Anesthesiology
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Anesthesiologists, like all other specialists, need to examine carefully their clinical practices so that excessive costs and waste can be reduced without compromising patient care or safety. While costs of drugs used for anesthesia constitute only a small fraction of total health care cost, they are highly visible costs which are easy for administrators to scrutinize. Although cost savings in an individual case may be small, the total savings may be impressive because of the large volume of cases performed. ⋯ Excessive emphasis on the acquisition costs of drugs may lead to blanket bans on the use of new drugs because of their higher costs rather than permitting physicians to individualize therapy according to their clinical experience and the perceived needs of a given patient. Institutional and individual variations in clinical practices, their associated costs and outcomes may alter conclusions about acceptability and economic evaluation of a particular drug or technique. The information in this review can be used to provide a rational basis for incorporating cost considerations into the decision-making process regarding the drugs, devices and techniques used in anesthesiology.
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Clinical Trial
Bronchoscopy via a redesigned Combitube in the esophageal position. A clinical evaluation.
The esophageal-tracheal Combitube (Kendall-Sheridan Catheter Corp., Argyle, NY) is an effective device for providing adequate gas exchange. However, tracheal suctioning is impossible with the Combitube placed in the esophageal position. To eliminate this disadvantage, the Combitube was redesigned by creating an enlarged hole in the pharyngeal lumen that allows fiberoptic access, tracheal suctioning, and tube exchange over a guide wire. ⋯ The redesigned Combitube enables fiberoptic bronchoscopy, fine-tuning of its position in the esophagus, and guided airway exchange in patients with normal airways. Further studies are warranted to demonstrate its value in patients with abnormal airways.
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Randomized Controlled Trial Clinical Trial
Reduction of the minimum alveolar concentration of isoflurane by dexmedetomidine.
alpha 2-Adrenergic agonists have been shown to reduce anesthetic requirements of other anesthetics, and they may even act as complete anesthetics by themselves at high doses in animal models. The present study was designed to define the interaction of intravenous infusion of dexmedetomidine, an alpha 2-adrenergic agonist, and isoflurane in patients having surgery by using the minimum alveolar concentration (MAC) of isoflurane as the measure of anesthetic potency. ⋯ The MAC of isoflurane in the control group was lower than that reported previously in similar patients having surgery, probably due to anesthesia induction with thiopental and alfentanil. Nevertheless, with the high dose of dexmedetomidine, the MAC of isoflurane was still 47% less than that without dexmedetomidine.
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Clinical Trial Controlled Clinical Trial
Meperidine decreases the shivering threshold twice as much as the vasoconstriction threshold.
Meperidine administration is a more effective treatment for shivering than equianalgesic doses of other opioids. However, it remains unknown whether meperidine also profoundly impairs other thermoregulatory responses, such as sweating or vasoconstriction. Proportional inhibition of vasoconstriction and shivering suggests that the drug acts much like alfentanil and anesthetics but possesses greater thermoregulatory than analgesic potency. In contrast, disproportionate inhibition would imply a special antishivering mechanism. Accordingly, the authors tested the hypothesis that meperidine administration produces a far greater concentration-dependent reduction in the shivering than vasoconstriction threshold. ⋯ The special antishivering efficacy of meperidine results at least in part from an uncharacteristically large reduction in the shivering threshold rather than from exaggerated generalized thermoregulatory inhibition. This pattern of thermoregulatory impairment differs from that produced by alfentanil, clonidine, propofol, and the volatile anesthetics, all which reduce the vasoconstriction and shivering thresholds comparably.
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Intrathecal injection of amitriptyline enhances antinociception from intravenous morphine and reduces neuropathic pain behavior in animals. This study represents part of a preclinical assessment of intrathecal amitriptyline to determine its safety for use in humans. ⋯ Although other preclinical toxicity studies are necessary before introducing intrathecal amitriptyline for use in humans, this study did not reveal dangerous changes in blood pressure or spinal cord blood flow from this agent.