Journal of clinical anesthesia
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To determine if the ordering of unindicated preoperative laboratory tests is different for healthy (ASA physical status I and II) versus sicker (ASA physical status III) patients, and to examine the financial implications at our institution of unindicated preoperative testing. ⋯ A large percentage of preoperative tests ordered by surgeons at our institution are not indicated. Eliminating unindicated tests would cut hospital revenues in a climate where testing is fee-for-service and would save the hospital money in a managed-care or capitated system.
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Case Reports
Management of Jehovah's Witness patients for scoliosis surgery: the use of platelet and plasmapheresis.
Four patients whose religious beliefs prohibited accepting blood during surgery for scoliosis were anesthetized and managed successfully using plateletpheresis and plasmapheresis. Blood losses were replaced with crystalloid and hetastarch solutions. In addition, a moderate hypotensive technique was used to minimize surgical blood loss. ⋯ Three of these patients had an uncomplicated postoperative course, however, the fourth patient had some postoperative bleeding with initial hemodynamic instability. We believe that patients who refuse to receive blood transfusion during surgery because of religious beliefs or health issues can be managed safely using other alternatives and techniques such as plateletpheresis and plasmapheresis, which conserve and minimize blood loss. Each case should be assessed on an individual basis.
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Multiple drugs are used to provide anesthesia. Volatile anesthetics are commonly combined with opioids. Several studies have demonstrated that small doses of opioid (i.e., within the analgesic range) result in a marked reduction in minimum alveolar concentration (MAC) of the volatile anesthetic that will prevent purposeful movement in 50% of patients at skin incision). ⋯ Recovery from anesthesia when an opioid is combined with a volatile anesthetic is dependent on the rate of decrease of both drugs to their respective concentrations that are associated with adequate spontaneous ventilation and awakening. Through an understanding of the pharmacodynamic interaction of volatile anesthetics with opioids and the pharmacokinetic processes responsible for the recovery from drug effect, optimal dosing schemes can thus be developed. A review of these pharmacodynamic and pharmacokinetic principles that will allow clinicians to administer drugs to provide a more optimal anesthetic is provided.
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Clinical Trial Controlled Clinical Trial
Perioperative hypercoagulability in uremic patients: a viscoelastic study.
To examine whole blood coagulation in uremic patients presenting for surgery with the thromboelastogram and the Sonoclot analyzer. ⋯ The high incidence of arteriovenous graft and fistulae thromboses in uremic patients belies in vitro laboratory evidence of platelet dysfunction. We have demonstrated perioperative hypercoagulability in uremic patients with viscoelastic measures of whole blood coagulation. These data suggest that traditional concern for coagulopathy and platelet dysfunction in uremic patients may require re-assessment in light of this "pro-thrombotic" state.
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Modern anesthetic techniques involve combinations of intravenous (i.v.) and inhaled anesthetic drugs that may produce synergistic (supraadditive), additive, or antagonistic interactions. Synergistic interaction is most likely to occur when two or more drugs produce similar effects by different mechanisms. ⋯ The usefulness of a drug interaction depends on whether it produces greater efficacy or reduced toxicity. Surprisingly, these outcomes have only been specifically measured for a handful of common drug combinations.