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Steve Davis

Publications and source records attributed to Steve Davis.

15 recordsLinked to original sources
PubMed2004

Factors associated with early extubation after cardiac surgery in young children.

OBJECTIVE: Children undergoing congenital heart surgery require mechanical ventilation. We sought to identify pre- and intraoperative factors (PrO, IO) associated with successful early extubation <24 hrs. DESIGN AND PATIENTS: We performed a retrospective chart review of children <36 months old who underwent congenital heart surgery from January 1998 to July 1999. SETTING: Pediatric intensive care unit in a children's hospital. MEASUREMENTS: Generalized Estimating Equation models were fit to assess the association between PrO and IO and early extubation while accounting for the correlation between surgeries performed on the same patient. Estimated odds ratios (EOR) and 95% confidence intervals were calculated. Multivariable models were constructed using a forward selection process with inclusion criteria of p<.05. Multivariable models, which included PrO and IO variables, were adjusted for procedure group. The area under the receiver operating characteristic curve was computed for each model. RESULTS: A total of 203 children underwent 219 surgeries; 103 (47%) children were extubated in <24 hrs, with only one (1%) failed extubation. PrO variables associated with successful early extubation included age >6 months (EOR, 6.1), absence of pulmonary hypertension (EOR, 9.1), gestational age >36 wks (EOR, 4.6), and absence of congestive heart failure (EOR, 2.4). IO variables were less likely to be associated with successful early extubation. Our model of PrO variables with multiple factors showed that presence of two factors was associated with an EOR of 4.2 for successful early extubation compared with children with zero or one factor. Presence of three and four factors was associated with an EOR of 18.0 and 76.5, respectively. The area under the receiver operating characteristic curve for this model is 0.816. Incision type, complex vs. simple procedure, and palliative vs. complete repair were not associated with success of early extubation. CONCLUSIONS: Early extubation is possible in many very young children undergoing congenital heart surgery, with a low rate of failed extubation. The model would be improved by prospective validation with larger numbers at multiple institutions.

Female↗
PubMed2003

Applying theory to the design of cultural competency training for medical students: a case study.

Although literature suggests that providing culturally sensitive care promotes positive health outcomes for patients, undergraduate medical education currently does not provide adequate cultural competency training. At most schools, cultural competency, as a formal, integrated, and longitudinal thread within the overall curriculum, is still in its infancy. In this article, the authors summarize the current practice of cultural competency training within medical education and describe the design, implementation, and evaluation of a theoretically based, year-long cultural competency training course for second-year students at Wake Forest University School of Medicine. Evaluation of the results indicate that the course was successful in improving knowledge, attitudes, and skills related to cultural competence as well as bringing about positive changes in the medical school's approach to cultural competency training. Also discussed are the implications of the outcomes for the development of culturally competent physicians and how using appropriate theory can help achieve desired outcomes.

Clinical Competence↗
PubMed2003

Serum creatinine and estimated creatinine clearance do not predict perioperatively measured creatinine clearance in neonates undergoing congenital heart surgery.

OBJECTIVE: To describe changes in creatinine clearance (CrCl) in a small group of neonates who underwent surgery for repair of transposition of the great arteries or palliation of hypoplastic left heart syndrome. To determine whether serum creatinine, urine output, or the Schwartz formula accurately predict measured CrCl in these patients. DESIGN: Prospective, randomized controlled trial with subsequent extraction of information regarding renal function from the database. SETTING: A 14-bed pediatric intensive care unit in a children's hospital. PATIENTS: A total of 14 neonates (hypoplastic left heart syndrome, 6; transposition of the great arteries, 8). MEASUREMENTS: Demographic information, urine output, serum creatinine, and 24-hr CrCl preoperatively and postoperatively on days 1 and 2. MAIN RESULTS: Weight, age, and body surface area were 3.3 +/- 0.6 kg, 8.2 +/- 6.9 days, and 0.2 +/- 0.02 m2, respectively. Urine output increased from 1.8 +/- 0.5 mL x kg(-1) x hr(-1) preoperatively to 2.4 +/- 0.8 mL x kg(-1) x hr(-1) on postoperative day 1 (p = .02) and 2.8 +/- 1.1 mL x kg(-1) x hr(-1) on postoperative day 2 (p = .007). Serum creatinine changed from 0.64 +/- 0.15 mg/dL preoperatively to 0.72 +/- 0.40 mg/dL on postoperative day 1 (p = .4, not significant) to 0.78 +/- 0.41 mg/dL on postoperative day 2 (p = .17, not significant). Measured CrCl changed from 22.8 +/- 9.4 mL x min(-1) x 1.73 m(-2) preoperatively to 25.1 +/- 31 mL x min(-1) x 1.73 m(-2) on postoperative day 1 (p = .77, not significant) and 24.9 +/- 19.9 on postoperative day 2 (p = .69, not significant). No difference in measured CrCl was noted based on hypoplastic left heart syndrome vs. transposition of the great arteries. Median overestimation of CrCl by the Schwartz equation was 58% preoperatively, 78% on postoperative day 1, and 53% on postoperative day 2. Clinically significant correlations were not noted between measured CrCl and serum creatinine or urine production preoperatively, on postoperative day 1, or on postoperative day 2. Bland-Altman plot demonstrated that the Schwartz equation was a biased and imprecise estimate of CrCl at all three time points. CONCLUSIONS: Perioperative CrCl is unpredictable in neonates with transposition of the great arteries and hypoplastic left heart syndrome. Serum creatinine, urine output, and the Schwartz formula do not accurately predict CrCl. Reliance on estimates of CrCl could result in toxic concentrations of drugs eliminated by the kidneys.

Cardiopulmonary Bypass↗
PubMed2002

Indications for tracheotomy in the pediatric intensive care unit population: a pilot study.

OBJECTIVE: To define the indications for tracheotomy in patients requiring prolonged intubation (>1 week) in the pediatric intensive care unit (PICU). DESIGN: Retrospective chart review and follow-up telephone survey. SETTING: A tertiary care center PICU. OUTCOME MEASURE: Tracheotomy or extubation. PATIENTS: All patients older than 30 days in the PICU intubated for longer than 1 week between 1997 and 1999. RESULTS: During the study, 63 total admissions required intubation for longer than 1 week. A tracheotomy was necessary in 14% of admissions (n = 9). The mean length of intubation before the tracheotomy was 424 hours, whereas the mean length of intubation without the need for tracheotomy was 386 hours. Length of intubation, age, and number of intubations did not increase the probability of having a tracheotomy. Of those requiring a tracheotomy, 2 had tracheomalacia, 1 had subglottic edema, 1 had plastic bronchitis, 1 had Down syndrome with apnea resulting in right heart failure, 3 required long-term ventilation after cardiopulmonary collapse, and 1 had mitochondrial cytopathy. Of these 9 children, 7 were successfully decannulated, 1 patient died of underlying disease, and 1 patient remained cannulated secondary to the mitochondrial cytopathy. Twenty families of the patients who did not undergo a tracheotomy were reached by telephone after discharge. Most of the families reported that their children were free of stridor and hoarseness after extubation. CONCLUSIONS: Children tolerate prolonged intubation without laryngeal complications. The consideration for tracheotomy in the PICU setting must be highly individualized for each child.

Airway Obstruction↗
PubMed2002

Failed extubation after cardiac surgery in young children: Prevalence, pathogenesis, and risk factors.

Background: Most children who undergo congenital heart surgery require postoperative mechanical ventilation. Failed extubation (FE) may result in physiologic instability, delay, or set back of the weaning process. FE is statistically associated with prolonged mechanical ventilation. Purpose: We sought to identify frequency, pathogenesis, and risk factors for FE after congenital heart surgery in young children. SETTING: Pediatric intensive care unit. PATIENTS: Children </=36 months of age who underwent congenital heart surgery in the period between January 1998 and July 1999 at our children's hospital. Measurements and Statistical Methods: We performed a retrospective chart review. We defined reintubation within 24 hrs as an FE. Demographic, preoperative, intraoperative, and postoperative data were collected. A modified version of logistic regression, which accounts for lack of independence in data with multiple records per subject, was used to assess the impact of risk factors for FE. A forward selection process was used with p <.05 as the criterion for entry into the model. Estimated odds ratios (EORs) are reported with 95% confidence intervals (CI). The predictive ability of the final model was assessed by using area under the receiver operating characteristic curve. MAIN RESULTS: A total of 212 children </=36 months of age underwent 230 congenital heart operations. Eleven children (5.2%) died perioperatively. After excluding patients who died, there were 219 surgeries among 202 patients; 25.9% (51 of 197), 51.8% (102 of 197), and 72.6% (143 of 197) of patients were successfully extubated by 12, 24, and 48 hrs, respectively. There were 22 cases in which an initial attempt at extubation failed at a median of 67.8 hrs (range, 2.4-335.5 hrs). Five patients failed a subsequent attempt at extubation at a median of 189.5 hrs (range, 115.8-602.5 hrs). The most common causes of initial FE were cardiac dysfunction (n = 6), lung disease (n = 6), and airway edema (n = 3). Risk factors for FE included pulmonary hypertension (EOR, 38.7; 95% CI, 2.9-25.8; p <.001), Down syndrome (EOR, 4.6; 95% CI, 1.8-11.8; p =.002), and deep hypothermic circulatory arrest (EOR, 4.5; 95% CI, 1.3-17.5; p =.018). All were independent predictors of FE (area under the curve, 0.837). The strongest predictor was pulmonary hypertension, which when used alone to predict FE provided a sensitivity of 0.83 (95% CI, 0.59-0.94) and a specificity of 0.75 (95% CI, 0.68-0.80). CONCLUSIONS: Extubation fails after approximately 10% of congenital heart surgery in young patients. Causes of FE are diverse. In our population, preoperative pulmonary hypertension, presence of a congenital syndrome, and intraoperative circulatory arrest are risk factors for FE. Prospective validation of our predictive model with larger numbers and at multiple institutions would improve its utility.

Journal Article↗