Perioperative monitoring with the electroencephalogram and the bispectral index monitor.

Recent clinical studies using the bispectral index monitor to predict movement, measure the level of consciousness, and reduce the cost of anesthesia have renewed interest in the use of a monitor to assess the effects of anesthetics on the brain. In 1937, Gibbs described electroencephalographic changes during the administration of general anesthetics. Artusio in 1954 used unprocessed electroencephalographic waveform analysis during an ether anesthetic to study the first stage of anesthesia. Some of the first automated electroencephalographic processors used power spectrum analysis for assessment of the patient's brain activity during surgery and anesthesia. The purpose of this article is to provide a historical perspective of the development and use of the processed electroencephalographic monitor. This article also describes studies of clinical usefulness of the bispectral index monitoring device in anesthesia practice today.

Provider-owned health plans: El Dorado or Armageddon?

The development of provider-owned health plans continues to be an important strategy of integrated delivery systems (IDSs). While HMO enrollment growth has continued, reaching almost 70 million people, average health plan profit margins have declined from 8 percent in 1994 to less than 1 percent in 1997. About 56 percent of HMOs lost money in 1998. The ability to successfully develop and operate a provider-owned HMO is affected by conditions inherent to the managed care industry, the level of cooperation among IDS business, units, and local market conditions.

The effect of intrathecal and epidural narcotic analgesia on the length of labor.

A number of studies have shown conflicting results on the effect of epidural (EPI) analgesia on the length of labor. Combined spinal-epidural (CSE) and intrathecal analgesia (ITA) techniques have been used to provide pain relief for parturients, but currently there are few studies comparing EPI, CSE, and ITA techniques and their effect on the length of labor. Intrathecal opioids provide immediate pain relief for the parturient without autonomic, sensory, or motor blockade. The purpose of this retrospective study is to identify the effects of ITA on the length of labor compared with other regional anesthesia techniques. A total of 213 uncomplicated obstetric charts were reviewed in a 70-bed Air Force hospital that provided EPI, CSE, and ITA for obstetrical patients. The study consisted of the following four groups: (1) CSE (n = 76), (2) EPI(n = 41), (3) ITA (n = 49), and (4) no regional analgesia (NR) (n = 47). The results showed that the length of first-stage labor was statistically significantly less for those who received ITA compared with those who received CSE, EPI, and NR (P < .001). Second-stage labor was statistically significantly shorter for the NR group compared with the CSE and EPI groups (P < .01). No statistically significant difference was found between the length of second stage for ITA and NR groups. ITA analgesia shortened the first stage significantly in both primipara and multipara patients (P < .01). These results imply that the use of intrathecal opioids in the obstetrical patient does not prolong labor and seems to shorten the first stage of labor in both the primipara and multipara patients.

A guide to understanding informed consent.

Anesthesia providers are expected to provide information to the patient during the preanesthesia interview that enables the patient to make informed choices. Adequate disclosure during the informed consent process ensures the equalization of the practitioner/patient relationship and the decision-making rights of the patient. Both certified registered nurse anesthetists (CRNAs) and anesthesiologists are not only legally required to provide information that will allow a patient to make an informed judgment about how to proceed with various anesthetic modalities but are also obligated by their standards of practice. This article informs the CRNA about the principles of informed consent so that they can better understand their role in the informed consent process.

AANA Journal course: new technologies in anesthesia: update for nurse anesthetists--high frequency ventilation.

The introduction of high frequency ventilation (HFV) to the clinical arena has offered patients with severe respiratory disease a method for adequate ventilation and oxygenation with improved hemodynamics and diminished lung barotrauma. The scientific community has been investigating for a number of years the mechanism of gas transport in the airways using high frequencies with tidal volumes approaching or less than anatomical dead space. Clinicians have been attempting to identify the clinical circumstances for which this new technology can be applied. This course will discuss some of these theoretical mechanisms responsible for gas transport during three types of HFV, and also present the high frequency ventilators which have been recently approved by the U.S. Food and Drug Administration and the clinical indications for use for each of them.

How much should hospitals spend on advertising?

Hospitals are using several methods to establish a budget for advertising. The Strategic Planning Institute of Cambridge, Massachusetts, has developed a study of advertising practices on nearly 200 corporations and over 1,000 individual businesses. Decision rules, developed in the study, are used to show how hospitals can use a more scientific approach to budgeting for advertising.