Subject(s)
Critical Care/standards , Outcome and Process Assessment, Health Care/organization & administration , Patient Care Planning/organization & administration , Respiration, Artificial/nursing , Respiration, Artificial/standards , Total Quality Management/organization & administration , Critical Care/statistics & numerical data , Critical Care/trends , Humans , Length of Stay/statistics & numerical data , Program Development , Respiration, Artificial/statistics & numerical data , Respiration, Artificial/trends , Time FactorsABSTRACT
This article examines the structure and process of a collaborative practice team established specifically to improve the quality and financial outcomes of ventilator-dependent patients in a tertiary care teaching hospital. A brief overview of descriptors regarding ventilator-dependent patients is synthesized from the literature and compared with the population at St. Luke's Episcopal Hospital in Houston, Tex. An analysis of statistically significant physiologic variances that have been found to increase mechanical ventilation time or length of stay is detailed. Focused quality initiatives are discussed. Specific criteria indicative of improved outcomes are presented along with recommendations for future improvements.
Subject(s)
Critical Care/standards , Critical Pathways , Outcome and Process Assessment, Health Care , Patient Care Team/organization & administration , Respiration, Artificial/nursing , Humans , Respiration, Artificial/adverse effects , Respiration, Artificial/mortalityABSTRACT
Heparin preparations vary in chemical content and in antiproliferative activity for pulmonary artery smooth muscle cells (PASMC). Intracellular alkalinization via stimulation of the Na+/H+ antiporter appears to be a permissive event for proliferation of PASMC. We wondered whether the variable effect of heparin preparations on PASMC growth might be due to different degrees of inhibition of the Na+/H+ antiporter and whether variations in chemical formulation might correlate with the inhibition. Fluorescent microscopy of bovine PASMC was done using a dye with which fluorescence varies directly with intracellular pH (pHi). Bovine PASMC were preincubated with three heparin preparations previously shown to vary in antiproliferative activity, at 1.0 microgram/ml for 24 h. Platelet-derived growth factor (PDGF; 60 ng/ml) on PASMC without heparin resulted in a rise in pHi of 0.27 +/- 0.02 pH units. The rise in pH units in heparin-treated PASMC was 0.34 +/- 0.03 with Choay, 0.21 +/- 0.02 with Elkins-Sinn, and 0.07 +/- 0.02 with Upjohn (+/-SE; all P < 0.05; n = 5). Upjohn heparin incubation for as little as 15 min still impeded the rise in pH induced by PDGF. Heparin did not block the Na+/H+ exchanger directly, as it still restored pHi in response to an acid load. Compared with PASMC proliferation induced by 60 ng/ml PDGF, 1 microgram/ml of Choay, Elkins-Sinn, and Upjohn heparin produced -4 +/- 7.4, 1.4 +/- 4.8, and 48 +/- 2.2% inhibition of PDGF control, respectively (P < 0.05 for Upjohn compared with PDGF and Choay). The heparins varied in protein content and amino acid composition. However, amino acid and glucosamine composition, total sulfation, and extent of 3-O-sulfation did not predict their activity. Thus inhibition of PDGF activation of the Na+/H+ antiporter by a given heparin preparation correlated well with its ability to inhibit PASMC proliferation.
Subject(s)
Heparin/chemistry , Heparin/pharmacology , Muscle, Smooth/drug effects , Muscle, Smooth/metabolism , Pulmonary Artery/drug effects , Pulmonary Artery/metabolism , Sodium-Hydrogen Exchangers/metabolism , Animals , Cattle , Cell Division/drug effects , Cells, Cultured , Muscle, Smooth/cytology , Platelet-Derived Growth Factor/pharmacology , Pulmonary Artery/cytologyABSTRACT
Chronic hypoxia produces pulmonary hypertension, in part because of hypertrophy and hyperplasia of pulmonary artery smooth muscle cells (PA SMC). Platelet-derived growth factor (PDGF) and epidermal growth factor (EGF) have been shown to stimulate SMC proliferation and may be involved in these vascular changes. Both factors cause a rise in intracellular pH (pHi) in systemic vascular SMC through stimulation of the Na+/H+ exchanger, an event that has been thought to be permissive, allowing cell proliferation in response to the growth factor. The present studies examined the possibility that the activation of Na+/H+ exchange is involved in the PA SMC mitogenic response to these growth factors. Na+/H+ exchange activity was assessed by monitoring pHi in cultured cells using the pH-sensitive dye, 2'7'-bis(carboxyethyl)-5(6)-carboxyfluorescein (BCECF). PDGF (60 ng/ml) exposure led to a marked activation of Na+/H+ exchange, evidenced by a rise in pHi (mean +/- SEM) of 0.20 +/- 0.03 pH units (n = 5, P < 0.05). EGF (60 ng/ml) exposure produced a rise in pHi of 0.27 +/- 0.03 pH units (n = 5, P < 0.05). Dimethyl amiloride (DMA, 50 microM), a competitive inhibitor of Na+/H+ exchange, blocked the pH response to PDGF and EGF. PA SMC showed a proliferative response when exposed to PDGF and EGF which was attenuated by 50 microM DMA (n = 6). Thus, activation of the Na+/H+ exchanger may be important in pulmonary cell signaling in response to growth factors as it has been found to be in systemic vessels.
