[Show abstract][Hide abstract] ABSTRACT: Various clinical trials have assessed how intraoperative anesthetics can affect early recovery, hemodynamics and nociception after supratentorial craniotomy. Whether or not the difference in recovery pattern differs in a meaningful way with anesthetic choice is controversial. This review examines and compares different anesthetics with respect to wake-up time, hemodynamics, respiration, cognitive recovery, pain, nausea and vomiting, and shivering. When comparing inhalational anesthetics to intravenous anesthetics, either regimen produces similar recovery results. Newer shorter acting agents accelerate the process of emergence and extubation. A balanced inhalational/intravenous anesthetic could be desirable for patients with normal intracranial pressure, while total intravenous anesthesia could be beneficial for patients with elevated intracranial pressure. Comparison of inhalational anesthetics shows all appropriate for rapid emergence, decreasing time to extubation, and cognitive recovery. Comparison of opioids demonstrates similar awakening and extubation time if the infusion of longer acting opioids was ended at the appropriate time. Administration of local anesthetics into the skin, and addition of corticosteroids, NSAIDs, COX-2 inhibitors, and PCA therapy postoperatively provided superior analgesia. It is also important to emphasize the possibility of long-term effects of anesthetics on cognitive function. More research is warranted to develop best practices strategies for the future that are evidence-based.
Full-text · Article · Sep 2015 · Journal of Clinical Medicine Research
[Show abstract][Hide abstract] ABSTRACT: As management of patients in extremis becomes increasingly complex, the need for a resuscitation consultant is apparent. This physician must be able to provide and/or coordinate care for the acutely ill and injured patient across the continuum of care; from presentation to definitive care to disposition. The resuscitation consultant produced by a residency in anesthesiology and emergency medicine will capitalize on the complementary strengths of both programs; a 60-month residency will offer board eligibility in both specialties. The first (PGY-1) year will be spent as an intern on the emergency medicine service and the second (PGY-2) year will be spent on the anesthesiology service as a clinical anesthesiology-1 resident. The remaining 3 years will be split into 18 months each of anesthesiology and emergency medicine. Approval of the program in anesthesiology and emergency medicine by appropriate governing bodies is a pre-requisite for program establishment. While medical students will determine the success of the program in anesthesiology and emergency medicine (for it is they who are the prospective applicants to the program), it is the patient who will be the beneficiary of a uniquely trained resuscitation consultant. A physician who is at ease diagnosing undifferentiated disease, managing resuscitation in the operating room or interventional radiology suite and managing the critically ill patient throughout the care continuum will define the future specialty.
[Show abstract][Hide abstract] ABSTRACT: Objective: Cost comparison between three common anesthetic agents. Design: Retrospective analysis. Patients had been randomized to anesthetic maintenance with either desflurane, sevoflurane, or propofol. Setting: Operating room in an academic medical center Patients: 103 patients undergoing general endotracheal anesthesia. Patients were ASA class I-III and between 18 and 75 years old. Cardiac, Neurologic, and regional cases were excluded. Outcome Measures: Volatile anesthetic cost was determined using the following formula: Cost = [(concentration) (FGF)(duration)(MW)(cost/ml)]/[2412)(D)]. To determine propofol cost, average infusion rate (mcg/kg/min.), patient weight, and duration were measured. Cost for each agent was then divided by surgical time to compare the results on a cost/min. basis. Results: Per minute of surgery, propofol was the least expensive agent for anesthetic maintenance at $0.12/min. Sevoflurane cost $0.18/min and desflurane cost $0.48/min. The differences between all three agents were statistically significant (p <0.05). Propofol maintenance was associated with a higher intra-operative fentanyl dose. The average fentanyl dose in the propofol group was 468 mcg, sevoflurane was 321 mcg, and desflurane was 284 mcg. There was no association between intra-operative fentanyl dose and anesthetic maintenance cost per minute of surgery. Surgical time did not significantly differ between the three groups and averaged over three hours. Conclusion: Anesthetic maintenance with propofol may help peri-operative physicians deliver care in the most cost effective manner possible.. Anesthetic maintenance with propofol infusion is less expensive per minute of surgery than sevoflurane or desflurane.
Full-text · Article · Sep 2014 · Anaesthesia, Pain and Intensive Care
[Show abstract][Hide abstract] ABSTRACT: Objective:
To examine the impact of intravenous antihypertensive selection on hospital health resource utilization using data from the Evaluation of CLevidipine In the Perioperative Treatment of Hypertension Assessing Safety Events (ECLIPSE) trials.
Analysis of ECLIPSE trial data comparing clevidipine to nitroglycerin, sodium nitroprusside, and nicardipine and unit costs based on the Premier Hospital database to assess surgery duration, time to extubation, and length of stay (LOS) with the associated cost.
A total of 1414 patients from the ECLIPSE trials and the Premier hospital database were included for analysis. The duration of surgery and postoperative LOS were similar across groups. The time from chest closure to extubation was shorter in patients receiving clevidipine group compared with the pooled comparator group (median 7.0 vs 7.6 hours, P = 0.04). There was shorter intensive care unit (ICU) LOS in the clevidipine group versus the nitroglycerin group (median 27.2 vs 33.0 hours, P = 0.03). A trend toward reduced ICU LOS was also seen in the clevidipine compared with the pooled comparator group (median 32.3 vs 43.5 hours, P = 0.06). The costs for ICU LOS and time to extubation were lower with clevidipine than with the comparators, with median cost savings of $887 and $34, respectively, compared with the pooled comparator group, for a median cost savings of $921 per patient.
Health resource utilization across therapeutic alternatives can be derived from an analysis of standard costs from hospital financial data to matched utilization metrics as part of a randomized controlled trial. In cardiac surgical patients, intravenous antihypertensive selection was associated with a shorter time to extubation in the ICU and a shorter ICU stay compared with pooled comparators, which in turn may decrease total costs.
No preview · Article · Aug 2014 · Hospital practice (1995)
[Show abstract][Hide abstract] ABSTRACT: To examine the impact of blood pressure control on hospital health resource utilization using data from the ECLIPSE trials.
Post-hoc analysis of data from 3 prospective, open-label, randomized clinical trials (ECLIPSE trials).
Sixty-one medical centers in the United States.
Patients 18 years or older undergoing cardiac surgery.
Clevidipine was compared with nitroglycerin, sodium nitroprusside, and nicardipine.
The ECLIPSE trials included 3 individual randomized open-label studies comparing clevidipine to nitroglycerin, sodium nitroprusside, and nicardipine. Blood pressure control was assessed as the integral of the cumulative area under the curve (AUC) outside specified systolic blood pressure ranges, such that lower AUC represents less variability. This analysis examined surgery duration, time to extubation, as well as intensive care unit (ICU) and hospital length of stay (LOS) in patients with AUC≤10 mmHg×min/h compared to patients with AUC>10 mmHg×min/h. One thousand four hundred ten patients were included for analysis; 736 patients (52%) had an AUC≤10 mmHg×min/h, and 674 (48%) had an AUC>10 mmHg×min/h. The duration of surgery and ICU LOS were similar between groups. Time to extubation and postoperative LOS were both significantly shorter (p = 0.05 and p<0.0001, respectively) in patients with AUC≤10. Multivariate analysis demonstrates AUC≤10 was significantly and independently associated with decreased time to extubation (hazard ratio 1.132, p = 0.0261) and postoperative LOS (hazard ratio 1.221, p = 0.0006).
Based on data derived from the ECLIPSE studies, increased perioperative BP variability is associated with delayed time to extubation and increased postoperative LOS.
No preview · Article · Apr 2014 · Journal of cardiothoracic and vascular anesthesia
[Show abstract][Hide abstract] ABSTRACT: Trauma systems are designed to care optimally for a population and its injured members. These systems extend far beyond in-hospital care of the injured patient. They must also include injury prevention, prehospital care, hospital care, education, and research, as well as long-term rehabilitation and recovery. Trauma systems require coordination between hospitals, physicians, nurses, allied health professionals, policy makers, governing bodies, community leaders, and many others to be successful. This review will describe the history and development of trauma systems, the key components of such systems, and the impact that trauma systems have on a population.
[Show abstract][Hide abstract] ABSTRACT: High-frequency percussive ventilation (HFPV) is an effective rescue therapy in ventilated patients with acute lung injury. High levels of inspired oxygen (FiO(2)) are toxic to the lungs. The objective of this study was to review a low FiO(2) (0.25)/HFPV protocol as a protective strategy in burn patients receiving mechanical ventilation greater than 10days.
A single-center, retrospective study in burn patients between December 2002 and May 2005 at the LAC+USC Burn Center. Demographic and physiologic data were recorded from time of admission to extubation, 4weeks, or death.
32 subjects were included in this study, 1 patient failed the protocol. 23 of 32 (72%) patients were men and mean age was 46±15years. Average TBSA burn was 30±20 with 9 of 32 (28%) having >40% TBSA involved. Average burn index was 76±21. 22 of 32 (69%) had inhalation injury and 23 of 32 (72%) had significant comorbidities. Average ventilator parameters included ventilator days 24±12, FiO(2) 0.28±0.03, PaO(2) 107±15Torr, PaCO(2) 42±4Torr, and PaO(2)/FiO(2) ratio 395±69. 16 of 32 (50%) patients developed pneumonia and 9 of 32 (28%) died. No patient developed ARDS, barotrauma, or died from respiratory failure. There was no association between inhalation injury and mortality in this group of patients.
A low FiO(2)/HFPV protocol is a safe and effective way to ventilate critically ill burn patients. Reducing the oxidative stress of high inspired oxygen levels may improve outcome.
No preview · Article · Jul 2012 · Burns: journal of the International Society for Burn Injuries