Critical pathways for postoperative care after simple congenital heart surgery.

OBJECTIVE: To evaluate the clinical, financial, and parent/patient satisfaction impact of critical pathways on the postoperative care of pediatric cardiothoracic patients with simple congenital heart lesions. STUDY DESIGN: Critical pathways were developed by pediatric intensive care nurses and implemented under the direction of pediatric cardiothoracic surgeons. PATIENTS AND METHODS: Critical pathways were used during a 12-month study on 46 postoperative patients with simple repair of atrial septal defect (ASD), coarctation of the aorta (CoA), and patent ductus arteriosus (PDA). Using the study criteria, a control group of 58 patients was chosen from 1993. Prospective and control group data collected included postoperative intubation time, total laboratory tests, arterial blood gas utilization, morphine utilization, time in the pediatric intensive care unit, total hospital stay, total hospital charges, total hospital cost, and complications. Variances from the critical pathway and satisfaction data were also recorded for study patients. RESULTS: Resource utilization was reduced after implementation of critical pathways. Significant reductions were seen in total hours in the pediatric intensive care unit, total number of laboratory tests, postoperative intubation times, arterial blood gas utilization, morphine utilization, length of hospitalization (ASD, 4.9 to 3.1 days; CoA, 5.2 to 3.2 days; and PDA, 4.1 to 1.4 days; all P < 0.05), total hospital charges (ASD, $16,633 to $13,627; CoA, $14,292 to $8319; and PDA, $8249 to $4216; all P < 0.05), and total hospital costs. There was no increase in respiratory complications or other complications. Patients and families were generally satisfied with their hospital experience, including analgesia and length of hospitalization. CONCLUSIONS: Implementation of critical pathways reduced resource utilization and costs after repair of three simple congenital heart lesions, without obvious complications or patient dissatisfaction.

Plantar pressures with total contact casting.

Total contact casting has been used to aid in the healing of plantar neurotrophic ulcerations. The efficacy of total contact casts in promoting ulcer healing is presumably due to a reduction in the load over high pressure areas with pressure redistribution over the entire surface of the foot. The purpose of this study was to quantify the effectiveness of total contact casting in reducing plantar pressures. A portable microprocessor-based data-acquisition system was used for recording plantar pressures. Plantar pressures were collected from six nondisabled individuals with and without total contact casting at cast-walking cadence. In our study, there was a decrease in plantar loading under the metatarsal heads (first, fourth, fifth), the great toe, and the heel. The average decrease was 32% under the fifth metatarsal, 63% under the fourth metatarsal, 69% under the first metatarsal, 65% under the great toe, and 45% under the heel. Our study quantitatively showed that total contact casting does reduce vertical plantar pressures in high load areas.

Management of complications associated with an excision of a lipoma from the ankle.

This case study demonstrates the following: close proximity of lipoma to underlined skin can compromise circulation; the size of the lipoma and the resulting redundant skin after the incision can lead to fluid development and impede the healing process; and a patient who is noncompliant and stands or walks excessively after the excision of a lipoma can cause buildup of a hematoma, which can compromise the incision site. Lipomas associated with the foot or ankle are rarely symptomatic. When they do cause pain and are surgically treated, possible complications because of their size and location must be considered. Finally, these complications could have been avoided if the redundant skin had been excised and a Penrose drain inserted to eliminate excess fluid buildup. Also, better communication should have been maintained with the patient during the entire postoperative course.

Acute volume expansion in humans releases a factor which inhibits the vascular Na+-K+ pump.

The authors previously observed increased Na+-K+ pump inhibitory activity in the plasma of low renin essential hypertensive unselected with respect to renin status. The present experiments were done to determine the effect of acute volume expansion on plasma Na+-K+ pump inhibitory activity in normotensive subjects. The data show that acute volume expansion increases vascular Na+-K+ pump inhibitory activity in plasma, suggesting that the increased level of this inhibitory activity in low essential hypertensives is probably volume dependent. The unique feature of this study is the use of vascular tissue for the bioassay.

A quick and easy guide to neurological assessment.

A quick and easy guide with step-by-step pictorial descriptions has been developed for use as a uniform approach to neurological assessment by the nurse. It is the packaging of the information and the visual aids that may be useful, educational tools for nurses in performing a systematic assessment of the patient.

Utilization of selected leucine peptide amides by Escherichia coli.

Studies on the utilization of leucine peptide amides as a source of leucine for a leucine auxotroph showed that in general compounds with the structure leu-chi amide (where chi is any amide) are utilized as well as the free peptide, but that compounds with the structure chi-leu amide (where chi is not leucine) are used less effectively than the free peptide. Growth and enzymological experiments indicated that the lower capacity of Escherichia coli to utilize amides of the structure chi-leu amide is not a result of poor transport of these compounds, but rather the inability to rapidly liberate leucine from the amide when it is supplied to the cell in the form of a peptide. Competition studies indicated that the peptide amides enter the cell via the oligopeptide permease system.

Financial impact of elimination of routine chest radiographs in a pediatric intensive care unit.

OBJECTIVE: To determine the change in chest radiograph use if each chest radiograph requires a separate order and clinical indication. DESIGN: Prospective, nonrandomized, controlled design with an intervention. SETTING: The pediatric intensive care unit (PICU) at Primary Children's Medical Center, Salt Lake City, UT. PATIENTS: The study comprised 3,727 PICU patients treated between 1992 and 1996. INTERVENTIONS: A change in ordering practice: There will be no standing orders for routine daily morning chest radiographs. Each radiograph requires a written order and a clinical indication. MEASUREMENTS AND MAIN RESULTS: During a 29-month control phase when routine daily chest radiographs were obtained for all intubated patients, 1.026 chest radiographs per patient day were performed. After the intervention, the ratio dropped to 0.653 chest radiographs per patient day, a decrease of 36.4%. This resulted in a (projected) variable cost savings of $45,476. Data were also collected for quality assurance purposes. CONCLUSIONS: These results demonstrate the impact of an evaluation and subsequent change in radiology ordering practice in our PICU. The change resulted in decreased variability in ordering practice, fewer chest radiographs per patient, and an accompanying cost savings to our patients and payors.

Sensate and insensate in-shoe plantar pressures.

In the individual with loss of protective sensation, the presence of high plantar pressures has been considered a risk factor for the development of plantar ulceration. Previous studies of insensate plantar pressures have measured a limited number of isolated, barefoot steps in a laboratory setting. Such isolated snapshots of barefoot plantar pressures do not give us insight into possible step-to-step variations or what plantar pressures occur when wearing shoes. The purpose of this study was to quantitatively examine and compare in-shoe plantar pressures during continuous walking by normal sensate and diabetic insensate subjects. A portable, insole data-acquisition system was used for pressure measurement during 4 minutes of normal continuous walking. Seven pressure sensors were placed in each insole under posterior and anterior heels, the metatarsal heads, and hallux. Twelve sensate and five insensate subjects were studied. We found that the insensate group had higher plantar pressures under posterior and anterior heels and the first metatarsals compared with the sensate group. From the study of the coefficients of variation, we demonstrated a larger step-to-step variation in plantar pressures for the insensate during continuous walking, suggesting the need for caution in interpreting the data from isolated force plate steps when studying insensate individuals.

Foot pressure distribution during walking and shuffling.

The insensate foot is vulnerable to tissue damage from areas of repetitive, excessive pressures. It has been previously stated that a shuffling gait with short steps would increase the period of foot flat and thus minimize any excessive local plantar pressures. This theory was quantitatively evaluated with a portable, in-shoe pressure data-acquisition system. Seven pressure sensors were located in the left and right insoles under the metatarsal heads, hallux, and posterior and anterior heels. Plantar pressure data were acquired from ten able-bodied subjects during four minutes of continuous shuffling and walking at a metronome-controlled cadence. Peak pressures, foot-to-floor contact durations, and pressure-time integrals under each sensor during shuffling and walking were analyzed and compared. Peak pressures were decreased at all sensor sites during a shuffling gait. The greatest decreases were noted at the first and second metatarsals (up to 57.8%) and hallux (up to 63.2%). A 41.6% decrease in overall summated peak plantar pressures during shuffling was found. Foot-to-floor contact durations during shuffling were increased from 22.0% to 76.9% at all 14 sensor locations. Pressure-time integrals during shuffling were increased at the heels (up to 78.9%) and decreased at the metatarsal heads and great toes (up to 26.7%). There was a 3.3% increase in the overall summated pressure-time integral during shuffling. Our findings are consistent with the hypothesis that a shuffling gait increases the period of foot flat and the area of weight bearing, resulting in lower peak plantar pressures on any one area.