Practical methods of cost containment in anesthesia and surgery.

With the increasing focus of national attention on health care and health care costs, anesthesiologists, along with all other medical specialists, must become more cost conscious in their practice behaviors. This review describes the current concerns about health care in the United States, including a discussion of some of the forces causing the increase in health care spending. The role of anesthesiology in the increase in health care costs is discussed. Practical methods for controlling anesthesia costs are outlined, including reducing preoperative testing, decreasing blood product use, and employing more regional and local anesthetic techniques. Several ideas for reducing the costs of anesthetic gases and drugs, including low-flow anesthesia and less expensive alternative drugs, are presented. The final section describes the changes in anesthesia drug use that occurred from 1992 to 1993 at one health care center (St. Francis Regional Medical Center, Wichita, KS, which is associated with the University of Kansas School of Medicine-Wichita). These changes resulted in a 13% reduction in anesthesia drug costs, which amounted to a savings of $127,472. The largest decreases were in anesthetic gases (16%), resulting from an increase in the use of low-flow techniques, and in muscle relaxants (26%), resulting from a switch to older lower-cost drugs.

Dilution of proparacaine in balanced salt solution reduces pain of anesthetic instillation in the eye.

BACKGROUND AND OBJECTIVES: Proparacaine (P), 0.5%, is often applied topically to the eye to diminish the pain of injection of anesthetic for eye surgery; however, application of 0.5% P itself can cause some degree of discomfort. This study evaluated the use of balanced salt solution to dilute P before instillation in the eye to prevent discomfort. METHODS: In a double-blinded manner, 42 consenting adults about to undergo cataract surgery were given 0.5% P in one eye and 0.03% P in the other eye. One minute later the same solutions were instilled into each eye. Ten minutes later, 0.5% P was instilled into both eyes. After each instillation the patients were asked to describe the pain in each eye on a 0 to 10 scale. RESULTS: Those receiving 0.5% as the first drop had a mean pain score of 1.28, which was greater than the score of 0.09 for the 0.03% P group (P < .01). No one reported pain after the second drop was applied 1 minute later. After receiving 0.5% P 10 minutes later, the group that had received 0.5% P reported a mean pain score of 0.09 while those who had received 0.03% P reported a score of 0.76, which was significantly greater than that reported by the 0.5% P group after the 10 minute instillation (P < .01) but significantly lower than the score reported after the first instillation of 0.5% P (P < .05). CONCLUSIONS: Dilution of P in balanced salt solution to a concentration of 0.03% produces a solution that is significantly less painful than 0.5% P and reduces the discomfort of the instillation of 0.5% P.

Diluting lidocaine and mepivacaine in balanced salt solution reduces the pain of intradermal injection.

BACKGROUND AND OBJECTIVES: Intradermal injection of local anesthetics prior to percutaneous needle insertion is often painful. This study evaluated the effect of diluting lidocaine and mepivacaine with balanced salt solution on perception of pain on intradermal injection. METHODS: Twenty healthy volunteers were each intradermally injected with six solutions in random order. These solutions were: normal saline (NS), 0.9% benzyl alcohol in NS, 0.2% lidocaine in NS, 0.2% lidocaine in balanced salt solution, 0.2% mepivacaine in NS, and 0.2% mepivacaine in balanced salt solution. Discomfort of each injection was reported on a 0-2 pain scale. The degree of anesthesia at each site was evaluated by pinprick every minute for 20 minutes. RESULTS: Benzyl alcohol and lidocaine and mepivacaine in balanced salt solution caused the least injection pain. However, mepivacaine in NS and NS alone caused the most pain. The anesthetic effect of benzyl alcohol was judged adequate for only 4 minutes whereas both lidocaine and mepivacaine in either NS or balanced salt solution gave adequate anesthesia for at least 15 minutes. CONCLUSIONS: The dilution of lidocaine and mepivacaine with balanced salt solution produces a solution that is both painless on injection and of moderate duration.

[The cost of pacemaker therapy from 1970 to 1975 with particular reference to the new hospital legislation (author's transl)]. / Kosten der Herz-schrittmacher-Therapie 1970 bis 1975 mit besonderer Berücksichtigung der neuen Krankenhausgesetze.

The changes introduced by the new legislation on hospital allowances are discussed with reference to the costs (1970 to 1975) for inpatient treatment of patients with pacemakers. As a result of the new legislation, centralizing pacemaker therapy must cause a great strain on the regional statutory insurance authorities if the area served by the pacemaker center is greater than that of the health insurance authority.

Cardiovascular effects of plasma levels of thiopental necessary for anesthesia.

The cardiovascular effects of plasma levels of thiopental necessary for anesthesia were studied using systolic time intervals (STI). In ten healthy patients anesthesia was induced with thiopental, 2-2.5 mg/kg, intravenously, and maintained with an infusion of 1-1.5 mg/kg/min. STI and thiopental plasma levels were measured before induction and when corneal reflex and trapezius muscle response, indicators of anesthetic depth equivalent to response to surgical stimulation, were lost. Significant changes included: an increase in heart rate with induction of anesthesia; a decrease in 1/pre-ejection period2--indexed for heart rate (1/PEP2-I) at loss of corneal reflex; a decrease in systolic blood pressure and 1/PEP2-I at loss of trapezius muscle response. No other variable was significantly different from control. Control values for STI were in the high-normal range, indicating some sympathetic stimulation. With induction of anesthesia these values decreased to a normal range. Free and total plasma levels were 5.4 and 37.6 microgram/ml at loss of corneal reflex; 6.1 and 41.6 microgram/ml at loss of trapezius muscle response. In comparison with other studies, thiopental causes less cardiac depression than inhalational agents at approximately the same anesthetic depth. It is concluded from this study in healthy patients that plasma levels of thiopental producing surgical anesthesia result in minimal cardiac depression as determined by systolic time intervals.

Pentobarbital distribution in discrete brain areas of tolerant and nontolerant mice.

Uptake and distribution of pentobarbital in tolerant and nontolerant mice were studied. Mice were implanted with pentobarbital or placebo pellets s.c. 3 days prior to the injection of 60 mg/kg sodium pentobarbital i.p. One group of animals was sacrificed when they first awakened. Whole brain, five discrete brain areas, and plasma were assayed for pentobarbital by gas chromatography. In a second group, time studies were performed on brain sections and plasma. In tolerant vs nontolerant animals, sleeping time was markedly decreased (10-20 vs 50-70 min); whole brain, brain sections, and plasma levels on awakening were not significantly different; linear and exponential curves of pentobarbital levels vs time showed an increase in slope (-1.05 vs-0.40) and a decrease in T 1/2 (10.2 VS 35.7 min). These findings suggest that the tolerance development to pentobarbital in the central nervous system is due to functional mechanism rather than brain dispositional mechanism.

Gas chromatographic assay for free and total plasma levels of thiopental.

A rapid gas chromatographic assay for the determination of free and total plasma thiopental is described. Free thiopental was obtained by ultrafiltration through Amicon Centroflo membrane cones. Gas chromatographic assay utilized secobarbital as an internal standard and employed on-column methylation of the barbiturates to improve peak resolution. In 73 blood samples from 22 patients total thiopental concentrations ranged from 4.2 to 134 mug/ml plasma, with a mean of 28 mug/ml. Free thiopental values ranged from 8.6 to 22.7 per cent of total, with a mean of 13.7 per cent free thiopental and a standard deviation of 3.2 per cent. At a total thiopental level of 10 mug/ml, unbound thiopental averaged 10.7 per cent with ultrafiltration, compared with 11.5 per cent with equilibrium dialysis. Assays of thiopental by gas chromatography and 14C scintillation counting gave similar results. There were progressive increases in the percentages of thiopental that were unbound when thiopental was added to plasma, purified crystalline albumin (4.5 g/l), and normal serum albumin (5 g/l), and a solution of purified protein fractions (5 g/l). Differences in protein binding determined by this method and previously reported methods are discussed.

Surface IgE on human basophils during histamine release.

The distribution of surface IgE on human basophils was studied using fluorescence microscopy and immunoferritin electronmicroscopy. Redistribution of the IgE was dose, time and temperature dependent and required divalent anti-IgE. Cells which can release histamine in vitro were indistinguishable in these respects from cells which cannot. The redistribution was unaffected by the presence or absence of Ca(++). No correlation between the conditions required for optimal histamine release and for redistribution was observed. At low doses, optimal histamine release occurred in the absence of, or before, redistribution. At higher doses redistribution occurred in the absence of histamine release. Antigen-induced histamine release was unaccompanied by gross redistribution of the surface IgE. Since both histamine release and redistribution require bridging of IgE on basophils it is concluded that only certain kinds of cross-linking of the IgE effectively stimulates these cells.