Ethical triage and scarce resource allocation during public health emergencies: tenets and procedures.

Public health emergencies may result in mass casualties and a surge in demand for hospital-based care. Healthcare standards may need to be altered to respond to an imbalance between demands for care and resources. Clinical decisions that involve triage and scarce resource allocation may present unique ethical challenges. To address these challenges, the authors detailed tenets and procedures to guide triage and scarce resource allocation during public health emergencies. The authors propose health care organizations deploy a Triage and Scarce Resource Allocation Team to over-see and guide ethically challenging clinical decision-making during a crisis period. The authors' goal is to help healthcare organizations and clinicians balance public health responsibilities and their duty to individual patients during emergencies in as equitable and humane a manner as possible.

High mortality rate in patients with advanced liver disease independent of exposure to general anesthesia.

STUDY OBJECTIVE: To evaluate the survival of patients with advanced liver disease to determine if known exposure to general anesthesia within a 5-year period has a measurable effect on mortality. DESIGN: Retrospective survival analysis of male veterans with advanced liver disease. SETTING: Tertiary referral VA Medical Center and university-affiliated teaching hospital. MEASUREMENTS: One hundred twenty-seven patients with a history of alcoholic cirrhosis and documented hepatitis C infection and stable platelet counts were identified and then divided into 3 groups. The 5-year survival rates in all 3 groups were compared using Kaplan-Meier survival curves. MAIN RESULTS: Ninety patients had marked thrombocytopenia (<100000/mm3). Their survival rates with and without known exposure to general anesthesia were compared with those of control subjects with alcoholic cirrhosis and hepatitis C infection but with platelet counts greater than 100000/mm3. The 5-year survival rate of 57% in the group that received general anesthesia was comparable to the 58% rate observed in the group without this exposure. Both groups' rates were statistically lower than the 5-year survival rate of 77% in the group with advanced liver disease but without thrombocytopenia. CONCLUSION: Comparably high mortality rates were observed in patients with advanced liver disease with or without exposure to general anesthesia. Higher survival rates were noted in patients with advanced liver disease who were not thrombocytopenic.

The impact of hepatitis C status on postoperative outcome.

UNLABELLED: The impact of the hepatitis C virus (HCV) infection on the postoperative complication rate is unknown. We identified a population of surgical patients (n = 2457) for whom the HCV antibody (anti-HCV) had been measured and compared after surgical complications and mortality between those who were positive (17.9%) versus negative. The complication rates were 10% in the anti-HCV positive and 13% in the negative group (P = 0.125), whereas the mortality rates were 0.7% and 2.5%, respectively (P = 0.017). The anti-HCV positive patients were younger, had lower ASA physical status, and underwent shorter procedures. In the univariate analysis, emergent surgery and high ASA physical status but not anti-HCV positivity were associated with a more frequent complication. In the multivariate analysis, the urgency of surgery, age, ASA physical status, length of surgery, and preoperative hematocrit (but not platelet count) were associated with complications. Anti-HCV positivity was associated with an odds ratio for having a complication of 1.08 (95% confidence interval, 0.90-1.30), which was not statistically significant (P = 0.405). In conclusion, we were unable to show HCV antibody status to be an independent risk factor for postoperative complications when other co-factors were considered. IMPLICATIONS: In this large study at a Veterans Administration medical center, the urgency of surgery, age, ASA physical status, length of surgery, and preoperative hematocrit were all independently associated with postoperative complications. However, hepatitis C infection was not an independent risk factor for postoperative complications.

Common mechanisms and strategies for prevention and treatment of cardiac arrest during epidural anesthesia.

Cardiac arrests continue to occur during epidural anesthesia and frequently result in death or brain damage. Although unintentional "total spinal" anesthesia, respiratory depression, myocardial ischemia, and local anesthetic toxicity can also lead to cardiac arrest, often the arrests do not fit any of these four categories. Many of the unexplained arrests may be attributed to vagal predominance. The evidence for a vagal-linked circulatory mechanism for these arrests is reviewed, and the characteristics that are associated with an increased risk for cardiac arrest during epidural anesthesia are identified. Specific strategies to forestall vagal predominance are discussed. In case these strategies fail, multiple interventions are discussed that should increase the likelihood of a successful resuscitation in the setting of extensive sympathetic blockade.

Effectiveness of preprinted order forms in promoting perioperative beta-blocker use.

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Economic aspects of an anesthesia preoperative evaluation clinic.

Studies continue to demonstrate that preoperative evaluation clinics help to prepare patients for surgery in a manner that minimizes cost and optimizes outcomes. These clinics are becoming common in both teaching and community hospitals. Many full service preoperative assessment clinics utilize specially trained nurses who are under the direction of an anesthesiologist. These clinics are associated with favorable outcomes, dramatic decreases in preoperative testing, infrequent subspecialty consultation and shorter lengths of stay. The current literature is reviewed and organizational and clinical changes that improve efficiency and patient care are highlighted.