[Cost-effectiveness analysis of an autotransfusion program in primary knee and hip replacement surgery]. / Análisis de la relación coste-efectividad de un programa de autotransfusión en cirugía protésica primaria de rodilla y cadera.

OBJECTIVE: To evaluate the cost-effectiveness of a program for autotransfusion in patients undergoing primary prosthetic surgery of the knee and hip (cemented and non-cemented). MATERIAL AND METHODS: A case-control comparison. Retrospective group: review of case histories of patients undergoing surgery in 1993, screened to identify the subpopulation that would be candidates for a program of autotransfusion and to evaluate the blood transfusion policy. Prospective group: patients undergoing surgery between 1995 and 1996 who participated in an autotransfusion program. We studied the following variables in both groups: prevalence of exposure to homologous blood and the amount, perioperative course of hemoglobin/hematocrit, and mean cost of the blood treatment given. In the prospective group we examined agreement between autologous blood extracted before surgery and later reinfused. RESULTS: The prevalence of exposure to homologous blood fell significantly from the retrospective to the prospective phases as follows: knee surgery 43.8% to 11.6%, cemented hip replacement 75% to 17.4%, non-cemented hip replacement 73.5% to 15.2%. The amount of packed red cells from homologous blood also fell: knee surgery 0.9 +/- 1.1 units to 0.2 +/- 0.5 units, cemented hip replacement 1.4 +/- 1 to 0.3 +/- 0.6 units, non-cemented hip surgery 1.8 +/- 1.3 to 0.3 +/- 0.7 units. The most commonly used techniques were preoperative donation and postoperative blood salvage from drains. The mean direct costs of hemotherapy in the prospective phase (homologous + autologous) were greater than in the retrospective phase, with the highest costs incurred in cases using autotransfusion (preoperative donation + blood salvage). The least differences in cost were seen in preoperative donation, which was also associated with the lowest rate of reinfusion in knee surgery. CONCLUSIONS: The autotransfusion program described is effective for lowering and even preventing exposure to homologous blood. The efficacy of the program is adequate, though it could be improved. The costs related to autologous hemotherapy are greater when combined autotransfusion techniques are used. When only one technique is used, the best cost-benefit ratio comes with preoperative donation.

[Anesthesia and lumbar epidural anesthesia in an infant with third-degree burns]. / Anestesia y analgesia epidural lumbar en un lactante afecto de quemaduras de tercer grado.

Epidural route is widely used in adults for injection of drugs, but it is not so often used in pediatric patients. We present the case of a 8 month old burned infant who received anesthesia and analgesia through a lumbar epidural catheter. The insertion of epidural catheter is described. Two surgical procedures were performed under epidural anesthesia with 0.5% bupivacaine an epinephrine 1:200.000 (2.5 mg/kg). 16 hours of postoperative analgesia was obtained with epidural morphine (0.05 mg/kg). No side effects were seen. We analyze the uses of epidural anesthesia in pediatric patients, the catheter care in the burned child, the hemodynamic changes observed during anesthesia and the results of peridural morphine.

[Comparison of venous pressure in the external jugular vein and the superior vena cava during anesthesia]. / Comparación de la presión venosa en vena yugular externa y vena cava superior durante la anestesia.

Venous pressure between the external jugular vein (EJV), and the superior caval vein (SCV) was compared in 15 patients, free of cardiorespiratory disease and undergoing abdominal surgery. In each patient data was taken in four different positions: A) anaesthetized patient in supine position and mechanical ventilation; B) anaesthetized patient in Trendelenburg position and mechanical ventilation; C) anaesthetized patient in anti-Trendelenburg and mechanical ventilation, and D) awake patient in supine position and spontaneous ventilation. A short, thick catheter with unique end lumen was used for EJV, and a long catheter from the basilic vein, to the SCV. Significant differences between mean and standard deviations of EJV and SCV were not founded. Linea correlation for the 4 positions was performed (r = 0.97, 0.91, 0.88 and 0.60 respectively) being significant for A-B y C positions. 4.5 cm H2O was the maximal difference obtained between SCV and EJV for A, B and C positions, and 10 cm H2O the maximal difference for the D position. The mean changes between the positions A-B, A-C and A-D was compared and significant differences (p less than or equal to 0.001) for A-C were seen, whereas A-B did not attain significant differences. We conclude that the EJV cannulation, with a short and thick catheter, allow the central venous pressure control during anaesthesia, in supine position, Trendelenburg and anti-Trendelenburg, but not during the recovery.