Long-term pharmaceutical cost reduction using a data management system.

UNLABELLED: Cost containment is an important issue in medicine today, and the ability to control costs and maintain quality patient care presents a challenge to practitioners. Educating practitioners about drug costs has been identified as an effective method, but the benefits of education are usually short-lived. To evaluate the role of education in cost control, pharmaceutical use and performance improvement data were analyzed at a tertiary care institution during two time periods. A total of 4,530 anesthesia records and associated performance improvement data from March to June 1993 were analyzed as a baseline. These data were shared with the clinicians of an anesthesia department and used to educate practitioners regarding the costs and use of injectable pharmaceuticals and to identify areas in which cost savings could be achieved. The same information from 10,600 cases during January to October 1996 were compared with the early group. The expenditures for injectable pharmaceuticals to provide anesthesia were decreased by more than $30,000 per month, or $32 per case, without changing the performance indicators that were monitored, and has been maintained for >3 yr. IMPLICATIONS: By using a data management system, the cost for medications to provide anesthesia has been reduced without changing the quality of patient care.

Autonomic hyperreflexia in a pregnant paraplegic patient. Case report.

BACKGROUND AND OBJECTIVES: Pregnant patients with spinal cord injuries are predisposed to autonomic hyperreflexia, which if unrecognized or untreated can lead to death. Hypertension occurring in laboring patients at risk for autonomic hyperreflexia must be managed aggressively. METHODS: Epidural anesthesia can safely control autonomic hyperreflexia during labor and delivery, but because spinal cord impaired patients lack sensory and motor function below the level of injury, it is difficult to determine the dermatomal spread of epidural anesthesia by the usual methods. This difficulty is highlighted by the following case, reporting an epidural that failed during labor, with the subsequent development of autonomic hyperreflexia. RESULTS: Previously, autonomic hyperreflexia occurring in pregnant patients (undergoing surgical procedures) was treated with intravenous antihypertensive agents. During labor, however, titrating these agents to coincide with uterine contractions is difficult. In this case, epidural anesthesia was repeated and the autonomic hyperreflexia resolved. CONCLUSIONS: Autonomic hyperreflexia can develop in unanesthetized laboring paraplegic patients (failed epidural) but it can be successfully managed with adequate epidural anesthesia.

Epidural morphine with butorphanol for postoperative analgesia after cesarean delivery.

Epidural morphine has been used more and more to provide long-lasting postoperative analgesia after cesarean delivery. However, the incidence of pruritus (20%-93%) and nausea (17%-60%) detract from the usefulness of epidural morphine. The purpose of this study was to evaluate, in 30 patients having epidural anesthesia for cesarean delivery, the analgesic efficacy and side effects when a combination of epidural morphine, a mu-receptor agonist, and butorphanol, a mu-receptor antagonist and kappa-receptor agonist, was administered. After clamping of the umbilical cord, patients received 4 mg epidural morphine with 3 mL of normal saline (group 1), 4 mg epidural morphine with 1 mg butorphanol and 2 mL of normal saline (group 2), or 4 mg epidural morphine with 3 mg butorphanol (group 3). Patients were monitored for 24 h after administration of the study medications. There were no significant differences between the groups in visual analogue pain scores, time to first analgesic request, respiratory rate, or Trieger dot test performance in the 24 h immediately after these epidural injections. There were three patients in group 1 and one patient in group 2 who experienced oxygen saturations less than 90%. (No patients in group 3 developed an oxygen saturation less than 92%.) The patients in group 3 did not require treatment for pruritus or nausea, a response significantly different (P less than 0.001 and P less than 0.05, respectively) from group 1 or group 2.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of epidural analgesia: some questions and answers.

The effects of epidural analgesia on first labors have been studied by Thorp and colleagues. One study has been published and is the subject of a question-and-answer discussion, presented here. In this study 711 consecutive nulliparous women at term, with spontaneous onset of labor and cephalic presentation, were divided into one group (n = 447) who received epidural analgesia in labor and another group (n = 264) who received narcotics or no analgesia. The frequency of cesarean section for dystocia was significantly greater (p less than 0.005) in the epidural group (10.3%) than in the nonepidural group (3.8%), even after selection bias was corrected and the variables of maternal age and race; gestational age; cervical dilatation on admission; use, duration, and maximum infusion rate of oxytocin; labor duration; presence of meconium; and birth weight were controlled. For both groups the frequency of cesarean section for fetal distress was similar (p less than 0.20), and the frequency of low Apgar scores at 5 minutes and cord blood gas values showed no significant differences. The authors concluded that "epidural analgesia in labor may increase the incidence of cesarean section for dystocia in nulliparous women".