Anesthesia and analgesia
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Anesthesia and analgesia · Jul 2017
A Hospital Is Not Just a Factory, but a Complex Adaptive System-Implications for Perioperative Care.
Many methods used to improve hospital and perioperative services productivity and quality of care have assumed that the hospital is essentially a factory, and therefore, that industrial engineering and manufacturing-derived redesign approaches such as Six Sigma and Lean can be applied to hospitals and perioperative services just as they have been applied in factories. However, a hospital is not merely a factory but also a complex adaptive system (CAS). The hospital CAS has many subsystems, with perioperative care being an important one for which concepts of factory redesign are frequently advocated. ⋯ These examples present complementary and contrasting cases from 2 leading delivery systems. The Mayo Clinic example illustrates the application of manufacturing-based redesign principles to a factory-like (high-volume, low-risk, and mature practice) clinical program, while the Kaiser Permanente example illustrates the application of both manufacturing-based and self-organization-based approaches to programs and processes that are not factory-like but CAS-like. In this article, we describe how factory-like processes and CAS can coexist within a hospital and how self-organization-based approaches can be used to improve care delivery in many situations where manufacturing-based approaches may not be appropriate.
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Anesthesia and analgesia · Jul 2017
Multimodal Analgesic Therapy With Gabapentin and Its Association With Postoperative Respiratory Depression.
Gabapentinoids are widely used in perioperative multimodal analgesic regimens. The primary aim of this study was to determine whether gabapentin was associated with respiratory depression during phase-I postanesthesia recovery after major laparoscopic procedures. ⋯ The use of gabapentin is associated with increased rates of respiratory depression among patients undergoing laparoscopic surgery. When gabapentinoids are included in multimodal analgesic regimens, intraoperative opioids must be reduced, and increased vigilance for respiratory depression may be warranted, especially in elderly patients.
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Anesthesia and analgesia · Jul 2017
Physician-Directed Versus Computerized Closed-Loop Control of Blood Pressure Using Phenylephrine in a Swine Model.
Vasopressors provide a rapid and effective approach to correct hypotension in the perioperative setting. Our group developed a closed-loop control (CLC) system that titrates phenylephrine (PHP) based on the mean arterial pressure (MAP) during general anesthesia. As a means of evaluating system competence, we compared the performance of the automated CLC with physicians. We hypothesized that our CLC algorithm more effectively maintains blood pressure at a specified target with less blood pressure variability and reduces the dose of PHP required. ⋯ The CLC system performed as well as an anesthesiologist totally focused on MAP control by infusing PHP. Computerized CLC infusion of PHP provided tight blood pressure control under conditions of experimental vasodilation.
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Anesthesia and analgesia · Jul 2017
Default Drug Doses in Anesthesia Information Management Systems.
In the United States, anesthesia information management systems (AIMS) are well established, especially within academic practices. Many hospitals are replacing their stand-alone AIMS during migration to an enterprise-wide electronic health record. This presents an opportunity to review choices made during the original implementation, based on actual usage. One area amenable to this informatics approach is the configuration in the AIMS of quick buttons for typical drug doses. The use of such short cuts, as opposed to manual typing of doses, simplifies and may improve the accuracy of drug documentation within the AIMS. We analyzed administration data from 3 different institutions, 2 of which had empirically configured default doses, and one in which defaults had not been set up. Our first hypothesis was that most (ie, >50%) of drugs would need at least one change to the existing defaults. Our second hypothesis was that for most (>50%) drugs, the 4 most common doses at the site lacking defaults would be included among the most common doses at the 2 sites with defaults. If true, this would suggest that having default doses did not affect the typical administration behavior of providers. ⋯ We recommend that default drug doses should be analyzed when switching to a new AIMS because most drugs needed at least one change. Such analysis is also recommended periodically so that defaults continue to reflect current practice. The use of default dose buttons does not appear to modify the selection of drug doses in clinical practice.
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Anesthesia and analgesia · Jul 2017
Magic Mirror, On the Wall-Which Is the Right Study Design of Them All?-Part II.
The assessment of a new or existing treatment or other intervention typically answers 1 of 3 central research-related questions: (1) "Can it work?" (efficacy); (2) "Does it work?" (effectiveness); or (3) "Is it worth it?" (efficiency or cost-effectiveness). There are a number of study designs that, on a situational basis, are appropriate to apply in conducting research. ⋯ Attention is focused on the strengths and weaknesses of each study design to assist in choosing which is appropriate for a given study objective and hypothesis as well as the particular study setting and available resources and data. Specific studies and papers are highlighted as examples of a well-chosen, clearly stated, and properly executed study design type.