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Unstable Patients (unstable + patient)
Selected AbstractsConcomitant Coronary and Peripheral Arterial Disease: Single-Stage RevascularizationJOURNAL OF CARDIAC SURGERY, Issue 3 2008Onur S. Goksel M.D. Coexistence of two entities is usually managed with a staged approach; however, decision to treat which entity first may be difficult clinically. We present a 49-year-old man with acute infrarenal aortic occlusion and cardiac ischemia who was treated with single-stage ascending aorta-bifemoral bypass following saphenous vein grafting to left anterior descending artery. Concomitant coronary and peripheral vascular revascularization is a practical method with a high flow inflow source as ascending aorta. We believe that a single-stage approach may be performed in the unstable patient as presented in this report. [source] Surgical Management of Pyoderma Gangrenosum: Case Report and ReviewDERMATOLOGIC SURGERY, Issue 11 2000Murad Alam MD Background. Commonly used treatments for pyoderma gangrenosum are medical, with immunosuppressive agents employed most often. Objective. To report a case and discuss the indications for radical surgical treatment of pyoderma gangrenosum. Methods. Analysis of a case of Crohn's disease-associated pyoderma gangrenosum treated with immunosuppression followed by amputation, and a review of the literature on surgical management of pyoderma gangrenosum. Results. In unstable patients with intractable multiple medical problems, surgical treatment of pyoderma gangrenosum may be indicated by the existence of these life-threatening comorbidities. The recent literature suggests that surgical management of pyoderma gangrenosum may also be appropriate in other special circumstances. Conclusions. Surgical management, including amputation, may have a role in the management of pyoderma gangrenosum. Further research is needed to delineate precisely the circumstances and patient factors that are appropriate indications for such surgery. [source] Abciximab Treatment for Obstructive Prosthetic Aortic and Mitral Valve Thrombosis in the Presence of Large Thrombi, Cardiogenic Shock, and Acute Evolving Embolic StrokeECHOCARDIOGRAPHY, Issue 1 2004Atiar M Rahman M.D., Ph.D. Obstructive thrombosis of left-sided mechanical prosthetic valves is a life-threatening complication. Intravenous thrombolytic therapy is contraindicated due to risk of clot embolization and surgical treatment is often required for hemodynamically unstable patients. We report for the first time the successful use of abciximab in the management of a patient in cardiogenic shock with multiple prosthetic valve obstructive thrombosis and evolving embolic stroke. Serial Doppler echocardiography and cinefluoroscopy demonstrated resolution of thrombi, improvements in transvalvular gradients and improvement in leaflet motion. This observation suggests abciximab should be considered as a therapeutic option in the treatment of obstructed prosthetic heart valves. (ECHOCARDIOGRAPHY, Volume 21, January 2004) [source] Thirty-day Outcomes of Emergency Department Patients Undergoing Electrical Cardioversion for Atrial Fibrillation or FlutterACADEMIC EMERGENCY MEDICINE, Issue 4 2010Frank Xavier Scheuermeyer MD Abstract Objectives:, While the short-term (<7-day) safety and efficiency of electrical cardioversion for emergency department (ED) patients with atrial fibrillation or flutter have been established, the 30-day outcomes with respect to stroke, thromboembolic events, or death have not been investigated. Methods:, A two-center cohort of consecutive ED patients undergoing cardioversion for atrial fibrillation or flutter between January 1, 2000, and September 30, 2007, was retrospectively investigated. This cohort was probabilistically linked with both a regional ED database and the provincial health registry to determine which patients had a subsequent ED visit or hospital admission, stroke, or thromboembolic event or died within 30 days. In addition, trained reviewers performed a detailed chart abstraction on 150 randomly selected patients, with emphasis on demographics, vital signs, medical treatment, and predefined adverse events. Hemodynamically unstable patients or those whose condition was the result of an underlying acute medical diagnosis were excluded. Data were analyzed by descriptive methods. Results:, During the study period, 1,233 patients made 1,820 visits for atrial fibrillation or flutter to the ED. Of the 400 eligible patients undergoing direct-current cardioversion (DCCV), no patients died, had a stroke, or had a thromboembolic event in the following 30 days (95% confidence interval [CI] = 0.0 to 0.8% for all outcomes). A total of 141 patients were included in the formal chart review, with five patients (3.5%, 95% CI = 0.5% to 6.6%) failing cardioversion, six patients (4.3%, 95% CI = 0.9% to 7.6%) having a minor adverse event that did not change disposition, and five patients (3.5%, 95% CI = 0.5% to 6.6%) admitted to hospital at the index visit. Conclusions:, Cardioversion of patients with atrial fibrillation or flutter in the ED appears to have a very low rate of long-term complications. ACADEMIC EMERGENCY MEDICINE 2010; 17:408,415 © 2010 by the Society for Academic Emergency Medicine [source] A Multifaceted Intervention to Implement Guidelines Improved Treatment of Nursing Home,Acquired Pneumonia in a State Veterans HomeJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 11 2006Evelyn Hutt MD OBJECTIVES: To assess the feasibility of a multifaceted strategy to translate evidence-based guidelines for treating nursing home,acquired pneumonia (NHAP) into practice using a small intervention trial. DESIGN: Pre-posttest with untreated control group. SETTING: Two Colorado State Veterans Homes (SVHs) during two influenza seasons. PARTICIPANTS: Eighty-six residents with two or more signs of lower respiratory tract infection. INTERVENTION: Multifaceted, including a formative phase to modify the intervention, institutional-level change emphasizing immunization, and availability of appropriate antibiotics; interactive educational sessions for nurses; and academic detailing. MEASUREMENTS: Subjects' SVH medical records were reviewed for guideline compliance retrospectively for the influenza season before the intervention and prospectively during the intervention. Bivariate comparisons-of-care processes between the intervention and control facility before and after the intervention were made using the Fischer exact test. RESULTS: At the intervention facility, compliance with five of the guidelines improved: influenza vaccination, timely physician response to illness onset, x-ray for patients not being hospitalized, use of appropriate antibiotics, and timely antibiotic initiation for unstable patients. Chest x-ray and appropriate and timely antibiotics were significantly better at the intervention than at the control facility during the intervention year but not during the control year. CONCLUSION: Multifaceted, evidence-based, NHAP guideline implementation improved care processes in a SVH. Guideline implementation should be studied in a national sample of nursing homes to determine whether it improves quality of life and functional outcomes of this debilitating illness for long-term care residents. [source] Multi-detector CT angiography for lower gastrointestinal bleeding: Can it select patients for endovascular intervention?JOURNAL OF MEDICAL IMAGING AND RADIATION ONCOLOGY, Issue 1 2010PT Foley§ Summary This is a retrospective review of the results at our institution of using multi-detector CT angiography (CTA) to localise lower gastrointestinal (GI) bleeding. We hypothesised that in our patient population: (i) CTA was unlikely to demonstrate bleeding in patients who were haemodynamically stable; (ii) in haemodynamically unstable patients in whom CTA was undertaken, the results could be used to select patients who would benefit from catheter angiography; and (iii) in haemodynamically unstable patients in whom CTA was undertaken, a subgroup of patients could be identified who would benefit from primary surgical treatment, avoiding invasive angiography completely. A retrospective review was conducted of the clinical records of all patients undergoing CTA for lower GI haemorrhage at our institution between 1 January 2005 and 30 June 2007. Out of the 20 patients examined, 10 had positive CTAs demonstrating the bleeding site. Nine were haemodynamically unstable at the time of the study. Four patients with positive CT angiograms were able to be treated directly with surgery and avoided invasive angiography. Ten patients had negative CTAs. Four of these were haemodynamically unstable, six haemodynamically stable. Only one required intervention to secure haemostasis, the rest stopped spontaneously. No haemodynamically stable patient who had a negative CTA required intervention. CTA is a useful non-invasive technique for localising the site of lower GI bleeding. In our patient population, in the absence of haemodynamic instability, the diagnostic yield of CTA was low and bleeding was likely to stop spontaneously. In haemodynamically unstable patients, a positive CTA allowed patients to be triaged to surgery or angiography, whereas there was a strong association between a negative CTA and spontaneous cessation of bleeding. [source] Sensitivity of Bedside Ultrasound and Supine Anteroposterior Chest Radiographs for the Identification of Pneumothorax After Blunt TraumaACADEMIC EMERGENCY MEDICINE, Issue 1 2010R. Gentry Wilkerson MD Abstract Objectives:, Supine anteroposterior (AP) chest radiographs in patients with blunt trauma have poor sensitivity for the identification of pneumothorax. Ultrasound (US) has been proposed as an alternative screening test for pneumothorax in this population. The authors conducted an evidence-based review of the medical literature to compare sensitivity of bedside US and AP chest radiographs in identifying pneumothorax after blunt trauma. Methods:, MEDLINE and EMBASE databases were searched for trials from 1965 through June 2009 using a search strategy derived from the following PICO formulation of our clinical question: patients included adult (18 + years) emergency department (ED) patients in whom pneumothorax was suspected after blunt trauma. The intervention was thoracic ultrasonography for the detection of pneumothorax. The comparator was the supine AP chest radiograph during the initial evaluation of the patient. The outcome was the diagnostic performance of US in identifying the presence of pneumothorax in the study population. The criterion standard for the presence or absence of pneumothorax was computed tomography (CT) of the chest or a rush of air during thoracostomy tube placement (in unstable patients). Prospective, observational trials of emergency physician (EP)-performed thoracic US were included. Trials in which the exams were performed by radiologists or surgeons, or trials that investigated patients suffering penetrating trauma or with spontaneous or iatrogenic pneumothoraces, were excluded. The methodologic quality of the studies was assessed. Qualitative methods were used to summarize the study results. Data analysis consisted of test performance (sensitivity and specificity, with 95% confidence intervals [CIs]) of thoracic US and supine AP chest radiography. Results:, Four prospective observational studies were identified, with a total of 606 subjects who met the inclusion and exclusion criteria. The sensitivity and specificity of US for the detection of pneumothorax ranged from 86% to 98% and 97% to 100%, respectively. The sensitivity of supine AP chest radiographs for the detection of pneumothorax ranged from 28% to 75%. The specificity of supine AP chest radiographs was 100% in all included studies. Conclusions:, This evidence-based review suggests that bedside thoracic US is a more sensitive screening test than supine AP chest radiography for the detection of pneumothorax in adult patients with blunt chest trauma. ACADEMIC EMERGENCY MEDICINE 2010; 17:11,17 © 2010 by the Society for Academic Emergency Medicine [source] Therapeutic hypothermia after out-of-hospital cardiac arrest: experiences with patients treated with percutaneous coronary intervention and cardiogenic shockACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 2 2007J. Hovdenes Background:, Therapeutic hypothermia has been shown to increase survival after out-of-hospital cardiac arrest (OHCA). The trials documenting such benefit excluded patients with cardiogenic shock and only a few patients were treated with percutaneous coronary intervention prior to admission to an intensive care unit (ICU). We use therapeutic hypothermia whenever cardiac arrest patients do not wake up immediately after return of spontaneous circulation. Methods:, This paper reports the outcome of 50 OHCA patients with ventricular fibrillation admitted to a tertiary referral hospital for immediate coronary angiography and percutaneous coronary intervention when indicated. Patients were treated with intra-aortic balloon counterpulsation (IABP) (23 of 50 patients) if indicated. All patients who were still comatose were treated with therapeutic hypothermia at 32,34 °C for 24 h before rewarming. The end-points were survival and cerebral performance category (CPC: 1, best; 5, dead) after 6 months. Results:, Forty-one patients (82%) survived until 6 months. Thirty-four patients (68%) were in CPC 1 or 2, and seven (14%) were in CPC 3. Of the 23 patients treated with IABP, 14 (61%) survived with CPC 1 or 2. In patients not treated with IABP, 20 patients (74%) survived with CPC 1 or 2. Forty patients (80%) developed myocardial infarction. Percutaneous coronary intervention was performed in 36 patients (72%). Conclusion:, In OHCA survivors who reached our hospital, the survival rate was high and the neurological outcome acceptable. Our results indicate that the use of therapeutic hypothermia is justified even in haemodynamically unstable patients and those treated with percutaneous coronary intervention. [source] Adequacy Indices for Dialysis in Acute Renal Failure: Kinetic ModelingARTIFICIAL ORGANS, Issue 5 2010Malgorzata Debowska Abstract Many aspects of the management of renal replacement therapy in acute renal failure (ARF), including the appropriate assessment of dialysis adequacy, remain unresolved, because ARF patients often are not in a metabolic steady state. The aim of this study was to evaluate a system of adequacy indices for dialysis in ARF patients using urea and creatinine kinetic modeling. Kinetic modeling was performed for two different fictitious patients (A and B) with characteristics described by the average parameters for two patient groups and for two blood purification treatments: sustained low efficiency daily dialysis (SLEDD) in Patient A and continuous venovenous hemofiltration (CVVH) in Patient B, based on data from a clinical report. Urea and creatinine generation rates were estimated according to the clinical data on the solute concentrations in blood. Then, using estimated generation rates, two hypothetical treatments were simulated, CVVH in Patient A and SLEDD in Patient B. KT/V, fractional solute removal (FSR) and equivalent renal clearance (EKR) were calculated according to the definitions developed for metabolically unstable patients. CVVH appeared as being more effective than SLEDD because KT/V, FSR, and EKR were higher for CVVH than SLEDD in Patients A and B. Creatinine KT/V, FSR, and EKR were lower and well correlated to the respective indices for urea. Urea and creatinine generation rates were overestimated more than twice in Patient A and by 30,40% in Patient B if calculated assuming the metabolically stable state than if estimated by kinetic modeling. Adequacy indices and solute generation rates for ARF patients should be estimated using the definition for unsteady metabolic state. EKR and FSR were higher for urea and creatinine with CVVH than with SLEDD, because of higher K·T and minimized compartmental effects for CVVH. [source] Population pharmacokinetic modelling of gentamicin and vancomycin in patients with unstable renal function following cardiothoracic surgeryBRITISH JOURNAL OF CLINICAL PHARMACOLOGY, Issue 2 2006Christine E. Staatz Aims To describe the population pharmacokinetics of gentamicin and vancomycin in cardiothoracic surgery patients with unstable renal function. Methods Data collected during routine care were analyzed using NONMEM. Linear relationships between creatinine clearance (CLCr) and drug clearance (CL) were identified, and two approaches to modelling changing CLCr were examined. The first included baseline (BCOV) and difference from baseline (DCOV) effects and the second allowed the influence of CLCr to vary between individuals. Final model predictive performance was evaluated using independent data. The data sets were then combined and parameters re-estimated. Results Model building was performed using data from 96 (gentamicin) and 102 (vancomycin) patients, aged 17,87 years. CLCr ranged from 9 to 172 ml min,1 and changes varied from ,76 to 58 ml min,1 (gentamicin) and ,86 to 93 ml min,1 (vancomycin). Inclusion of BCOV and DCOV improved the fit of the gentamicin data but had little effect on that for vancomycin. Inclusion of interindividual variability (IIV) in the influence of CLcr resulted in a poorly characterized model for gentamicin and had no effect on vancomycin modelling. No bias was seen in population compared with individual CL estimates in independent data from 39 (gentamicin) and 37 (vancomycin) patients. Mean (95% CI) differences were 4% (,3, 11%) and 2% (,2, 6%), respectively. Final estimates were: CLGent (l h,1) = 2.81 × (1 + 0.015 × (BCOVCLCr -BCOVCLCr,Median) + 0.0174 × DCOVCLCr); CLVanc (l h,1) = 2.97 × (1 + 0.0205 ×, (CLCr -CLCr,Median)). IIV in CL was 27% for both drugs. Conclusions A parameter describing individual changes in CLcr with time improves population pharmacokinetic modelling of gentamicin but not vancomycin in clinically unstable patients. [source] Stent implantation in variant angina refractory to medical treatmentCLINICAL CARDIOLOGY, Issue 12 2006Dr Vicens Martí M.D. Abstract Background Vasospastic angina usually responds well to medical treatment. Hypothesis The present study describes our experience in patients who received a coronary stent because of recurrent variant angina refractory to medical treatment and evaluates stent implantation as an alternative treatment. Materials and methods Between March 1998 and February 2005, recurrent variant angina was diagnosed in 22 patients admitted to our coronary care unit. Of these, five patients (22.7%), were refractory to pharmacologic treatment. Coronary angiography and coronary stents were indicated. Clinical follow-up was 29 ± 6 months. Results Stenting was performed during diagnostic coronary angiography in two patients. In the other three patients, the stent was implanted 24,48 h later. We observed coronary spasm recurrences proximal or distal to the stent in four patients,two during the stent implantation procedure and the other two in the coronary care unit within 48 h post angioplasty. Three patients where treated with additional stenting and the fourth patient improved with pharmacologic treatment. During follow-up three patients remained asymptomatic. The fourth patient had diffuse in-stent restenosis in the third month, and the fifth patient showed a de novo lesion in the treated segment 2 years later. Conclusions Stent implantation in patients with recurrent variant angina refractory to medical treatment may be an alternative treatment in carefully selected, clinically unstable patients. Spasm recurrences may occur in other segments of the treated artery, probably due to the diffuse nature of the disease. Immediate and continued surveillance is recommended because of the risk of adverse clinical events. Copyright © 2006 Wiley Periodicals, Inc. Wiley Periodicals, Inc. [source] Staged revascularization in critically ill patients with coronary artery diseaseCLINICAL CARDIOLOGY, Issue 5 2001Nasser Jowhar Hayat M.D., Ph.D. Abstract Background: Critically ill patients undergoing bypass surgery experience a higher mortality and morbidity. Hypothesis: The study was undertaken to evaluate the efficacy and value of percutaneous transluminal coronary angioplasty (PTCA) as a bridge to coronary artery bypass graft surgery (CABG) in high-risk patients with refractory unstable angina or cardiogenic shock. Methods: We present 11 seriously unstable patients with severe multivessel coronary artery disease undergoing culprit vessel PTCA. Angioplasty was performed not as a definitive procedure but rather as a bridge to surgical revascularization. All the patients had sustained at least one myocardial infarction prior to catheterization, all had refractory unstable angina, eight patients had only a single patent coronary artery, and five patients were in cardiogenic shock. Results: Following PTCA, all patients enjoyed a stable in-hospital period. One patient died 12 weeks after successful PTCA while awaiting second CABG. Seven patients subsequently underwent CABG and are doing well. The remaining three patients were also advised to undergo CABG, but elected to continue medical management. Conclusions: Coronary angioplasty of the culprit vessel may play a role as a bridge to surgery in critically ill patients. [source] Endothelial dysfunction, subangiographic atheroma, and unstable symptoms in patients with chest pain and normal coronary arteriogramsCLINICAL CARDIOLOGY, Issue 9 2000Jonathan R. Clague M.D. Abstract Background: Patients with chest pain and normal coronary arteriograms (CPNA) may present with unstable symptoms and other evidence of ischemia during clinical follow-up. Although repeat angiography usually proves negative, functional assessment of coronary vasomotor abnormalities may provide additional pathophysiologic information. Hypothesis: The study was undertaken to evaluate the relationship between endothelial dysfunction and subangiographic atheroma in patients with CPNA undergoing repeat angiography because of unstable symptoms. Methods: We investigated nine patients with CPNA (8 women, mean age 57 ± 9 years) undergoing repeat angiography because of unstable anginal symptoms. After normal angiography, simultaneous coronary epicardial and microvascular vasomotor responses to intracoronary vasodilators [acetylcholine (10,6 M), adenosine (18 ,g) and nitroglycerin (300 ,g)] were investigated in the left anterior descending artery using quantitative angiography and Doppler flow measurements. The presence of subangiographic atheroma was assessed by intravascular ultrasound. Results: Three patients demonstrated proximal and distal epicardial vasoconstriction and a reduction in coronary flow in response to acetylcholine, indicating concordant epicardial and microvascular endothelial dysfunction. These changes were associated with chest pain and ischemic electrocardio-graphic changes in two patients. None of the remaining patients suffered chest pain in response to intracoronary acetylcholine. Six patients had significant subangiographic disease (intimal thickness >0.3 mm) on intravascular ultrasound imaging, and multivariate analysis indicated a significant relationship (R2 = 0.89, overall p = 0.001) between the extent of subangiographic disease and both plasma cholesterol concentration and hypertensive history. No significant relationship was demonstrated between endothelial dysfunction and the extent of subangiographic disease. Conclusion: Concordant epicardial and microvascular endothelial dysfunction may be pathophysiologically and clinically significant in unstable patients with CPNA but does not appear to be directly related to the extent of subangiographic atheroma. [source] Perceived adverse patient outcomes correlated to nurses' workload in medical and surgical wards of selected hospitals in KuwaitJOURNAL OF CLINICAL NURSING, Issue 4 2009Fatimah Al-Kandari Aim., This study was carried out to identify the perceived adverse patient outcomes as related to nurses' workload. It also assessed nurses' perception of variables contributing to the workload and adverse patient outcomes. Background., Several studies have been published on adverse patient outcomes in which a correlation was found between nurses' workload and some adverse patient outcomes. Design., A cross-sectional survey was conducted between registered nurses (n = 780) working in medical and surgical wards of five general governmental hospitals in Kuwait. Data collection instruments., Data were collected using a self-administered questionnaire consisting of three sections to elicit information about the sample characteristics, perception of workload and perceived adverse patient outcomes during the last shift and last working week. Results., The three major perceived adverse outcomes reported by the nurses while on duty during their last shift were: complaints from patients and families (2%), patients received a late dose or missed a dose of medication (1·8%) and occurrences of pressure ulcer (1·5%). Similarly, the reported adverse outcomes over the past week were complaints from patients and families (5%), patients received a late dose or missed a dose of medication (5·3%) and discovery of a urinary tract infection (3·7%). Increases in nurse-patient load, bed occupancy rate, unstable patients' condition, extra ordinary life support efforts and non-nursing tasks; all correlated positively with perceived adverse patient outcomes. Conclusion., This study sheds light on an important issue affecting patient safety and quality of care as perceived by the nurses themselves as caregivers. Relevance to clinical practice., Nurses' perception of variables contributing to adverse patient outcomes and their workload could significantly affect the provided nursing care and nursing care recipients. The findings could help in policy formulation and planning strategies to decrease adverse patient outcomes in many countries with a health care structure similar to that of Kuwait. [source] | ||||||||||