Anesthesia and analgesia
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Anesthesia and analgesia · May 2003
The influence of hemorrhagic shock on etomidate: a pharmacokinetic and pharmacodynamic analysis.
We studied the influence of hemorrhagic shock on the pharmacology of etomidate in swine. Sixteen swine were randomly assigned to control and shock groups. The shock group was bled to a mean arterial blood pressure of 50 mm Hg and held there until 30 mL/kg blood was removed. Etomidate 300 micro g x kg(-1) x min(-1) was infused for 10 min to both groups. Fifteen arterial samples were collected until 180 min after the infusion began to determine drug concentration. Pharmacokinetic variables for each group were estimated by using a three-compartment model. The bispectral index scale was used as a measure of drug effect. The pharmacodynamics were characterized by using a sigmoid inhibitory maximal effect model. The raw data revealed a 25% increase in the plasma etomidate concentration at the end of the 10-min infusion which resolved after termination of the infusion in the shock group. The pharmacokinetic analysis revealed subtle changes in the variable estimates between groups. The etomidate infusion produced a similar Bispectral Index Scale change in both groups. These results demonstrated that, unlike the influence of hemorrhagic shock on other sedative hypnotics and opioids, moderate hemorrhagic shock produced minimal changes in the pharmacokinetics and no change in the pharmacodynamics of etomidate. ⋯ Hemorrhagic shock produced minimal changes in the pharmacokinetics and no change in the pharmacodynamics of etomidate in swine. These results suggest that, unlike other sedative hypnotics and opioids, minimal adjustment in the dose of etomidate is required to achieve the same drug effect during hemorrhagic shock.
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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
The diagnosis of obstructive sleep apnea as a risk factor for unanticipated admissions in outpatient surgery.
The goal of this study was to determine whether the preoperative diagnosis of obstructive sleep apnea (OSA) is an independent risk factor for perioperative complications in patients undergoing nonotorhinolaryngologic outpatient surgical procedures. We used existing databases to identify 234 patients with polysomnography-confirmed OSA who had outpatient surgical procedures in the years 1997 through 2000. Control patients were matched for type of anesthesia, age, sex, body mass index, surgical procedure, and surgical date. Their perioperative medical records were reviewed. There was no significant difference in the intraoperative management of OSA and control patients, except that the laryngeal mask airway was less likely to be used in OSA patients. There was no significant difference in the rate of unplanned hospital admissions (23.9% versus 18.8%; odds ratio, 1.4; 95% confidence interval, 0.8-2.5) or other adverse events (2.1% versus 1.3%; odds ratio, 1.7; 95% confidence interval, 0.4-7.0) between OSA and non-OSA patients. Further, when admission did occur, it was generally unrelated to cardiac or respiratory events. In this retrospective analysis, the preoperative diagnosis of OSA was not a risk factor for either unanticipated hospital admission or for other adverse events among patients undergoing outpatient surgical procedures in a tertiary referral center. ⋯ In patients scheduled for outpatient surgery in a large academic practice, the diagnosis of obstructive sleep apnea confirmed by polysomnography was not an independent risk factor for unanticipated hospital admission or for other adverse perioperative events.