Anesthesia and analgesia
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Anesthesia and analgesia · May 2003
Randomized Controlled Trial Comparative Study Clinical TrialRecovery of neuromuscular function after cardiac surgery: pancuronium versus rocuronium.
The use of pancuronium in fast-track cardiac surgical patients may be associated with delays in clinical recovery. Our objective in this study was to evaluate the incidence and severity of residual neuromuscular blockade after cardiac surgery in patients randomized to receive either pancuronium (0.08-0.1 mg/kg) or rocuronium (0.6-0.8 mg/kg). Eighty-two patients undergoing cardiopulmonary bypass were randomized to a pancuronium (n = 41) or rocuronium (n = 41) group. Intraoperative and postoperative management was standardized. In the intensive care unit, train-of-four (TOF) ratios were measured each hour until weaning off ventilatory support was initiated. Neuromuscular blockade was not reversed. After tracheal extubation, patients were examined for signs and symptoms of residual paresis. When weaning of ventilatory support was initiated, significant neuromuscular blockade was present in the pancuronium subjects (TOF ratio: median, 0.14; range, 0.00-1.11) compared with the rocuronium subjects (TOF ratio: median, 0.99; range, 0.87-1.21) (P < 0.05). Patients in the rocuronium group were more likely to be free of signs and symptoms of residual paresis than patients in the pancuronium group. Our findings suggest that the use of longer-acting muscle relaxants in cardiac surgical patients is associated not only with impaired neuromuscular recovery, but also with signs and symptoms of residual muscle weakness in the early postoperative period. ⋯ The use of long-acting muscle relaxants in fast-track cardiac surgical patients is associated with significant residual neuromuscular block in the intensive care unit, including signs and symptoms of residual paresis.
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Anesthesia and analgesia · May 2003
ReviewEducating patients about anesthesia: a systematic review of randomized controlled trials of media-based interventions.
In this systematic review, we compared the effectiveness of media-based patient education about anesthesia. Fifteen randomized controlled trials (n = 1506) were identified after a systematic search of electronic databases (MEDLINE, EMBASE, CINAHL, PSYCINFO, The Cochrane Controlled Trials Registry), published articles, and contact with authors. Outcomes assessed were anxiety, knowledge, and patient satisfaction. Anxiety levels before anesthesia were less intense in subjects receiving the video and printed information compared with those receiving no intervention (weighted mean difference of 3; 95% confidence interval [95%CI], 1-5 Spielberger's State and Trait Anxiety Inventory). Patients in the video group were more likely to answer all knowledge questions correctly compared with patients with no intervention (relative risk of 6.64; 95%CI, 2.05-21.52). The level of knowledge about pain management was higher in the video group compared with patients with no intervention (weighted mean difference of 17%; 95%CI, 9-25). However, the level of patient satisfaction with the intervention (expectation versus actual anesthetic experience) was similar between the groups (relative risk of 1.06; 95%CI, 0.93-1.22). This systematic review supports the use of video and printed information about general process and risks of anesthesia for patient education before surgery. ⋯ The effectiveness of media-based interventions for educating patients about general process and risks of anesthesia were compared in this systematic review. The use of video and/or printed information can decrease patient anxiety and increase patient knowledge. However, patient satisfaction was similar between media-based intervention and nonintervention groups.
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Anesthesia and analgesia · May 2003
Clinical TrialRenal dysfunction after cardiac surgery with normothermic cardiopulmonary bypass: incidence, risk factors, and effect on clinical outcome.
Renal dysfunction is a frequent and severe complication after conventional hypothermic cardiac surgery. Little is known about this complication when cardiopulmonary bypass (CPB) is performed under normothermic conditions (e.g., more than 36 degrees C). Thus, we prospectively studied 649 consecutive patients undergoing coronary artery bypass surgery or valve surgery with normothermic CPB. The association between renal dysfunction (defined as a > or =30% preoperative-to-maximum postoperative increase in serum creatinine level) and perioperative variables was studied by univariate and multivariate analysis. Renal dysfunction occurred in 17% of the patients. Twenty-one (3.2%) patients required dialysis. Independent preoperative predictors of this complication were: advanced age, ASA class >3, active infective endocarditis, radiocontrast agent administration <48 h before surgery, and combined surgery. When all the variables were entered, active infective endocarditis, radiocontrast agent administration, postoperative low cardiac output, and postoperative bleeding were independently associated with renal dysfunction. The in-hospital mortality rate was 27.5% when this complication occurred (versus 1.6%; P < 0.0001). Furthermore, postoperative renal dysfunction was independently associated with in-hospital mortality (odds ratio, 4.1 [95% confidence interval, 1.3-12.8]). We conclude that advanced age, active endocarditis, and recent (within 48 h) radiocontrast agent administration, as well as postoperative hemodynamic dysfunction, are more consistently predictive of postoperative renal dysfunction than CPB factors. ⋯ We found that postoperative renal dysfunction was a frequent and severe complication after normothermic cardiac surgery, independently associated with poor outcome. Independent predictors of this complication were advanced age, active endocarditis, and recent (within 48 h) radiocontrast agent administration (the only preoperative modifiable factor), as well as postoperative hemodynamic dysfunction.
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Anesthesia and analgesia · May 2003
A demographic, service, and financial survey of anesthesia training programs in the United States.
In February 2000, a demographic, service, and finance survey was sent to the directors of anesthesiology training programs in the United States under the auspices of the Society of Academic Anesthesia Chairs/Association of Academic Program Directors. In August of 2000, 2001, and 2002, shorter follow-up surveys were sent to the same program directors requesting the numbers of vacancies in faculty positions and certified registered nurse anesthetists (CRNA) positions. The August 2001 survey also inquired if departments had positive or negative financial margins for the fiscal year ending June 2001. The August 2002 survey included the questions of the 2001 survey and additionally asked if the departments had had an increase or decrease in institutional support and the amount of that current support. The survey results revealed that the average program had 36 anesthetizing locations and 36 faculty. Those faculty spent 69% of their time providing clinical service. Approximately one-half of the departments paid for some of their residents, whereas the other 50% paid for none. Eighty-five percent of the departments employed CRNAs who were funded by the hospital in one third of the departments. In 2000, departments received $34,319/yr in support per faculty full-time equivalent (FTE) from their institutions and had a mean revenue of $407,000/yr/faculty FTE. In 2002, the department's institutional support per FTE increased to $59,680 (a 74% increase since 2000). The departments in academic medical centers paid 20% in overhead expenses, whereas departments in nonacademic medical centers paid 10%. In 2000, 2001, and 2002, the percentage of departments with positive margins was 53%, 53%, and 65%, respectively, whereas the departments with a negative margin decreased from 44% in the year 2000 to 38% in 2001 and 33% in 2002. For the departments with a positive margin, the amount of margin per FTE over this 3-yr period was approximately $50,000, $15,000, and $30,000, respectively. Although the percentage of departments with a negative margin has been decreasing, the negative margin per FTE seems to be increasing from approximately $24,000 to $43,000. The number of departments with open faculty positions has decreased from 91.5% in the year 2000 to 83.5% in 2001 and 78.4% in 2002; in these departments, the number of open faculty positions has also decreased from 3.8 in 2000 to 3.9 in 2001 to 3.4 in 2002. The number of open CRNA positions seems to have been relatively constant with approximately two thirds of the departments requiring an average of approximately four CRNAs each. Overall, academic anesthesiology departments fiscal security seems to have eroded with an increased dependence on institutional support. Departments pay larger overhead rates relative to private practice, and there seems to be a continued, but possibly decreasing, shortage of faculty. ⋯ A survey was conducted of anesthesia training program directors that demonstrated that their departments' financial conditions have been eroding over the years 2000 to 2002. During this same period of time, departments were receiving an increase in institutional support from $34,319/full-time equivalent (FTE) faculty in the year 2000 to $59,680/FTE in the year 2002. Although there seems to be an approximate 10% shortage in academic faculty, the number of departments with open positions has progressively decreased from 91% to 73% over the past 3 yr. On average, the financial condition of the training departments has deteriorated over the past 3 yr despite a significant increase in institutional support to enable departments to recruit and retain faculty in an era of an apparent national shortage of anesthesiologists.