Anesthesia and analgesia
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Anesthesia and analgesia · Apr 2003
Sustained increases in productivity with maintenance of quality in an academic anesthesia practice.
Previously, the authors reported trends in anesthesia quality and productivity in a university-based anesthesia practice as it responded to increasing service demands with shortages of qualified staff and decreasing reimbursement. From 1992 to 1997, productivity increased, with a significant decrease in patient injury. In this study, we analyzed whether previous productivity and quality gains were sustained from 1998 to 2000 despite continued staff shortages. Productivity, caseload, and outcome data were abstracted from departmental administrative and quality-improvement reports. Retrospective cohort analysis compared trends during 3 yr of moderate productivity (1994-1996) with those during 3 yr of high productivity (1998-2000). The mean monthly productivity in 1998-2000 (15 +/- 0.6 billed hours per attending per clinical day) was larger than levels from 1994 to 1996 (mean, 14 +/- 0.7 h; P < 0.01). The overall continuous quality improvement report rate was slower at larger productivity levels, as were rates of patient injuries. When adjusted for declining report rates, patient injury rates showed no change between smaller- and larger-productivity years. Adjusted rates of operational inefficiencies and human errors were more frequent at larger productivity levels. Although the pressures of increased demands, shrinking resources, and shortages of qualified academic anesthesiologists have not abated, productivity and quality have been sustained. Future management must be directed toward reductions in operational inefficiencies and human error. ⋯ Our academic anesthesia service sustained increases in productivity with maintenance of quality. During a 3-yr period of high productivity, patient injury rates did not increase compared with prior years with lower productivity.
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Anesthesia and analgesia · Apr 2003
Clinical TrialA small preoperative test dose of intravenous fentanyl can predict subsequent analgesic efficacy and incidence of side effects in patients due to receive epidural fentanyl.
Because individual variation is a likely factor affecting both the incidence and severity of side effects and the analgesic efficacy of epidural opioids, assessment of individual variation could be useful in deciding optimal dosage. By evaluating the response to a small test dose of IV fentanyl, we designed this study to predict the degree of pain relief and the incidence of side effects in patients who would be receiving postoperative epidural fentanyl. Before the induction of anesthesia, 50 micro g of fentanyl was administered IV, and 2 min after fentanyl, the patient response was evaluated. Twenty-three patients, who reported nausea, sleepiness, dizziness, sensation of warmth, and other symptoms, were categorized as responders (Group R); the remaining 20 patients were categorized as nonresponders (Group NR). At the completion of surgery, infusion of epidural fentanyl was administered (0.3 mg/d in 0.25% bupivacaine) for 96 h. At postoperative Hours 6 and 24, Group R had significantly lower visual analog scale scores for postoperative pain intensity and required fewer analgesics than Group NR. The incidence of side effects, however, was 74% for Group R and 10% for Group NR (P < 0.05), and side effects were more serious in Group R. This study demonstrates that preoperative administration of a small dose of fentanyl during the induction of anesthesia enables prediction of the analgesic efficacy of postoperative epidural fentanyl and the incidence and severity of side effects. ⋯ Preoperative administration of a small dose of fentanyl during the induction of anesthesia enables prediction of the analgesic efficacy of postoperative epidural fentanyl and the incidence and severity of side effects.
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Anesthesia and analgesia · Apr 2003
Antinociception with intrathecal alpha-methyl-5-hydroxytryptamine, a 5-hydroxytryptamine 2A/2C receptor agonist, in two rat models of sustained pain.
Type 2 serotonin (5-hydroxytryptamine [5-HT](2)) receptors in the spinal cord have been reported to mediate antinociception using pain threshold tests, but little is known about the actions of spinal 5-HT(2) receptors in sustained pain. In rats, we examined antinociceptive effects of the intrathecal administration of a 5-HT(2A/2C) receptor agonist, alpha-methyl-5-HT maleate (alpha-m-5-HT), using the formalin test and the chronic constriction injury (CCI) model. An intrathecal catheter was implanted for injection of drugs. In the formalin test, flinches were counted from Minute 1 to 2 and Minute 5 to 6 (Phase 1) and then for 1-min periods at 5-min intervals from 10 to 60 min (Phase 2). In rats with CCI, hind paw withdrawal latency after thermal stimulation was measured. In the formalin test, intrathecal administration of alpha-m-5-HT (1 to 100 microg) dose-dependently suppressed the number of flinches in both Phases 1 and 2. In the CCI model, intrathecally administered alpha-m-5-HT (10 to 100 microg) attenuated thermal hyperalgesia in a dose-dependent manner. These effects were reversed by intrathecal pretreatment with a 5-HT(2A/2C) antagonist, ketanserin (30 microg), or a muscarinic receptor antagonist, atropine (30 microg). These findings suggest that spinal 5-HT(2A/2C) receptors mediate antinociception in inflammatory pain and neuropathic pain, and the muscarinic receptors contribute to this action. ⋯ Activation of spinal 5-hydroxytryptamine(2A/2C) receptors mediate antinociception in rat-sustained pain models such as inflammatory pain and neuropathic pain, and spinal muscarinic receptors are involved in this action.
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Anesthesia and analgesia · Apr 2003
The influence of induced hypothermia for hemostatic function on temperature-adjusted measurements in rabbits.
In hypothermic patients, a tendency to bleed may be observed even when hemostatic tests seem to be normal. Coagulation and platelet function tests are usually performed at 37 degrees C. We investigated the influence of induced hypothermia on temperature-adjusted hemostasis function testing using Sonoclot Analyzer (Sonoclot) and Thromboelastography (TEG). Anesthesia was induced and maintained with IV ketamine and fentanyl on 15 male New-Zealand White rabbits. A water blanket was used to induce hypothermia to 30 degrees C and to rewarm to 37 degrees C. Blood samples were obtained at four points: before hypothermia, at 34 degrees C, at 30 degrees C, and after rewarming. Standard coagulation tests were performed at 37 degrees C (C method), and simultaneously, real temperature hemostasis function tests (R method) were run. In Sonoclot(R), activated clotting time and time to peak increased and clot rate decreased significantly at 30 degrees C in the R method compared with those in the C method. In TEG(R), reaction time and clot formation time were prolonged and clot formation rate was diminished at 30 degrees C in the R method compared with those in the C method. Induced hypothermia delayed the coagulation cascade and reduced platelet function. During hypothermia, hemostatic measurements should be performed at real temperature to avoid overestimating patient hemostatic function based on results measured at the standard 37 degrees C. ⋯ We investigated the influence of induced hypothermia on temperature-adjusted hemostasis function tests in rabbits using Sonoclot Analyzer and Thromboelastography. Induced hypothermia delayed the coagulation cascade and reduced platelet function. The conventional coagulation tests performed at 37 degrees C failed to detect these hypothermia-induced degradations in hemostasis performance.
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Anesthesia and analgesia · Apr 2003
Labor costs incurred by anesthesiology groups because of operating rooms not being allocated and cases not being scheduled to maximize operating room efficiency.
Determination of operating room (OR) block allocation and case scheduling is often not based on maximizing OR efficiency, but rather on tradition and surgeon convenience. As a result, anesthesiology groups often incur additional labor costs. When negotiating financial support, heads of anesthesiology departments are often challenged to justify the subsidy necessary to offset these additional labor costs. In this study, we describe a method for calculating a statistically sound estimate of the excess labor costs incurred by an anesthesiology group because of inefficient OR allocation and case scheduling. OR information system and anesthesia staffing data for 1 yr were obtained from two university hospitals. Optimal OR allocation for each surgical service was determined by maximizing the efficiency of use of the OR staff. Hourly costs were converted to dollar amounts by using the nationwide median compensation for academic and private-practice anesthesia providers. Differences between actual costs and the optimal OR allocation were determined. For Hospital A, estimated annual excess labor costs were $1.6 million (95% confidence interval, $1.5-$1.7 million) and $2.0 million ($1.89-$2.05 million) when academic and private-practice compensation, respectively, was calculated. For Hospital B, excess labor costs were $1.0 million ($1.08-$1.17 million) and $1.4 million ($1.32-1.43 million) for academic and private-practice compensation, respectively. This study demonstrates a methodology for an anesthesiology group to estimate its excess labor costs. The group can then use these estimates when negotiating for subsidies with its hospital, medical school, or multispecialty medical group. ⋯ We describe a new application for a previously reported statistical method to calculate operating room (OR) allocations to maximize OR efficiency. When optimal OR allocations and case scheduling are not implemented, the resulting increase in labor costs can be used in negotiations as a statistically sound estimate for the increased labor cost to the anesthesiology department.