Anesthesia and analgesia
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Anesthesia and analgesia · Feb 2004
Resident training level and quality of anesthesia care in a university hospital.
In this study, we analyzed the relationship between resident training and patient safety in anesthesia. A retrospective quality improvement database review was used to calculate the relative risk of any quality problem and specific types of quality problems (injury, escalation of care, or operational inefficiency) between anesthesia teams with CA1, CA2, and CA3 residents. It was expected that teams with less experienced residents (CA1) would have more frequent quality problems than teams with more experienced residents (CA2 and CA3 teams). Data showed that risk of injury did not differ between CA1, CA2, and CA3 teams. CA2 teams had higher rates of critical incidents and escalation of care than CA1 and CA3 teams and higher rates of operational inefficiency than CA3 teams. The CA2 yr is when residents move into specialty training, requiring more advanced skills and a larger knowledge base. Their higher relative risk for critical incidents, escalation of care, and operational inefficiencies may reflect lack of experience, uncertainty, and less skill mastery compared with CA3 residents. The higher inefficiency and escalation of care rates associated with CA2 teams may translate into larger costs for the institution. ⋯ Appropriate supervision of anesthesia residents helps to ensure patient safety. Anesthesia management problems are most common during the CA2 yr and result in higher costs for the institution.
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Anesthesia and analgesia · Feb 2004
Randomized Controlled Trial Clinical TrialThe effects of remifentanil and gabapentin on hyperalgesia in a new extended inflammatory skin pain model in healthy volunteers.
We tested the responsiveness of measures of hyperalgesia in a model of UVB-induced inflammatory hyperalgesia with remifentanil, gabapentin, and the combination of both drugs in a double-blinded, active placebo-controlled, 4-way-crossover design in 16 volunteers. A circular skin area was irradiated with UVB-light 20 h before the application of gabapentin (600 mg) and 2 h later remifentanil (0.08 microg.kg(-1).min(-1), 40 min). In the sunburn spots we observed stable decreases of the heat pain perception thresholds (HPPT, mean difference, 4.45 degrees C; 95% confidence interval [CI], 3.32 degrees -5.59 degrees ) and heat pain tolerance thresholds (HPTT; mean difference, 5.43 degrees C; 95% CI, 4.50 degrees -6.35 degrees ) compared with normal skin. Further, large areas of mechanical hyperalgesia to pinprick adjacent to the erythema spots developed in all subjects. Overall remifentanil increased the HPPT (mean increase, 2.47 degrees C; 95% CI, 1.86 degrees -3.09 degrees, P < 0.001) and HPTT (mean increase, 3.18 degrees C; 95% CI, 2.65 degrees -3.71 degrees, P < 0.001) and reduced the area of secondary hyperalgesia by 59% (mean decrease, 5326 mm(2); 95% CI, 4233-6419 mm(2), P < 0.001) compared with placebo. In the sunburn remifentanil markedly increased the HPTT by 86% compared with normal skin (additional increase, 2.57 degrees C; 95% CI, 1.71 degrees -3.43 degrees). This different effect was not seen in the HPPT. With the exception of a small increase of HPTT in the sunburn (P = 0.02) gabapentin had no noticeable effect on either hyperalgesia. In conclusion, opioid analgesia was reliably demonstrated in this new extended pain model. ⋯ Opioid analgesia was reliably demonstrated in a new inflammatory model of primary and secondary hyperalgesia. Gabapentin showed no antihyperalgesic and no opioid-enhancing effect in this model.
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Anesthesia and analgesia · Feb 2004
Randomized Controlled Trial Clinical TrialRapid onset of cutaneous anesthesia with EMLA cream after pretreatment with a new ultrasound-emitting device.
In this randomized, double-blinded, placebo-controlled, crossover trial of 42 human subjects, we examined the speed of onset of cutaneous anesthesia by eutectic mixture of local anesthetics (EMLA) cream after brief (approximately 10-s) pretreatment of the underlying skin with low-frequency (55 kHz) ultrasound. Four treatments were compared: ultrasound pretreatment followed by application of 1 g EMLA or placebo cream for 5 min, 10 min, 15 min, and 60 min without ultrasound pretreatment as positive control. Pain was tested by pricks with a 20 g needle. Pain scores and patient preference for EMLA or placebo cream were measured at each time point. Based on both pain scores and patient preference, cutaneous anesthesia was achieved in the EMLA groups as compared with placebo at all time points. After ultrasound pretreatment and then 5, 10, or 15 min after EMLA cream application, pain scores and overall preference were statistically indistinguishable from EMLA cream application for 60 min (without ultrasound pretreatment). There were no significant adverse effects. Low-frequency ultrasound pretreatment appears to be safe and effective in producing rapid onset of EMLA cream in this model, with results as early as 5 min. ⋯ A prospective, randomized, double-blinded, placebo-controlled clinical trial demonstrated rapid onset of cutaneous anesthesia by pretreatment of the skin with ultrasound before application of EMLA cream.