Design of a clinical alert system to facilitate development, testing, maintenance, and user-specific notification.

Creation and maintenance of electronic clinical alerts within a hospital's electronic medical record (EMR) or database poses a number of challenges. Development can require significant programming effort. Final testing should ideally be performed in a real clinical environment without clinician notification, which may create technical challenges. After an alert is in production, modifications may become necessary in response clinician feedback, changes in clinical factors, or technical issues. Changes may be required in the knowledge base utilized by the alert or in the presentation of the alert condition to the clinicians. Occasionally, different users within the clinical environment may wish to have the same alert data presented differently. We have developed a strategy which allows development of multi-functional alerts and facilitates modification of alert function and/or presentation with minimal to no programming effort. Some elements of this scheme may be appropriate for incorporation into clinical alerting standards.

L-2-oxothiazolidine-4-carboxylate, a cysteine precursor, stimulates growth and normalizes tissue glutathione concentrations in rats fed a sulfur amino acid-deficient diet.

The efficiency of L-2-oxothiazolidine-4-carboxylate, a cysteine precursor, in stimulating glutathione synthesis and growth was evaluated in growing rats. Animals were fed a sulfur amino acid-deficient diet (0.25% L-methionine and no cysteine) supplemented with L-2-oxothiazolidine-4-carboxylate (0.35%) for 3 wk and compared with age-matched animals receiving the sulfur amino acid-deficient diet alone. Rats fed the sulfur amino acid-deficient diet had lower glutathione concentrations in bronchoalveolar lining fluid, lung, lymphocytes, and liver than rats fed a sulfur amino acid-deficient diet supplemented with L-2-oxothiazolidine-4-carboxylate. Rats fed the supplemented diet had normal tissue and bronchoalveolar lining fluid glutathione levels. Central venous plasma glutathione concentrations, mostly reflecting liver excretion, were less affected by L-2-oxothiazolidine-4-carboxylate supplementation. Rats fed L-2-oxothiazolidine-4-carboxylate supplementation had normal weight gain compared with a much lower weight gain in animals fed the sulfur amino acid-deficient diet alone. Thus, L-2-oxothiazolidine-4-carboxylate increased tissue glutathione concentrations and stimulated growth in rats. The lung glutathione status of the rats was reflected by glutathione concentrations in lymphocytes and the bronchoalveolar lining fluid, but not by the central venous plasma glutathione concentrations.

Effect of endotracheal continuous positive airway pressure on sensitivity to carbon dioxide and on respiratory timing in preterm infants.

To determine the effects of continuous positive airway pressure (CPAP) on ventilatory response to CO2 and inspiratory and expiratory duration in preterm infants, 24 preterm infants with an average birth weight of 1220 g were studied at a mean age of 10.6 days. CPAP was applied via an uncuffed endotracheal tube. Testings were performed between ambient pressure and a positive airway pressure of 10 cm H2O. Approximately 2/3 of the applied pressure was transmitted to the esophagus. All infants demonstrated a ventilatory response to carbon dioxide of less than 50 ml/min per mm Hg Pco2 at ambient pressure, and no infant showed significant improvement at increasing levels of CPAP. Drive to breathe, as reflected in the inspiratory flow rate (Vt/Ti) also failed to change significantly. It may be concluded that in the apparent absence of significant changes in lung volume, CPAP fails to increase sensitivity to CO2 in preterm infants recovering from hyaline membrane disease.

Neonatal intensive care unit renovation. The New York Hospital--Cornell Medical Center 1975-1976.

The renovation of the neonatal intensive care unit at The New York Hospital has served to test several new ideas about the design of intensive care facilities for infants. Our experience has supported our original feelings that smaller rooms rather than large open spaces offer significant advantages to both staff and families of patients. The radial arrangement of beds around a central supply module has concentrated our available floor space immediately around the patient's bed while providing convenient access to virtually all supplies used in infant care with a minimum of labor devoted to stock maintenance. The anticipation of our relationships with supportive services such as radiology and biochemistry has allowed us to integrate these functions smoothly into the design of the unit in such a way that service and patient care are generally improved as a result of this advance planning. In short, the design has proved conceptually sound but shares flaws that many units before ours have recognized. You cannot have too much storage space or too much floor space. In general, this design has vindicated our original concept that facility design should offer unique solutions to individual problems. It is difficult to generalize about what will and what will not work in a particular setting. But, in general, careful consideration and good planning are excellent investments in the future success of a design for a new ICU or a facility renovation.

Noninvasive estimation of arterial oxygenation in newborn infants.

Two noninvasive methods of estimating arterial oxygenation were compared in a group of 48 infants ranging in birth weight from 870 to 4,000 gm, with diagnoses including apnea of prematurity, hyaline membrane disease, meconium aspiration, and congenital heart disease. Both transcutaneous oxygen measurements and ear oximetry gave reasonably accurate estimations of arterial oxygen levels within commonly used clinical ranges (PO2 50 to 70 mm Hg, arterial saturation 90 to 98%). Infants with shock demonstrated a wide range of values for transcutaneous oxygen levels, suggesting that this method has limited usefulness in this situation. Ear oximetry had limited ability to distinguish high, but safe, levels of arterial oxygen from excessively elevated levels. While neither method can be recommended for replacement of arterial oxygen sampling, both methods may be useful in a clinical setting if care is exercised in interpretation of the results and if the values obtained are checked against those from arterial blood.