Combined regional-general anesthesia: evaluation of remifentanil based general anesthesia and postoperative epidural analgesia.

OBJECTIVES: To evaluate whether remifentanil based general anesthesia combined with epidural analgesia for postoperative pain, has any advantages with respect to consumption of drugs, blood loss, quality of pain control, hemodynamic profile, in major abdominal surgery, as compared to other combined techniques. METHODS: A retrospective study based on chart reviews of patients who have undergone colectomy, radical cystectomy and radical prostatectomy over one year period in our Institution, operated under combined regional-general anesthesia. Twenty-six patients were analyzed and were divided into three groups according to the type of anesthesia received. Group A: combined general-epidural for per-operative and postoperative pain (10 patients). Group B: combined spinal-general anesthesia (8 patients) post-operative analgesia consisted of parenteral mepiridine and paracetamol. Group C: remifentanil based general anesthesia followed by epidural for postoperative analgesia (8 patients). RESULTS: The demographic data, age and M/F distribution were comparable in the three groups. The remifentanil group showed less utilization of muscle relaxant (Cisatracurium) with respect to other groups (p < 0.001). The amount of intraoperative blood loss was not significantly different among the three groups. The efficacy of the postoperative epidural analgesia was demonstrated by the minimal utilization of analgesics (p < 0.05 and 0.01) in group A and C as compared to group B. In the group of remifentanil, the blood pressure was more stable and maintained at a systolic of 80-100 mmHg as compared to initial hypotension mainly in group C. CONCLUSION: The use of remifentanil based general anesthesia offers the advantage of non-accumulation of drugs and hemodynamic stability. Post-operative analgesia can be provided by epidural route which proved to be satisfactory in the remifentanil group. The effect on blood loss was not conclusive in this study.

A telemedicine consultative service for the evaluation of patients with urolithiasis.

OBJECTIVES: A 6-month pilot teleconsultative project linking Georgetown University Medical Center (GUMC) in Washington, DC, and City Hospital in Martinsburg, West Virginia, 90 miles away, was designed to assess the effectiveness of telemedicine on the clinical decision-making process for patients with urolithiasis. METHODS: The telemedicine system designed and tested for this project was based on a PC-based platform. Videoconferencing and review of the patient's imaging studies were performed over an Integrated Service Digital Network (ISDN) with 3 Basic Rate (BRI) ISDN lines providing a 336-kilobytes/s bandwidth through an Inverse Multiplexor (IMUX). Treatment options were recorded for the clinical trial group and a simulated study group by the consulting urologist after the initial telephone consultation, after the telemedicine consultation, and after examination of those patients transferred to GUMC. RESULTS: A total of 32 telemedicine consultations were performed: 14 in the clinical trial group and 18 in the simulated study group. The recommendation of the consulting urologist at the tertiary center was altered in 12 patients (37.5%) after the telemedicine consultation compared with the recommended treatment after the initial telephone consultation. CONCLUSIONS: In the evaluation of patients with urolithiasis, this telemedicine application enhanced the clinical decision-making process by allowing for improved quality of care through immediate access and effective transfer of information between the referring urologist, the patient, and the stone center specialist.

Hemodialysis patient management by telemedicine: design and implementation.

The authors describe the design and implementation of a personal computer based telemedicine system for managing patients by telemedicine. With three identical systems connected by high speed T1 lines, the physician (or allied healthcare giver) can interact, by videoconferencing, and by using multimedia files, with patients at two remote hemodialysis sites. The physician is able to visualize specifically the patient's fistula/graft, and auscultate fistula, heart and lung sounds, and incorporate still pictures or audio sounds in the patient's multimedia database folder, which also contains an electronic and paperless medical record. In addition there is the capability of downloading into this database all the machine parameters during dialysis.

Requirements for urology and renal dialysis PC-based telemedicine applications: comparative analysis.

The Imaging Science and Information Systems (ISIS) Center of the Department of Radiology at Georgetown University Medical Center (GUMC) has been developing technical requirements for different telemedicine applications. This paper details the process through which those technical requirements are determined and shows how they may differ substantially, depending on the clinical need. This information is presented in light of two telemedicine applications being undertaken at GUMC: a urology application for the management of patients with surgical stone disease and a nephrology application for monitoring of renal dialysis patients.

Health systems evaluation of telemedicine: a staged approach.

Telemedicine promises greater access to health care of higher quality, potentially at lower cost. The diverse applications of telemedicine technology developed to date have not been evaluated systematically in terms of their ability to achieve these goals. Furthermore, the great variety in telemedicine applications and the far-reaching consequences of new information systems for health care delivery pose challenges to traditional methods of technology assessment. Methods appropriate for mature technologies may not be suitable for emerging ones and, indeed, may risk stifling their development with premature negative conclusions. The staged approach to technology assessment proposed here matches the analysis to the technology's stage of development. It focuses on access, quality, and cost and considers the communication pathway employed in the telemedicine application. A staged approach to technology assessment can inform and foster the development of new telemedicine technology while allowing health care delivery systems to make rational decisions about adopting telemedicine.

Teleradiology/telepathology requirements and implementation.

Teleradiology and telepathology form an integral part of the telemedicine concept. Teleradiology is becoming a mature technology because of advances in imaging technology, database design and communications infrastructure and capabilities. Telepathology has also made significant progress but more development is needed in the definition of required images, database design and standards. While the requirements of most clinical applications of teleradiology are well established, telemammography still presents some impediments. Technical difficulties in telemammography are presented in terms of the lack of a clinically accepted digital imaging system and large data volume required per image. Another important aspect in tele-imaging is the database question. Workstations constitute a window into database. Comprehensive database development is the most difficult and expensive technology for tele-imaging and operational features of such systems are discussed. Finally, we explore current examples of the use of telepathology and teleradiology in the global telemedicine context.