Michael J Breslow

Philips | Philips

Objective: Many ICU patients do not require critical care interventions. Whether aggressive care environments increase risks to low-acuity patients is unknown. We evaluated whether ICU acuity was associated with outcomes of low mortality-risk patients. We hypothesized that admission to high-acuity ICUs would be associated with worse outcomes. This...

Introduction: Tele-ICU programs have been associated with lower mortality and shorter length of stay (LOS). However, the impact of tele-ICU on a large cohort of patients (pts) over a sustained time period is lacking. The goal of this study was to evaluate changes in ICU outcomes in the years (yrs) following tele-ICU implementation. We hypothesize t...

Introduction: Early discharge from the ICU is desirable because it shortens time in the ICU and reduces care costs, but can also increase the likelihood of ICU readmission and post-discharge unanticipated death if patients are discharged before they are stable. We postulated that, using eICU® Research Institute (eRI) data from >400 ICUs, we could...

Variables evaluated for inclusion in ICU Discharge Readiness Score models. (DOCX)

APACHE Admission Diagnosis Groupings. (DOCX)

Direct variable costs were determined on each hospital day for all patients with an intensive care unit (ICU) stay in four Phoenix-area hospital ICUs. Average daily direct variable cost in the four ICUs ranged from $1,436 to $1,759 and represented 69.4 percent and 45.7 percent of total hospital stay cost for medical and surgical patients, respectiv...

Part 2 of this review of ICU scoring systems examines how scoring system data should be used to assess ICU performance. There often are two different consumers of these data: lCU clinicians and quality leaders who seek to identify opportunities to improve quality of care and operational efficiency, and regulators, payors, and consumers who want to...

This review examines the use of scoring systems to assess ICU performance. APACHE (Acute Physiology and Chronic Health Evaluation), MPM (mortality probability model), and SAPS (simplified acute physiology score) are the three major ICU scoring systems in use today. Central to all three is the use of physiologic data for severity adjustment. Differe...

PURPOSE: Most ICU patients have a stay of 2-4 days, after which they are able to leave the ICU. Although less prevalent, patients with long stays account for a disproportionate number of ICU days and costs. While there is wide recognition of the large impact of outliers, little is known about the makeup of this important sub-group of ICU patients....

The desire to provide continuous intensivist management for all intensive care unit (ICU) patients in the face of a massive shortfall of available intensivists prompted the introduction of remote ICU care programs in 1999. The past several years have seen a dramatic increase in the number of health systems adopting this care model. These health sys...

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Information technology tools have transformed most industries, increasing safety, productivity and efficiency. Healthcare, however, continues to rely on hand-written documents, verbal communication and individual performances. Recent data highlighting high error rates, avoidable deaths and poor compliance with demonstrated best practices highlight...

To examine whether a supplemental remote intensive care unit (ICU) care program, implemented by an integrated delivery network using a commercial telemedicine and information technology system, can improve clinical and economic performance across multiple ICUs. Before-and-after trial to assess the effect of adding the supplemental remote ICU teleme...

The Solucient study highlighted broad variation in ICU performance across US hospitals and the opportunity to improve clinical and economic outcomes. The study attempted to adjust for important patient and hospital characteristics that affect ICU outcomes but was limited by the narrow scope of data contained in national administrative databases. Th...

Intensive care units (ICUs) are major sites for medical errors and adverse events. Suboptimal outcomes reflect a widespread failure to implement care delivery systems that successfully address the complexity of modern ICUs. Whereas other industries have used information technologies to fundamentally improve operating efficiency and enhance safety,...

Murine adenocarcinoma 16 (MAC16) tumors and cell lines induce cachexia in NMRI nude mice, whereas histologically similar MAC13 tumors do not. After confirming these findings in BALB/c nude mice, we demonstrated that this tissue wasting was not related to decreased food intake or increased total body oxidative metabolism. Previous studies have sugge...

The purpose was to assess the current variation in complication rates and evaluate the association between specific types of complications and in-hospital mortality and total hospital charges for patients having abdominal aortic surgery. We studied 2987 patients for abdominal aortic surgery in Maryland from 1994 to 1996 and used discharge diagnoses...

Intensive care units (ICUs) are major sites for medical errors and adverse events. Suboptimal outcomes reflect a widespread failure to implement care delivery systems that successfully address the complexity of modern ICUs. Whereas other industries have used information technologies to fundamentally improve operating efficiency and enhance safety,...

To evaluate the effectiveness of nicardipine and nitroprusside for breakthrough hypertension following carotid endarterectomy. Prospective, randomized, double-blind, controlled effectiveness trial. University-based surgical intensive care unit. 60 ASA physical status I, II, III, and IV patients experiencing breakthrough hypertension at the time of...

Pathological weight loss is a feature of many diseases and contributes to mortality and morbidity. Although cytokines have been implicated in some models of pathological weight loss, little is known about cellular mechanisms responsible for cachexia in patients with cancer. Leptin is a fat cell product that acts centrally to reduce appetite and dec...

Study Objective: To evaluate the effectiveness of nicardipine and nitroprusside for breakthrough hypertension following carotid endarterectomy.Design: Prospective, randomized, double-blind, controlled effectiveness trial.Setting: University-based surgical intensive care unit.Patients: 60 ASA physical status I, II, III, and IV patients experiencing...

Intensive care units (ICUs) account for an increasing percentage of hospital admissions and resource consumption. Adverse events are common in ICU patients and contribute to high mortality rates and costs. Although evidence demonstrates reduced complications and mortality when intensivists manage ICU patients, a dramatic national shortage of these...

Telemedicine offers off-site physicians the ability to care for patients by providing them with audio-video links and access to relevant clinical data. Traditionally, this care modality has been used to overcome geographic barriers by bringing needed expertise to patients in remote locations. The same technology can be used to bring intensivist exp...

The potential to use technology to deliver medical services across large distances has excited futurists and technology-oriented health care professionals for almost 50 years. Telemedicine offers the means to bring medical expertise to patients instantly, regardless of location. Realization of this promise means that no geographic areas will be med...

Despite extensive data examining perioperative risk in patients with coronary artery disease, little attention has been devoted to the implications of conduction system abnormalities. To define the clinical significance of bundle-branch block (BBB) as a perioperative risk factor. Retrospective, cohort-controlled study of all noncardiac, nonophthalm...

To examine the functional outcome and costs of a prolonged illness requiring a stay in the surgical intensive care unit (SICU) of 7 of more days. The long-term benefits and costs after a prolonged SICU stay have not been well studied. All patients with an SICU length of stay of 7 or more days from July 1, 1996, to June 30, 1997, were enrolled. One...

To evaluate the association between patient characteristics and both clinical and economic outcomes in patients having abdominal aortic surgery in Maryland between 1994 and 1996. Retrospective study using an administrative data set. All Maryland hospitals that performed abdominal aortic surgery from 1994 through 1996 (n = 46). All patients who had...

Morbidity and mortality rates in intensive care units (ICUs) vary widely among institutions, but whether ICU structure and care processes affect these outcomes is unknown. To determine whether organizational characteristics of ICUs are related to clinical and economic outcomes for abdominal aortic surgery patients who typically receive care in an I...

Reduced metabolic rate may contribute to weight gain in leptin-deficient (ob/ob) mice; however, available studies have been criticized for referencing O2 consumption (VO2) to estimated rather than true lean body mass. To evaluate whether leptin deficiency reduces energy expenditure, four separate experiments were performed: 1) NMR spectroscopy was...

The integrated stress response to tissue trauma is crucial for the maintenance of homeostasis. An exaggerated or prolonged response may be detrimental in compromised patients. Knowledge of the involved afferent pathways will suggest therapeutic interventions that may modulate the intensity of the stress response. Described are these concepts as the...

Introduction: Studies have demonstrated reduced mortality, length-of-stay (LOS) and resource utilization when intensive care units (ICU) are managed by on-site critical care specialists. We believe that a large part of the benefit of on-site Intensivists resides in continuous physiologic monitoring. We hypothesized that telemedical methodologies co...

Introduction: Complications of hospital care are associated with increased morbidity, mortality, and costs, however, the exact relationship between complications and these outcomes has not been established. The specific aims of this study were to evaluate the variation m postoperative complications and the association between postoperative complica...

Background Postoperative supraventricular tachyarrhythmia is a common complication of surgery. Because chemical cardioversion is often ineffective, ventricular rate control remains a principal goal of therapy. The authors hypothesized that patients with supraventricular tachyarrhythmia after major noncardiac surgery who receive intravenous beta-adr...

Radial artery pressure is known to differ from central arterial pressure in normal patients (distal pulse amplification) and in the early postcardiopulmonary bypass period. The adequacy of the radial artery as a site for blood pressure monitoring in critically ill patients receiving high-dose vasopressors has not been carefully examined. Prospectiv...

Cytokines, such as tumor necrosis factor (TNF) and interleukin-6, may contribute to the anorexia and cachexia of infection, cancer, and AIDS. The present study tests the hypothesis that endotoxin alters the expression of two key fat cell proteins, leptin and beta3-adrenergic receptor (beta3-AR), through a mechanism involving TNF-alpha. Increasing d...

Cytokines, such as tumor necrosis factor (TNF) and interleukin-g, may contribute to the anorexia and cachexia of infection, cancer, and AIDS. The present study tests the hypothesis that endotoxin alters the expression of two key fat cell proteins, leptin and beta(3)-adrenergic receptor (beta(3)-AR), through a mechanism involving TNF-alpha. Increasi...

"Renal dose" dopamine is widely used in the perioperative period to provide renal protection. A comprehensive review of the literature was performed to determine whether dopamine does in fact confer protection on the kidneys of surgical patients. Studies in healthy animals and human volunteers reveal that dopamine causes diuresis and natriuresis, a...

Objective: To assess the relationship between body temperature and cardiac morbidity during the perioperative period. Design: Randomized controlled trial comparing routine thermal care (hypothermic group) to additional supplemental warming care (normothermic group). Setting: Operating rooms and surgical intensive care unit at an academic medic...

Surgical trauma results in diffuse sympathoadrenal activation which is thought to contribute to perioperative cardiovascular complications in high-risk patients. Regional anesthetic and analgesic techniques can attenuate this "stress response" and reduce the occurrence rate of adverse perioperative events; however, their use in the postoperative pe...

To assess the relationship between body temperature and cardiac morbidity during the perioperative period. Randomized controlled trial comparing routine thermal care (hypothermic group) to additional supplemental warming care (normothermic group). Operating rooms and surgical intensive care unit at an academic medical center. Three hundred patients...

The adrenergic, respiratory, and cardiovascular responses to isolated core cooling were assessed in awake human subjects. Mild core hypothermia was induced by intravenous infusion of 30 or 40 ml/kg of cold saline (4 degrees C) on 2 separate days. A warm intravenous infusion (30 ml/kg, 37 degrees C) was given on a third day as a control treatment. M...

Leptin-deficient Ob/Ob mice are hypometabolic and have reduced fat cell expression of beta-3 adrenoceptors (ARs). To determine whether leptin repletion restores beta-3 AR number, C57BL/6J Ob/Ob mice were given exogenous leptin (5 mg/kg I.P. daily) for 21 days. Leptin administration reduced body weight from 43.1+/-3.7 to 34.1+/-3.7 g in Ob/Ob animal...

Anorexia and cachexia, syndromes of progressive weight loss and wasting, frequently accompany many clinical settings including cancer, AIDS, infection, and other critical illness. Because of the importance of leptin (a novel peptide hormone released by fat cells which regulates appetite and metabolism), and b3AR (a novel metabolic beta receptor imp...

To evaluate the effects of hemocarboperfusion on hemodynamics, organ blood flow, and survival in endotoxin shock. Prospective, placebo-controlled, animal trial. Research laboratory in a major university teaching hospital. Pentobarbital-anesthetized pigs. Twenty-eight pentobarbital-anesthetized pigs (18.5 to 22.3 kg) received 100 micrograms/kg of Es...

Comment: This very well-conceived and conducted study demonstrates that the increase in oxygen consumption caused by shivering in the elderly is less than has been reported in earlier studies of younger subjects. An interesting related observation from this study is that there was a higher correlation between core body temperature and oxygen consum...

To determine whether catecholamine and cortisol secretory responses to surgery contribute to postoperative complications. Prospective, randomized, case series. A university hospital operating suite and surgical intensive care unit. Sixty patients undergoing lower extremity vascular surgery. Patients were randomized to receive either epidural anesth...

Objective: To determine whether cate-cholamine and cortisol secretory responses to surgery contribute to postoperative complications. Design: Prospective, randomized, case series. Setting: A university hospital operating suite and surgical intensive care unit. Patients: Sixty patients undergoing lower extremity vascular surgery. Interventions: Pati...

Previous investigators have proposed that postoperative shivering may be poorly tolerated by patients with cardiopulmonary disease because of the associated significant increase in total-body oxygen consumption. However, the often-quoted 300-400% increase in oxygen consumption with shivering was derived from relatively few studies performed in a sm...

Unintended hypothermia occurs frequently during surgery and may have adverse effects on the cardiovascular system. Although the mechanisms responsible for the cardiovascular manifestations of hypothermia are unclear, it is possible that they are sympathetically mediated. In this prospective study, relationships between body temperature, the neuroen...

Bovine adrenal medullary membranes were incubated with [125I]cyanopindolol to assess beta-adrenoceptor binding. Binding was saturable and specific; a single low affinity site (Kd = 750 pM) was identified. [125I]Cyanopindolol binding was displaced by micromolar concentrations of classic beta-adrenoceptor antagonists and by sodium-4-[-2-[2-hydroxy-2-...

It has been postulated that nitric oxide (NO) is a neurotransmitter involved in consciousness, analgesia, and anesthesia. Halothane has been shown to attenuate NO-mediated cyclic guanosine monophosphate accumulation in neurons, and a variety of anesthetic agents attenuate endothelium-mediated vasodilation, suggesting an interaction of anesthetic ag...

To evaluate effects of adrenergic receptor stimulation on regional adrenal blood flow and secretion, pentobarbital-anesthetized dogs (n = 5-6/group) received the beta-agonist isoproterenol (group I), the alpha 1-agonist phenylephrine (group II), or the alpha 2-agonist dexmedetomidine (group III). Measurements of adrenal cortical (CQ) and medullary...

Surgical trauma elicits diffuse changes in hormonal secretion and autonomic nervous system activity. Despite studies demonstrating modulation of the stress response by different anesthetic/analgesic regimens, little is known regarding the determinants of catecholamine and cortisol responses to surgery. Plasma catecholamines and cortisol secretion d...

Ischemic cardiac morbidity is the most common cause of death in the United States in patients undergoing surgery as well as in the non-perioperative setting.(l). Coronary artery disease is ultimately the predisposing factor in patients who suffer cardiac death, but usually a triggering event disrupts the delicate balance between myocardial oxygen s...

Background: Surgical trauma elicits diffuse changes in hormonal secretion and autonomic nervous system activity. Despite studies demonstrating modulation of the stress response by different anesthetic/analgesic regimens, little is known regarding the determinants of catecholamine and cortisol responses to surgery.

The purpose of this clinical trial was to compare the effects of different anesthetic and analgesic regimens on hemostatic function and postoperative arterial thrombotic complications. Ninety-five patients scheduled for elective lower extremity vascular reconstruction were randomized to receive either epidural anesthesia followed by epidural fentan...

To evaluate effects of cholinergic receptor stimulation on regional adrenal blood flow (Q, radiolabeled microspheres) and catecholamine secretion, acetylcholine (ACh) was infused into pentobarbital-anesthetized, ventilated dogs. Unilateral adrenal denervation and placement of lumboadrenal catheters preceded intra-aortic infusion of 1) ACh alone (n...

Background: The purpose of this clinical trial was to compare the effects of different anesthetic and analgesic regimens on hemostatic function and postoperative arterial thrombotic complications.

Increased postoperative platelet reactivity may contribute to arterial thrombotic complications following surgery. alpha 2 Agonists, which are being used increasingly to blunt the stress response of surgery, increase platelet aggregation in vitro. We compared perioperative changes in platelet reactivity in 21 patients receiving either clonidine or...

To determine whether nitric oxide (NO) is involved in adrenal medullary vasodilation during splanchnic nerve stimulation (NS)-induced catecholamine secretion, blood flow (Q) and secretory responses were measured in pentobarbital-anesthetized dogs before and after administration of the NO synthase inhibitor, NG-nitro-L-arginine methyl ester (L-NAME)...

The frequency of adult surgical and medical intensive care unit (ICU) admissions related to substance abuse was determined at a large community, trauma, and tertiary referral hospital. Of 435 ICU admissions, 14 percent (95 percent confidence interval [CI], 5 to 23 percent) were tobacco related generating 16 percent of costs, 9 percent (95 percent C...

Septic shock continues to be a major cause of inhospital mortality (Ziegler et al. 1991). However, improvements in the acute resuscitation of patients presenting with septic shock have changed the nature of this illness. Fewer patients are dying of the early hemodynamic disturbances accompanying bacteremia. Rather, prolonged survival with progressi...

Muscarinic cholinergic receptor stimulation has been reported to modulate adrenal catecholamine and steroid secretion and influence medullary vascular tone. The present study was undertaken to localize and characterize muscarinic cholinergic receptor binding sites in canine adrenal medulla and cortex. Binding studies using semipurified membranes de...

Management of extensive trauma often requires immediate tracheal intubation and mechanical ventilation. The role of anesthetic induction agents and neuromuscular blockade in the airway management of the trauma victim is disputed. To better define the role of these agents in the acute management of trauma, the adult trauma registry of The Johns Hopk...

Before 1986, little was known concerning regulation of blood flow to adrenal medulla and cortex. With the introduction of a radiolabeled microsphere methodology, which permitted independent measurement of blood flow to the two regions, it became apparent that medulla and cortex regulate blood flow independently and that both regions receive levels...

To study the effect of serum from patients with fungemia and control patients on sinoatrial node function. Prospective, observational study. Surgical ICU in a university hospital. Fourteen patients with fungemia and 14 control patients. Serum samples from all patients were assayed in an in vitro sinus node preparation. Serum samples from 11 (78%) o...

Pages H410–H415: N. T. Sakima, M. J. Breslow, H. Raff, and R. J. Traystman. “Lack of coupling between adrenal cortical metabolic activity and blood flow in anesthetized dogs.” Page H412: The units for oxygen consumption in Fig. 3 should read as cc O 2 /min/100 g adrenal gland.

Pages H410–H415: N. T. Sakima, M. J. Breslow, H. Raff, and R. J. Traystman. “Lack of coupling between adrenal cortical metabolic activity and blood flow in anesthetized dogs.” Page H412: The units for oxygen consumption in Fig. 3 should read as cc O2/min/100 g adrenal gland.

In this chapter I have tried to illustrate how trauma-induced changes in plasma catecholamines and other stress hormones can result in physiological alterations that may in turn increase the likelihood of developing myocardial ischemia. Data have been presented about potential mechanisms by which these hormones can lead to the development of ischem...

To review the physiologic and pathophysiologic hyperadrenergic states and the pharmacologic use of sympathomimetic agents. Pharmacologic and physiologic studies in experimental animals and humans. Plasma catecholamines are increased in a variety of clinical situations. Following major injury, catecholamines act to support vital organ perfusion and...

To determine the relative role of nicotinic and muscarinic mechanisms in splanchnic nerve stimulation (NS)-induced adrenal catecholamine secretion and medullary vasodilation, 12 pentobarbital-anesthetized dogs were subjected to three identical stimulations. The first NS was performed before drug administration and served as a control. The second NS...

Pages H410–H415: N. T. Sakima, M. J. Breslow, H. Raff, and R. J. Traystman. “Lack of coupling between adrenal cortical metabolic activity and blood flow in anesthetized dogs.” Page H412: The units for oxygen consumption in Fig. 3 should read as cc O2/min/100 g adrenal gland.

To determine whether adrenal O2 consumption and cortical blood flow (CBF) increase during stimulation of cortical secretory activity, exogenous adrenocorticotrophic hormone (ACTH) was infused at 0, 2, and 10 ng.kg-1.min-1 (groups 1, 2, and 3, respectively) into dexamethasone-pretreated, pentobarbital-fentanyl-anesthetized, ventilated dogs. ACTH lev...