Anesthesia and analgesia
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Anesthesia and analgesia · Jan 2002
Colostrum morphine concentrations during postcesarean intravenous patient-controlled analgesia.
Patient-controlled analgesia (PCA) with morphine is a convenient method for providing postoperative analgesia. Despite the fact that it is used after cesarean delivery, data on transfer of morphine and of its active metabolite morphine-6 glucuronide (M6G) into maternal milk are scarce. It is not known whether breast-feeding during PCA with morphine has neonatal implications. We sought to measure morphine and M6G concentrations in colostrum during postpartum IV PCA and evaluate the potential for drug intake by neonates being breast-fed by these mothers. Seven informed and consenting mothers, given IV PCA with morphine, were investigated. Plasma and milk samples were obtained at titration, and at 12, 24, 36, and 48 h. Morphine and M6G were measured by high-performance liquid chromatography. In plasma, morphine concentrations ranged from <1 to 274 ng/mL, M6G ranged from <5 to 974 ng/mL. In milk, opioids were found in only 3 patients in whom morphine concentrations ranged from <1 to 48 ng/mL and M6G from <5 to 1084 ng/mL. The milk-to-plasma ratio was always <1 for morphine. In conclusion, we observed very small morphine and M6G concentrations in colostrum during PCA with morphine. Under these conditions, the amounts of drug likely to be transferred to the breast-fed neonate are negligible. ⋯ Colostrum concentrations of morphine and its active metabolite morphine-6 glucuronide were measured in mothers receiving patient-controlled analgesia with morphine after cesarean delivery. The concentrations were found to be very small, thus supporting the safety of breast-feeding in mothers receiving IV patient-controlled analgesia with morphine.
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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
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.