Intravenous regional anesthesia using lidocaine and clonidine.

BACKGROUND: Clonidine has been added to local anesthetic regimens for various peripheral nerve blocks, resulting in prolonged anesthesia and analgesia. The authors postulated that using clonidine as a component of intravenous regional anesthesia (IVRA) would enhance postoperative analgesia. METHODS: Forty-five patients undergoing ambulatory hand surgery received IVRA with lidocaine, 0.5%, and were assigned randomly and blindly to three groups. The control group received intravenous saline, the intravenous clonidine group received 1 microg/kg clonidine intravenously, and the IVRA clonidine group received 1 microg/kg clonidine as part of the IVRA solution. After their operations, the patients' pain and sedation scores and analgesic use were recorded. RESULTS: Patients in the IVRA clonidine group had a significantly longer period of subjective comfort when they required no analgesics (median [range]) for 460 min (215-1,440 min), compared with 115 min (14-390 min) for the control group and 125 min (17-295 min) for the intravenous clonidine group (P<0.0001). The patients who received IVRA with clonidine reported significantly lower pain scores 1 and 2 h after tourniquet deflation compared with the other groups, and they required no fentanyl in the postanesthesia care unit. They also required fewer analgesic tablets (325 mg acetaminophen with 30 mg codeine) in the first 24 h (2+/-1, mean +/- SD) compared with the other two groups, 5+/-1 tablets (control) and 4+/-2 tablets (intravenous clonidine) (P<0.0001). No significant postoperative sedation, hypotension, or bradycardia developed in any of the patients. CONCLUSION: The addition of 1 microg/kg clonidine to lidocaine, 0.5%, for IVRA in patients undergoing ambulatory hand surgery improves postoperative analgesia without causing significant side effects during the first postoperative day.

Alaska's model program for surveillance and prevention of occupational injury deaths.

The National Institute for Occupational Safety and Health (NIOSH) established its Alaska Field Station in Anchorage in 1991 after identifying Alaska as the highest-risk state for traumatic worker fatalities. Since then, the Field Station, working in collaboration with other agencies, organizations, and individuals, has established a program for occupational injury surveillance in Alaska and formed interagency working groups to address the risk factors leading to occupational death and injury in the state. Collaborative efforts have contributed to reducing crash rates and mortality in Alaska's rapidly expanding helicopter logging industry and have played an important supportive role in the substantial progress made in reducing the mortality rate in Alaska's commercial fishing industry (historically Alaska's and America's most dangerous industry). Alaska experienced a 46% overall decline in work-related acute traumatic injury deaths from 1991 to 1998, a 64% decline in commercial fishing deaths, and a very sharp decline in helicopter logging-related deaths. Extending this regional approach to other parts of the country and applying these strategies to the entire spectrum of occupational injury and disease hazards could have a broad effect on reducing occupational injuries.

Preventing deaths in Alaska's commercial fishing industry.

BACKGROUND AND PURPOSE: The arctic and sub-arctic waters of Alaska provide a very hazardous work setting, with special hazards posed by great distances, seasonal darkness, cold waters, high winds, brief fishing seasons, and icing. Our intent is to reduce the remarkably high occupational fatality rate (200/100,000/year in 1991-1992) among Alaska's commercial fishing workers. Over 90% of these deaths have been due to drowning or drowning plus hypothermia, primarily associated with vessel capsizings and sinkings. METHODS: Comprehensive surveillance for commercial fishing occupational fatalities was established during 1991 in Alaska. During 1990 through 1994, the U.S. Commercial Fishing Industry Vessel Safety Act of 1988 required the implementation of comprehensive prevention measures for all fishing vessels in offshore cold waters, including immersion suits and other personal flotation devices, survival craft (life rafts), emergency position-indicating radio beacons, and crew training in emergency response and first aid. Parallel to this, voluntary training efforts by nonprofit organizations have greatly increased. RESULTS: During 1990-1994, drowning was the leading cause of occupational death in Alaska. During this period, 117 fishers died, 101 of them from drowning or drowning/hypothermia. During 1991-1994, there was a substantial decrease in Alaskan commercial fishing-related deaths, from 34 in 1991 to 35 in 1992, 22 in 1993, and 10 in 1994. While man-overboard drownings and some other categories of deaths (falls, fires) have continued to occur, the most marked progress has been in vessel-related events. CONCLUSION: Specific measures tailored to prevent drowning in vessel capsizings and sinkings in Alaska's commercial fishing industry have been very successful so far. Additional efforts must be made to reduce the frequency of vessel events and to prevent man-overboard events and drownings associated with them.

Effective injury prevention using surveillance data: helicopter logging, Alaska, 1992-1995.

BACKGROUND AND PURPOSE: To reduce the fatality rate in helicopter sling-load logging in Alaska. These operations--on rugged terrain, due to environmental restrictions and economics--are an emerging technology application worldwide. During 1992 and 1993, crashes during these operations in Alaska resulted in multiple fatalities. METHODS: During 1992, comprehensive surveillance for these events was established, combining electronic media and interagency notification with active investigation to identify preventable risk factors. These data were applied in mid-1993 by an interagency working group, which included representatives of the Alaska Department of Health and Social Services, Alaska Department of Labor, Federal Aviation Administration, National Transportation, Safety Board, U.S. Coast Guard, Occupational Safety and Health Administration, U.S. Forest Service, and National Institute for Occupational Safety and Health. In response to surveillance data, consensus safety recommendations were developed. Working closely with industry, immediate improvements were made in worker training, work/rest cycles, and oversight. Surveillance results are being used to evaluate the effectiveness of interventions. On March 1-2, 1995, an international workshop was convened in Ketchikan, Alaska, to involve industry and government agencies in planning for durable prevention in this industry. RESULTS: In Alaska between January 1, 1992, and June 30, 1993, there were 6 helicopter crashes, with 9 fatal (4 in pilots) and 10 severe nonfatal injuries, out of only 25 helicopters flying in helicopter logging operations. Alaska logging helicopters thus had the extraordinarily high annual crash rate of 16% and a catastrophic pilot fatality rate of 5,000/100,000/year. Investigation revealed that all crashes involved improper operational and/or maintenance practices. Since these recommendations were implemented in July 1993, there have been no additional helicopter logging fatalities in Alaska through 1995. The 1995 meeting resulted in further recommendations, including more vigorous oversight; development of rigorous voluntary industry standards for equipment, maintenance, and training; exclusive use of multi-engine rotocraft; and more vigorous controls on alcohol and drug use in this industry.

Years of potential life lost and lost future productivity due to occupational fatalities--Alaska, 1990-1994.

INTRODUCTION: Alaska had the highest occupational fatality rate of any state for the 1980s. The impact of these events is estimated by the index of years of potential life lost before age 65 (YPLL), which was developed to measure the potentially preventable mortality occurring early in life. METHODS: Lost future productivity (wages) and YPLL were calculated from surveillance statistics for all workers killed on the job during this 5-year period. RESULTS: During 1990-1994, Alaska experienced 343 work-related deaths among civilians under age 65. YPLL was 9,690 years with an estimated lost future productivity of $367,000,000. DISCUSSION: Premature death due to occupational traumatic injury in Alaska for 1990-1994 was extremely costly to society. Premature death not only adversely affects the deceased workers' family, friends, and coworkers, but also society economically. Effective intervention strategies are needed to significantly reduce both the number and the cost of fatal occupational trauma in Alaska.