RESUMO
INTRODUCTION: Intravenous (IV) iron is typically the preferred treatment for patients with iron deficiency anemia (IDA) who cannot tolerate or absorb oral iron, or who require fast replenishment of iron stores pre-operatively. Several IV iron formulations are available with different dosing characteristics affecting infusion speed and maximum dose. The aim was to develop a resource impact model to calculate the cost of establishing an IV iron clinic and model resource impact of different IV irons to inform clinicians and service providers implementing innovative pre-operative IV iron services in Ireland. METHODS: A resource impact tool was developed to model resource utilization and IDA treatment costs. Two fast-administration, high-dose formulations of IV iron are available in Ireland: iron isomaltoside 1000/ferric derisomaltose (IIM) and ferric carboxymaltose (FCM). The tool modeled clinic throughput based on their different dosing characteristics in a specific IDA population, capturing fixed overheads, variable costs, clinic income from private and publicly-funded patients, and savings associated with IV iron. RESULTS: Based on a 70:30 split between public and private patients in a new pre-operative service with capacity for 12 infusion slots weekly, IIM would facilitate correction of iron deficits in 474 patients annually, resulting in a net annual clinic balance of 42,736 on income of 159,887 and net costs of 117,151. FCM would facilitate treatment of 353 patients, resulting in a net annual clinic balance of 36,327 on income of 116,050 and costs of 79,722, a difference of 6408 and 121 patients treated in favor of using IIM over FCM. CONCLUSION: Based on this provider-perspective analysis, IIM would maximize clinic throughput relative to other IV iron formulations, allowing clinicians in Ireland to optimize their current service provision and expenditure, and model the impact of introducing IV iron clinics for pre-operative patients with IDA.
Assuntos
Instituições de Assistência Ambulatorial/organização & administração , Anemia Ferropriva/tratamento farmacológico , Dissacarídeos/uso terapêutico , Compostos Férricos/uso terapêutico , Maltose/análogos & derivados , Cuidados Pré-Operatórios/métodos , Administração Intravenosa , Instituições de Assistência Ambulatorial/economia , Custos e Análise de Custo , Dissacarídeos/administração & dosagem , Dissacarídeos/economia , Compostos Férricos/administração & dosagem , Compostos Férricos/economia , Recursos em Saúde/economia , Recursos em Saúde/estatística & dados numéricos , Humanos , Irlanda , Maltose/economia , Maltose/uso terapêutico , Modelos Econômicos , Cuidados Pré-Operatórios/economiaRESUMO
Ultrasound technology has transformed the practice of regional anaesthesia. Anaesthesiologists routinely use real-time images to guide needle and local anaesthetic placement adjacent to nerves. It is widely accepted that the era of ultrasonography has improved peripheral nerve block success rates and lessened the dose of local anaesthetic required to achieve success. Contemporary reports of harm in relation to nerve injury or local anaesthetic systemic toxicity are reassuring. The safety and efficacy of regional anaesthesia have thus been enhanced. Ultrasound guidance is, however, not a panacea. Ultrasound guidance requires the development of complex psychomotor skills. Harm may still occur where the needle or local anaesthetic is misplaced, resulting in nerve injury, vascular injury or local anaesthetic systemic toxicity. Advances in both imaging and needle technology may further enhance the safety and efficacy of ultrasound-guided regional anaesthesia. This review will focus on peer review literature to characterise the clinical challenges and explore the potential solutions.
Assuntos
Anestesia por Condução/métodos , Impedância Elétrica/uso terapêutico , Nervos Periféricos/diagnóstico por imagem , Ultrassonografia de Intervenção/métodos , Anestesia por Condução/tendências , Previsões , Humanos , Bloqueio Nervoso/métodos , Bloqueio Nervoso/tendências , Ultrassonografia de Intervenção/tendênciasRESUMO
BACKGROUND: Local infiltration analgesia (LIA) is an effective pain management technique following total knee arthroplasty (TKA). OBJECTIVE: To investigate if LIA provides better analgesia for patients undergoing unilateral TKA than intrathecal morphine. DESIGN: Randomised controlled trial. SETTING: Single tertiary referral centre. PATIENTS: Consecutive American Society of Anesthesiologists Physical Status I to III patients scheduled to undergo unilateral TKA were randomised to two groups. INTERVENTION: The control group received spinal anaesthesia with intrathecal bupivacaine and preservative-free morphine 0.3âmg. The intervention group received opioid-free spinal anaesthesia with bupivacaine, followed by intra-operative infiltration of the knee with levobupivacaine 2âmgâkg and adrenaline 0.5âmg diluted to a volume of 100âml with 0.9% saline. An intra-articular catheter was placed during surgery and used to give a bolus of 15âml of levobupivacaine 0.5% on the morning of the first postoperative day. MAIN OUTCOME MEASURES: Visual analogue scale (VAS) scores for pain were assessed repeatedly for 48âh postoperatively, at rest and on passive knee flexion to 30°. The primary outcome was VAS scores for pain at rest and on movement at 24 postoperative hours. Secondary outcomes were VAS scores at rest and on movement at 2, 6, 12 and 48 postoperative hours, opioid consumption, degree of active flexion of operative knee achieved in the first 48âh and the incidence of opioid-related side effects. RESULTS: Forty three patients completed the study. Mean (± SD) VAS scores for pain at 24âh were lower in the intervention group than the control group at rest; 16.43 (± 20.3) vs. 37.2 (± 33.6), (Pâ=â0.029). VAS scores for pain at 24âh on movement were also lower in the intervention group vs. the control group; 39.1 (± 22.8) vs. 57.0 (± 30.9), (Pâ=â0.037). VAS scores were also lower on movement; 25.9 (± 16.8) vs. 40.5 (± 24.0), (Pâ=â0.028) at 48âh. CONCLUSION: We conclude that LIA conferred superior analgesia compared with intrathecal morphine 0.3âmg at 24 and 48âh following TKA. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01312415.
Assuntos
Analgésicos Opioides/administração & dosagem , Anestésicos Locais/administração & dosagem , Artroplastia do Joelho/efeitos adversos , Manejo da Dor/métodos , Dor Pós-Operatória/terapia , Idoso , Anestesia Local/métodos , Raquianestesia/métodos , Feminino , Humanos , Injeções Intra-Articulares , Injeções Espinhais , Cuidados Intraoperatórios/métodos , Masculino , Pessoa de Meia-Idade , Morfina/administração & dosagem , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Resultado do TratamentoRESUMO
BACKGROUND AND AIMS: Routine use of pre-procedural ultrasound guided midline approach has not shown to improve success rate in administering subarachnoid block. The study hypothesis was that the routine use of pre-procedural (not real time) ultrasound-guided paramedian spinals at L5-S1 interspace could reduce the number of passes (i.e., withdrawal and redirection of spinal needle without exiting the skin) required to enter the subarachnoid space when compared to the conventional landmark-guided midline approach. METHODS: After local ethics approval, 120 consenting patients scheduled for elective total joint replacements (Hip and Knee) were randomised into either Group C where conventional midline approach with palpated landmarks was used or Group P where pre-procedural ultrasound was used to perform subarachnoid block by paramedian approach at L5-S1 interspace (real time ultrasound guidance was not used). RESULTS: There was no difference in primary outcome (difference in number of passes) between the two groups. Similarly there was no difference in the number of attempts (i.e., the number of times the spinal needle was withdrawn from the skin and reinserted). The first pass success rates (1 attempt and 1 pass) was significantly greater in Group C compared to Group P [43% vs. 22%, P = 0.02]. CONCLUSION: Routine use of paramedian spinal anaesthesia at L5-S1 interspace, guided by pre-procedure ultrasound, in patients undergoing lower limb joint arthroplasties did not reduce the number of passes or attempts needed to achieve successful dural puncture.
RESUMO
BACKGROUND: Multiple passes and attempts while administering spinal anesthesia are associated with a greater incidence of postdural puncture headache, paraesthesia, and spinal hematoma. We hypothesized that the routine use of a preprocedural ultrasound-guided paramedian technique for spinal anesthesia would reduce the number of passes required to achieve entry into the subarachnoid space when compared with the conventional landmark-guided midline approach. METHODS: One hundred consenting patients scheduled for elective total joint replacements (hip and knee) were randomized into group C (conventional) and group P (preprocedural ultrasound-guided paramedian technique) with 50 in each group. The patients were blinded to the study group. All spinal anesthetics were administered by a consultant anesthesiologist. In group C, spinal anesthetic was done via the midline approach using clinically palpated landmarks. In group P, a preprocedural ultrasound scan was used to mark the paramedian insertion site, and spinal anesthetic was performed via the paramedian approach. RESULTS: The average number of passes (defined as the number of forward advancements of the spinal needle in a given interspinous space, i.e., withdrawal and redirection of spinal needle without exiting the skin) in group P was approximately 0.34 times that in group C, a difference that was statistically significant (P = 0.01). Similarly, the average number of attempts (defined as the number of times the spinal needle was withdrawn from the skin and reinserted) in group P was approximately 0.25 times that of group C (P = 0.0021). In group P, on an average, it took 81.5 (99% confidence interval, 68.4-97 seconds) seconds longer to identify the landmarks than in group C (P = 0.0002). All other parameters, including grading of palpated landmarks, time taken for spinal anesthetic injection, periprocedural pain scores, periprocedural patient discomfort visual analog scale score, conversion to general anesthetic, paresthesia, and radicular pain during needle insertion, were similar between the 2 groups. CONCLUSIONS: Routine use of paramedian spinal anesthesia in the orthopedic patient population undergoing joint replacement surgery, guided by preprocedure ultrasound examination, significantly decreases the number of passes and attempts needed to enter the subarachnoid space.
Assuntos
Raquianestesia/normas , Procedimentos Cirúrgicos Eletivos/normas , Cuidados Pré-Operatórios/normas , Ultrassonografia de Intervenção/normas , Idoso , Raquianestesia/métodos , Procedimentos Cirúrgicos Eletivos/métodos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios/métodos , Estudos Prospectivos , Ultrassonografia de Intervenção/métodosAssuntos
Unidades Hospitalares/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Cirurgia Plástica , Ferimentos e Lesões/epidemiologia , Ferimentos e Lesões/cirurgia , Procedimentos Cirúrgicos Ambulatórios/estatística & dados numéricos , Plexo Braquial , Humanos , Bloqueio Nervoso/estatística & dados numéricos , Reino UnidoRESUMO
We evaluated the systemic and local effects of clonidine as an analgesic adjunct to psoas compartment block (PCB) with levobupivacaine. In a randomized, prospective, double-blind trial, 36 patients requiring hip fracture surgery received PCB and general anesthesia. Patients were randomized into three groups. Each patient received PCB with 0.4 mL/kg of levobupivacaine 0.5%. The control group (group L) received IV saline, the systemic clonidine group (group IC) received IV clonidine 1 mug/kg, and the peripheral clonidine group (group C) received IV saline and PCB with clonidine 1 microg/kg. The interval from time of completion of block injection to first supplementary analgesic administration was longer in group IC compared with group L (mean +/- sd, 13.4 +/- 6.1 versus 7.3 +/- 3.6 h; P = 0.03). There was no difference between group C and group L (10.3 +/- 5.9 versus 7.3 +/- 3.6 h; P > 0.05). The groups were similar in terms of 24 h cumulative morphine and acetaminophen consumption. There were no significant differences among groups regarding postoperative adverse effects (bradycardia, hypotension, sedation, and nausea). We conclude that IV but not perineural clonidine (1 microg/kg) prolongs analgesia after PCB without increasing the incidence of adverse effects.