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The radical neck dissection is an operation for the management of lymph node metastases from primary sites involving the oral cavity, larynx, and other areas of the head and neck. In this procedure, the spinal accessory nerve is removed along with other structures. In modified neck dissection the spinal accessory nerve is preserved. Patients undergoing the modified neck dissection have had variable functional outcomes from little or no pain or disability, to significant muscle dysfunction. Our group hypothesized that patients with good functional outcomes following modified neck dissection may have had motor contributions from C2, C3, or C4 branches, while those with less favorable outcomes did not. To demonstrate the presence of motor input and its significance both from the spinal accessory nerve and the branches of the cervical plexus, we utilized intraoperative electroneurography. We find that although there is motor contribution from C2, C3, and C4 to the trapezius muscle, it was not consistent or significant.

A radiofrequency resonator whose normal modes correspond to those of a ladder network of finite length is described. When formed into a semicylindrical geometry, the lowest frequency mode of the resulting “half-birdcage” resonator yields a B 1 distribution which can be exploited for imaging.

Mass spectrometers are used in ICUs and ORs to measure the concentration of medical and anesthetic gases gathered from multiple sites. This investigation was designed to determine the accuracy of a clinical system, which included 12 ICU bedside stations monitored by a medical mass spectrometer (Perkin-Elmer RMS III, Pomona, CA). Each site station was connected to the analyzing unit via two Teflon tubes, one permanently installed, 30-m long, and the second disposable, 2.4-m long. A gas mixture containing 95% O2 and 5% CO2, alternating with room air, was delivered to a solenoid valve and from there to the connecting tubes. Gas flow-rate, delay time, rise time, and peak and trough concentrations were determined for each gas at solenoid cycling frequencies of 25, 50, and 100/min. After the first set of measurements, the 30-m tubes were thoroughly cleaned and all measurements repeated. In addition, the authors also measured CO2 delay and rise times when the gas was delivered to the mass spectrometer through an unused 30-m tube or a new 2.4-m tube. Gas flow-rate increased from 143 +/- 12 ml/min (mean +/- SD) to 238 +/- 9 ml/min after the tubes were cleaned. Delay time was identical for all gases at all solenoid cycling rates but decreased significantly (P less than 0.05), from 11.5 +/- 0.3 to 4.8 +/- 0.7 s after the ceiling tubes were cleaned. As solenoid valve rate increased, the difference between measured and actual gas concentration increased. The lowest accuracy was 63.6 +/- 2.1%, for CO2 at 100 cycles/min.(ABSTRACT TRUNCATED AT 250 WORDS)

Once the requirement for a biomedical information network has been articulated, the process of development and implementation can then be approached. Although the general architecture of such a system may appear to be self evident, there are careful design considerations that will allow the network to be robust and achieve increased levels of functionality as additional systems come on-line and become integrated into the network. As of this writing, there are few interoperability standards between the various medical systems that comprise the desired network. We have chosen the Emergin Orchestrator product (Boca Raton, Fl) as the vehicle for integrating these systems. The major design and implementation tasks include defining the basic information architecture, assessing the performance of the existing IT infrastructure, and understanding the native capabilities and limitations of each system involved in the network.

Radio Frequency Identification (RFID) is an evolving technology that can utilize its capabilities within a healthcare environment to locate and track staff, equipment, and patients. RFID has the potential to significantly improve operations by actively monitoring asset flow through an organization and enabling this data to be analyzed for process improvement. It can also help to provide validation to existing process improvement initiatives set forth by an institution. Furthermore, RFID can be integrated into other operations including patient safety, clinical operations, billing, and theft prevention. 1

The deployment of new wireless and networked technology and advanced clinical applications has significantly increased the quality and the quantity of patient diagnostic and monitoring information throughout the patient care environment. Coupled with increasing workloads and reduced staffing, the difficulties in effectively prioritizing and handling this information have resulted in a rise in equipment-related errors, patient dissatisfaction, a potential for patient injury, and an increasing overall concern for patient safety. Concerns about this trend have prompted the Joint Commission to established seven patient safety initiatives geared to the patient environment of care, establishing methodologies and protocols to reduce the probability of errors, and to provide an enhanced level of communications. Planned deployment of advanced medical devices and supporting technologies coupled with our existing wired / wireless network infrastructure, need to consider the potential integrating clinical device, onto a unified network infrastructure providing advanced capabilities to share and effectively manage this key patient clinical information. Implementation of a Biomedical Device Information Network represents a significant advance in the management of clinical patient information, and enables device data, specifically critical patient alarms to be shared, coordinated, prioritized and sent directly to specific assigned care providers. The care giver utilizing a common hands-free wireless device can receive a prioritized audible (or a simulated voice) alarm message and utilize this same device for directed staff-to-staff or staff-to-patient communication. The Biomedical Information Network implementation identifies or associates patients with devices and consequently critical alarms, filters low priority or nuisance alarms, and eliminates the need for multiple costly communication devices. This implementation establishes an enhanced environment of care, providing increased patient safety, and a clear proactive response to the national patient safety initiatives.

ObjectivesThis study was designed to evaluate autonomic changes preceding atrial fibrillation/flutter (AF) after thoracotomy.BackgroundAutonomic fluctuations before the onset of postoperative AF have been reported but with conflicting results.MethodsIn 48 patients with postoperative AF, 2-h Holter recordings before the onset of AF were compared with corresponding data from 48 age- and gender-matched surgical controls without AF. Five-minute segments of heart rate variability (HRV) were studied using linear regression methods.ResultsThere was a near-significant trend for the RR interval among patients with AF to be lower than controls (p = 0.06), whereas the standard deviation of RRs (p < 0.0001), root mean square of successive RR differences (p < 0.0001), proportion of RRs >50 ms different (p < 0.0001), low-frequency power (p = 0.0003) and its log (p < 0.0001), and high-frequency-power (p < 0.0001) and its log (p < 0.0001) were all significantly greater in patients with AF, respectively. In comparison to controls, AF patients had a significant decrease in RR interval (p = 0.02) and significant increments in all time- and frequency-domain analyses studied.ConclusionsIn the period before the onset of postoperative AF, there are significant increases in HRV during a time when heart rate also increases. These novel findings are consistent with parasympathetic resurgence competing with increasing sympathetic activity as the triggering mechanism for postoperative AF.

Background: The mechanisms of atrial fibrillation/flutter (AF) after major thoracic surgery remain controversial. The goal of the present study was to evaluate autonomic changes preceding postoperative AF. Methods: In 48 patients with postoperative AF 2 h Halter recordings prior to the onset of AF were compared wth corresponding data from 48 ageand gender-matched surgical controls without AF. Five-minute segments of heart rate variability were studied using reoeated measwes ANOVA. Results: There was a near significant trend for the RR-interval among AF patients to be lower than controls IP=O.OE& while the standard deviation of RRs fP

Background & Aims: Metabolic monitoring devices used in the critical care setting are subject to a range of conditions that may compromise their accuracy. We sought to investigate the error and precision of the Deltatrac metabolic monitor under these conditions. Methods: A modified version of the funnel burner, described by Miodownik et al. (8), was ventilated by a mechanical ventilator. This was used to examine the performance of the Deltatrac metabolic monitor over a wide range of inspired oxygen concentrations, minute ventilation, and positive end expiratory pressure at different levels of oxygen consumption and carbon dioxide production. Results: The Deltatrac measured V 0 2 with a mean error±precision of 9.4%±19.5% (range, 9.3%±1.9%–72.6%±13.6%). The mean V CO 2 error±precision was 1.2%±3.1% (range–2.0%±1.2%–5.4%±3.1%). Error was significantly affected by oxygen concentration and minute ventilation but was largely independent of positive and expiratory pressure. Conclusions: The methodology of Miodownik et al. permits the expression of metabolic device errors over a wide range of simulated clinical conditions.

Resection of carcinoma of the esophagus may be curative or palliative and usually results in either total esophagectomy or esophagogastrectomy. Continuity of the upper gastrointestinal tract is maintained via a gastric pull-up procedure or, when feasible, by primary reanastomosis of the gastric remnant to the proximal esophagus. 1 If a large part of the stomach has been previously resected or is unsuitable for use, colonic or jejunal interposition may be utilized to maintain continuity. However, these operations are associated with substantial surgical morbidity and mortality and a myriad of postoperative complications, including luminal narrowing caused by edema or ischemia, anastomotic leaks, formation of fistulae and strictures, and development of graft ischemia. 2, 3 These procedures may be precluded in the elderly or in patients with complex medical problems who are poor surgical risks. In these patients and in those with unresectable esophageal carcinoma, palliative cervical esophagostomies are sometimes performed to reduce the discomfort of dysphagia and lessen the at tendant risk for aspiration pneumonia. Nutrition is maintained through surgically placed gastrostomies or jejunostomies and, in rare instances when feeding tube place: ment is not possible or the distal gastrointestinal tract is obstructed, total parenteral nutrition. 2 Although these procedures are palliative, patients usually remain uncomfortable, are unable to eat, and have the extra burden of repeatedly emptying the esophagostomy bag, in which saliva accumulates. They also have the problem of administering enteral feedings and fluids to replace the salivary losses. We have developed an active esophageal prosthesis (AESOP) that, via a small pneumatically driven extracorporeal pump, can maintain a functioning conduit between a cervical esophagostomy and the remainder of the gastrointestinal tract in a closed circuit.

To elucidate the delayed effects of midazolam, we assessed electrophysiologic and motor responses by measuring auditory event-related potentials and a button-press reaction time response in 10 normal volunteers (aged 25-36 yr). Fifty minutes after intravenous infusion of 0.07 mg/kg of midazolam, subjects were mildly sedated, oriented, and readily responsive to verbal commands. To obtain ERPs, frequent tones (85%: 1000 Hz) and rare tones (15%: 2500 Hz) were presented at intervals of 1.5 s. Electroencephalographic signals were collected from FZ, CZ, and PZ for 1000 ms after stimulus presentation until 40 artifact-free rare-tone responses were obtained (average time, 6 min). Peak-to-peak amplitudes and latencies for N2, P3, and the subsequent negative slow wave (N3) were averaged within condition and were analyzed by repeated measures analysis of variance. After midazolam infusion, there was a 50% decrease in amplitude of P3 in response to target tones (P less than 0.006), whereas N3 latency increased by 40 ms (P less than 0.05). Event-related potential amplitudes were still significantly larger to rare (target) stimuli (P less than 0.003) after midazolam infusion. Although reaction time increased by 70 ms (P = 0.031), performance accuracy remained unchanged. Self-ratings of sleepiness and concentration show that a significant sedation effect was still present 50 min after infusion. Although routine clinical examination may be normal, full recovery from the effects of a typical intravenous dose of midazolam requires more than 50 min. The potential for adverse drug interaction, particularly with narcotics, is still present at this time.

Three hundred nine patients were randomly allocated to two ventilatory protocols; 157 patients were supported with a volume-cycled ventilator (VCV) (Bear Medical BEAR 1) and 152 with a high-frequency jet ventilatory (HFJV) developed at our institution. The two ventilators were compared for safety, reliability, ease of use, and efficacy in maintaining gas exchange. On VCV, end points of therapy were: fractional concentration of oxygen in the inspired gas (FIo 2 ) ≤ 0.40; arterial oxygen pressure (PaO 2 ) ≥ 70 mm Hg; cardiac index (CI) ≥ 3.5 L/min/sq m; and spontaneous respiratory rate ≤ eight breaths per minute. On HFJV, end points were: FIo 2 ≤ 0.45; arterial oxygen saturation ≥ 0.90; and CI ≥ 3.5 L/min/sq m. Spontaneous ventilation and pulmonary venous admixture reduction were the goals on VCV, with oxygen transport the goal on HFJV, Total duration of use of the ventilators was approximately 800 days with both types of devices; there were no technical failures, and the incidence of barotrauma was less than 5 percent. The end point of mechanical ventilation was reached by a significantly higher percentage of the patients randomized to HFJV. Patients who failed to reach the therapeutic goal within 24 hours were crossed over to the other form of support. Those crossed from VCV to HFJV improved more rapidly and in greater number than those crossed from HFJV to VCV. When survival and total duration of stay in the intensive care unit were considered, there was no difference between VCV and HFJV. Considering data on gas exchange, VCV provided a higher PaO 2 at equivalent positive end-respiratory pressure than HFJV. Alveolar ventilation was slightly better on HFJV. Differences were statistically but not clinically significant. On HFJV, oxygenation and ventilation were maintained with lower peak inspiratory pressures and smaller tidal volumes than those required for VCV. This investigation proves that HFJV is a safe and reliable method to provide mechanical support which does not, at this time, offer obvious benefits over VCV.

High frequency jet ventilation (HFJV) is an incompletely studied technique of mechanical respiratory support. The authors have built a ventilator based on a solenoid valve, that allows independent selection of respiratory rate and inspiratory/expiratory ratio. The ventilator can be synchronized to the heart rate. Hum-idification is provided by warm saline dripped in front of the injector nozzle, so that the jet stream itself acts as a nebulizer. Tube diameter, length, and deformability are fundamental determinants of inspiratory flow rate and wave form. Cannula kinking and inadequate humidifi-cation were the most significant sources of complications.

Respiratory failure of different origins often requires therapy with mechanical ventilation and positive end-expiratory pressure (PEEP). These supports are occasionally inadequate if the damage to one lung is significantly more pronounced than that to the other lung. Technical means exist to ventilate each lung independently or to provide a different PEEP to each lung. The findings from nine patients in whom one of these techniques was applied are presented, and advantages and disadvantages are discussed.

We used indirect calorimetry to measure oxygen consumption (VO2) and carbon dioxide production in 29 mechanically ventilated patients. These data were compared to VO2 measured simultaneously by a standard thermodilution technique. A good correlation was demonstrated between the methods, but VO2 measured by indirect calorimetry was 15% higher than VO2 measured by thermodilution.

The design and construction of solenoidal resonators for use with small animals in a 1.5-Tesla clinical imaging system are described. The coils have been designed to exploit the B1 distributions of two resonant modes of a four-turn solenoid whose windings are in parallel. Both singly and doubly tuned versions have been constructed. 1H images of normal and pathologic anatomy in mice and rats as well as a 31P spectrum of a Walker 256 rat sarcoma are presented. A primary advantage of this design is that the coils are easy to build and implement while providing the necessary sensitivity to allow high quality images to be obtained with no changes to the hardware or software of the clinical unit.

An apparatus for precision calibration of ion chambers in the x‐ray region from 16 to 320 kV is described. The development of a fast‐acting shutter with ‘‘opening’’ and ‘‘closing’’ times of less than 3‐ms eliminates the requirement for operating time corrections. Controls from outside the radiation room permit changing x‐ray filters and alternately positioning both test and standard ion chambers in the x‐ray beam. Thus, the remote controls eliminate the need to enter the x‐ray room in the course of a series of calibrations. The potential advantages resulting from the capabilities of this apparatus are described in this Technical Report.

A variety of technical decisions are required for the proper selection and safe and efficacious application of high-frequency jet ventilation (HFJV). Criteria for analyzing the performance of an HFJV system are presented, along with discussions of some of the more common respiratory measurements and their applicability to HFJV.

Capnography, the science of CO2 waveforms analysis, can play a role in the management of mechanically ventilated patients. Mass spectrometers are the devices most commonly used to collect sequentially and examine CO2 waveforms from multiple patients in the ICU or operating rooms. We present here a review of some clinical and technical problems, which may be resolved efficiently and expeditiously through the use of mass spectrometry and capnography. Mechanical failures, especially those that lead to rebreathing of exhaled gases, can be readily detected. The patient's progress during weaning and the consequences of changes in mechanical assistance can be virtually and noninvasively determined. An expanded role of capnography in mechanically ventilated patients can increase the use of mass spectrometers in the ICU.

A pneumatic-to-electrical circuit analog is used to describe 2 separate mechanisms by which high-frequency jet ventilators sustain ventilation and oxygenation in the presence of large airway disruptions. The frequency-dependent mechanism is based on variations in the pneumatic equivalent to capacitive reactance. The pressure-dependent mechanism models lung defects on a voltage-controlled resistor. The electrical circuit model is also used to explain the factors leading to gas trapping and inadvertent positive end-expiratory pressure during high-frequency jet ventilation.

The consensus of available studies indicates that high-frequency jet ventilation (HFJV) can adequately ventilate animals in respiratory failure, although a clear superiority to volume-cycled ventilation (VCV) cannot be established. HFJV is probably useful in the presence of airway disruption and in tracheal or pulmonary surgery. Clinical trials and additional bench and animal studies must be performed, to reach a full understanding of the potential benefits of this technique.