Anesthesia and analgesia
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Anesthesia and analgesia · May 2003
A demographic, service, and financial survey of anesthesia training programs in the United States.
In February 2000, a demographic, service, and finance survey was sent to the directors of anesthesiology training programs in the United States under the auspices of the Society of Academic Anesthesia Chairs/Association of Academic Program Directors. In August of 2000, 2001, and 2002, shorter follow-up surveys were sent to the same program directors requesting the numbers of vacancies in faculty positions and certified registered nurse anesthetists (CRNA) positions. The August 2001 survey also inquired if departments had positive or negative financial margins for the fiscal year ending June 2001. The August 2002 survey included the questions of the 2001 survey and additionally asked if the departments had had an increase or decrease in institutional support and the amount of that current support. The survey results revealed that the average program had 36 anesthetizing locations and 36 faculty. Those faculty spent 69% of their time providing clinical service. Approximately one-half of the departments paid for some of their residents, whereas the other 50% paid for none. Eighty-five percent of the departments employed CRNAs who were funded by the hospital in one third of the departments. In 2000, departments received $34,319/yr in support per faculty full-time equivalent (FTE) from their institutions and had a mean revenue of $407,000/yr/faculty FTE. In 2002, the department's institutional support per FTE increased to $59,680 (a 74% increase since 2000). The departments in academic medical centers paid 20% in overhead expenses, whereas departments in nonacademic medical centers paid 10%. In 2000, 2001, and 2002, the percentage of departments with positive margins was 53%, 53%, and 65%, respectively, whereas the departments with a negative margin decreased from 44% in the year 2000 to 38% in 2001 and 33% in 2002. For the departments with a positive margin, the amount of margin per FTE over this 3-yr period was approximately $50,000, $15,000, and $30,000, respectively. Although the percentage of departments with a negative margin has been decreasing, the negative margin per FTE seems to be increasing from approximately $24,000 to $43,000. The number of departments with open faculty positions has decreased from 91.5% in the year 2000 to 83.5% in 2001 and 78.4% in 2002; in these departments, the number of open faculty positions has also decreased from 3.8 in 2000 to 3.9 in 2001 to 3.4 in 2002. The number of open CRNA positions seems to have been relatively constant with approximately two thirds of the departments requiring an average of approximately four CRNAs each. Overall, academic anesthesiology departments fiscal security seems to have eroded with an increased dependence on institutional support. Departments pay larger overhead rates relative to private practice, and there seems to be a continued, but possibly decreasing, shortage of faculty. ⋯ A survey was conducted of anesthesia training program directors that demonstrated that their departments' financial conditions have been eroding over the years 2000 to 2002. During this same period of time, departments were receiving an increase in institutional support from $34,319/full-time equivalent (FTE) faculty in the year 2000 to $59,680/FTE in the year 2002. Although there seems to be an approximate 10% shortage in academic faculty, the number of departments with open positions has progressively decreased from 91% to 73% over the past 3 yr. On average, the financial condition of the training departments has deteriorated over the past 3 yr despite a significant increase in institutional support to enable departments to recruit and retain faculty in an era of an apparent national shortage of anesthesiologists.
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Anesthesia and analgesia · May 2003
Randomized Controlled Trial Comparative Study Clinical TrialThe influence of local active warming on pain relief of patients with cholelithiasis during rescue transport.
Upper abdominal pain, a frequent symptom of the presence of gallstone disease, is the cause of 6% of the emergency calls of the Austrian emergency system. Pain resulting from cholelithiasis is characteristically severe. Recent data show that active warming during emergency transport of trauma victims is effective in reducing pain. Therefore, we hypothesized that local active warming of the abdomen would be an effective pain treatment for patients with acute cholelithiasis and could be provided by paramedics. Sixty patients (>19 yr) consented to participate in this study. They were divided into two groups: Group 1, who received active warming of the upper abdomen with a carbon-fiber warming blanket (42 degrees C), and Group 2, who received no warming of the abdomen. Neither group received any drug-based pain care. Patients were asked to rate their pain and anxiety by using visual analog scales (VAS). Statistical evaluation was performed with Student's t-test; P < 0.05 was considered significant. In Group 1, a significant (P < 0.01) pain reduction was recorded in all cases on a visual analog scale (VAS), from 86.8 +/- 5.5 mm to 41.2 +/- 16.2 mm. In Group 2, the patients' pain scores remained comparable, from 88.3 +/- 9.9 mm to 88.1 +/- 10.0 mm on a VAS. In comparing Group 1 with Group 2 on arrival at the hospital, pain scores showed a significant difference (P < 0.01). In Group 1, the VAS score changes for anxiety were significantly reduced (P < 0.01), from 82.7 +/- 10.8 mm before treatment to 39.0 +/- 14.0 mm after treatment. In Group 2, a nonsignificant change of this score was noted, from 84.5 +/- 14.6 mm to 83.5 +/- 8.4 mm. Comparing Group 1 with Group 2 on arrival at the hospital showed a significant difference in anxiety scores (P < 0.01). We conclude that local active warming is an effective and easy-to-learn treatment for pain resulting from acute cholelithiasis in emergency care. ⋯ Active local warming of the upper abdomen is an effective treatment for patients with cholelithiasis being transported to the hospital by paramedics who are not permitted to provide any drug-based pain care. We observed no negative side effects of this treatment.
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Anesthesia and analgesia · May 2003
Anesthetic technique influences brain temperature, independently of core temperature, during craniotomy in cats.
Because anesthetic technique has the potential to dramatically affect cerebral blood flow and metabolism (two determinants of brain thermoregulation), we tested the hypothesis that, after craniotomy, anesthetic technique would influence brain temperature independent of core temperature. Twenty-one cats (2.7 +/- 0.4 kg; mean +/- SD) undergoing a uniform right parasagittal craniotomy received 1) halothane 1.5% end-expired and normocapnia (HN), 2) halothane 1.5% and hypocapnia (HH), or 3) large-dose pentobarbital and normocapnia (PN) (n = 7 per group). Heating devices initially maintained core and right subdural normothermia (38.0 degrees C). Thereafter, cranial heating was discontinued. Brain-to-core temperature gradients during the 3 h study were greatest in the right subdural area, averaging -2.5 degrees C +/- 0.9 degrees C in HN, -2.5 degrees C +/- 0.8 degrees C in HH, and -4.1 degrees C +/- 1.1 degrees C in PN. Gradients within the unexposed left subdural area and in the right cortex 0.5 and 1.0 cm below the brain surface were -0.8 degrees C +/- 0.5 degrees C to -1.1 degrees C +/- 0.6 degrees C for both HN and HH but were twice this amount in PN (-1.9 degrees C +/- 0.5 degrees C to -2.1 degrees C +/- 0.7 degrees C) (P < 0.05 for PN versus HN and HH). Deep barbiturate anesthesia can reduce brain temperature independently of core temperature, presumably by reducing the metabolic rate and associated brain heat production. The magnitude is sufficient to augment any direct cerebroprotective properties of the barbiturates. ⋯ Deep barbiturate anesthesia reduced brain temperature independently of body temperature in cats and significantly more than the reduction seen with halothane anesthesia. The magnitude of temperature reduction was sufficient to account for cerebral protection by barbiturates independently of any other properties of the drug.
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Anesthesia and analgesia · May 2003
Randomized Controlled Trial Clinical TrialClonidine combined with small-dose bupivacaine during spinal anesthesia for inguinal herniorrhaphy: a randomized double-blinded study.
The aim of this randomized double-blinded study was to see whether the addition of small-dose clonidine to small-dose bupivacaine for spinal anesthesia prolonged the duration of postoperative analgesia and also provided a sufficient block duration that would be adequate for inguinal herniorrhaphy. We randomized 45 patients to 3 groups receiving intrathecal hyperbaric bupivacaine 6 mg combined with saline (Group B), clonidine 15 micro g (Group BC15), or clonidine 30 micro g (Group BC30); all solutions were diluted with saline to 3 mL. The sensory block level was insufficient for surgery in five patients in Group B, and these patients were given general anesthesia. Patients in Groups BC15 and BC30 had a significantly higher spread of analgesia (two to four dermatomes) than those in Group B. Two-segment regression, return of S1 sensation, and regression of motor block were significantly longer in Group BC30 than in Group B. The addition of clonidine 15 and 30 micro g to bupivacaine prolonged time to first analgesic request and decreased postoperative pain with minimal risk of hypotension. We conclude that clonidine 15 micro g with bupivacaine 6 mg produced an effective spinal anesthesia and recommend this dose for inguinal herniorrhaphy, because it did not prolong the motor block. ⋯ The addition of clonidine 15 micro g to 6 mg of hyperbaric bupivacaine increases the spread of analgesia, prolongs the time to first analgesic request, and decreases postoperative pain, compared with bupivacaine alone, during inguinal herniorrhaphy under spinal anesthesia.
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Anesthesia and analgesia · May 2003
Randomized Controlled Trial Clinical TrialRemifentanil with thiopental for tracheal intubation without muscle relaxants.
Tracheal intubation may be accomplished with remifentanil and a non-opioid IV anesthetic without a muscle relaxant. In this study, we evaluated in double-blinded, prospective, randomized manner the dose requirements for remifentanil with thiopental without muscle relaxant administration to obtain clinically acceptable intubation conditions and cardiovascular responses. After premedication with midazolam 0.03 mg/kg IV, 105 patients were randomized equally to one of three study groups, each receiving the following: remifentanil 2 micro g/kg (Group I), 3 micro g/kg (Group II), and 4 micro g/kg (Group III). Remifentanil was administered over 30 s, and anesthesia was induced with thiopental 5 mg/kg. Tracheal intubation conditions were assessed by the anesthesiologist performing the intubation as: (a) excellent, (b) satisfactory, (c) fair, and (d) unsatisfactory. There were no statistically significant differences among groups regarding to demographic data. Blood pressure and heart rate did not increase in any group after accomplishing intubation. There was a significant improvement in intubation conditions between Groups I and II, I and III, and II and III (P < 0.001). We conclude that remifentanil 4 micro g/kg administered before thiopental 5 mg/kg provided excellent or satisfactory intubation conditions in 94% of patients and prevented cardiovascular responses to intubation. ⋯ We evaluated in a double-blinded manner the dose requirements for remifentanil with thiopental without muscle relaxants for obtaining acceptable intubation condition. Our results show that remifentanil 4 micro g/kg administered before thiopental provided excellent or satisfactory intubation condition in 94% of patients.