Anesthesia and analgesia
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Anesthesia and analgesia · Aug 1998
Randomized Controlled Trial Comparative Study Clinical TrialNasotracheal intubation in patients with immobilized cervical spine: a comparison of tracheal tube cuff inflation and fiberoptic bronchoscopy.
Tracheal intubation may pose problems in patients with cervical spine injury (CSI). In patients without CSI, the success rate of blind nasotracheal intubation is increased by endotracheal tube (ETT) cuff inflation in the pharynx. The purpose of this study was to assess the efficacy of ETT cuff inflation in the pharynx as an aid to blind nasotracheal intubation in patients with an immobilized cervical spine. The technique was compared with fiberoptic bronchoscopy. Twenty ASA physical status I and II patients undergoing elective surgery in which the trachea was to be intubated nasally were enrolled in this prospective, randomized study. The cervical spine of each patient was immobilized. The trachea of each patient was intubated twice, once using fiberoptic bronchoscopy and once blindly using the technique of ETT cuff inflation in the pharynx. A maximum of three attempts was allowed for intubation using ETT cuff inflation. A maximum of 3 min was allowed for intubation using fiberoptic bronchoscopy. When ETT cuff inflation was used, intubation was successful in 19 of 20 patients (95%); the first attempt at intubation was successful in 14 of 20 patients (70%). Intubation was successful in 19 of 20 patients (95%) when using fiberoptic bronchoscopy. Mean times to intubate were 20.8 +/- 23 s when the ETT cuff was inflated in the pharynx and 60.1 +/- 56 s when using fiberoptic laryngoscopy (P < 0.01). We conclude that both ETT cuff inflation in the pharynx and fiberoptic bronchoscopy are valuable for nasotracheal intubation in patients with an immobilized cervical spine and that ETT cuff inflation can be used as an alternative to fiberoptic bronchoscopy in patients with CSI. ⋯ We compared the technique of endotracheal tube cuff inflation in the pharynx for blind nasotracheal intubation in patients with an immobilized cervical spine with fiberoptic bronchoscopy. There was no significant difference between the success rates of the techniques.
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Anesthesia and analgesia · Aug 1998
Valuing the work performed by anesthesiology residents and the financial impact on teaching hospitals in the United States of a reduced anesthesia residency program size.
We performed a financial analysis at a large university tertiary care hospital to determine the incremental cost of replacing its anesthesiology residents with alternative dependent providers (i.e., certified registered nurse anesthetists in the operating room, advanced practice nurses and physician assistants outside the operating room). The annual average net cost of an anesthesiology resident during a 3-yr residency is approximately $38,000, and residents performed an average of $89,000 of essential clinical work annually based on replacement costs. The incremental cost (replacement labor cost minus net resident cost) to replace all essential clinical duties performed by an anesthesiology resident at Duke University Medical Center and affiliated hospitals is approximately $153,000 throughout 3 yr of clinical anesthesiology training. If this approach were applied nationwide, incremental costs of substitution would range from $36,000,000 to $93,000,000 per year. We conclude that maintaining clinical service in the face of anesthesiology residency reductions can have a marked impact on the overall cost of providing anesthesiology services in teaching hospitals. Simply replacing residents with alternate nonphysician providers is a very expensive option. ⋯ We sought to calculate the financial burden resulting from a decreased number of anesthesiology residents. Replacing each resident's essential clinical work with similarly skilled healthcare providers would cost hospitals approximately $153,000 over the course of a 3-yr residency. Varying projections yield future nationwide costs of $36,000,000 to $93,000,000 per year. Simply replacing residents with alternate nonphysician providers is a very expensive option.
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Anesthesia and analgesia · Aug 1998
Randomized Controlled Trial Comparative Study Clinical TrialA comparison of clonidine with conventional preanesthetic medication in patients undergoing coronary artery bypass grafting.
In this controlled study, we compared clonidine with conventional premedication in 35 patients undergoing coronary artery bypass grafting (CABG). After premedication with clonidine 5 microg/kg p.o. (Group C, n = 11), lorazepam 60 microg/kg p.o. (Group L, n = 13), or morphine 0.1 mg/kg plus scopolamine 6 microg/kg i.m. (Group M, n = 11), sedation, anxiety, and quality of premedication were graded. After the administration of sufentanil 2.0 microg/kg over 12.5 min, a computer-assisted infusion device targeted a sufentanil effect-site concentration of 0.75 ng/mL. Hemodynamic variables, end-tidal isoflurane concentration (ET-ISO), the electroencephalographic spectral edge, and the serum sufentanil concentration (SUF) were measured. There were no intergroup differences in anxiety, sedation, quality of premedication, the dose of sufentanil causing unconsciousness, or the electroencephalographic (EEG) response to induction. Intraoperative SUF was stable, with no intergroup difference. The average prebypass ET-ISO was lower in Group C than in Group M. The ET-ISO and peak ET-ISO after intense surgical stimulation were lower in Group C versus Groups L and M. Mean arterial blood pressure was lower in Group C versus Groups L and M. There were no intergroup differences in pharmacologic intervention, time to extubation, or intensive care unit stay. Clonidine produces sedation, anxiolysis, and quality of premedication comparable to conventional premedication. Compared with other drugs, clonidine does not alter the dose of sufentanil inducing unconsciousness or EEG slowing, but it uniquely reduces isoflurane requirements. ⋯ In patients undergoing coronary artery bypass grafting, clonidine produces sedation and relieves anxiety as effectively as conventional premedication. Clonidine does not uniquely alter the dose of sufentanil inducing unconsciousness or electroencephalographic slowing, but it significantly reduces isoflurane requirements.
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Anesthesia and analgesia · Aug 1998
Randomized Controlled Trial Clinical TrialKetamine attenuates the interleukin-6 response after cardiopulmonary bypass.
Cardiopulmonary bypass (CPB) has been proposed as a model for studying the inflammatory cascade associated with the systemic inflammatory response syndrome. Serum interleukin-6 (IL-6) concentration seems to be a good indicator of activation of the inflammatory cascade and predictor of subsequent organ dysfunction and death. Prolonged increases of circulating IL-6 are associated with morbidity and mortality after cardiac operations. In the present study, we compared the effects of adding ketamine 0.25 mg/kg to general anesthesia on serum IL-6 levels during and after elective coronary artery bypass grafting (CABG). Thirty-one patients undergoing elective CABG were randomized to one of two groups and prospectively studied in a double-blind manner. The patients received either ketamine 0.25 mg/kg or a similar volume of isotonic sodium chloride solution in addition to large-dose fentanyl anesthesia. Blood samples for analysis of serum IL-6 levels were drawn before the operation; after CPB; 4, 24, and 48 h after surgery; and daily for 6 days beginning the third day postoperatively. Ketamine suppressed the serum IL-6 response immediately after CPB and 4, 24, and 48 h postoperatively (P < 0.05). During the first 7 days after surgery, the serum IL-6 levels in the ketamine group were significantly lower than those in the control group (P < 0.05). On Day 8 after surgery, IL-6 levels were no different from baseline values in both groups. A single dose of ketamine 0.25 mg/kg administered before CPB suppresses the increase of serum IL-6 during and after CABG. ⋯ In this randomized, double-blind, prospective study of patients during and after coronary artery bypass surgery, we examined whether small-dose ketamine added to general anesthesia before cardiopulmonary bypass suppresses the increase of the serum interleukin-6 (IL-6) concentration. Serum IL-6 levels correlate with the patient's clinical course during and after coronary artery bypass. Ketamine suppresses the increase of serum IL-6 during and after coronary artery bypass surgery.