The parturograph is a composite record designed for the monitoring of fetal and maternal well-being and the progress of labour. It permits the early recognition of abnormalities and pinpoints the patients who would benefit most from intervention. Observations are made from the time of admission of the mother to the caseroom and recorded graphically. Factors assessed include fetal heart rate, maternal vital signs and urine, cervical dilatation, descent of the presenting fetal part, and frequency, duration and intensity of uterine contractions. (+info)
Chronic compartment syndrome affecting the lower limb: MIBI perfusion imaging as an alternative to pressure monitoring: two case reports.
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Intracompartmental pressure monitoring remains the primary method of diagnosing chronic compartment syndrome. MIBI perfusion imaging is widely available and offers a radionuclear imaging technique for diagnosing this condition. Although the results are not identical with those from pressure monitoring, MIBI may offer a useful screening test for this condition. (+info)
Validation of haemodialysis recirculation and access blood flow measured by thermodilution.
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BACKGROUND: Recirculation (R) and access blood flow (Qac) measurements are considered useful indicators of adequate delivery of haemodialysis. It was the purpose of this study to compare measurements of R and Qac obtained by two different techniques which are based on the same principle of indicator dilution, but which differ because of the characteristics of the injection and detection of the different indicators used. METHODS: Recirculation measured by a thermal dilution technique using temperature sensors (BTM, Fresenius Medical Care) was compared with recirculation measured by a validated saline dilution technique using ultrasonic transducers placed on arterial and venous segments of the extracorporeal circulation (HDM, Transonic Systems, Inc.). Calculated access flows were compared by Bland Altman analysis. Data are given as mean +/- SD. RESULTS: A total of 104 measurements obtained in 52 treatments (17 patients, 18 accesses) were compared. Recirculation measured with correct placement of blood lines and corrected for the effect of cardiopulmonary recirculation using the 'double recirculation technique' was -0.02 +/- 0.14% by the BTM technique and not different from the 0% measured by the HDM technique. Recirculation measured with reversed placement of blood lines and corrected for the effect of cardiopulmonary recirculation was 19.66 +/- 10.77% measured by the BTM technique compared with 20.87 +/- 11.64% measured by the HDM technique. The difference between techniques was small (-1.21 +/- 2.44%) albeit significant. Access flow calculated from BTM recirculation was 1328 +/- 627 ml/min compared with 1390 +/- 657 ml/min calculated by the HDM technique. There was no bias between techniques. CONCLUSION: BTM thermodilution yields results which are consistent with the HDM ultrasound dilution technique with regard to both recirculation and access flow measurement. (+info)
Use of cardiopulmonary exercise testing with hemodynamic monitoring in the prognostic assessment of ambulatory patients with chronic heart failure.
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OBJECTIVES: We studied whether direct assessment of the hemodynamic response to exercise could improve the prognostic evaluation of patients with heart failure (HF) and identify those in whom the main cause of the reduced functional capacity is related to extracardiac factors. BACKGROUND: Peak exercise oxygen consumption (VO2) is one of the main prognostic variables in patients with HF, but it is influenced also by many extracardiac factors. METHODS: Bicycle cardiopulmonary exercise testing with hemodynamic monitoring was performed, in addition to clinical evaluation and radionuclide ventriculography, in 219 consecutive patients with chronic HF (left ventricular ejection fraction, 22 +/- 7%; peak VO2, 14.2 +/- 4.4 ml/kg/min). RESULTS: During a follow-up of 19 +/- 25 months, 32 patients died and 6 underwent urgent transplantation with a 71% cumulative major event-free 2-year survival. Peak exercise stroke work index (SWI) was the most powerful prognostic variable selected by Cox multivariate analysis, followed by serum sodium and left ventricular ejection fraction, for one-year survival, and peak VO2 and serum sodium for two-year survival. Two-year survival was 54% in the patients with peak exercise SWI < or = 30 g x m/m2 versus 91% in those with a SWI >30 g x m/m2 (p < 0.0001). A significant percentage of patients (41%) had a normal cardiac output response to exercise with an excellent two-year survival (87% vs. 58% in the others) despite a relatively low peak VO2 (15.1 +/- 4.7 ml/kg/min). CONCLUSIONS: Direct assessment of exercise hemodynamics in patients with HF provides additive independent prognostic information, compared to traditional noninvasive data. (+info)
Medical liability risk avoidance: a case for adopting the International Normalized Ratio (INR) system.
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Since bleeding is a common adverse effect associated with the oral anticoagulant warfarin, maximizing the therapeutic potential of this drug requires close laboratory monitoring. The International Normalized Ratio (INR) is a system that has been developed to improve and standardize the assessment of the intensity of oral anticoagulation therapy. Clinical information and medicolegal arguments supporting the adoption of this system are reviewed. The potential for improvement in patient outcomes and minimization of medical liability favors the adoption of the INR system. (+info)
Disease management interventions to improve outcomes in congestive heart failure.
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This study is part of a planned 24-month, multicenter, longitudinal comparison of a comprehensive congestive heart failure (CHF) disease management program and was designed to determine effectiveness after 12 months of implementation. The impact of interventions such as telemonitoring of patients, post-hospitalization follow-up, and provider education on selected primary outcomes (hospital admission and readmission rates, length of stay, total hospital days, and emergency room utilization) in a managed care setting was evaluated. Subjects in the study included all participants in the managed care plan, as well as 149 selected program participants. The effects of the program were analyzed for pure CHF and CHF-related diagnoses, with outcomes for the third quarter of 1996 (postintervention follow-up) being compared with those for the third quarter of 1995 (preintervention baseline). Overall, the data demonstrated significantly reduced admission and readmission rates for patients with the pure CHF diagnosis. Among the entire CHF patient population, the third quarter admission rate declined 63% (P = 0.00002), and the 30-day and 90-day readmission rates declined 75% (P = 0.02) and 74% (P = 0.004), respectively. Among program participants with pure CHF diagnoses, the 30-day readmission rate was reduced to 0, and an 83% reduction occurred for both the third quarter admission (P = 0.008) and 90-day readmission (P = 0.06) rates. In addition, the average length of stay for patients with CHF-related diagnoses was significantly reduced among both plan participants (P = 0.03) and program participants (P = 0.001). Reductions were also seen in total hospital days and emergency room utilization. These data thus indicate that a comprehensive disease management program can reduce healthcare utilization not only among CHF patients in the program but also among the entire managed care plan population. (+info)
A risk management audit: are we complying with the national guidelines for sedation by non-anaesthetists?
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OBJECTIVES: To assess the effect of a preprinted form in ensuring an improved and sustained quality of documentation of clinical data in compliance with the national guidelines for sedation by non-anaesthetists. DESIGN: The process of retrospective case note audit was used to identify areas of poor performance, reiterate national guidelines, introduce a post-sedation advice sheet, and demonstrate improvement. SETTING: Emergency Department, Musgrove Park Hospital, Taunton. SUBJECTS: Forty seven patients requiring sedation for relocation of a dislocated shoulder or manipulation of a Colles' fracture between July and October 1996 and July and October 1997. MAIN OUTCOME MEASURES: Evidence that the following items had been documented: consent for procedure, risk assessment, monitored observations, prophylactic use of supplementary oxygen, and discharging patients with printed advice. Case note review was performed before (n = 23) and after (n = 24) the introduction of a sedation audit form. Notes were analysed for the above outcome measures. The monitored observations analysed included: pulse oximetry, respiratory rate, pulse rate, blood pressure, electrocardiography, and conscious level. RESULTS: Use of the form significantly improved documentation of most parameters measured. CONCLUSIONS: Introduction of the form, together with staff education, resulted in enhanced documentation of data and improved conformity with national guidelines. A risk management approach to preempting critical incidents following sedation, can be adopted in this area of emergency medicine. (+info)
Gastric tonometry: in vivo comparison of saline and air tonometry in patients with cardiogenic shock.
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Measurement of gastric intramucosal pH (pHi) has been advocated to assess gastric perfusion. Regional PCO2 (rPCO2) values are measured using saline tonometry (rsPCO2) and more recently using air tonometry (raPCO2). We compared 237 measurements of saline and air tonometry in 19 consecutive, severely ill patients (mean age 59 (range 31-76) yr, 19 males, APACHE II 22 +/- 7) with cardiogenic shock. Equilibration period was set to 90 min. Nineteen independent paired samples of mean raPCO2 and mean rsPCO2 of each patient showed good correlation (r = 0.93, P < 0.001). Mean raPCO2 was 6.5 (1.8) kPa and mean rsPCO2 6.8 (2.4) kPa. PCO2 measured by saline was significantly higher than that measured by air (P < 0.05). Bland and Altman analysis showed a bias (mean rsPCO2-mean raPCO2) of 0.3 kPa and a precision of 1.2 kPa. Agreement between the two methods decreased with increasing rPCO2 concentrations. Although air tonometry of rPCO2 is a promising technique, a systematic disagreement with saline tonometry at high rPCO2 values requires further investigation and cautious interpretation of these values. (+info)