Anesthesia and analgesia
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Anesthesia and analgesia · Jan 2002
Peripheral nerve blockade with long-acting local anesthetics: a survey of the Society for Ambulatory Anesthesia.
Despite the growth of ambulatory anesthesia and the renewed popularity of regional techniques, there is little current information concerning outpatient regional anesthesia practices or attitudes about discharge with an insensate extremity. We present results from a survey sent to all members of the Society for Ambulatory Anesthesia (SAMBA). The survey was mailed in January 2001 to 2373 SAMBA members, along with a self-addressed stamped return envelope. After 3 mo, 1078 surveys were returned (response rate 45%). Respondents indicated that they were most likely to perform axillary (77%), interscalene (67%), and ankle blocks (68%) on ambulatory patients. They were less likely to perform lower extremity conduction blocks in ambulatory patients (femoral blocks, 40%; all other types of blocks, <23%]. Eighty-five percent of respondents discharged patients with long-acting blocks, but this was mainly limited to three types. Of the 16% who never or rarely discharged patients with long-acting blocks, the primary reasons were concern about patient injury (49%) and the inability for patients to care for themselves (28%). Only 22% of office-based anesthesiologists would perform upper extremity blocks and only 28% would perform lower extremity blocks (P < 0.001). This survey demonstrates that use of regional anesthesia in outpatients is common but restricted to a few techniques. Discharge with an insensate upper extremity is prevalent but discharge with an insensate lower extremity is not common and remains controversial. Despite the reasoning for the reported practices, randomized data are necessary to confirm the validity of these concerns. ⋯ This survey demonstrates that use of regional anesthesia in outpatients is common but restricted to a few techniques. Discharge with an insensate upper extremity is common but discharge with an insensate lower extremity is not prevalent and remains controversial.
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Anesthesia and analgesia · Jan 2002
Postoperative analgesia: economics, resource use, and patient satisfaction in an urban teaching hospital.
We sought to describe the economic and humanistic burden after total abdominal hysterectomy (TAH), total hip replacement (THR), or total knee replacement (TKR) surgery. Resource use and costs were estimated from the hospital perspective. The mean worst pain severity was 8.9, 8.1, and 7.6 on a 0- to 10-point scale after TAH, THR, and TKR, respectively. Postoperative pain was worst on postoperative day 1 after TAH or THR, and on postoperative day 2 after TKR. Analgesic medications relieved from 60% to nearly 78% of postoperative pain, but participants re- ported moderate-to-high levels of interference with general activity, walking ability, and sleep because of postoperative pain. Most costs were attributed to the hospital admission and operating room. The average length of hospitalization was 2.8 days after TAH, and 3.9 days after THR or TKR. This study provides insight into patients' experience with pain after common surgeries, perioperative costs, and medical resource use. ⋯ Despite impressive relief with analgesics, postoperative pain interferes with patients' ability to sleep, walk, and participate in other activities. Medications used postoperatively account for a small portion of total costs. Satisfaction ratings alone are a poor indicator of pain control. These data can be used to help improve pain relief.
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Anesthesia and analgesia · Jan 2002
Calculating a potential increase in hospital margin for elective surgery by changing operating room time allocations or increasing nursing staffing to permit completion of more cases: a case study.
Administrators routinely seek to increase contribution margin (revenue minus variable costs) to better cover fixed costs, provide indigent care, and meet other community service responsibilities. Hospitals with high operating room (OR) utilizations can allocate OR time for elective surgery to surgeons based partly on their contribution margins per hour of OR time. This applies particularly when OR caseload is limited by nursing recruitment. From a hospital's annual accounting data for elective cases, we calculated the following for each surgeon's patients: variable costs for the entire hospitalization or outpatient visit, revenues, hours of OR time, hours of regular ward time, and hours of intensive care unit (ICU) time. The contribution margin per hour of OR time varied more than 1000% among surgeons. Linear programming showed that reallocating OR time among surgeons could increase the overall hospital contribution margin for elective surgery by 7.1%. This was not achieved simply by taking OR time from surgeons with the smallest contribution margins per OR hour and giving it to the surgeons with the largest contribution margins per OR hour because different surgeons used differing amounts of hospital ward and ICU time. We conclude that to achieve substantive improvement in a hospital's perioperative financial performance despite restrictions on available OR, hospital ward, or ICU time, contribution margin per OR hour should be considered (perhaps along with OR utilization) when OR time is allocated. ⋯ For hospitals where elective surgery caseload is limited by nursing recruitment, to increase one surgeon's operating room time either another surgeon's time must be decreased, nurses need to be paid a premium for working longer hours, or higher-priced "traveling" nurses can be contracted. Linear programming was performed using Microsoft Excel to estimate the effect of each of these interventions on hospital contribution margin.
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Anesthesia and analgesia · Jan 2002
Randomized Controlled Trial Clinical TrialAlkalinization of intracuff lidocaine improves endotracheal tube-induced emergence phenomena.
We sought to evaluate the effect of filling an endotracheal tube cuff with 40 mg lidocaine alone (Group L) or alkalinized lidocaine (Group LB) in comparison to an Air Control group (Group C) on adverse emergence phenomena in a randomized controlled study (n = 25 in each group). The incidence of sore throat was decreased for Group LB in comparison to Group L during the 24 postextubation hours. The difference between Group L and Group C remained significant in the two postextubation hours only. Plasma lidocaine levels increased when lidocaine was alkalinized (C(max) were 62.5 +/- 34.0 ng/mL and 3.2 +/- 1.0 ng/mL for Groups LB and L, respectively). Cough and restlessness before tracheal extubation were decreased in Group LB compared with Group L and in Group L compared with Group C. Nausea, postoperative vomiting, dysphonia, and hoarseness were increased after extubation in Group C compared with the liquid groups, and a better tolerance was recorded with Group LB compared with Group L. The increase of arterial blood pressure and cardiac frequencies during the extubation period was less in the liquid groups than in the control group and less in Group LB compared with Group L. We concluded that use of intracuff alkalinized lidocaine is an effective adjunct to endotracheal intubation. ⋯ Use of 40 mg of alkalinized lidocaine, rather than lidocaine or air, to fill the endotracheal tube cuff reduces the incidence of sore throat in the postoperative period. This approach also decreases hemodynamic effects, restlessness, dysphonia, and hoarseness.