bluuebunny/crossref_metadata_2025_split huggingface dataset:
Early Tracheal Extubation after Coronary Artery Bypass Graft Surgery Reduces Costs and Improves Resource Use
Authors: Cheng Davy C. H. , Karski Jacek , Peniston Charles , Raveendran Ganesh , Asokumar Buvanendran , Carroll Jo , David Tirone , Sandler Alan 
Published: November 2003

Background
Economics has caused the trend of early tracheal extubation after cardiac surgery, yet no prospective randomized study has directly validated that early tracheal extubation anesthetic management decreases costs when compared with late extubation after cardiac surgery.

Methods
This prospective, randomized, controlled clinical trial was designed to evaluate the cost savings of early (1-6 h) versus late tracheal extubation (12-22 h) in patients after coronary artery bypass graft (CABG) surgery. The total cost for the services provided for each patient was determined for both the early and late groups from hospital admission to discharge home. All costs applicable to each of the services were classified into direct variables, direct fixed costs, and overhead (an indirect cost). Physician fees and heart catheterization costs were included. The total service cost was the sum of unit workload and overhead costs.

Results
One hundred patients having elective CABG who were younger than 75 yr were studied. Including all complications, early extubation (n = 50) significantly reduced cardiovascular intensive care unit (CVICU) costs by 53% (P < 0.026) and the total CABG surgery cost by 25% (P < 0.019) when compared with late extubation (n = 50). Forty-one patients (82%) in each group were tracheally extubated within the defined period. In the early extubation group, the actual departmental cost savings in CVICU nursing and supplies was 23% (P < 0.005), in ward nursing and supplies was 11% (P < 0.05), and in respiratory therapy was 12% (P < 0.05). The total cost savings per patient having CABG was 9% (P < 0.001). Further cost savings using discharge criteria were 51% for CVICU nursing and supplies (P < 0.001), 9% for ward nursing and supplies (P < 0.05), and 29% for respiratory therapy (P < 0.001), for a total cost savings per patient of 13% (P < 0.001). Early extubation also reduced elective case cancellations (P < 0.002) without any increase in the number of postoperative complications and readmissions.

Conclusions
Early tracheal extubation anesthetic management reduces total costs per CABG surgery by 25%, predominantly in nursing and in CVICU costs. Early extubation reduces CVICU and hospital length of stay but does not increase the rate or costs of complications when compared with patients in the late extubation group. It shifts the high CVICU costs to the lower ward costs. Early extubation also improves resource use after cardiac surgery when compared with late extubation.
Effects of Eltanolone on Myocardial Performance and Coronary Flow in Intact and Catecholamine-depleted Isolated Rabbit Hearts
Authors: Mouren Stephane , Abdenour Lamine , Souktani Rachid , Coriat Pierre 
Published: November 2003

Background
Experimental studies suggest that the new short-acting intravenous anesthetic agent eltanolone does not markedly alter hemodynamics or cardiac function. However, because its intrinsic effects on myocardial performance and coronary blood flow are not yet known, they were examined in isolated blood-perfused rabbit hearts.

Methods
Coronary blood flow, myocardial contractility, relaxation, and oxygen consumption were measured during perfusion of hearts with 0.1 to 10 micrograms/ml eltanolone (n = 7) or its vehicle (n = 7). To determine whether the cardiac effects of eltanolone are mediated by indirect sympathetic activation, the same dose-response curve was studied in another group of five hearts depleted of catecholamine with reserpine treatment.

Results
Coronary blood flow significantly increased with 10 micrograms/ml eltanolone and significantly decreased with 10 micrograms/ ml eltanolone vehicle. At eltanolone concentrations less than 10 micrograms/ml, myocardial contractility and relaxation remained unchanged but decreased at 10 micrograms/ml. Myocardial contractility and relaxation were not affected by perfusion of eltanolone vehicle alone. In eltanolone-perfused hearts, unchanged myocardial oxygen consumption was associated with significant increases in coronary venous oxygen content and tension, but in vehicle-perfused hearts, it was associated with reduced coronary venous oxygen content and tension. In catecholamine-depleted hearts, the variations in myocardial performance and coronary blood flow induced by eltanolone were similar to those observed in intact hearts.

Conclusions
Eltanolone (0.1 to 3 micrograms/ml) did not alter myocardial performance or coronary blood flow in isolated blood-perfused rabbit hearts. These effects were not due to an eltanolone-induced indirect sympathetic activation. Cardiac depression and coronary vasodilatation were only observed at concentrations of eltanolone far greater than those in clinical range.
Intraabdominal Carbon Dioxide Insufflation in the Pregnant Ewe
Authors: Cruz Antonio M. , Southerland Lucy C. , Duke Tanya , Townsend Hugh G. G. , Ferguson James G. , Crone Lesley-Ann L. 
Published: November 2003

Background
Laparoscopic surgical procedures are being performed in pregnant women with increasing frequency. Maternal-fetal physiologic changes occurring during intraabdominal carbon dioxide insufflation are poorly understood, and maternal-fetal safety is of concern during carbon dioxide pneumoperitoneum. A previous pilot study using end-tidal carbon dioxide-guided ventilation resulted in maternal and fetal acidosis and tachycardia during carbon dioxide pneumoperitoneum. Using serial arterial PCO2 to guide ventilation, this study was designed to evaluate maternal-fetal cardiopulmonary status, uterine blood flow, and the intraamniotic pressure effects of intraabdominal carbon dioxide insufflation in singleton pregnant ewes between 120 and 135 days of gestation.

Methods
In a prospective randomized cross-over study, nine ewes were to receive either abdominal insufflation with carbon dioxide to an intraabdominal pressure of 15 mmHg (n = 9; insufflation group) or receive no insufflation (n = 9; control group). Anesthesia was induced with thiopental and maintained with end-tidal halothane (1 to 1.5 minimum alveolar concentration/100% oxygen). Mechanical ventilation was guided by serial maternal arterial blood gas analysis to maintain PaCO2 between 35 and 40 mmHg. Data from insufflated animals were collected during insufflation (60 min) and after desufflation (30 min). Control group data were collected and matched to similar time intervals for 90 min. Ewes were allowed to recover, and after a rest period (48 h) they were entered in the cross-over study.

Results
During insufflation there was a significant increase (P < 0.05) in maternal PaCO2 to end-tidal carbon dioxide gradient and minute ventilation, with concomitant decreases in maternal end-tidal carbon dioxide and PaO2. Intraamniotic pressure increased significantly during insufflation. No significant changes were observed in maternal hemodynamic variables, fetal variables, or in uterine blood flow during the study. There were no fetal deaths or preterm labor in any of the animals during the experiment.

Conclusions
During the 1-h insufflation, a marked increase in PaCO2-to-end-tidal carbon dioxide gradient was observed, suggesting that capnography may be an inadequate guide to ventilation during carbon dioxide pneumoperitoneum in the pregnant patient. No other significant circulatory changes were observed.
Halothane Blocks Synaptic Excitation of Inhibitory Interneurons
Authors: Perouansky Misha , Kirson Eilon D. , Yaari Yoel 
Published: November 2003

Background
Activation of principal hippocampal neurons is controlled by feedforward and feedback inhibition mediated by gamma-aminobutyric acidergic interneurons. The effects of halothane on glutamate receptor-mediated synaptic excitation of inhibitory interneurons have not been reported yet.

Methods
The effects of halothane on glutamatergic excitatory postsynaptic currents and on spike threshold in visually identified interneurons were studied with tight-seal, whole-cell voltage- and current-clamp recordings in thin slices from adult mouse hippocampus. The excitatory postsynaptic currents were pharmacologically isolated into their N-methyl-D-aspartate and non-N-methyl-D-aspartate receptor-mediated components using selective antagonists.

Results
Halothane (0.37-2.78 mM) reversibly blocked non-N-methyl-D-aspartate and N-methyl-D-aspartate excitatory postsynaptic currents in hippocampal oriens-alveus interneurons. Half-maximal inhibition was observed at similar concentrations (0.59 mM and 0.50 mM, respectively). Halothane inhibited synaptically generated action potentials at concentrations that did not elevate the spike threshold.

Conclusions
Halothane blocks glutamate receptor-mediated synaptic activation of inhibitory interneurons in the mouse hippocampus.
Immediate-early Gene Expression in Ovine Brain after Cardiopulmonary Bypass and Hypothermic Circulatory Arrest
Authors: Bokesch Paula M. , Marchand James , Seirafi Peter A. , Deiss Judith M. , Warner Kenneth G. , Bronson Roderick T. , Kream Richard M. 
Published: November 2003

Background
Cardiopulmonary bypass (CPB) and hypothermic circulatory arrest (HCA) are associated with neurological injury. Altered immediate-early gene expression occurs rapidly in the brain in response to ischemia, hypoxia, and severe metabolic stress, which results in long-term changes in the molecular phenotype of neurons. This study determined the effects of CPB and HCA on the expression of the immediate-early gene c-fos.

Methods
Neonatal lambs were subjected to 2 h of CPB at 38 degrees C (n = 4) or 60 min (n = 6), 90 min (n = 7), and 120 min (n = 6) of HCA at 15 degrees C. One hour after terminating CPB at 38 degrees C, the brains were analyzed for FOS-encoding mRNA and FOS-like immunoreactivity in the hippocampal formation. Other animals (n = 15), subjected to the same CPB and HCA protocol, were allowed to survive 3-5 days before their brains were examined for dead neurons.

Results
Minimal c-fos mRNA and FOS proteins were observed in neurons of animals subjected to normothermic bypass and of those that served as controls. Non-neuronal FOS proteins were observed in the choroid plexus, ependyma, and blood vessels at all times, including normothermic CPB, but not in the control animals without CPB. The magnitude of c-fos mRNA expression in hippocampal neurons increased directly with the duration of HCA. In contrast, expression of FOS proteins peaked after 90 min of HCA and declined significantly thereafter. Dead neurons were seen in surviving animals after 2 h of HCA only.

Conclusions
Cardiopulmonary bypass and HCA alter immediate-early gene expression in the brain. Translational processes are impaired after 120 min of HCA and correlate with neuron death in the hippocampus.
Cricoid Cartilage Pressure Decreases Lower Esophageal Sphincter Tone
Authors: Tournadre Jean-Pierre , Chassard Dominique , Berrada Khalid R. , Bouletreau Paul 
Published: November 2003

Background
Cricoid cartilage pressure induced to prevent pulmonary aspiration from regurgitation of gastric contents has been recommended, and its efficacy requires a force greater than 40 Newtons. For regurgitation to occur, both an increase in gastric pressure and relaxation of the lower esophageal sphincter (LES) are necessary. However, the effect of cricoid cartilage pressure on the LES is unknown. This study evaluated the effects of cricoid cartilage pressure on LES in human volunteers.

Methods
Lower esophageal sphincter and esophageal barrier pressures (which equals LES pressure-gastric pressure) were measured using a manometric method in eight unanesthetized volunteers (4 men, 4 women) classified as American Society of Anesthesiologists physical status 1. The force applied to the cricoid cartilage was measured continuously, and LES pressure was recorded at a cricoid force of 20 and 40 Newtons.

Results
Cricoid pressure decreased LES pressure from 24 +/- 3 mmHg to 15 +/- 4 mmHg at a force of 20 Newtons (P < 0.05) and to 12 +/- 4 mmHg with a force of 40 Newtons (P < 0.01).

Conclusions
These findings may explain the occurrence of pulmonary aspiration before tracheal intubation despite application of cricoid cartilage pressure.
Influence of Age and Gender on the Pharmacokinetics and Pharmacodynamics of Remifentanil
Authors: Minto Charles F. , Schnider Thomas W. , Egan Talmage D. , Youngs Elizabeth , Lemmens Harry J. M. , Gambus Pedro L. , Billard Valerie , Hoke John F. , Moore Katherine H. P. , Hermann David J. , Muir Keith T. , Mandema Jaap W. , Shafer Steven L. 
Published: November 2003

Background
Previous studies have reported conflicting results concerning the influence of age and gender on the pharmacokinetics and pharmacodynamics of fentanyl, alfentanil, and sufentanil. The aim of this study was to determine the influence of age and gender on the pharmacokinetics and pharmacodynamics of the new short-acting opioid remifentanil.

Methods
Sixty-five healthy adults (38 men and 27 women) ages 20 to 85 y received remifentanil by constant-rate infusion of 1 to 8 micrograms.kg-1.min-1 for 4 to 20 min. Frequent arterial blood samples were drawn and assayed for remifentanil concentration. The electroencephalogram was used as a measure of drug effect. Population pharmacokinetic and pharmacodynamic modeling was performed using the software package NONMEM. The influence of volunteer covariates were analyzed using a generalized additive model. The performances of the simple (without covariates) and complex (with covariates) models were evaluated prospectively in an additional 15 healthy participants ages 41 to 84 y.

Results
The parameters for the simple three-compartment pharmacokinetic model were V1 = 4.98 l, V2 = 9.01 l, V3 = 6.54 l, Cl1 = 2.46 l/min, Cl2 = 1.69 l/min, and Cl3 = 0.065 l/min. Age and lean body mass were significant covariates. From the ages of 20 to 85 y, V1 and Cl1 decreased by approximately 25% and 33%, respectively. The parameters for the simple sigmoid Emax pharmacodynamic model were Ke0 = 0.516 min-1, E0 = 20 Hz, Emax = 5.62 Hz, EC50 = 11.2 ng/ml, and gamma = 2.51. Age was a significant covariate of EC50 and Ke0, with both decreasing by approximately 50% for the age range studied. The complex pharmacokinetic-pharmacodynamic model performed better than did the simple model when applied prospectively.

Conclusions
This study identified (1) an effect of age on the pharmacokinetics and pharmacodynamics of remifentanil; (2) an effect of lean body mass on the pharmacokinetic parameters; and (3) no influence of gender on any pharmacokinetic or pharmacodynamic parameter.
Changes in Cerebrospinal Fluid Pressure and Lactate Concentrations during Thoracoabdominal Aortic Aneurysm Surgery
Authors: Drenger Benjamin , Parker Stephen D. , Frank Steven M. , Beattie Charles 
Published: November 2003

Background
Although ischemic injury to the spinal cord is a well-known complication of aortic surgery, no metabolic markers have been identified as predictors of an adverse outcome. This study evaluated the effect of cerebrospinal fluid (CSF) drainage, with and without distal femoral perfusion or moderate hypothermia on blood and CSF lactate concentrations and CSF pressure during thoracoabdominal aortic aneurysm surgery.

Methods
Three nonconcurrent groups of patients were studied prospectively: patients with normal body temperature (35 degrees C) but without distal femoral bypass (n = 6), patients with normal body temperature with bypass (n = 7), and patients with hypothermia (30 degrees C) and bypass (n = 8). In all patients, CSF pressure was recorded before, during, and after aortic cross-clamping. During the surgical repair, CSF drainage was performed using a 4-Fr intrathecal silicone catheter. Blood and CSF lactate concentrations were measured throughout the operation.

Results
Significant increases in blood (490%) and CSF (173%) lactate concentrations were observed during and after thoracic aortic occlusion in patients with normothermia and no bypass (P < 0.02 and 0.05, respectively). Distal perfusion attenuated the increase in both blood and CSF lactate (P < 0.01), and a further reduction was achieved with hypothermia of 30 degrees C (P < 0.001). Patients who became paraplegic showed a greater increase in CSF lactate concentrations after aortic clamp release compared with those who suffered no neurological damage (275% vs. 123% of baseline; P < 0.05). Increased CSF pressure of 42-60% (P < 0.005) was noted soon after thoracic aortic occlusion, both with and without distal femoral bypass.

Conclusions
Incremental reductions in CSF lactate concentrations were achieved using distal femoral bypass and hypothermia. The reduction in CSF lactate correlated with the methods used to protect the spinal cord during thoracoabdominal aortic aneurysm surgery and was associated with better outcome. Decompression by distal bypass of the hemodynamic overload caused by aortic occlusion was insufficient to eliminate the acute increase in CSF pressure. Cerebrospinal fluid lactate measurements during high aortic surgery may accurately represent the spinal cord metabolic balance.
Incidence of Neurologic Complications Related to Thoracic Epidural Catheterization
Authors: Giebler Reiner M. , Scherer Ralf U. , Peters Jurgen 
Published: November 2003

Background
Due to potential neurologic sequelae, the risk:benefit ratio of thoracic epidural analgesia is controversial. Surprisingly, however, few available data address neurologic complications. The incidence of neurologic complications occurring after thoracic epidural catheterization was studied in patients scheduled for abdominal or abdominothoracic surgery.

Methods
A total of 4,185 patients were studied, including 2,059 during the prospective phase of the study and 2,126 during the retrospective phase. After thoracic epidural catheterization, all patients received general anesthesia. Patients' neurologic status was assessed by an anesthesiologist using clinical criteria after operation and after epidural catheter removal. If neurologic complications were suspected, a neurologist was consulted. The incidence of specific complications was compared for different thoracic puncture sites: upper (T3/4-6/7), mid (T7/8-8/9), and lower (T9/10-11/12) catheter insertion levels.

Results
The overall incidence of complications after thoracic epidural catheterization was 3.1% (n = 128). This included dural perforation (0.7%; n = 30); unsuccessful catheter placement (1.1%; n = 45); postoperative radicular type pain (0.2%; n = 9), responsive to catheter withdrawal in all cases; and peripheral nerve lesions (0.6%; n = 24), 0.3% (n = 14) of which were peroneal nerve palsies probably related to surgical positioning or other transient peripheral nerve lesions (0.2%; n = 10). No signs suggesting epidural hematoma were recognized, and there were no permanent sensory or motor defects attributable to epidural catheterization. Unintentional dural perforation was observed significantly more often in the lower (3.4%) than in the mid (0.9%), or upper (0.4%) thoracic region. A single patient experienced severe respiratory depression after receiving epidural buprenorphine but recovered without sequelae.

Conclusions
Thoracic epidural catheterization for abdominal and thoracoabdominal surgery is not associated with a high incidence of serious neurologic complications. In fact, the incidence of puncture- and catheter-related complications is less in the mid and upper than in lower thoracic region, and the predicted maximum risk for permanent neurologic complications (upper bound of the 95% confidence interval) is 0.07%.
Decreased Thiopental Requirements in Early Pregnancy
Authors: Gin Tony , Mainland Phoebe , Chan Matthew T. V. , Short Timothy G. 
Published: November 2003

Background
Anesthetic requirements for inhalational agents are decreased during pregnancy, but there are no data regarding requirements for intravenous agents. The quantal dose-response curves for thiopental were calculated for 70 nonpregnant women having gynecologic surgery and for 70 pregnant women of 7-13 weeks' gestation having elective abortions.

Methods
Groups of 10 patients were given 2, 2.4, 2.8, 3.3, 3.8, 4.5, or 5.3 mg/kg thiopental as a bolus dose during a period of 10 s. Two minutes later, patients were asked to open their eyes as a test for hypnosis. Patients who did not open their eyes were given a 10-s, 50-Hz, 80-mA transcutaneous tetanic electrical stimulus to the ulnar nerve as a test for anesthesia. Purposeful movement indicated that there was no anesthesia. Log dose-response curves for hypnosis and anesthesia were calculated after logit transformation.

Results
In the nonpregnant women, the median effective doses (ED50s) (95% confidence interval) for hypnosis and anesthesia were 3.1 (2.8-3.4) mg/kg and 4.9 (4.5-5.4) mg/kg, whereas in the pregnant women the corresponding ED50s were 2.6 (2.3-2.8) mg/kg and 4 (3.7-4.4) mg/kg. In the non-pregnant women, the ED95s (95% CI) for hypnosis and anesthesia were 4.4 (3.9-5.4) mg/kg and 6.4 (5.7-7.9) mg/kg, whereas in the pregnant women the corresponding ED95s were 3.7 (3.3-4.5) mg/kg and 5.2 (4.7-6.3) mg/kg. The pregnant to nonpregnant relative median potency (95% CI) ratio for hypnosis was 0.83 (0.67-0.96) and for anesthesia it was 0.82 (0.62-0.94).

Conclusions
The dose of thiopental for hypnosis was 17% less and that for anesthesia was 18% less in pregnant women of 7-13 weeks' gestation compared with that in nonpregnant women.
Hospital Costs and Severity of Illness in Three Types of Elective Surgery
Authors: Macario Alex , Vitez Terry S. , Dunn Brian , McDonald Tom , Brown Byron 
Published: November 2003

Background
If patients who are more severely ill have greater hospital costs for surgery, then health-care reimbursements need to be adjusted appropriately so that providers caring for more seriously ill patients are not penalized for incurring higher costs. The authors' goal for this study was to determine if severity of illness, as measured by either the American Society of Anesthesiologists Physical Status (ASA PS) or the comorbidity index developed by Charlson, can predict anesthesia costs, operating room costs, total hospital costs, or length of stay for elective surgery.

Methods
The authors randomly selected 224 inpatients (60% sampling fraction) having either colectomy (n = 30), total knee replacement (n = 100), or laparoscopic cholecystectomy (n = 94) from September 1993 to September 1994. For each surgical procedure, backward-elimination multiple regression was used to build models to predict (1) total hospital costs, (2) operating room costs, (3) anesthesia costs, and (4) length of stay. Explanatory candidate variables included patient age (years), sex, ASA PS, Charlson comorbidity index (which weighs the number and seriousness of coexisting diseases), and type of insurance (Medicare/Medicaid, managed care, or indemnity). These analyses were repeated for the pooled data of all 224 patients. Costs (not patient charges) were obtained from the hospital cost accounting software.

Results
Mean total hospital costs were $3,778 (95% confidence interval +/- 299) for laparoscopic cholecystectomy, $13,614 (95% CI +/- 3,019) for colectomy, and $18,788 (95% CI +/- 573) for knee replacement. The correlation (r) between ASA PS and Charlson comorbidity scores equaled 0.34 (P < .001). No consistent relation was found between hospital costs and either of the two severity-of-illness indices. The Charlson comorbidity index (but not the ASA PS) predicted hospital costs only for knee replacement (P = .003). The ASA PS, but not the Charlson index, predicted operating room and anesthesia costs only for colectomy (P < .03).

Conclusions
Severity of illness, as categorized by ASA PS categories 1-3 or by the Charlson comorbidity index, was not a consistent predictor of hospital costs and lengths of stay for three types of elective surgery. Hospital resources for these lower-risk elective procedures may be expended primarily to manage the consequences of the surgical disease, rather than to manage the patient's coexisting diseases.