ABSTRACT
BACKGROUND AND AIMS: Development of opioid tolerance in the perioperative period due to remifentanil remains controversial. We evaluated occurrence of opioid tolerance and other adverse effects due to remifentanil in patients undergoing head and neck surgery. MATERIAL AND METHODS: We recruited adult participants with ASA status I to III who received general anesthesia for approximately 2 h for elective head and neck procedures. Remifentanil infusion was used in one group and intermittent boluses of morphine or fentanyl were administered in another group. Postoperative pain was treated with intermittent boluses of morphine and fentanyl in post-anaesthesia care unit (PACU) to achieve a numerical rating scale score of 3. Opioid requirement was assessed as an indicator of opioid tolerance. Patients were also evaluated for time to discharge from PACU. RESULTS: We studied 222 adults aged between 21 and 80 years. One hundred and eleven patients received a combination of remifentanil infusion and morphine boluses, and another 111 patients received only fentanyl and/or morphine boluses intraoperatively. Fifty-one patients in the remifentanil group and 25 in the fentanyl/morphine group required opioids in the PACU. Opioid requirement were significantly more (mean ± SD, 44.98 ± 59.7 Vs 20.23 ± 46.66 mcg.kg-1; P = 0.001) and required longer time to discharge from PACU in the remifentanil group compared to the fentanyl/morphine group (Mean ± SD, 88.6 ± 39.5 min Vs 73.1 ± 38.4 min; P < 0.001). No difference in the incidence of adverse effects in two groups was noted. CONCLUSION: At clinically relevant doses, intraoperative remifentanil infusion appears to increase opioid consumption in the immediate postoperative period. This can result in delayed discharge from PACU for patients undergoing elective head and neck procedures.
ABSTRACT
PURPOSE: The aim of this study was to assess a newly introduced hospitalist care model in a Singapore hospital. Clinical outcomes of the family medicine hospitalists program were compared with the traditional specialists-based model using the hospital's administrative database. METHODS: Retrospective cohort study of hospital discharge database for patients cared for by family medicine hospitalists and specialists in 2008. Multivariate analysis models were used to compare the clinical outcomes and resource utilization between patients cared for by family medicine hospitalists and specialist with adjustment for demographics, and comorbidities. RESULTS: Of 3493 hospitalized patients in 2008 who met the criteria of the study, 601 patients were under the care of family medicine hospitalists. As compared with patients cared for by specialists, patients cared for by family medicine hospitalists had a shorter hospital length of stay (adjusted LOS, geometric mean, GM, 4.4 vs. 5.3 days; P < 0.001) and lower hospitalization costs (adjusted cost, GM, $2250.7 vs. $2500.0; P= 0.003), but a similar in-patient mortality rate (4.2% vs. 5.3%, P= 0.307) and 30-day all-cause unscheduled readmission rate (7.5% vs. 8.4%, P= 0.231) after adjustment for age, ethnicity, gender, intensive care unit (ICU) admission, numbers of organ failures, and comorbidities. CONCLUSION: The family medicine hospitalist model was associated with reductions in hospital LOS and cost of care without adversely affecting mortality or 30-day all-cause readmission rate. These findings suggest that the hospitalist care model can be adapted for health systems outside North America and may produce similar beneficial effects in care efficiency and cost savings.