Postoperative costs associated with outcomes after cardiac surgery with extracorporeal circulation: role of antithrombin levels.

OBJECTIVE: To study the impact on postoperative costs of a patient's antithrombin levels associated with outcomes after cardiac surgery with extracorporeal circulation. DESIGN: An analytic decision model was designed to estimate costs and clinical outcomes after cardiac surgery in a typical patient with low antithrombin levels (<63.7%) compared with a patient with normal antithrombin levels (≥63.7%). The data used in the model were obtained from a literature review and subsequently validated by a panel of experts in cardiothoracic anesthesiology. SETTING: Multi-institutional (14 Spanish hospitals). PARTICIPANTS: Consultant anesthesiologists. MEASUREMENTS AND MAIN RESULTS: A sensitivity analysis of extreme scenarios was carried out to assess the impact of the major variables in the model results. The average cost per patient was €18,772 for a typical patient with low antithrombin levels and €13,881 for a typical patient with normal antithrombin levels. The difference in cost was due mainly to the longer hospital stay of a patient with low antithrombin levels compared with a patient with normal levels (13 v 10 days, respectively, representing a €4,596 higher cost) rather than to costs related to the management of postoperative complications (€215, mostly owing to transfusions). Sensitivity analysis showed a high variability range of approximately ±55% of the base case cost between the minimum and maximum scenarios, with the hospital stay contributing more significantly to the variation. CONCLUSIONS: Based on this analytic decision model, there could be a marked increase in the postoperative costs of patients with low antithrombin activity levels at the end of cardiac surgery, mainly ascribed to a longer hospitalization.

Does epidural versus combined spinal-epidural analgesia prolong labor and increase the risk of instrumental and cesarean delivery in nulliparous women?

STUDY OBJECTIVE: To compare duration of labor, mode of delivery, and local anesthetic consumed in women who received labor analgesia with epidural or combined spinal-epidural technique. DESIGN: Retrospective, observational study. SETTING: Delivery room of a university hospital. PATIENTS: 788 nulliparous women in labor at term with cervical dilation between three and 5 cm. INTERVENTIONS: In Group E (epidural alone), parturients received an epidural solution of 8 mL (levobupivacaine 0.125% with fentanyl 5 microg/mL). In Group CSE (combined spinal-epidural), parturients received a spinal injection of levobupivacaine two mg with fentanyl 15 microg (total volume two mL). Then an epidural catheter was placed in all patients and connected to a patient-controlled analgesia pump (basal infusion rate of 8 mL/hr of 0.1% levobupivacaine and fentanyl two microg/mL, patient-controlled bolus dose of three mL, and lockout time of 30 min). MEASUREMENTS: Labor duration, mode of delivery (spontaneous vaginal vs. instrumental delivery vs. cesarean section), and local anesthetic consumed, were recorded. MAIN RESULTS: Labor analgesia was performed with an epidural technique in 322 patients (40.9%), and a combined spinal-epidural technique in 466 patients (59.1%), of whom 39 Group E women (12.1%) and 46 Group CSE women (9.9%) required cesarean section (P=ns). No differences in the mode of delivery were observed between the groups. Time from analgesia to delivery (Group E: 217 +/- 111 min vs. Group CSE: 213 +/- 115 min; P=ns), and epidural local anesthetic consumed (Group E: 35 +/- 20 mL vs. Group CSE: 33 +/- 20 mL; P=ns), were similar in both groups. CONCLUSIONS: No significant differences were observed between epidural and combined spinal-epidural given for labor analgesia in nulliparous women in duration of labor, mode of delivery, or local anesthetic consumed.

Two unusual cases of urinary incontinence during continuous sciatic nerve block with stimulating catheters.

One of the advantages of lower extremity peripheral nerve blocks compared with neuroaxial Neuraxial techniques is the lack of effect on urinary function. We report two cases of urinary incontinence during continuous sciatic nerve block with stimulating catheters placed using the posterior gluteal Labat approach. The two patients were able to control micturition 6 h after the catheter was removed.

Low volume and high concentration of local anesthetic is more efficacious than high volume and low concentration in Labat's sciatic nerve block: a prospective, randomized comparison.

BACKGROUND: Various factors markedly affect the onset time and success rate, of peripheral nerve blockade. This prospective, randomized, double-blind study, compared a dose of mepivacaine 300 mg, in a 20 or 30 mL injection volume for sciatic nerve blockade using Labat's posterior approach. METHODS: A total of 90 patients undergoing foot surgery were randomly allocated to receive sciatic nerve block with 20 mL of 1.5% mepivacaine (n = 45) or 30 mL of 1% mepivacaine (n = 45). All blocks were performed with the use of a nerve stimulator (stimulation frequency 2 Hz; intensity 1.5-0.5 mA). In the two groups, appropriate nerve stimulation was elicited at <0.5 mA and the targeted evoked motor response was plantar flexion of the foot. Time required for onset of sensory and motor block in the distribution of the tibial and common peroneal nerves were recorded. A successful block was defined as a complete loss of pinprick sensation in the sciatic nerve distribution with concomitant inability to perform plantar or dorsal flexion of the foot. RESULTS: A greater success rate was observed with 20 mL of 1.5% mepivacaine (96.6%) than with 30 mL of 1% mepivacaine (68.9%; P < 0.05). Time to onset of complete sensory and motor block was shorter after injection of 20 mL of 1.5% mepivacaine (11 +/- 6 min and 13 +/- 7 min, respectively) than after 30 mL of 1% mepivacaine (17 +/- 8 min and 19 +/- 8 min, respectively, P < 0.05). CONCLUSION: In Labat's sciatic nerve blockade, administering a low volume and a high concentration of local anesthetic (1.5% mepivacaine) is associated with a higher success rate and a shorter onset time than a high volume and a low concentration of solution (1% mepivacaine).

A "new" automated bolus technique for continuous popliteal block: a prospective, randomized comparison with a continuous infusion technique.

BACKGROUND: We designed the present, prospective, randomized, double-blind study to compare the administration of an automated intermittent bolus dose with a conventional technique of continuous infusion of local anesthetic for postoperative analgesia in continuous popliteal sciatic nerve blockade. METHODS: Forty-four patients undergoing hallux valgus repair were randomly assigned to receive either a continuous infusion of 0.125% levobupivacaine with an infusion rate of 5 mL/h (continuous infusion group, n=22) or automated bolus doses of 5 mL every hour of the same local anesthetic (automated bolus group, n=22) for 24 h. Postoperative pain scores were assessed using a verbal rating pain score. The amount of rescue tramadol medication for pain was also recorded. RESULTS: In patients of the automated bolus group there was a reduction in pain scores (P<0.05) during the postoperative period, when compared to patients of the continuous infusion group. Five patients in the automated bolus group (24%) and 11 patients of the continuous group (52%) required rescue tramadol analgesia (P=0.055). CONCLUSION: The present investigation demonstrated that local anesthetic administered by an automated bolus technique provided better postoperative pain relief than a continuous infusion technique for continuous popliteal nerve block after foot surgery.

A prospective, randomized comparison between the popliteal and subgluteal approaches for continuous sciatic nerve block with stimulating catheters.

In this prospective, blinded study, we randomized 56 patients undergoing hallux valgus repair to receive continuous sciatic nerve block using a subgluteal (n = 28) or a posterior popliteal approach (n = 28) with a perineural stimulating catheter. Postoperatively, the stimulating catheter was connected to a patient-controlled analgesia pump with 0.0625% levobupivacaine (basal infusion rate of 3 mL/h, patient-controlled bolus dose of 3 mL, and lockout time of 20 min). Both approaches provided similar postoperative analgesia; however, local anesthetic consumption was larger in the popliteal group (4.9 +/- 1.4 mL/h) compared with the subgluteal group (3.8 +/- 1.1 mL/h; P < 0.05). We conclude continuous postoperative analgesia using stimulating catheters was effective at both injection sites; however, a subgluteal approach reduced the overall amount of local anesthetic.

A comparison of stimulation patterns in axillary block: part 2.

BACKGROUND AND OBJECTIVES: Radial plus musculocutaneous nerve stimulation may have a predominant role in the success of an axillary block, producing more extensive anesthesia of the upper limb than median plus musculocutaneous nerve stimulation. However, no comparison has been made with ulnar plus musculocutaneous nerve stimulation. We compared the extent of both sensory and motor block after ulnar plus musculocutaneous nerve stimulation or radial plus musculocutaneous nerve stimulation. METHODS: Sixty patients were randomly assigned to receive an axillary block using either radial plus musculocutaneous or ulnar plus musculocutaneous nerve stimulation with 40 mL plain 1.5% mepivacaine. Patients were assessed for sensory block by the pinprick method at 5 and 20 minutes. RESULTS: No statistically significant differences were found in the rates of anesthesia at 20 minutes in the cutaneous nerve distributions of the upper limb between radial plus musculocutaneous and ulnar plus musculocutaneous nerve stimulation except for the following nerves: radial (90% and 63.3%, respectively), medial cutaneous of the forearm (83.3% and 100%, respectively), and medial cutaneous of the arm (73.3% and 93.3%, respectively). Global sensory score (minimum: 0; maximum: 12 points) at 20 minutes was significantly higher after radial plus musculocutaneous than after ulnar plus musculocutaneous nerve stimulation: 12 (11-13) and 11 (10-12), respectively. The rates of median nerve blockade were 50% and 53%, respectively. CONCLUSIONS: Radial plus musculocutaneous nerve stimulation produced more extensive anesthesia of the upper limb than did ulnar plus musculocutaneous nerve stimulation. However, there is not an optimal combination of 2 responses in axillary brachial plexus block.

What is the minimum effective volume of local anesthetic required for sciatic nerve blockade? A prospective, randomized comparison between a popliteal and a subgluteal approach.

For sciatic nerve blockade, no study has defined the optimal volume of local anesthetic required to block the nerve. The current, prospective, randomized investigation was designed to find a minimum volume of 1.5% mepivacaine required to block the sciatic nerve using the subgluteal and posterior popliteal approaches. A total of 56 patients undergoing foot surgery were randomly assigned to receive sciatic nerve block by means of a posterior subgluteal (group subgluteal, n = 28) or a posterior popliteal (group popliteal, n = 28) approaches. All blocks were performed with the use a nerve stimulator (stimulating frequency, 2 Hz, intensity 1.5-0.5 mA) and a perineural stimulating catheter. In all patients, plantar flexion of the foot was elicited at <0.5 mA, to maintain consistency among groups. The volume of local anesthetic used in each patient was based on the modified Dixon's up-and-down method. Complete anesthesia was defined as complete loss of pinprick sensation in the sciatic nerve distribution with concomitant inability to perform plantar or dorsal flexion of the foot 20 min after injection. The mean volume of local anesthetic required to block the sciatic nerve was 12 +/- 3 mL in the subgluteal group and 20 +/- 3 mL in the popliteal group (P < 0.05). The ED95 for adequate block of the sciatic nerve was 17 mL in the subgluteal group and 30 mL in the popliteal group. The authors conclude that a larger volume of local anesthetic is necessary to block the sciatic nerve at a more distal site (popliteal approach) as compared with a more proximal level (subgluteal approach).

Diseño de una vía clínica para el tratamiento quirúrgico del carcinoma gástrico a partir del análisis del proceso / Design of a clinical pathway for the surgical treatment of gastric cancer based on an analysis of the process

Introducción: Las vías clínicas son herramientas de gran utilidad para la sistematización y la mejora de los procesos asistenciales. Se presenta la metodología para la gestión del proceso asistencial en el tratamiento quirúrgico del cáncer gástrico mediante la evaluación previa del proceso y el desarrollo de una vía clínica. Material y método: Estudio descriptivo, retrospectivo y transversal. Se revisaron las historias clínicas de los pacientes intervenidos por adenocarcinoma gástrico durante el período 1998-2000. Se analizaron las características clínicas, la calidad científico-técnica, la efectividad clínica y el consumo de recursos. Toda esta información, junto con la revisión bibliográfica sobre el tema, se utilizó para diseñar una vía clínica para la mejora del proceso. Resultados: Los puntos fuertes fueron: intervalo correcto entre el diagnóstico y el tratamiento quirúrgico (mediana, 27 días), baja tasa de complicaciones mayores (18,1%) y mortalidad (1,8%). Las áreas susceptibles de mejora fueron: valoración anestésica ambulatoria (23,5%), estancia media hospitalaria (mediana, 21 días), obtención del consentimiento informado (53,5%), cumplimiento del protocolo de profilaxis antibiótica (62,5%) y tromboembólica (78,5%), consumo de antibióticos (55,3%) y nutrición parenteral (96,4%), realización de tomografía computarizada abdominal preoperatoria (83,9%), número insuficiente de ganglios aislados (mediana, 14), índice de transfusiones (61,8%) y aplicación de una encuesta de satisfacción. Con toda esta información se diseñaron los documentos de la vía clínica y se definieron indicadores y estándares de calidad adaptados a la realidad de la unidad quirúrgica

Introduction: Clinical pathways are highly useful tools for the systematization and improvement of clinical processes. We present the methodology for the management of the surgical treatment of gastric cancer, through a prior analysis of the process and design of a clinical pathway. Material and method: A descriptive, retrospective, cross sectional study was performed. The medical records of patients who underwent surgery for gastric adenocarcinoma from 1998-2000 were reviewed. Clinical characteristics, scientific-technical quality, clinical effectiveness, and resource use were analyzed. All this information, together with a review of the literature on the topic, was used to design a clinical pathway to improve the process. Results: The following strengths were identified: appropriate interval between diagnosis and surgical treatment (median 27 days), low index of major complications (18.1%) and mortality (1.8%). Areas requiring improvement were outpatient anesthetic evaluation (23.5%), mean length of hospital stay (median 21 days), obtaining of informed consent (53.5%), application of thromboembolic (78.5%) and antibiotic prophylactic protocols (62.5%), use of antibiotic (55.3%) and parenteral nutrition (96.4%), performance of preoperative abdominal computed tomography (83.9%), insufficient number of isolated nodes (median 14), transfusion rate (61.8%), and application of the patient satisfaction survey. The above information was used to design the clinical pathway documents and define the quality indicators and standards according to the real situation of the surgical unit

An unusual expression of hyperplastic gastropathy (Menetrier type) in twins.

Menetrier's disease is an uncommon condition of unknown aetiology. We describe two cases of male identical twins with haematemesis aged 29 and 35 years that exhibited a similar and particular form of this hyperplastic gastropathy. Their stomachs showed confluent polypoid mucosal projections affecting mainly the gastric fundus and the antrum. To the best of our knowledge, only four previous cases have been reported in a familial setting, and this is the first documented example of an occurrence in twins. These two cases suggest the possibility of a genetic predisposition for this condition.