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1.
J Clin Anesth ; 53: 56-63, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30326379

RESUMO

STUDY OBJECTIVE: Intravenous patient-controlled opioid analgesia (IVPCA), epidural analgesia and transversus abdominis plane (TAP) infiltrations are frequently used postoperative pain management modalities. The aim of this study was to conduct a cost-effectiveness analysis comparing the use of epidural, IVPCA, and TAP infiltrations with liposomal bupivacaine for analgesia in the first 72 h postoperatively in patients undergoing major lower abdominal surgery. DESIGN: Retrospective cost effectiveness analysis. SETTING: Operating room. PATIENTS: We obtained data on major lower-abdominal surgeries performed under general anesthesia on adult patients between January 2012 and July 2014. INTERVENTIONS: A cost-effectiveness analysis was comparing the use of epidural, IVPCA, and TAP infiltrations with liposomal bupivacaine for analgesia in the first 72 h postoperatively. MEASUREMENTS: A decision analytic model was used to estimate the health outcomes for patients undergoing major lower abdominal surgery. The primary outcome was time-weighted pain from 0 to 72 h after surgery, as measured by numerical rating scale pain scores. The analysis was conducted from the perspective of the hospital as the party responsible for most costs related to surgery. MAIN RESULTS: From the base case analysis, IVPCA was the optimal strategy regarding cost and effect. TAP with LB, however, was only narrowly dominated, while epidural was clearly dominated. From the sensitivity analysis at willingness-to-pay (WTP) of $150, IV PCA and TAP infiltration were each the optimal strategy for approximately 50% of the iterations. At WTP of $10,000, epidural was only the optimal strategy in 10% of the iterations. CONCLUSIONS: This is the first study in the literature to compare the cost-effectiveness of epidural, IVPCA, and TAP infiltrations with LB. Within reasonable WTP values, there is little differentiation in cost-effectiveness between IVPCA and TAP infiltration with LB. Epidural does not become a cost-effective strategy even at much higher WTP values.


Assuntos
Analgesia Epidural/economia , Analgesia Controlada pelo Paciente/economia , Analgésicos Opioides/economia , Bupivacaína/economia , Bloqueio Nervoso/economia , Dor Pós-Operatória/terapia , Músculos Abdominais/inervação , Adulto , Idoso , Analgesia Epidural/métodos , Analgesia Controlada pelo Paciente/métodos , Analgésicos Opioides/administração & dosagem , Bupivacaína/administração & dosagem , Análise Custo-Benefício , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Econômicos , Bloqueio Nervoso/métodos , Manejo da Dor/economia , Manejo da Dor/métodos , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Estudos Retrospectivos , Resultado do Tratamento
2.
Am J Surg ; 217(3): 520-524, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30473226

RESUMO

BACKGROUND: Thoracic Epidural has long been the most recommended treatment for postoperative pain management in general thoracic surgery. This study compares liposomal bupivacaine (LB) as an alternative method for pain control and compares it to the standard. METHODS: LB was compared to thoracic epidural bupivacaine hydrochloride (TE BH) in 387 patients who underwent video-assisted thoracoscopic pulmonary resection (VATS-R) at our institution. Patients received either continuous TE BH or intraoperative LB at a predetermined dose. A total of 237 patients received TE BH from April 2010 to March 2014 and 143 patients received LB from April 2014 to March 2016. After propensity matching, 95 patients in each group had similar demographics and clinical characteristics including gender, age, race, American Society of Anesthesia (ASA) classification, Zubrod scores, and FEV1 and DLCO percent predicted measurements. Outcome measures included hospital costs, length of stay (LOS), adverse events, postoperative opioid medication use, and pain scores. RESULTS: Compared to the TE BH group, the LB group had significantly lower pain scores (average visual analogue scale the day of surgery: 3.9 versus 4.5, p < 0.05), decreased postoperative opioid medication (morphine equivalent dose during the first 3 days: 344.5 versus 269.5, p < 0.05), and lower total and direct hospital costs ($2906 and $1865 respectively, p < 0.05). Although a shorter LOS in the LB group was not statistically significant (4.3 versus 5.1 days, p = 0.156), more patients in the LB group were discharged directly home than the control group (44.2% versus 28.4%, p < 0.05). There was no difference noted in overall adverse events including 30-day readmissions between the two groups. CONCLUSION: LB is a viable alternative for pain management in patients undergoing VATS-R. With recent scrutiny on healthcare costs and the opioid epidemic, these results are encouraging and should be further investigated.


Assuntos
Analgesia Epidural/economia , Anestésicos Locais/economia , Bupivacaína/uso terapêutico , Preparações de Ação Retardada/economia , Pneumopatias/cirurgia , Manejo da Dor/economia , Dor Pós-Operatória/prevenção & controle , Cirurgia Torácica Vídeoassistida , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Lipossomos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Estudos Retrospectivos
3.
PLoS One ; 13(10): e0205220, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30307986

RESUMO

OBJECTIVE: To compare the costs of a strategy of patient controlled remifentanil versus epidural analgesia for pain relief in labour. DESIGN: We performed a multicentre randomised controlled trial in 15 hospitals in the Netherlands, the RAVEL trial. Costs were analysed from a health care perspective alongside the RAVEL trial. POPULATION: Pregnant women of intermediate to high risk beyond 32 weeks gestation who planned vaginal delivery. METHODS: Women were randomised before the onset of labour, to receive either patient controlled remifentanil or epidural analgesia when pain relief was requested during labour. MAIN OUTCOME MEASURES: Primary outcome for effectiveness was satisfaction with pain relief, expressed as the area under the curve (AUC). A higher AUC represents higher satisfaction with pain relief. Here, we present an economic analysis from a health care perspective including costs from the start of labour to ten days postpartum. Health-care utilization was documented in the Case Report Forms and by administering an additional questionnaire. RESULTS: The costs in the patient controlled remifentanil group (n = 687) and in the epidural group (n = 671) were €2900 versus €3185 respectively (mean difference of -€282 (95% CI -€611 to €47)). The (non-significant) higher costs in the epidural analgesia group could be mainly attributed to higher costs of neonatal admission. CONCLUSION: From an economic perspective, there is no preferential pain treatment in labouring intermediate to high risk women. Since patient controlled remifentanil is not equivalent to epidural analgesia with respect to AUC for satisfaction with pain relief we recommend epidural analgesia as the method of choice. However, if appropriately counselled on effect and side effects there is, from an economic perspective, no reason to deny women patient controlled remifentanil.


Assuntos
Analgesia Epidural/economia , Analgesia Obstétrica/economia , Analgesia Controlada pelo Paciente/economia , Análise Custo-Benefício , Dor do Parto/tratamento farmacológico , Adolescente , Adulto , Analgesia Epidural/métodos , Analgesia Obstétrica/métodos , Analgesia Controlada pelo Paciente/métodos , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/economia , Anestesistas/economia , Área Sob a Curva , Feminino , Custos de Cuidados de Saúde , Humanos , Dor do Parto/diagnóstico , Dor do Parto/economia , Países Baixos , Manejo da Dor/economia , Manejo da Dor/métodos , Medição da Dor , Satisfação do Paciente , Gravidez , Remifentanil/administração & dosagem , Remifentanil/economia , Adulto Jovem
4.
Dis Colon Rectum ; 61(10): 1196-1204, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30192328

RESUMO

BACKGROUND: Multimodal pain management is an integral part of enhanced recovery pathways. The most effective pain management strategies have not been determined. OBJECTIVE: The purpose of this study was to compare liposomal bupivacaine transversus abdominis plane block with epidural analgesia in patients undergoing colorectal surgery. DESIGN: This is a single-institution, open-label randomized (1:1) trial. SETTING: This study compared liposomal bupivacaine transversus abdominis plane block with epidural analgesia in patients undergoing elective open and minimally invasive colorectal surgery in an enhanced recovery pathway. PATIENTS: Two hundred were enrolled. Following randomization, allocation, and follow-up, there were 92 patients with transversus abdominis plane block and 87 patients with epidural analgesia available for analysis. INTERVENTIONS: The interventions comprised liposomal bupivacaine transversus abdominis plane block versus epidural analgesia. MAIN OUTCOME MEASURES: The primary outcomes measured were numeric pain scores and the overall benefit of analgesia scores. RESULTS: There were no significant differences in the Numeric Pain Scale and Overall Benefit of Analgesia Score between groups. Time trend analysis revealed that patients with transversus abdominis plane block had higher numeric pain scores on the day of surgery, but that the relationship was reversed later in the postoperative period. Opioid use was significantly less in the transversus abdominis plane block group (206.84 mg vs 98.29 mg, p < 0.001). There were no significant differences in time to GI recovery, hospital length of stay, and postoperative complications. Cost was considerably more for the epidural analgesia group. LIMITATIONS: This study was conducted at a single institution. CONCLUSIONS: This randomized trial shows that perioperative pain management with liposomal bupivacaine transversus abdominis plane block is as effective as epidural analgesia and is associated with less opioid use and less cost. These data and the more favorable risk profile suggest that liposomal bupivacaine transversus abdominis plane block is a viable multimodal perioperative pain management option for this patient population in an established enhanced recovery pathway. CLINICAL TRIAL REGISTRATION: http://www.clinicaltrials.gov (NCT02591407). See Video Abstract at http://links.lww.com/DCR/A737.


Assuntos
Músculos Abdominais/efeitos dos fármacos , Analgesia Epidural/métodos , Bupivacaína/farmacologia , Colo/cirurgia , Cirurgia Colorretal/normas , Bloqueio Nervoso/métodos , Dor Pós-Operatória/tratamento farmacológico , Músculos Abdominais/inervação , Músculos Abdominais/fisiopatologia , Adulto , Analgesia Epidural/economia , Analgesia Epidural/estatística & dados numéricos , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/uso terapêutico , Anestésicos Locais/administração & dosagem , Anestésicos Locais/farmacologia , Bupivacaína/administração & dosagem , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Manejo da Dor/métodos , Manejo da Dor/normas , Medição da Dor/métodos , Assistência Perioperatória/normas , Período Pós-Operatório
5.
J Med Econ ; 21(1): 11-18, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28828882

RESUMO

AIMS: To estimate the cost to hospitals of materials (i.e. medications, equipment, and supplies) required to administer common interventions for post-surgical analgesia after total knee arthroplasty (TKA), including single-injection peripheral nerve block (sPNB), continuous peripheral nerve block (cPNB), periarticular infiltration of multi-drug cocktails, continuous epidural analgesia, intravenous patient-controlled analgesia (IV PCA), and local infiltration of bupivacaine liposome injectable suspension (BLIS). MATERIALS AND METHODS: This analysis was conducted using a mixed methods approach combining published literature, publicly available data sources, and administrative data, to first identify the materials required to administer these interventions, and then estimate the cost to the hospital of those materials. Medication costs were estimated primarily using the Wholesale Acquisition Costs (WAC), the cost of reusable equipment was obtained from published sources, and costs for disposable supplies were obtained from the US Government Services Administration (GSA) database. Where uncertainty existed about the technique used when administering these interventions, costs were calculated for multiple scenarios reflecting different assumptions. RESULTS: The total cost of materials (i.e. medications, equipment, and supplies) required to provide post-surgical analgesia was $41.88 for sPNB with bupivacaine; $756.57 for cFNB with ropivacaine; $16.38 for periarticular infiltration with bupivacaine, morphine, methylprednisolone, and cefuroxime; $453.84 for continuous epidural analgesia with fentanyl and ropivacaine; $178.94 for IV PCA with morphine; and $319.00 for BLIS. LIMITATIONS: This analysis did not consider the cost of healthcare providers required to administer these interventions. In addition, this analysis focused on the cost of materials and, therefore, did not consider aspects of relative efficacy or safety, or how the choice of intervention for post-surgical analgesia might impact outcomes such as length of stay, re-admissions, discharge status, adverse events, or total hospitalization costs. CONCLUSIONS: This study provided an estimate of the costs to hospitals for materials required to administer commonly used interventions for post-surgical analgesia after TKA.


Assuntos
Analgesia Controlada pelo Paciente/economia , Analgésicos Opioides/economia , Artroplastia do Joelho/métodos , Custos Hospitalares , Dor Pós-Operatória/tratamento farmacológico , Idoso , Analgesia/economia , Analgesia/métodos , Analgesia Epidural/economia , Analgesia Epidural/métodos , Analgesia Controlada pelo Paciente/métodos , Analgésicos Opioides/uso terapêutico , Artroplastia do Joelho/efeitos adversos , Estudos de Coortes , Análise Custo-Benefício , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Bloqueio Nervoso/economia , Bloqueio Nervoso/métodos , Manejo da Dor/economia , Manejo da Dor/métodos , Medição da Dor , Dor Pós-Operatória/fisiopatologia , Estudos Retrospectivos , Medição de Risco , Estados Unidos
6.
Pain Med ; 19(1): 160-168, 2018 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-28340013

RESUMO

Objective: Rib fractures are present in more than 150,000 patients admitted to US trauma centers each year. Those who fracture two or more ribs are typically treated with oral analgesic drugs and are discharged with few complications. The cost of this care generally reflects its brevity. When a patient fractures three or more ribs, there is an elevated risk of complication. In response, treatments are often broadened and their durations prolonged; this affects cost. While health, function, and survival have been widely explored, patient billing has not. Thus, we evaluated the financial implications of one mode of treatment for patients with rib fractures: thoracic epidural analgesia (TEA). Methods: We retrospectively analyzed the registry of a level II trauma center. All patients who fractured one or more ribs (n = 1,344) were considered; 382 of those patients were not candidates for epidural placement and were eliminated from analyses. Epidural placement was determined by individual clinicians. We used multiple linear regressions to determine predictors of cost. Results: After eliminating patients who were not eligible to receive TEA, the average patient bill was $59,123 ($10,631 per day of treatment). The administration of TEA predicted a 25% reduction in total billing (99% CI = -$21,429.55- -$7,794.66) and a 24% reduction in per-day billing (99% CI = -$3,745.99- -$1,276.14). Conclusions: Patients who received TEA were more severely injured and required longer treatments; controlling for these variables, the use of TEA associated with reductions in the cost of receiving care. From an administrative and insurance perspective, more frequent reliance on TEA may be indicated.


Assuntos
Analgesia Epidural/economia , Preços Hospitalares/estatística & dados numéricos , Manejo da Dor/economia , Fraturas das Costelas/complicações , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Analgesia Epidural/métodos , Analgésicos/economia , Analgésicos/uso terapêutico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dor/tratamento farmacológico , Dor/etiologia , Manejo da Dor/métodos , Estudos Retrospectivos , Vértebras Torácicas , Adulto Jovem
7.
Eur J Obstet Gynecol Reprod Biol ; 207: 23-31, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27816738

RESUMO

OBJECTIVE: To assess the cost-effectiveness of routine labour epidural analgesia (EA), from a societal perspective, as compared with labour analgesia on request. STUDY DESIGN: Women delivering of a singleton in cephalic presentation beyond 36+0 weeks' gestation were randomly allocated to routine labour EA or analgesia on request in one university and one non-university teaching hospital in the Netherlands. Costs included all medical, non-medical and indirect costs from randomisation to 6 weeks postpartum. Effectiveness was defined as a non-operative, spontaneous vaginal delivery without EA-related maternal adverse effects. Incremental cost-effectiveness ratio (ICER) was defined as the ratio of the difference in costs and the difference in effectiveness between both groups. Data were analysed according to intention to treat and divided into a base case analysis and a sensitivity analysis. RESULTS: Total delivery costs in the routine EA group (n=233) were higher than in the labour on request group (n=255) (difference -€ 322, 95% CI -€ 60 to € 355) due to more medication costs (including EA), a longer stay in the labour ward, and more operations including caesarean sections. Total postpartum hospital costs in the routine EA group were lower (difference -€ 344, 95% CI -€ 1338 to € 621) mainly due to less neonatal admissions (difference -€ 472, 95% CI -€ 1297 to € 331), whereas total postpartum home and others costs were comparable (difference -€ 20, 95% CI -€ 267 to € 248, and -€ 1, 95% CI -€ 67 to € 284, respectively). As a result, the overall mean costs per woman were comparable between the routine EA group and the analgesia on request group (€ 8.708 and € 8.710, respectively, mean difference -€ 2, 95% CI -€ 1.012 to € 916). Routine labour EA resulted in more deliveries with maternal adverse effects, nevertheless the ICER remained low (€ 8; bootstrap 95% CI -€ 6.120 to € 8.659). The cost-effectiveness acceptability curve indicated a low probability that routine EA is cost-effective. CONCLUSION: Routine labour EA generates comparable costs as analgesia on request, but results in more operative deliveries and more EA-related maternal adverse effects. Based on cost-effectiveness, no preference can be given to routine labour EA as compared with analgesia on request.


Assuntos
Analgesia Epidural/efeitos adversos , Analgesia Obstétrica/efeitos adversos , Doenças do Recém-Nascido/prevenção & controle , Trabalho de Parto , Complicações do Trabalho de Parto/prevenção & controle , Preferência do Paciente , Adulto , Analgesia Epidural/economia , Analgesia Obstétrica/economia , Cesárea/efeitos adversos , Cesárea/economia , Efeitos Psicossociais da Doença , Análise Custo-Benefício , Feminino , Gastos em Saúde , Custos Hospitalares , Hospitais de Ensino , Hospitais Universitários , Humanos , Recém-Nascido , Doenças do Recém-Nascido/economia , Doenças do Recém-Nascido/epidemiologia , Doenças do Recém-Nascido/terapia , Trabalho de Parto/efeitos dos fármacos , Tempo de Internação , Masculino , Países Baixos/epidemiologia , Complicações do Trabalho de Parto/economia , Complicações do Trabalho de Parto/epidemiologia , Complicações do Trabalho de Parto/terapia , Unidade Hospitalar de Ginecologia e Obstetrícia , Gravidez , Estudos Retrospectivos , Risco , Nascimento a Termo/efeitos dos fármacos
8.
Anesth Analg ; 123(6): 1591-1602, 2016 12.
Artigo em Inglês | MEDLINE | ID: mdl-27870743

RESUMO

BACKGROUND: The aim of this review was to compare the effects of postoperative epidural analgesia with local anesthetics to postoperative systemic or epidural opioids in terms of return of gastrointestinal transit, postoperative pain control, postoperative vomiting, incidence of gastrointestinal anastomotic leak, hospital length of stay, and cost after abdominal surgery. METHODS: Trials were identified by computerized searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 12), Medical Literature Analysis and Retrieval System Online (MEDLINE) (from 1950 to December, 2014) and Excerpta Medica dataBASE (EMBASE) (from 1974 to December 2014) and by checking the reference lists of trials retained. We included parallel randomized controlled trials comparing the effects of postoperative epidural local anesthetic with regimens based on systemic or epidural opioids. The quality of the studies was rated according to the Cochrane tool. Two authors independently extracted data. We judged the quality of evidence according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) working group scale. RESULTS: Based on 22 trials including 1138 participants, an epidural containing a local anesthetic will decrease the time required for return of gastrointestinal transit as measured by time required to observe the first flatus after an abdominal surgery standardized mean difference (SMD) -1.28 (95% confidence interval [CI], -1.71 to -0.86; high quality of evidence; equivalent to 17.5 hours). The effect is proportional to the concentration of local anesthetic used. Based on 28 trials including 1559 participants, we also found a decrease in time to first feces (stool): SMD -0.67 (95% CI, -0.86 to -0.47; low quality of evidence; equivalent to 22 hours). Based on 35 trials including 2731 participants, pain on movement at 24 hours after surgery is also reduced: SMD -0.89 (95% CI, -1.08 to -0.70; moderate quality of evidence; equivalent to 2.5 on a scale from 0 to 10). Based on 22 trials including 1154 participants, we did not find a difference in the incidence of vomiting within 24 hours: risk ratio 0.84 (95% CI, 0.57-1.23); low quality of evidence. Based on 17 trials including 848 participants we did not find a difference in the incidence of gastrointestinal anastomotic leak: risk ratio 0.74 (95% CI, 0.41-1.32; low quality of evidence). Based on 30 trials including 2598 participants, epidural analgesia reduces length of hospital stay for an open surgery: SMD -0.20 (95% CI, -0.35 to -0.04; very low quality of evidence; equivalent to 1 day). Data on cost were very limited. CONCLUSIONS: An epidural containing a local anesthetic, with or without the addition of an opioid, accelerates the return of the gastrointestinal transit (high quality of evidence). An epidural containing a local anesthetic with an opioid decreases pain after an abdominal surgery (moderate quality of evidence). An epidural containing a local anesthetic does not affect the incidence of vomiting or anastomotic leak (low quality of evidence). For an open surgery, an epidural containing a local anesthetic would reduce the length of hospital stay (very low quality of evidence).


Assuntos
Abdome/cirurgia , Analgesia Epidural/métodos , Analgésicos Opioides/administração & dosagem , Anestésicos Locais/administração & dosagem , Motilidade Gastrointestinal/efeitos dos fármacos , Pseudo-Obstrução Intestinal/etiologia , Laparoscopia/efeitos adversos , Laparotomia/efeitos adversos , Dor Pós-Operatória/prevenção & controle , Náusea e Vômito Pós-Operatórios/etiologia , Analgesia Epidural/efeitos adversos , Analgesia Epidural/economia , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/economia , Fístula Anastomótica/etiologia , Anestésicos Locais/efeitos adversos , Anestésicos Locais/economia , Distribuição de Qui-Quadrado , Defecação/efeitos dos fármacos , Custos de Medicamentos , Custos Hospitalares , Humanos , Pseudo-Obstrução Intestinal/economia , Pseudo-Obstrução Intestinal/fisiopatologia , Laparoscopia/economia , Laparotomia/economia , Tempo de Internação , Razão de Chances , Dor Pós-Operatória/economia , Dor Pós-Operatória/etiologia , Náusea e Vômito Pós-Operatórios/economia , Náusea e Vômito Pós-Operatórios/fisiopatologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Recuperação de Função Fisiológica , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
9.
J Pediatr Surg ; 51(1): 149-53, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26577910

RESUMO

PURPOSE: Management of postoperative pain following repair of pectus excavatum has traditionally included thoracic epidural analgesia, narcotics, and benzodiazepines. We hypothesized that the use of intercostal or paravertebral regional blocks could result in decreased inpatient length of stay (LOS). METHODS: We conducted a retrospective cohort study of 137 patients (118 Nuss and 19 Ravitch - Nuss and Ravitch patients were analyzed separately) who underwent surgical repair of pectus excavatum with pain management via epidural, intercostal, or paravertebral analgesia from January 2009-December 2012. Measured outcomes included LOS, pain scores, benzodiazepine/narcotic requirements, emesis, professional fees, hospital cost, and total cost. RESULTS: In the Nuss patients, LOS was significantly reduced in the paravertebral group (p<0.005) and the intercostal group (p<0.005) compared to the epidural group, but was paradoxically countered by a nonsignificant increase in total cost (p=0.09). While benzodiazepine doses/day was not increased in the paravertebral group (p=0.08), an increase was seen in narcotic use (p<0.005). Despite increased narcotic use, no differences were seen in emesis between epidural and paravertebral use. Compared to epidural, pain scores were higher for both intercostal and paravertebral on day one (p<0.005), but equivalent for paravertebral on day three (p=0.62). The Ravitch group was too small for detailed independent statistical analysis but followed the same overall trend seen in the Nuss patients. CONCLUSION: Our use of paravertebral continuous infusion pain catheters for pectus excavatum repair was an effective alternative to epidural analgesia resulting in shorter LOS but not a decrease in overall cost.


Assuntos
Analgesia Epidural , Tórax em Funil/cirurgia , Tempo de Internação , Bloqueio Nervoso/métodos , Dor Pós-Operatória/prevenção & controle , Analgesia Epidural/economia , Analgésicos/administração & dosagem , Analgésicos Opioides/administração & dosagem , Benzodiazepinas/administração & dosagem , Cateteres , Criança , Humanos , Infusões Intravenosas , Bloqueio Nervoso/economia , Estudos Retrospectivos
10.
Tech Coloproctol ; 19(9): 515-20, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26188986

RESUMO

PURPOSE: The aim of this study was to compare short-term outcomes between epidural analgesia and conventional intravenous analgesia for patients undergoing laparoscopic colectomy. This paper uses a large national database to add a current perspective on trends in analgesia and the outcomes associated with two analgesia options. Our evidence augments the opinions of recent randomized controlled trials. METHODS: The University HealthSystem Consortium, an alliance of more than 300 academic and affiliate institutions, was reviewed for the time period of October 2008 through September 2014. International Classification of Disease 9th Clinical Modification codes for laparoscopic colectomy and epidural catheter placement were used. RESULTS: A total of 29,429 patients met our criteria and underwent laparoscopic colectomy during the study period. One hundred and ten (0.374%) patients had an epidural catheter placed for analgesia. Baseline patient demographics were similar for the epidural and conventional analgesia groups. Total charges were significantly higher in the epidural group ($52,998 vs. $39,277; p < 0.001). Median length of stay was longer in the epidural group (6 vs. 5 days; p < 0.001). There was no statistical difference between the epidural and conventional analgesia groups in death (0 vs. 0.03%; p = 0.999), urinary tract infection (0 vs. 0.1%; p = 0.999), ileus (11.8 vs. 13.6%; p = 0.582), or readmission rate (9.1 vs. 9.3%; p = 0.942). CONCLUSION: Compared to conventional analgesic techniques, epidural analgesia does not reduce the rate of postoperative ileus, and it is associated with increased cost and increased length of stay. Based on our data, routine use of epidural analgesia for laparoscopic colectomy cannot be justified.


Assuntos
Administração Intravenosa/estatística & dados numéricos , Analgesia Epidural/estatística & dados numéricos , Analgésicos/administração & dosagem , Colectomia/estatística & dados numéricos , Manejo da Dor/métodos , Administração Intravenosa/efeitos adversos , Administração Intravenosa/economia , Adulto , Idoso , Analgesia Epidural/efeitos adversos , Analgesia Epidural/economia , Colectomia/métodos , Feminino , Preços Hospitalares/estatística & dados numéricos , Humanos , Íleus/epidemiologia , Íleus/etiologia , Laparoscopia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Manejo da Dor/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Resultado do Tratamento
11.
HPB (Oxford) ; 17(6): 551-8, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25728855

RESUMO

BACKGROUND: In spite of limited evidence demonstrating a benefit, epidural analgesia (EA) is often used for patients undergoing a pancreatectomy. In the present study, the impact of epidural analgesia on post-operative outcomes after a pancreatectomy is examined. METHODS: Utilizing the Nationwide Inpatient Sample, the effect of EA on peri-operative outcomes after a pancreatectomy was examined. Multivariable logistic and linear regression with propensity score matching were utilized for risk adjustment. RESULTS: From 2008-2011, 12,440 patients underwent a pancreatectomy. Of these, 1130 (9.1%) patients received epidural analgesia. Using univariate comparison, patients receiving EA had a significantly decreased length of stay (LOS), hospital charges and post-operative inpatient mortality. In multivariate analyses, EA was independently associated with a decreased post-operative LOS (adjusted mean difference = -1.19 days, P < 0.001), decreased hospital charges (adjusted mean difference = -$16,814, P = 0.002) and decreased post-operative inpatient mortality [adjusted odds ratio (OR) = 0.42, P < 0.001]. Using 1:1 propensity score matching, patients who received an EA (n = 1070) had significantly decreased post-operative LOS (11.0 versus 12.1 days, P = 0.011), lower hospital charges ($112,086 versus $128,939, P = 0.001) and decreased post-operative inpatient mortality (1.5% versus 3.6%, P = 0.002) compared with matched controls without EA (n = 1070). CONCLUSION: Analysis of a large hospital database reveals that EA is associated with improved peri-operative outcomes after a pancreatectomy. Additional studies are required to understand fully if this relationship is causal.


Assuntos
Analgesia Epidural , Pancreatectomia , Complicações Pós-Operatórias/prevenção & controle , Idoso , Analgesia Epidural/efeitos adversos , Analgesia Epidural/economia , Analgesia Epidural/mortalidade , Distribuição de Qui-Quadrado , Redução de Custos , Bases de Dados Factuais , Feminino , Custos Hospitalares , Mortalidade Hospitalar , Humanos , Tempo de Internação , Modelos Lineares , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Pancreatectomia/efeitos adversos , Pancreatectomia/economia , Pancreatectomia/mortalidade , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/mortalidade , Pontuação de Propensão , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
12.
J Obstet Gynaecol Res ; 41(7): 1023-31, 2015 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-25771920

RESUMO

AIM: Neuraxial blockade (epidural or spinal anesthesia/analgesia) with external cephalic version increases the external cephalic version success rate. Hospitals and insurers may affect access to neuraxial blockade for external cephalic version, but the costs to these institutions remain largely unstudied. The objective of this study was to perform a cost analysis of neuraxial blockade use during external cephalic version from hospital and insurance payer perspectives. Secondarily, we estimated the effect of neuraxial blockade on cesarean delivery rates. METHODS: A decision-analysis model was developed using costs and probabilities occurring prenatally through the delivery hospital admission. Model inputs were derived from the literature, national databases, and local supply costs. Univariate and bivariate sensitivity analyses and Monte Carlo simulations were performed to assess model robustness. RESULTS: Neuraxial blockade was cost saving to both hospitals ($30 per delivery) and insurers ($539 per delivery) using baseline estimates. From both perspectives, however, the model was sensitive to multiple variables. Monte Carlo simulation indicated neuraxial blockade to be more costly in approximately 50% of scenarios. The model demonstrated that routine use of neuraxial blockade during external cephalic version, compared to no neuraxial blockade, prevented 17 cesarean deliveries for every 100 external cephalic versions attempted. CONCLUSIONS: Neuraxial blockade is associated with minimal hospital and insurer cost changes in the setting of external cephalic version, while reducing the cesarean delivery rate.


Assuntos
Analgesia Obstétrica/efeitos adversos , Apresentação Pélvica/cirurgia , Sistemas de Apoio a Decisões Clínicas , Bloqueio Nervoso/efeitos adversos , Versão Fetal/efeitos adversos , Adulto , Analgesia Epidural/efeitos adversos , Analgesia Epidural/economia , Analgesia Obstétrica/economia , Anestesia Epidural/efeitos adversos , Anestesia Epidural/economia , Anestesia Obstétrica/efeitos adversos , Anestesia Obstétrica/economia , Raquianestesia/efeitos adversos , Raquianestesia/economia , Apresentação Pélvica/economia , Cesárea/efeitos adversos , Cesárea/economia , Redução de Custos , Custos e Análise de Custo , Árvores de Decisões , Feminino , Custos Hospitalares , Humanos , Reembolso de Seguro de Saúde , Bloqueio Nervoso/economia , Gravidez , Estados Unidos , Versão Fetal/economia
13.
Trials ; 15: 400, 2014 Oct 21.
Artigo em Inglês | MEDLINE | ID: mdl-25336055

RESUMO

BACKGROUND: Thoracic epidural analgesia (TEA) is recommended for post-operative pain relief in patients undergoing major abdominal surgery via a midline incision. However, the effectiveness of TEA is variable with high failure rates reported post-operatively. Common side effects such as low blood pressure and motor block can reduce mobility and hinder recovery, and a number of rare but serious complications can also occur following their use.Rectus sheath catheters (RSC) may provide a novel alternative approach to somatic analgesia without the associated adverse effects of TEA. The aim of this study is to compare the efficacy of both techniques in terms of pain relief, patient experience, post-operative functional recovery, safety and cost-effectiveness. METHODS/DESIGN: This is a single-centre randomised controlled non-blinded trial, which also includes a nested qualitative study. Over a two-year period, 132 patients undergoing major abdominal surgery via a midline incision will be randomised to receive either TEA or RSC for post-operative analgesia. The primary outcome measures pain scores on moving from a supine to a sitting position at 24 hours post wound closure, and the patient experience between groups evaluated through in-depth interviews. Secondary outcomes include pain scores at rest and on movement at other time points, opiate consumption, functional recovery, morbidity and cost-effectiveness. DISCUSSION: This will be the first randomised controlled trial comparing thoracic epidurals to ultrasound-guided rectus sheath catheters in adults undergoing elective midline laparotomy. The standardised care provided by an Enhanced Recovery Programme makes this a comparison between two complex pain packages and not simply two analgesic techniques, in order to ascertain if RSC is a viable alternative to TEA. TRIAL REGISTRATION: Current Controlled Trials ISRCTN81223298 (16 January 2014).


Assuntos
Abdome/cirurgia , Dor Abdominal/prevenção & controle , Analgesia Epidural/instrumentação , Cateteres , Bloqueio Nervoso/instrumentação , Manejo da Dor/instrumentação , Dor Pós-Operatória/prevenção & controle , Projetos de Pesquisa , Dor Abdominal/diagnóstico , Dor Abdominal/economia , Dor Abdominal/etiologia , Analgesia Epidural/efeitos adversos , Analgesia Epidural/economia , Analgésicos Opioides/uso terapêutico , Cateteres/economia , Protocolos Clínicos , Análise Custo-Benefício , Inglaterra , Desenho de Equipamento , Custos de Cuidados de Saúde , Humanos , Entrevistas como Assunto , Bloqueio Nervoso/efeitos adversos , Bloqueio Nervoso/economia , Manejo da Dor/efeitos adversos , Manejo da Dor/economia , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/economia , Dor Pós-Operatória/etiologia , Satisfação do Paciente , Pesquisa Qualitativa , Recuperação de Função Fisiológica , Fatores de Tempo , Resultado do Tratamento
14.
J Pediatr Surg ; 49(5): 798-806, 2014 May.
Artigo em Inglês | MEDLINE | ID: mdl-24851774

RESUMO

BACKGROUND/PURPOSE: The minimally invasive pectus excavatum repair (MIPER) is a painful procedure. The ideal approach to postoperative analgesia is debated. We performed a systematic review and meta-analysis to assess the efficacy and safety of epidural analgesia compared to intravenous Patient Controlled Analgesia (PCA) following MIPER. METHODS: We searched MEDLINE (1946-2012) and the Cochrane Library (inception-2012) for randomized controlled trials (RCT) and cohort studies comparing epidural analgesia to PCA for postoperative pain management in children following MIPER. We calculated weighted mean differences (WMD) for numeric pain scores and summarized secondary outcomes qualitatively. RESULTS: Of 699 studies, 3 RCTs and 3 retrospective cohorts met inclusion criteria. Compared to PCA, mean pain scores were modestly lower with epidural immediately (WMD -1.04, 95% CI -2.11 to 0.03, p=0.06), 12 hours (WMD -1.12; 95% CI -1.61 to -0.62, p<0.001), 24 hours (WMD -0.51, 95%CI -1.05 to 0.02, p=0.06), and 48 hours (WMD -0.85, 95% CI -1.62 to -0.07, p=0.03) after surgery. We found no statistically significant differences between secondary outcomes. CONCLUSIONS: Epidural analgesia may provide superior pain control but was comparable with PCA for secondary outcomes. Better designed studies are needed. Currently the analgesic technique should be based on patient preference and institutional resources.


Assuntos
Analgesia Epidural , Analgesia Controlada pelo Paciente , Tórax em Funil/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos , Dor Pós-Operatória/prevenção & controle , Analgesia Epidural/efeitos adversos , Analgesia Epidural/economia , Analgesia Controlada pelo Paciente/efeitos adversos , Analgesia Controlada pelo Paciente/economia , Criança , Análise Custo-Benefício , Humanos , Tempo de Internação , Duração da Cirurgia , Projetos de Pesquisa/normas , Estudos Retrospectivos
15.
Pain ; 155(7): 1318-27, 2014 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-24726924

RESUMO

The aim of this paper is to estimate the relative cost-effectiveness of treatment regimens for managing patients with sciatica. A deterministic model structure was constructed based on information from the findings from a systematic review of clinical effectiveness and cost-effectiveness, published sources of unit costs, and expert opinion. The assumption was that patients presenting with sciatica would be managed through one of 3 pathways (primary care, stepped approach, immediate referral to surgery). Results were expressed as incremental cost per patient with symptoms successfully resolved. Analysis also included incremental cost per utility gained over a 12-month period. One-way sensitivity analyses were used to address uncertainty. The model demonstrated that none of the strategies resulted in 100% success. For initial treatments, the most successful regime in the first pathway was nonopioids, with a probability of success of 0.613. In the second pathway, the most successful strategy was nonopioids, followed by biological agents, followed by epidural/nerve block and disk surgery, with a probability of success of 0.996. Pathway 3 (immediate surgery) was not cost-effective. Sensitivity analyses identified that the use of the highest cost estimates results in a similar overall picture. While the estimates of cost per quality-adjusted life year are higher, the economic model demonstrated that stepped approaches based on initial treatment with nonopioids are likely to represent the most cost-effective regimens for the treatment of sciatica. However, development of alternative economic modelling approaches is required.


Assuntos
Analgesia Epidural/métodos , Analgésicos/uso terapêutico , Análise Custo-Benefício , Bloqueio Nervoso/métodos , Manejo da Dor/métodos , Ciática/terapia , Analgesia Epidural/economia , Analgésicos/economia , Gerenciamento Clínico , Humanos , Disco Intervertebral/cirurgia , Modelos Econômicos , Bloqueio Nervoso/economia , Manejo da Dor/economia , Modalidades de Fisioterapia/economia , Ciática/economia
18.
Plast Reconstr Surg ; 133(3): 687-99, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24263390

RESUMO

BACKGROUND: Ventral hernias are a common, challenging, and expensive problem for general and reconstructive surgeons. The authors assessed the impact of epidurals on morbidity following abdominal wall reconstruction for hernia. METHODS: A retrospective review of abdominal wall reconstruction patients operated on between 2007 and 2012 was performed with a specific focus on the use of epidurals. Bivariate and multivariate logistic regression analyses were used to assess independent predictors of morbidity. Subgroup analyses were also performed. RESULTS: The study included 134 consecutive reconstructions performed by a single surgeon over a 5-year period at an academic teaching center. Patient groups were similar in terms of demographics, preoperative characteristics, hernia grade, and intraoperative characteristics. Epidural use was associated with a lower incidence of major surgical complications (19.7 percent versus 36.1 percent; p = 0.04) and medical complications (26.8 percent versus 54.1 percent; p = 0.001). A significant and independent reduction in medical morbidity (OR, 0.09; p ≤ 0.001) and unplanned reoperations (OR, 0.23; p = 0.052), was found with patients receiving epidurals. Furthermore, a notable trend toward reduced major surgical complications (OR, 0.45; p = 0.141) and cost savings (-$22,184; p = 0.01) was found in patients who received epidurals. Subgroup analysis did not demonstrate statistically significant reductions in major surgical morbidity in reconstruction either with (p = 0.13) or without (p = 0.07) concurrent intra abdominal procedures when epidurals were not or were used, respectively. CONCLUSIONS: Epidural use may be associated with reduced morbidity and cost savings in abdominal wall reconstruction. This effect appears to be related to reduced medical morbidity and shortened length of stay in patients undergoing more complex, concurrent intraabdominal hernia procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.


Assuntos
Parede Abdominal/cirurgia , Analgesia Epidural , Hérnia Ventral/cirurgia , Procedimentos Cirúrgicos Reconstrutivos , Adulto , Analgesia Epidural/economia , Custos e Análise de Custo , Feminino , Hérnia Ventral/complicações , Hérnia Ventral/economia , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Reconstrutivos/efeitos adversos , Procedimentos Cirúrgicos Reconstrutivos/economia , Telas Cirúrgicas
19.
Clin Perinatol ; 40(3): 399-412, 2013 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-23972747

RESUMO

Breech presentation is common at term and its reduction through external cephalic version represents a noninvasive opportunity to avoid cesarean delivery and the associated maternal morbidity. In addition to uterine relaxants, neuraxial anesthesia is associated with increased success of version procedures when surgical anesthetic dosing is used. The intervention is likely cost effective given the effect size and the avoided high costs of cesarean delivery.


Assuntos
Analgesia Epidural/métodos , Analgesia Obstétrica/métodos , Apresentação Pélvica/terapia , Versão Fetal/métodos , Analgesia Epidural/economia , Analgesia Obstétrica/economia , Cesárea/economia , Feminino , Humanos , Satisfação do Paciente , Gravidez , Resultado do Tratamento , Versão Fetal/economia
20.
BMC Pregnancy Childbirth ; 13: 139, 2013 Jul 02.
Artigo em Inglês | MEDLINE | ID: mdl-23815762

RESUMO

BACKGROUND: The epidural route is still considered the gold standard for labour analgesia, although it is not without serious consequences when incorrect placement goes unrecognized, e.g. in case of intravascular, intrathecal and subdural placements. Until now there has not been a viable alternative to epidural analgesia especially in view of the neonatal outcome and the need for respiratory support when long-acting opioids are used via the parenteral route. Pethidine and meptazinol are far from ideal having been described as providing rather sedation than analgesia, affecting the cardiotocograph (CTG), causing fetal acidosis and having active metabolites with prolonged half-lives especially in the neonate. Despite these obvious shortcomings, intramuscular and intravenously administered pethidine and comparable substances are still frequently used in delivery units. Since the end of the 90 ths remifentanil administered in a patient-controlled mode (PCA) had been reported as a useful alternative for labour analgesia in those women who either don't want, can't have or don't need epidural analgesia. DISCUSSION: In view of the need for conversion to central neuraxial blocks and the analgesic effect remifentanil has been demonstrated to be superior to pethidine. Despite being less effective in terms of the resulting pain scores, clinical studies suggest that the satisfaction with analgesia may be comparable to that obtained with epidural analgesia. Owing to this fact, remifentanil has gained a place in modern labour analgesia in many institutions. However, the fact that remifentanil may cause harm should not be forgotten when the use of this potent mu-agonist is considered for the use in labouring women. In the setting of one-to-one midwifery care, appropriate monitoring and providing that enough experience exists with this potent opioid and the treatment of potential complications, remifentanil PCA is a useful option in addition to epidural analgesia and other central neuraxial blocks. Already described serious consequences should remind us not refer to remifentanil PCA as a "poor man's epidural" and to safely administer remifentanil with an appropriate indication. SUMMARY: Therefore, the authors conclude that economic considerations and potential cost-savings in conjunction with remifentanil PCA may not be appropriate main endpoints when studying this valuable method for labour analgesia.


Assuntos
Analgesia Controlada pelo Paciente , Analgésicos Opioides/administração & dosagem , Trabalho de Parto , Manejo da Dor/métodos , Piperidinas/administração & dosagem , Analgesia Epidural/economia , Analgesia Controlada pelo Paciente/economia , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/economia , Feminino , Humanos , Óxido Nitroso/administração & dosagem , Manejo da Dor/economia , Piperidinas/efeitos adversos , Piperidinas/economia , Gravidez , Remifentanil
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