of weaning should be placed on positive end-expiratory pressure during subsequent weaning attempts. Significant increases in cardiac output and atrial PCO2 occurred in both groups. Assessment of urinary catecholamine excretion during weaning suggests that sympathoadrenal stimulation often is intense and usually is greater in those patients who weaned successfully. Increased arterial PCO2 may be the mechanism for sympathoadrenal stimulation and rises in cardiac output (r = 0.39, p less than 0.01) during weaning.

Adrenal Medulla↗
PubMedDate not supplied

High dose barbiturates in non-traumatic brain swelling: ICP reduction and effect on outcome.

High dose barbiturates were used to treat intracranial hypertension in 15 patients with nontraumatic brain lesions; (3 hypertensive hemorrhage, 4 subarachnoid hemorrhage, 5 infarction, 2 global anoxia-ischemia and 2 encephalitis). All had persistently raised intracranial pressure (ICP) while being treated with aggressive conventional therapy. The addition of barbiturates caused an initial lowering of ICP in 11 patients, but only 5 of these had sustained ICP reductions. Survival of the 5 patients with persistently lowered ICP and death of the remaining 10 may indicate an improvement in outcome attributable to the addition of high dose barbiturates to conventional therapy in non-traumatic brain swelling. Because of the resources required for their prolonged use, randomized studied in patients with intracranial hypertension are required to determine the effect of barbiturates on outcome.

Adolescent↗