Patient preferences for anaesthesia management during cataract surgery.

BACKGROUND/AIMS: To assess patient preferences for different anaesthesia management strategies during cataract surgery. METHODS: Cross sectional clinic based study of patient preferences for anaesthesia management strategies. Patients rated their preferences using a linear rating scale from 0 to 100. RESULTS: Subjects tended to prefer block to topical anaesthesia and oral to intravenous sedation. On a scale from 0 to 100, subjects preferred oral to intravenous sedation and block to topical anaesthesia by about 8 points. CONCLUSIONS: When given the choice of four different anaesthesia management strategies, 72% of the study subjects preferred block anaesthesia to topical anaesthesia. More patients chose to have oral sedation than intravenous sedation. These findings indicate that patients may prefer anaesthesia management approaches other than the ones they are currently being offered.

A decision analysis of anesthesia management for cataract surgery.

PURPOSE: To compare the trade-offs in cost and preference of various anesthesia management strategies for cataract surgery. METHODS: Six strategies, differing in sedation, local anesthetic, and monitoring approach, were chosen for comparison. For each strategy, potential complications, and conversions to different anesthesia approaches were modeled. A panel of physicians and anesthetists, well versed in the literature and practice of the anesthesia management of cataract surgery, assigned preference values to the strategies and potential outcomes (0 to 1 scale). Probability estimates were obtained from a study of 19,557 cataract surgeries and from the panel. Cost estimates were derived from several sources. The model was analyzed to determine the strategies associated with the highest expected preference and lowest expected cost. RESULTS: The strategy associated with the highest net preference was intravenous sedation with block anesthesia and an anesthesiologist present throughout the case. The expected net preference for this strategy was 19% greater than the net preference for the next most preferred strategy, oral sedation with block anesthesia and an anesthesiologist on call (0.88 versus 0.74), but the expected anesthesia costs per case were much greater ($324 versus $42). Results were sensitive to plausible variation in the preference values assigned to the six initial management strategies and to the cost of topical versus block anesthesia. CONCLUSION: This analysis emphasizes that cost and preference are important considerations when choosing an anesthesia management strategy for cataract surgery. For some surgeries, substantial cost savings may be available for a small change in preference.

Synthesis of the literature on the effectiveness of regional anesthesia for cataract surgery.

OBJECTIVE: To synthesize the findings of the randomized trials of regional anesthesia management strategies for cataract surgery. DESIGN: Literature review and analysis. METHOD: The authors performed a systematic search of the literature to identify all articles pertaining to regional anesthesia during cataract surgery on adults. One investigator abstracted the content of each article onto a custom-designed form. A second investigator corroborated the findings. The evidence supporting the anesthesia approaches was graded by consensus as good, fair, poor, or insufficient. MAIN OUTCOME MEASURES: Evidence supporting the effectiveness of different forms of regional anesthesia. RESULTS: There was good evidence that retrobulbar and peribulbar blocks provide equivalent akinesia and pain control during cataract surgery. Additionally, sub-Tenon's blocks were at least as effective as retrobulbar and peribulbar blocks. There was good evidence that retrobulbar block provides better pain control during surgery than topical anesthesia, and there was fair evidence that peribulbar block provides better pain control than topical anesthesia. CONCLUSIONS: This synthesis of the literature demonstrates that currently used approaches to anesthesia management provide adequate pain control for successful cataract surgery, but there is some variation in the effectiveness of the most commonly used techniques. Data are needed on patient preferences to determine the optimal strategies for anesthesia management during cataract surgery.

The methodologic quality of clinical trials on regional anesthesia for cataract surgery.

OBJECTIVE: To assess the methodologic quality of published randomized trials of regional anesthesia management strategies for cataract surgery. DESIGN: Literature review and analysis. METHOD: We performed a systematic search of the literature to identify all articles pertaining to regional anesthesia for cataract surgery on adults. Overall quality scores and scores for individual methodologic domains were based on the evaluations of two investigators experienced in methodologic research who independently reviewed all relevant articles using a quality abstraction form. MAIN OUTCOME MEASURES: Study quality in each of five domains: representativeness, bias and confounding, intervention description, outcomes and follow-up, and statistical quality and interpretation. RESULTS: Eighty-two randomized clinical trials were identified with a mean overall quality score of 44%. The mean domain scores ranged from 37% for representativeness to 58% for outcomes and follow-up. Forty percent or fewer studies received the maximum score for reporting the setting, the population, and the start and end dates; describing the inclusion and exclusion criteria; adequately randomizing subjects; and adequately masking individuals participating in the study. Key outcomes were often inadequately reported, including the distribution of patient-reported pain scores and the mean surgical time. CONCLUSIONS: Greater attention to methodologic quality and detailed reporting of study results will improve the ability of readers to interpret the results of clinical trials assessing regional anesthesia for cataract surgery.

Effectiveness of a head injury program for children: a preliminary investigation.

OBJECTIVE: The purpose of this study was to investigate whether a more coordinated, comprehensive head injury rehabilitation program provided at a children's trauma center yielded better outcomes than a less coordinated, less comprehensive program. DESIGN: Using a quasi-experimental design, 64 children with head injury admitted to the center and who received rehabilitation services in either 1995 or 1993 were evaluated by using the Functional Independence Measure for children (WeeFIM)/The Functional Independence Measure (FIM) (e.g., primary outcome measure). Secondary outcomes included "psychosocial adjustment," "return to regular school," and "current problems related to the head injury." RESULTS: No statistically significant differences were found between the groups with respect to mean WeeFIM/FIM scores after controlling for age and injury severity. The 1993 group had poorer scores on the withdrawal subscale of the psychosocial measure (P = 0.02), yet a smaller proportion of these children were enrolled in a special education class (P = 0.02). CONCLUSIONS: This study serves as a model for a larger, definitive study of the effectiveness of rehabilitation for children with head injury. The trends suggest that more comprehensive care may lead to better outcomes.

Using the measure of processes of care with parents of children hospitalized for head injury.

Despite recommendations that rehabilitation programs adopt family/patient satisfaction as an outcome measure, few studies have addressed satisfaction with services for children with head injury. This report describes our use of the Measure of Processes of Care (MPOC) to document the perceptions of care of parents whose children were hospitalized with a head injury and to compare parental perceptions of care with those of the service providers (n = 16). The MPOC is a self-administered questionnaire consisting of 56 items, each of which is included in one of five care-giving scales: (1) enabling and partnership; (2) providing general information; (3) providing specific information about the child; (4) coordinated and comprehensive care; (5) respectful and supportive care. The MPOC was mailed to parents of children with a head injury who were consecutively admitted to a pediatric trauma center during a 5-mo period. The results, based on the responses of 73 parents (response rate, 59.3%), revealed that the needs of these parents are being met to varying degrees. Mean scores for the five scales ranged from 4.6 to 6.4 and from 5.9 to 6.6 for parents and providers, respectively. Significant differences between the groups were found for two scales: providing general and specific information. Because of the low percentage of valid responses for three of the five scales, the MPOC appears to be an inappropriate tool for use with parents of children with mild head injury (89%) in the acute care setting. The MPOC, however, is applicable for parents of children who are more severely injured (e.g., average hospital stay, 9 days) and is informative for rehabilitation service providers.

A 210-mumol dose of vitamin A provides more prolonged impact on vitamin A status than 105 mumol among preschool children.

A randomized controlled clinical trial was conducted to determine the relative protection afforded by two large doses of vitamin A against subclinical vitamin A deficiency among 345 preschool children. At baseline, children either had or were at high risk of developing non-corneal xerophthalmia. Vitamin A status was assessed by the relative dose response (RDR) test, serum retinol concentration, and ocular examination before and 3 and 6 mo following one oral dose of 105 mumol or 210 mumol of vitamin A. At 3 and 6 mo, mean serum retinol concentration was significantly higher in the 210-mumol group than in the 105-mumol group. The proportion of children with a positive RDR did not differ between groups at 3 mo, but by 6 mo there were three times more children positive in the 105-mumol group. Most of the observed difference was confined to children with xerophthalmia at baseline. The relative benefit of the 210-mumol dose was related to baseline vitamin A status. The current World Health Organization recommended prophylactic dose of 210 mumol seems appropriate.