RESUMEN
UNLABELLED: BACKGROUND AND AIM OF INVESTIGATION: Intramuscular (IM) administration has been considered to be safer than intravenous (IV) for opioids on wards, but a comparative knowledge of patient safety and analgesic potency following a single dose of IV and IM administration is lacking. This study was carried out to compare patient safety and analgesic efficacy of a single and high dose of morphine given IM or IV for post-operative pain management. MATERIALS AND METHODS: Thirty-eight patients with post-operative pain following hip replacement surgery were given IM or IV morphine 10 mg at a specified pain level. The study was randomized and double blinded. Time to onset of analgesic effect (11-point numeric rating scale), respiratory function (p(a)CO2, p(a)O2, and respiratory rate), level of sedation (5-point verbal rating scale), and hemodynamic function were recorded. RESULTS: In the IV group there was a slight but significant increase in p(a)CO2 after 5, 10, and 15 min compared with the IM group (5.2 vs. 4.8, 5.4, vs. 5.0 and 5.5 vs. 5.1 kPa, respectively). The IV group had a significantly faster onset of analgesic effect than the IM group (5 vs. 20 min). Between 5 and 25 min after morphine administration, pain status in the IV group was significantly improved compared with the IM group. Patients in the IV group were slightly more sedated than the IM group 5 and 10 min after morphine. CONCLUSION: A 10 mg bolus dose of IV morphine given to patients with moderate pain after surgery does not cause severe respiratory depression, but provides more rapid and better initial analgesia than 10 mg given IM. IV morphine even at a dose as high as 10 mg IV is well tolerated if there is a certain level of pain at its administration. The safety of IV morphine on the general ward needs to be further explored in adequately controlled studies.
Asunto(s)
Analgesia/métodos , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/efectos adversos , Morfina/administración & dosificación , Morfina/efectos adversos , Dolor Postoperatorio/tratamiento farmacológico , Anciano , Artroplastia de Reemplazo de Cadera , Análisis de los Gases de la Sangre , Método Doble Ciego , Femenino , Hemodinámica/efectos de los fármacos , Humanos , Inyecciones Intramusculares , Inyecciones Intravenosas , Masculino , Persona de Mediana Edad , Náusea/inducido químicamente , Dimensión del Dolor/métodos , Dimensión del Dolor/estadística & datos numéricos , Prurito/inducido químicamente , Respiración/efectos de los fármacos , Factores de Tiempo , Resultado del TratamientoRESUMEN
AIM: To compare the time course of morphine and metabolite concentrations in serum and cerebrospinal fluid (CSF) after intravenous and intramuscular administration after surgery. METHODS: This was a randomized double-blind, double-dummy study in patients who had undergone hip replacement surgery. Morphine (M, 10 mg) was administered intravenously (IV) or intramuscularly (IM). Arterial blood and CSF samples (from a spinal catheter) were drawn simultaneously at 10, 30, 60, and 120 min after administration. Morphine and metabolites [morphine-3-glucuronide (M-3-G), morphine-6-glucuronide (M-6-G), and normorphine (NM)] were determined by a validated liquid chromatography-tandem mass spectrometry method. RESULTS: Thirty-eight patients were included: 13 men and 25 women, 20 in the IV, 18 in the IM group. Serum concentrations of M after 10 min were consistently higher after IM than IV, concentrations of M-3-G and M-6-G after IM surpassed those of IV after 45 min. NM was not found. None of the metabolites was found in CSF. CSF morphine concentrations and CSF/serum concentration ratios were consistently higher after IV compared to IM. The mean AUC(CSF)/AUC(serum) (0-120 min) concentration ratios were 0.18 and 0.09 after IV and IM, respectively. CONCLUSIONS: The uptake of morphine to the CSF was consistently higher after IV administration than after IM already after 10 min. The higher CSF concentration may be caused by an initially higher morphine blood/CSF gradient following IV morphine injection. The pharmacokinetic findings are compatible with a more rapid and extensive initial effect of IV morphine compared with IM.
Asunto(s)
Analgésicos Opioides/farmacocinética , Artroplastia de Reemplazo de Cadera , Morfina/farmacocinética , Anciano , Analgésicos Opioides/administración & dosificación , Área Bajo la Curva , Bupivacaína/administración & dosificación , Bupivacaína/farmacocinética , Método Doble Ciego , Femenino , Humanos , Inyecciones Intramusculares , Inyecciones Intravenosas , Masculino , Midazolam/administración & dosificación , Midazolam/farmacocinética , Persona de Mediana Edad , Morfina/sangre , Morfina/líquido cefalorraquídeo , Derivados de la Morfina/sangre , Dimensión del Dolor/métodos , Dolor Postoperatorio/tratamiento farmacológico , Cuidados Posoperatorios/métodosRESUMEN
OBJECTIVES: To assess necessary treatment and degree of urgency for patients admitted to emergency rooms, and potential health consequences of transfer to nearest alternative hospital. METHODS: During 1 month, we included all 1,300 emergently admitted patients in all seven general hospitals in a Norwegian county with a population of 236,921 inhabitants. The number of patients in need of surgical and/or intensive medical treatment, the urgency of the necessary treatment, and the risk to each patient of adverse permanent health consequences of further transport to nearest alternative hospital were assessed by a multidisciplinary expert panel. RESULTS: Ninety-four patients (7.2% of 1300 patients) were considered in need of either surgical (n = 22) or intensive medical treatment (n = 70) or both (n = 2) within 8 hours of arrival in hospital. Medical treatment had the greatest urgency, while surgery most often could be postponed. In cases where the patients were initially to be given only stabilizing treatment and then transported (assisted by qualified personnel) to another hospital, the panel estimated the risk of losing health benefit to be high for 14 patients. In six of these cases the risk was linked to delay of thrombolytic treatment. CONCLUSIONS: Fewer than 10% of the patients who are admitted as emergency cases to general hospitals in Norway need surgical or intensive medical treatment within 8 hours of their arrival. The medical consequences of transport of patients to the nearest alternative hospital are generally small and can often be further reduced by simple means.
Asunto(s)
Urgencias Médicas , Servicio de Urgencia en Hospital/estadística & datos numéricos , Mal Uso de los Servicios de Salud/estadística & datos numéricos , Hospitales Generales/estadística & datos numéricos , Admisión del Paciente/estadística & datos numéricos , Adolescente , Adulto , Distribución por Edad , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Grupos Diagnósticos Relacionados/clasificación , Grupos Diagnósticos Relacionados/estadística & datos numéricos , Investigación sobre Servicios de Salud , Humanos , Lactante , Persona de Mediana Edad , Evaluación de Necesidades , Noruega , Factores de Tiempo , Triaje/métodos , Revisión de Utilización de RecursosAsunto(s)
Anestesia Local , Laminectomía/métodos , Humanos , Masculino , Persona de Mediana Edad , CuelloRESUMEN
BACKGROUND: The evacuation of emergency cases by air, usually by helicopter, is controversial because of the cost of the programme, the possibility of an accident (especially in an urban area), and unproven benefit. But such evacuations cannot be studied by a random intervention (eg, air versus ground ambulance). We used an expert-panel approach to estimate the health outcome for patients transferred by emergency helicopter compared with the potential outcome if they had gone by surface ambulance. METHODS: The helicopter programme is based at the University Hospital of Tromsø in northern Norway. 370 case-reports of helicopter evacuation from rural areas were screened by anaesthetists for routine and case-specific data. Two expert panels assessed the cases for potential additional health benefit arising from the fact of helicopter evacuation. The panels used a modified Delphi technique to reach consensus in life-years gained. One panel met for cases aged under 15 and pregnant women, the other for older cases. FINDINGS: 240 of the 370 cases were male (65%); the age range for both sexes was 0-86 years. The most common diagnosis for the 55 cases aged under 15 was infection (49%); in older patients, cardiovascular disease dominated (50%). Trauma accounted for just under a fifth of cases in both groups. On average, the patients arrived 69 min (range 0-615) earlier in hospital than if they had gone by ground transport. For 283 cases, the initial screening by the anaesthetists indicated no additional benefit compared with that obtainable by ground-ambulance transport. The main reason was that no treatment was given during the flight or early on in hospital that could not have been given otherwise. 90 cases entered the expert panel system. Of these 90, 49 cases were judged to have received no additional benefit. This left 41 (11% of the total of 370 evacuated) who were judged to have benefited, gaining 290.6 life-years. 96% of the total number of life-years gained was achieved in nine patients, six of whom were aged below 7 (four were aged 0-7 months). The life-year-gain per adult patient with cardiovascular disease was 0.54. INTERPRETATION: We conclude that an emergency helicopter service can provide considerable health benefits for selected patients, at least in this rural setting. Given the costs and risks of such a service, the benefits for most patients are small.
Asunto(s)
Ambulancias Aéreas , Evaluación de Resultado en la Atención de Salud , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Técnica Delphi , Urgencias Médicas , Femenino , Humanos , Lactante , Masculino , Persona de Mediana Edad , Embarazo , Años de Vida Ajustados por Calidad de Vida , Población RuralRESUMEN
Extracorporeal membrane oxygenation (ECMO) may serve as extracorporeal lung assist (ECLA) in patients with acute respiratory failure (ARF) or as extracorporeal heart assist (ECHA) in patients with low output syndrome (LOS) after open heart surgery. From 1988 to 1992 seven patients underwent ECMO in our hospital; four suffered from ARF and three from LOS. Various bypass techniques were employed. Two ARF patients, aged 58 and 18 years, had veno-venous bypass; in the latter, ECMO was reinstituted as a veno-arterial bypass one week after weaning. In a three-year-old boy, the ECMO outflow tubing was primarily connected to the pulmonary artery, and shortly afterwards relocated to the common carotid artery. In a 31-year-old man with ARF, and three LOS patients, a 56-year-old woman, and two men aged 68 and 70 years, ECMO was veno-arterial with direct access to the ascending aorta. A heparin-coated system was used, and all but one patient, who was treated with warfarin, received a daily low dose of heparin, which was withdrawn after from one to nine days. Six patients were weaned off ECMO after 4.5 to 21 days. Three ARF patients recovered completely; the child died. In one LOS patient, ECMO was withdrawn due to a poor general condition. Two others were weaned off ECMO and the intra-aortic balloon pump, and the inotropic support was significantly reduced, but both died of multiple system organ failure. Although no firm conclusions can be drawn from these few case reports, the heparin-coated system used as ECLA appears promising, whereas ECHA seems to imply a poor prognosis in patients who are not candidates for cardiac transplantation.
Asunto(s)
Gasto Cardíaco Bajo/terapia , Oxigenación por Membrana Extracorpórea , Corazón/fisiopatología , Pulmón/fisiopatología , Insuficiencia Respiratoria/terapia , Enfermedad Aguda , Adolescente , Adulto , Anciano , Anticoagulantes/administración & dosificación , Anticoagulantes/uso terapéutico , Aorta , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Arteria Carótida Común , Niño , Preescolar , Oxigenación por Membrana Extracorpórea/instrumentación , Oxigenación por Membrana Extracorpórea/métodos , Femenino , Heparina/administración & dosificación , Heparina/uso terapéutico , Humanos , Contrapulsador Intraaórtico , Masculino , Persona de Mediana Edad , Insuficiencia Multiorgánica , Arteria Pulmonar , Tasa de Supervivencia , Síndrome , Warfarina/administración & dosificación , Warfarina/uso terapéuticoRESUMEN
In 1988 a nation-wide aeromedical emergency service (AES) (12 helicopters and five fixed wing aircraft) was introduced in Norway. An important objective was equity--to offer equal access to treatment for the same need irrespective of age and geographical location. In 1989 cardiovascular disease accounted for 34% of the 282 missions in the county of Troms in Northern Norway, but the use of the helicopters did not reflect the age-related increase in the incidence of this disease. Across the municipalities there was considerable variation in use of helicopters which could not be accounted for by density of doctors, distance to the nearest hospital, population density or coverage by ground ambulances. We believe that the key determinant of the use of helicopters may be varying attitudes among the doctors to the use of AES. The findings indicate that AES does not meet the objective of equity. Stricter medical guidelines for use of AES are called for.
Asunto(s)
Aeronaves , Transporte de Pacientes/métodos , Adolescente , Adulto , Anciano , Aeronaves/estadística & datos numéricos , Niño , Preescolar , Urgencias Médicas/epidemiología , Servicios Médicos de Urgencia , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Noruega/epidemiología , Transporte de Pacientes/estadística & datos numéricosRESUMEN
Extracorporeal membrane oxygenation was introduced as a supplement ot mechanical ventilation in the treatment of two patients with severe acute respiratory failure and as heart assist in one patient with acute refractory cardiac failure after open heart surgery. The system includes a membrane oxygenator and a roller pump. The whole circuit is coated with partially degraded heparin covalently bound to the surface (Carmeda Bioactive Surface), reducing the need of systemic heparinization to a minimum. In the first case of acute respiratory failure a veno-venous bypass was employed, with cannulas in the right atrium and the femoral vein. Given a blood flow through the circuit of 2.5 l/min, ventilator settings could be favourably reduced. The patient was weaned off the bypass system after six days, off the ventilator after 120 days, and recovered completely. In two cases the system served as partial venoarterial bypass, and blood was returned to the ascending aorta. A 31 year-old male victim of a smoke inhalation lung injury was on bypass for four and a half days. He recovered completely after another 17 days of mechanical ventilation. A 68 year-old man with pump failure after cardiac surgery needed extracorporeal support as heart assist for seven days. On the eighth day he was weaned off intra-aortic balloon-pumping as well. Unfortunately, he died of septicemia, with multiple organ failure, 13 days later. The heparin-coated extracorporeal membrane oxygenation system may represent a major advancement in the treatment of critically ill patients in need of cardiopulmonary assist.
Asunto(s)
Oxigenación por Membrana Extracorpórea , Insuficiencia Cardíaca/terapia , Insuficiencia Respiratoria/terapia , Enfermedad Aguda , Adulto , Anciano , Dióxido de Carbono/sangre , Oxigenación por Membrana Extracorpórea/métodos , Insuficiencia Cardíaca/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Oxígeno/sangre , Presión Parcial , Respiración con Presión Positiva , Insuficiencia Respiratoria/fisiopatologíaRESUMEN
This historically prospective study analysed hospital costs and long-term outcome in 249 consecutive patients who required intensive care including intermittent positive pressure ventilation (IPPV) for 48 h or more. The mean age of the patients was 46.7 years and the mean duration on IPPV was 9.1 days. Mortality in hospital was 43%, increasing to 54.6% five years after admission. The mean cost per patient treated was 22,823 US dollars (USD (1980 value]. The mean cost to yield one survivor was 40,035 USD. The mean cost per survivor was 26,056 USD, whereas that of a non-survivor was 18,500 USD. The cost-benefit ratio, i.e. calculated cost per year of extended life until the age of 75 years, averaged 1420 USD (range 360-7980 USD). With the exception of patients suffering from cancerous diseases, the cost-benefit ratio found in this study was favourable in comparison to other high-cost medical care. This is further emphasized by the fact that for the years saved, the quality of life was mostly good.
Asunto(s)
Cuidados Críticos/economía , Ventilación con Presión Positiva Intermitente/economía , Evaluación de Procesos y Resultados en Atención de Salud , Respiración con Presión Positiva/economía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Análisis Costo-Beneficio , Cuidados Críticos/mortalidad , Femenino , Estudios de Seguimiento , Hospitales Universitarios , Humanos , Ventilación con Presión Positiva Intermitente/mortalidad , Masculino , Persona de Mediana Edad , Noruega , Calidad de Vida , Factores de TiempoRESUMEN
35S-thiopental 15 mg/kg and 14C-diazepam 5 mg/kg were injected intravenously in separate groups of rats (n = 6) at 1 ATA air and at 71 ATA air-He. Total radioactivity was measured in the brain, liver, kidney, muscle and fat after 1, 3, 5 and 15 min. The thiopental content was significantly reduced at pressure in the brain at 3, 5 and 15 min. The diazepam content of the brain was significantly reduced at pressure at 1, 5 and 15 min. The liver, muscle and kidney tissue generally contained slightly less of either drug at pressure, particularly at the earliest sampling times.