RESUMEN
The clinical characteristics of emergence delirium (ED) associated with post-traumatic stress disorder (PTSD) among military veterans encompass transient agitation, restlessness, disorientation, and violent verbal and physical behaviors due to re-experiencing of PTSD-related incidents. Two cases of ED after general anesthesia associated with PTSD are presented. Different anesthesia methods were applied for the two cases. A traditional medical approach appeared not to prevent the incidence of ED. In the second case, dexmedetomidine infusion along with verbal coaching was effective in preventing ED for a veteran known to have "wild wake-ups" with prior anesthetics. Further clinical studies in effectively utilizing dexmedetomidine in this population with PTSD at high risk for ED are warranted.
RESUMEN
BACKGROUND: The economic burden of caring for veterans with clinically severe obesity and its comorbidities is straining the Veterans Administration (VA) healthcare system. The authors determined the cost of Roux-en-Y Gastric Bypass (RYGBP) in the VA's single-payor healthcare system. METHODS: The records of all 25 patients who underwent RYGBP from May 1999 to October 2001 were reviewed. All obesity-related health-care costs including hospitalizations as well as outpatient visits, medications and home health devices were calculated for 12 months before and after the RYGBP. RESULTS: Age was 52+/-2 yr and preoperative BMI was 52+/-2 kg/m(2); ASA score was III (21 patients) and II (4 patients). Mean follow-up was 18 months. Total cost of care for these patients preoperatively was $10,778+/-2,460/patient (outpatient visits=$5,476+/-682, hospital admissions=$12,221+/-6,062, and home health devices=$1,383+/-349). Postoperative length of stay was 8+/-0.5 days. Cost of the gastric bypass was $8,976+/-497/pt (OR fixed cost=$1,900/patient + ICU and ward=$7,076+/-497/patient). For the first postoperative year, 6 patients had 12 admissions, but routine outpatient visits were significantly reduced from 55+/-6 to 18+/-2 postoperatively (P<0.001). The cost of all care excluding peri-operative charges for 1 year after gastric bypass was $2,840+/-622/patient (P=0.005 vs preop). CONCLUSIONS: Operative treatment of clinically severe obesity reduces obesity-related expenditures and utilization of healthcare resources. The cost of undertaking RYGBP at the VA is offset by reduction of health-care costs within the first year after surgery. These data support allocation of resources to support existing bariatric surgery programs throughout the VA system.