Anesthesia and analgesia
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Anesthesia and analgesia · Mar 2002
The correlation of the bispectral index monitor with clinical sedation scores during mechanical ventilation in the pediatric intensive care unit.
In patients who are mechanically ventilated in the pediatric intensive care unit (PICU), sedative and/or analgesic medications are routinely provided and titrated to effect based on clinical assessment of the patient. The bispectral index (BIS) monitor uses a modified electroencephalogram to quantify the effects of central nervous system-acting drugs on the level of consciousness. To evaluate the usefulness of the BIS monitor to predict clinical sedation levels in the PICU, we compared BIS values with simultaneously obtained clinical sedation scores in 24 mechanically ventilated pediatric patients aged 5.7 plus minus 6.1 yr. For each sedation scale used, the BIS value correlated with increasing depth of sedation (P < 0.0001) and was independent of the drug(s) used for sedation. To differentiate adequate from inadequate sedation, a BIS value <70 had a sensitivity of 0.87--0.89 and a positive predictive value of 0.68--0.84. To differentiate adequate from excessive sedation, a BIS value <50 had a sensitivity of 0.67--0.75 and a positive predictive value of 0.07--0.52. We conclude that the BIS monitor may be a useful adjunct for the assessment of sedation in PICU patients. ⋯ We demonstrate the usefulness of the bispectral index monitor for assessing sedation in pediatric intensive care unit patients. The bispectral index monitor correlated with clinically assessed sedation levels and was useful for differentiating adequate from inadequate sedation, which would be of value when the clinical examination is unavailable.
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Anesthesia and analgesia · Mar 2002
Statistical power analysis to estimate how many months of data are required to identify operating room staffing solutions to reduce labor costs and increase productivity.
We performed a statistical power analysis to determine how many historical data are needed for optimal operating room (OR) management decision making. The work applies to hospitals that provide service for all of its surgeons' elective cases on whatever workday the surgeons and patients choose. The hospital and anesthesia group adjust OR staffing and patient scheduling to care for the patients while minimizing OR staffing costs and maximizing labor productivity. Two years of data were obtained from a seven-OR surgical suite. The data were repeatedly split into training and testing datasets. The optimal staffing solution was calculated for each training dataset to maximize the efficiency of OR time usage and was then applied to the corresponding testing dataset. Training datasets ranged in size from 30 to 270 consecutive workdays. With 30 workdays of data, the statistical method identified staffing solutions that had an average of 35% decreased costs and 27% increased productivity as compared to the existing staffing plan. There was no significant improvement in performance with more than 210 workdays (10 mo) of data. With 30 workdays of OR or anesthesia group data, the optimization method can significantly reduce staffing costs and increase productivity compared with existing staffing. When applied routinely for adjusting staffing (e.g., on a quarterly basis), 9 to 12 mo of data should be used. ⋯ With 30 workdays of operating room or anesthesia group data, the optimization method can propose staffing solutions that significantly decrease costs and increase productivity compared with existing staffing solutions. We recommend that, when the statistical method is applied routinely for adjusting staffing (e.g., on a quarterly basis), 9 to 12 mo of data be used.
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Anesthesia and analgesia · Mar 2002
Randomized Controlled Trial Comparative Study Clinical TrialTramadol infusion for postthoracotomy pain relief: a placebo-controlled comparison with epidural morphine.
We compared continuous IV tramadol as an alternative to neuraxial or systemic opioids for the management of postthoracotomy pain in a prospective, randomized, double-blinded, controlled study. General anesthesia was supplemented by thoracic epidural analgesia with 0.25% bupivacaine. At rib approximation, patients received one of the following: IV tramadol (150-mg bolus followed by infusion, total 450 mg/24 h, n = 29), epidural morphine (2 mg, then 0.2 mg/h, n = 30), or patient-controlled analgesia (PCA) morphine only (n = 30). All patients received PCA morphine and rescue morphine as necessary postoperatively. For the first 24 h, pain and sedation scores and respiratory, cardiovascular, and side effect measures were monitored. There was no significant difference in pain scores and PCA morphine use between tramadol and epidural morphine. Pain scores at rest and on coughing were lower in the Tramadol and Epidural Morphine groups than in the PCA Morphine group at various time points over the first 12 h. The Tramadol and Epidural Morphine groups used significantly less hourly PCA morphine than the PCA Morphine group at specific time points in the first 10 h. Vital capacities in the Tramadol group were significantly closer to baseline values at the 20-h point than in the PCA Morphine group. We conclude that an intraoperative bolus of tramadol followed by an infusion was as effective as epidural morphine and avoided the necessity of placing a thoracic epidural catheter. ⋯ A prospective, randomized, double-blinded, placebo-controlled study of postthoracotomy pain relief showed that IV tramadol in the form of a bolus followed by continuous infusion was as effective as epidural morphine. The use of tramadol avoids the necessity of placing a thoracic epidural catheter.
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Anesthesia and analgesia · Mar 2002
Case Reports Randomized Controlled Trial Clinical TrialFast-track eligibility of geriatric patients undergoing short urologic surgery procedures.
Our primary objective was to assess the feasibility of geriatric patients (>65 yr) bypassing the postanesthesia care unit (PACU) after ambulatory surgery. A secondary objective was to compare recovery profiles when using three different maintenance anesthetics. Ninety ASA physical status I--III consenting outpatients (>65 yr) undergoing short urologic procedures were randomly assigned to one of three anesthetic treatment groups. After a standardized induction with fentanyl and propofol, anesthesia was maintained with propofol (75-150 microg center dot kg(-1) center dot min(-1) IV), isoflurane (0.7%-1.2% end tidal), or desflurane (3%-6% end tidal), in combination with nitrous oxide 70% in oxygen. In all three groups, the primary anesthetic was titrated to maintain an electroencephalographic-bispectral index value of 60-65. Recovery times, postanesthesia recovery scores, and therapeutic interventions in the PACU were recorded. Although emergence times were similar in the three groups, the time to achieve a fast-track discharge score of 14 was significantly shorter in patients receiving desflurane compared with propofol and isoflurane (22 +/- 23 vs 33 +/- 25 and 44 +/- 36 min, respectively). On arrival in the PACU, a significantly larger percentage of patients receiving desflurane were judged to be fast-track eligible compared with those receiving either isoflurane and propofol (73% vs 43% and 44%, respectively). The number of therapeutic interventions in the PACU was also significantly larger in the Isoflurane group when compared with the Propofol and Desflurane groups (21 vs 11 and 7, respectively). In conclusion, use of desflurane for maintenance of anesthesia should facilitate PACU bypass ("fast-tracking") of geriatric patients undergoing short urologic procedures. ⋯ Geriatric outpatients undergoing brief urologic procedures more rapidly achieve fast-tracking discharge criteria after desflurane (versus isoflurane and propofol) anesthesia. Use of isoflurane was also associated with an increased need for nursing interventions in the early recovery period compared with desflurane and propofol.