Pharmacotherapy
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Chronic pain is commonly encountered in elderly patients. About 20-50% of community-dwelling elderly experience it, and 45-80% of nursing home residents may be affected. ⋯ Major classes of drugs used to treat chronic pain (nonsteroidal antiinflammatory drugs, opioids, antidepressants) have adverse effects that occur more frequently in elderly than in younger patients. Given the often prolonged duration of therapy, optimal management requires minimizing the risk of adverse reactions.
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We attempted to determine health and economic outcomes from the perspective of an integrated health system of administering enoxaparin 30 mg twice/day versus heparin 5000 U twice/day for prophylaxis against venous thrombosis after major trauma. A decision-analytic model was developed from best literature evidence, institutional data, and expert opinion. We assumed that 40% of proximal deep vein thromboses (DVTs) and 5% of distal DVTs are diagnosed and confirmed with initial or repeat duplex scanning; 50% of undiagnosed proximal DVTs result in pulmonary embolism; 2% and 1% of undiagnosed proximal DVTs will lead to readmission for DVT and pulmonary embolism, respectively, and pulmonary embolism-related mortality rates range from 8-30%. ⋯ For 1000 patients with lower extremity fractures, enoxaparin versus heparin resulted in a cost of $751 (-$4200 to $3300) for each DVT or pulmonary embolus avoided and a discounted cost/life-year saved of $1017 (-$10,200 to $6300). Although enoxaparin increases overall health care costs, it is associated with a cost/additional life-year saved of only $2300, which is generally lower than the commonly used hurdle rate of $30,000/life-year saved. The cost-effectiveness ratio is more favorable in patients with lower extremity fractures than in the general mixed trauma population.
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Increased activity or inadequate inhibition of the autonomic nervous system is often the cause of perioperative hypertension. The goal of treatment is to maintain an adequate balance between myocardial oxygen supply and demand. ⋯ The cost:benefit ratio of therapy with these newer agents must also be considered. Despite the fact that perioperative hypertension is aggressively treated, there are no long-term, large-scale study data indicating that this treatment affects long-term patient outcomes.
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The discovery of ether anesthesia made modern surgery possible. Successive improvements produced today's inhaled anesthetics, compounds that allow precise control over the anesthetic state without compromising safety. Such control extends to induction and maintenance of, and recovery from, anesthesia. ⋯ Important among these is molecular stability that permits elimination of the unchanged anesthetic molecule in expired air and provides resistance to degradation by metabolism and by carbon dioxide absorbents. Halogenation with fluorine produces more stable, safer anesthetics. Greater stability, lower solubility, and rapid recovery can decrease direct and indirect costs.
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Comparative Study
Vancomycin pharmacokinetics in neonates receiving extracorporeal membrane oxygenation.
Vancomycin is administered as both prophylaxis and treatment in neonates receiving extracorporeal membrane oxygenation (ECMO), typically after surgery. An open-label, retrospective study was conducted to determine dosing strategies in all neonates who received vancomycin during ECMO and compare pharmacokinetic values with those of matched controls not receiving ECMO. Fifteen neonates receiving ECMO were given vancomycin infused into the circuit, with dosages based on weight and gestational age. ⋯ Volume of distribution and clearance were not significantly different in controls (0.39 +/- 0.12 L/kg, 0.79 +/- 0.41 ml/min/kg), but half-life was shorter (6.53 +/- 2.05 hrs, p = 0.02). Based on long volume of distribution in neonates receiving ECMO, we recommend that empiric vancomycin regimens incorporate a longer dosing interval than the 6-8 hours commonly recommended for term infants. The effects of severity of illness on drug elimination require additional study.