Anesthesia and analgesia
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Anesthesia and analgesia · May 1999
Computer simulation to determine how rapid anesthetic recovery protocols to decrease the time for emergence or increase the phase I postanesthesia care unit bypass rate affect staffing of an ambulatory surgery center.
Ambulatory surgery centers (ASC) are implementing new anesthetic techniques and rapid recovery protocols in the postanesthesia care unit (PACU) to achieve earlier discharge after general anesthesia. Using computer simulation, we addressed two questions. First, what is the decrease in an ASC's operating room (OR) staff if the time from which the surgery is finished to the time the patient leaves the OR is decreased? Second, what is the decrease in PACU nursing staffing if patients bypass phase I PACU (i.e., proceed from the OR directly to the phase II PACU)? The decrease in labor costs from rapid emergence or fast-tracking depends on how staff are compensated, how many ORs routinely run concurrently, and what percentage of patients undergo general anesthesia. The results show potential decreases in ASCs' labor costs ($7.39 per case) from technologies (e.g., new anesthetics or Bispectral Index [Aspect Medical Systems, Natick, MA] monitoring) to decrease emergence times or increase the phase I bypass rates. ⋯ Decreases in operating room and postanesthesia care unit labor costs resulting from faster emergence and phase I postanesthesia care unit bypass vary depending on the amount of routine overtime, how the staff are compensated, and how many patients are routinely anesthetized each day.
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Anesthesia and analgesia · May 1999
Cardiovascular autonomic dysfunction and hemodynamic response to anesthetic induction in patients with coronary artery disease and diabetes mellitus.
Autonomic neuropathy is a major complication of diabetes mellitus and is reported to be associated with increased perioperative hemodynamic instability. We investigated the relationship between autonomic dysfunction and hemodynamic response to anesthetic induction in diabetic and nondiabetic patients with coronary artery disease. We studied 60 patients scheduled for coronary artery surgery, 30 suffering from diabetes mellitus. Preoperative evaluation included traditional cardiovascular autonomic function tests (coefficient of variation of 150 beat-to-beat intervals in heart rate at rest, heart rate response to deep breathing, and heart rate and arterial blood pressure response to standing), spectral analysis of blood pressure and heart rate variability (HRV), and the computation of spontaneous baroreflex sensitivity. After premedication with clorazepate, anesthesia was induced with sufentanil (0.5 microg/kg), etomidate (0.1-0.2 mg/kg), and vecuronium (0.1 mg/kg). Heart rate and blood pressure before anesthetic induction and before and after tracheal intubation were compared between groups. Autonomic function tests, spectral analysis of HRV, and spontaneous baroreflex sensitivity revealed significant differences between patient groups. Most diabetic patients (n = 23) had one or more abnormal test results, in contrast to most nondiabetic patients, who did not show signs of autonomic neuropathy (n = 23). There was no relationship between cardiovascular autonomic function and hemodynamic behavior during anesthetic induction. The blood pressure response to anesthetic induction was not different between patient groups, even when comparing the subgroups with and without abnormal autonomic function tests. These findings indicate that increased hemodynamic instability during anesthetic induction is not obligatory in patients with diabetes mellitus and autonomic dysfunction. ⋯ This study indicates that increased hemodynamic instability during anesthetic induction is not obligatory in patients with coronary artery disease and autonomic dysfunction.
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Anesthesia and analgesia · May 1999
Intraoperative localization of an epileptogenic focus with alfentanil and fentanyl.
We evaluated the effectiveness of alfentanil and fentanyl in stimulating epileptogenic activity during surgery for intractable temporal lobe epilepsy under general anesthesia. Ten patients received a standardized anesthetic induction with i.v. fentanyl 5 microg/kg, propofol 3-5 mg/kg, and atracurium 0.5 mg/kg. Maintenance was with isoflurane, 70% N2O/30% O2, and an atracurium infusion. After dural opening, droperidol 0.02 mg/kg was administered i.v.. Both inhaled anesthetics were discontinued and verified to be at 0 end-tidal concentration before the study. Baseline electrocorticography over the surface of the temporal lobe and depth electrode recordings in the amygdala and hippocampus were obtained, followed by 10 min of recording before and after the i.v. administration of both alfentanil 50 microg/kg and fentanyl 10 microg/kg. Any changes in cardiovascular variables were documented. The number of interictal epileptiform spikes at the most active site for each patient was tabulated before and after the administration of each drug. Both alfentanil and fentanyl induced an increase in spike activity in all patients. Alfentanil was more potent, increasing the median number of spikes per epoch from 18 to 58, compared with fentanyl (20 to 42 spikes) (P < 0.05). Alfentanil had a shorter duration of action (4.9+/-1.3 min) compared with fentanyl (8.5+/-2 min) (P < 0.009). In nine patients, the most active site was the hippocampus or amygdala. There was a decrease in mean blood pressure, but only after the administration of alfentanil (P < 0.05). Two patients had electrographic evidence of seizure activity. These opioids can be used to assist in the localization of the epileptogenic focus during surgery. ⋯ Both alfentanil and fentanyl activate epileptiform activity in patients with temporal lobe epilepsy. These opioids can be used to assist in the localization of the epileptogenic focus during surgery.
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Anesthesia and analgesia · May 1999
Does epinephrine improve the diagnostic accuracy of aspiration during labor epidural analgesia?
Aspiration reliably detects almost all IV multiorifice epidural catheters. Although a supplemental epinephrine 15-microg test dose may detect the rare IV catheter that does not yield blood on aspiration, false-positive epinephrine responses may cause some women to unnecessarily undergo repeat epidural catheter insertion. We evaluated 532 consecutive eligible patients requesting neuraxial labor analgesia. Patients were excluded if they had a contraindication to epinephrine or if they received intrathecal sufentanil/bupivacaine. Multiorifice catheters were inserted 4-6 cm into the epidural space as part of an epidural (n = 305) or combined spinal-epidural (n = 270) technique. We used aspiration, a lidocaine/epinephrine test dose, and bolus injection or infusion of dilute bupivacaine/sufentanil solutions to systematically determine IV, intrathecal, or epidural catheter location. Aspiration alone detected 47 of 48 intravascular catheters. There were 10 positive epinephrine responses: 2 were true positives, 7 were falsely positive (subsequent local anesthetic injection/infusion produced bilateral sensory change and analgesia), and 1 catheter was removed without further testing. Aspiration detected almost all intravascular catheters. Although the epinephrine test dose did detect one catheter that proved to be in a blood vessel, 87.5% of positive responses occurred in women without intravascular catheters. ⋯ Epidural catheters may enter a blood vessel. Many clinicians use epinephrine to detect these catheters. Because aspiration alone detects almost all IV multiorifice catheters in laboring women, a subsequent epinephrine test dose may be unnecessary.
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Anesthesia and analgesia · May 1999
Which countries publish in important anesthesia and critical care journals?
Using a MEDLINE-based analysis, we studied the national origin of articles published in important anesthesia, pain, critical care, and emergency medicine journals. All journals in English listed in the Science Citation Index (SCI) of Journal Citation Reports under the subheadings Anesthesiology (n = 17) and Emergency Medicine & Critical Care (n = 13) were analyzed with the help of MEDLINE. Issues from 1996 and 1997 were included and summarized. Letters, abstracts, editorials, meeting reports, and news were not included. MEDLINE printouts were studied, and we classified the country of origin of the first author. The following subsets were defined: Anesthesia, Regional Anesthesia and Pain, Clinical Monitoring and Computing, Intensive Care Medicine and Resuscitation, and Emergency Medicine and Trauma. A total of 10,643 publications in 30 journals were published during 1996 and 1997. Of the 30 journals, 17 originate in the United States (US) and 8 from United Kingdom (UK). In 14 of the 17 US journals, >50% of the publications came from the US. The US was the most active nation, with a total of 4,283 articles (40.2% of all contributions), followed by the UK with 1,418 articles (13.3%). When looking at the number of publications with regard to inhabitants or impact factor per million inhabitants, small highly industrialized nations (Finland 35.41 and Sweden 33.9 articles/million inhabitants) were significantly more active than large highly industrialized countries (US 16.2, Germany 6.1, Japan 4.5 articles/million inhabitants). It is presumed that indicators of productivity in medical research are the number of articles published and the cumulative impact factor. During 1996 and 1997, the US was the most active nation with regard to publications in important journals in the areas of anesthesia, pain, critical care, and emergency medicine. Small highly industrialized nations, however, had a higher activity rate than larger countries. ⋯ In a MEDLINE-based analysis, we examined the number of publications in important anesthesia, pain, critical care, and emergency medicine journals (n = 30) for the years 1996 and 1997 and analyzed these with regard to national origin. The United States was by far the most active nation in this medical area (4283 articles [40.2%]), followed by the United Kingdom (13.3%). With regard to publications per million inhabitants, small highly industrialized nations contributed overproportionally to publications in this area.