RESUMEN
AIMS: To develop a computer processable algorithm, capable of running automated searches of routine data that flag miscoded and misclassified cases of diabetes for subsequent clinical review. METHOD: Anonymized computer data from the Quality Improvement in Chronic Kidney Disease (QICKD) trial (n = 942,031) were analysed using a binary method to assess the accuracy of data on diabetes diagnosis. Diagnostic codes were processed and stratified into: definite, probable and possible diagnosis of Type 1 or Type 2 diabetes. Diagnostic accuracy was improved by using prescription compatibility and temporally sequenced anthropomorphic and biochemical data. Bayesian false detection rate analysis was used to compare findings with those of an entirely independent and more complex manual sort of the first round QICKD study data (n = 760,588). RESULTS: The prevalence of definite diagnosis of Type 1 diabetes and Type 2 diabetes were 0.32% and 3.27% respectively when using the binary search method. Up to 35% of Type 1 diabetes and 0.1% of Type 2 diabetes were miscoded or misclassified on the basis of age/BMI and coding. False detection rate analysis demonstrated a close correlation between the new method and the published hand-crafted sort. Both methods had the highest false detection rate values when coding, therapeutic, anthropomorphic and biochemical filters were used (up to 90% for the new and 75% for the hand-crafted search method). CONCLUSIONS: A simple computerized algorithm achieves very similar results to more complex search strategies to identify miscoded and misclassified cases of both Type 1 diabetes and Type 2 diabetes. It has the potential to be used as an automated audit instrument to improve quality of diabetes diagnosis.
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Algoritmos , Diabetes Mellitus Tipo 1/diagnóstico , Diabetes Mellitus Tipo 2/diagnóstico , Sistemas de Registros Médicos Computarizados , Teorema de Bayes , Recolección de Datos/normas , Diabetes Mellitus Tipo 1/epidemiología , Diabetes Mellitus Tipo 2/epidemiología , Errores Diagnósticos , Humanos , Proyectos PilotoRESUMEN
BACKGROUND: End-digit preference (EDP) is a known cause of inaccurate BP recording. Distortion has been reported around pay-for-performance (P4P) indicators. METHODS: We studied sequential datasets (n = 148,000 to n = 900,000) and performed a longitudinal analysis of CONDUIT data (n = 250,000) over a 10-year period. We examined general trends in EDP and investigated the impact of diabetes and chronic kidney disease (CKD) P4P targets. RESULTS: EDP reduces over time in both datasets; the percentage of patients with a zero EDP declined from 70% to 27% and 68% to 26% for SBP and DBP respectively. There is more zero EDP at the extremes of BP, but in people with chronic disease, the use of zero EDP was mainly seen at higher BP levels. P4P targets are associated with increased preference for the even end-digit just below target: in diabetes odds ratio (OR) is 1.47 (p = 0.003) for SBP, 1.19 (p = 0.09) for DBP and in CKD OR 1.65 (p < 0.001) for SBP and 1.48 (p = 0.0001) for DBP. Trends observed in pilot data were validated with a longitudinal set. CONCLUSIONS: The decline in EDP is levelling off and P4P targets are associated with sub-target-EDP. Primary care should automate BP measurement and recording.
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Presión Sanguínea/fisiología , Diabetes Mellitus/fisiopatología , Enfermedades Renales/fisiopatología , Infarto del Miocardio/fisiopatología , Determinación de la Presión Sanguínea/métodos , Determinación de la Presión Sanguínea/normas , Determinación de la Presión Sanguínea/tendencias , Enfermedad Crónica , Humanos , Estudios Longitudinales , Reembolso de Incentivo , Sensibilidad y Especificidad , Esfigmomanometros/normasRESUMEN
AIMS: Incorrect classification, diagnosis and coding of the type of diabetes may have implications for patient management and limit our ability to measure quality. The aim of the study was to measure the accuracy of diabetes diagnostic data and explore the scope for identifying errors. METHOD: We used two sets of anonymized routinely collected computer data: the pilot used Cutting out Needless Deaths Using Information Technology (CONDUIT) study data (n = 221 958), which we then validated using 100 practices from the Quality Improvement in Chronic Kidney Disease (QICKD) study (n = 760,588). We searched for contradictory diagnostic codes and also compatibility with prescription, demographic and laboratory test data. We classified errors as: misclassified-incorrect type of diabetes; misdiagnosed-where there was no evidence of diabetes; or miscoded-cases where it was difficult to infer the type of diabetes. RESULTS: The standardized prevalence of diabetes was 5.0 and 4.0% in the CONDUIT and the QICKD data, respectively: 13.1% (n = 930) of CONDUIT and 14.8% (n = 4363) QICKD are incorrectly coded; 10.3% (n = 96) in CONDUIT and 26.2% (n = 1143) in QICKD are misclassified; nearly all of these cases are people classified with Type 1 diabetes who should be classified as Type 2. Approximately 5% of T2DM in both samples have no objective evidence to support a diagnosis of diabetes. Miscoding was present in approximately 7.8% of the CONDUIT and 6.1% of QICKD diabetes records. CONCLUSIONS: The prevalence of miscoding, misclassification and misdiagnosis of diabetes is high and there is substantial scope for further improvement in diagnosis and data quality. Algorithms which identify likely misdiagnosis, misclassification and miscoding could be used to flag cases for review.
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Recolección de Datos/normas , Diabetes Mellitus Tipo 1/diagnóstico , Diabetes Mellitus Tipo 2/diagnóstico , Errores Diagnósticos , Adulto , Algoritmos , Diabetes Mellitus Tipo 1/epidemiología , Diabetes Mellitus Tipo 2/epidemiología , Femenino , Humanos , Masculino , Sistemas de Registros Médicos Computarizados , Proyectos PilotoRESUMEN
Early identification of patients with chronic kidney disease (CKD) may allow health-care systems to implement interventions aimed at decreasing disease progression and eventual morbidity and mortality. Primary care in the United Kingdom is computerized suggesting a separate screening program for CKD may not be necessary because identifying data already populates primary care databases. Our study utilized a data set of 163 demographic, laboratory, diagnosis, and prescription variables from 130 226 adults in the regions of Kent, Manchester, and Surrey. The patients were 18 years of age and older in a 5-year study period culminating in November 2003. Estimated glomerular filtration rate was calculated from the four-variable Modification of Diet in Renal Disease equation using calibrated creatinine levels. A valid creatinine value was recorded in almost 30% of this cohort. The age-standardized prevalence of stage 3-5 CKD was 10.6% for females and 5.8% for males. In these patients, the odds ratio for hypertension was 2.1, for diabetes 1.33, and for cardiovascular disease 1.69. Only 20% of the diabetic people with stage 3-5 CKD had a blood pressure less than or equal to 130/80 mm Hg. The proportion of patients with anemia significantly rose as renal function declined. We suggest that stage 3-5 CKD is easily detected in existing computerized records. The associated comorbidity and management is readily available enabling intervention and targeting of specialist resources.
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Diagnóstico por Computador/métodos , Enfermedades Renales/diagnóstico , Enfermedades Renales/terapia , Tamizaje Masivo/métodos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Anemia/complicaciones , Anemia/diagnóstico , Enfermedades Cardiovasculares/complicaciones , Enfermedades Cardiovasculares/diagnóstico , Enfermedad Crónica , Creatinina/sangre , Complicaciones de la Diabetes/complicaciones , Complicaciones de la Diabetes/diagnóstico , Progresión de la Enfermedad , Femenino , Tasa de Filtración Glomerular/fisiología , Hemoglobinas/metabolismo , Humanos , Hipertensión/complicaciones , Hipertensión/diagnóstico , Riñón/metabolismo , Riñón/fisiopatología , Enfermedades Renales/etiología , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Reino UnidoRESUMEN
BACKGROUND: Statins are recommended for the secondary prevention of cardiovascular disease, although they are often used in suboptimal doses and some patients may not receive lipid-lowering therapy. The Primary Care Data Quality (PCDQ) programme is an audit-based educational intervention. OBJECTIVE: To report the PCDQ programme's effect on the cholesterol management in cardiovascular disease. Subjects and methods Anonymized general practice data from 99 practices; 5% (n = 29 915) had cardiovascular diagnoses. RESULTS: Mean cholesterol fell from 4.75 to 4.64 mmol l(-1); patients achieving cholesterol target (< 5 mmol l(-1)) rose from 45.3 to 53.2%. Coronary heart disease patients achieved better control (mean 4.57 mmol l(-1)) than those with stroke (4.87 mmol l(-1)) or peripheral vascular disease (4.93 mmol l(-1)). Statin prescribing increased from 57.5 to 62.7%. Patients with diabetes [odds ratio (OR) 2.06, 95% confidence interval (95% CI) 1.91-2.21], prior myocardial infarction (MI) (OR 1.93, 95% CI 1.80-2.07), revascularization (OR 1.52, 95% CI 1.33-1.73) and smokers (OR 1.31, 95% CI 1.23-1.39) were more likely to receive statins, whereas people aged 75+ (OR 0.48, 95% CI 0.45-0.50), females (OR 0.90, 95% CI 0.86-0.94) and non-CHD-diagnosed (OR 0.36, 95% CI 0.34-0.38) were less likely. CONCLUSIONS: Diagnostic coding and number of patients who had their cholesterol measured and treated increased. There was no significant change in dosage used or inequity between the different groups prescribed statins.
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Enfermedades Cardiovasculares/tratamiento farmacológico , Utilización de Medicamentos/estadística & datos numéricos , Medicina Familiar y Comunitaria/normas , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Hipercolesterolemia/tratamiento farmacológico , Auditoría Médica , Pautas de la Práctica en Medicina/estadística & datos numéricos , Atención Primaria de Salud/normas , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Enfermedades Cardiovasculares/complicaciones , Niño , Preescolar , Colesterol/sangre , Medicina Familiar y Comunitaria/educación , Femenino , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/administración & dosificación , Hipercolesterolemia/complicaciones , Hipercolesterolemia/diagnóstico , Lactante , Masculino , Persona de Mediana Edad , Selección de Paciente , Factores de Tiempo , Reino UnidoRESUMEN
BACKGROUND: National guidelines recommend bisphosphonates for secondary prevention of osteoporotic fractures; however, poor compliance may result in sub-optimal prevention. OBJECTIVE: This study reports the feasibility of using GP electronic records to identify poorly compliant post-menopausal women who may be at increased risk of fragility fractures. DESIGN: Cross-sectional study of general practice computer records. SUBJECTS: Women over 45 years, registered in 29 practices across England with a total population of approximately 200,000. METHODS: MIQUEST (Morbidity Information Query and Export Syntax) a data extraction application was used to extract prescription, diagnostic data and probable fragility fractures (hip, vertebral, wrist). All women >45 years who received a first prescription for a weekly bisphosphonate (alendronate or risedronate) at least a year before data extraction were identified. Each record was examined to determine the number of days of prescribed treatment. RESULTS: Of 97992 registered women, 44% (42734) were >45 years. Prevalence of likely fragility fractures in women over 45 was 5.1% (2195/42734). 3.0% (1286/42734, mean age 72 years) received a prescription for a bisphosphonate in the 360 day period prior to data extraction with a median duration of treatment of 267 days. 45% (584/1286) received prescriptions covering >288/360 days (Medicine Possession Ratio >80%); 13% (161/1286) collected prescriptions covering >360 days. In those prescribed bisphosphonates, 23% (294/1286) had a likely fragility fracture. CONCLUSIONS: Women >45 years with probable fragility fractures are more likely to be prescribed bisphosphonates, though less than half will be actually taking them as prescribed. GPs should use computer technology to identify poorly compliant patients who are unnecessarily at risk of fracture.
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Fracturas Óseas/etiología , Sistemas de Registros Médicos Computarizados , Osteoporosis Posmenopáusica/psicología , Cooperación del Paciente/psicología , Adolescente , Adulto , Distribución por Edad , Anciano , Anciano de 80 o más Años , Conservadores de la Densidad Ósea/uso terapéutico , Niño , Preescolar , Difosfonatos/uso terapéutico , Inglaterra/epidemiología , Métodos Epidemiológicos , Medicina Familiar y Comunitaria , Femenino , Fracturas Óseas/epidemiología , Humanos , Lactante , Masculino , Persona de Mediana Edad , Osteoporosis Posmenopáusica/complicaciones , Osteoporosis Posmenopáusica/tratamiento farmacológico , Distribución por SexoRESUMEN
OBJECTIVE: To determine the extent to which routinely collected general practitioner computer data could be used to create disease registers of patients with osteoporosis, and to report any improvement in data quality since previous studies. STUDY DESIGN: Audit using anonymized data extracted from general practice computer records from across England. METHODS: Morbidity Query Information and Export Syntax (MIQUEST) software was used to extract structured data from the 78 volunteer practices that participated in the study. The data were aggregated and analysed. RESULTS: There were 100-fold differences in the rates of recording of relevant data. Many patients receiving treatment had no diagnostic codes. Data about secondary causes of osteoporosis and fractures were more consistently recorded than data relating to falls. There were no data to indicate whether fractures were low impact. T-scores, the gold-standard measure of bone density, were very infrequently recorded. CONCLUSIONS: Sufficient data about secondary causes of osteoporosis exist, and these could be searched to identify patients at risk. Meanwhile, fracture recoding could be improved, including likely fragility fractures, and T-scores could be added to computer records. A systematic approach is needed to raise the computer records to a standard where they can be used as valid and reliable disease registers.
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Medicina Familiar y Comunitaria/organización & administración , Sistemas de Registros Médicos Computarizados/normas , Registros Médicos Orientados a Problemas/normas , Osteoporosis/diagnóstico , Osteoporosis/epidemiología , Sistema de Registros/normas , Accidentes por Caídas , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Enfermedades Óseas Metabólicas/complicaciones , Enfermedades Óseas Metabólicas/diagnóstico , Enfermedades Óseas Metabólicas/epidemiología , Niño , Preescolar , Inglaterra/epidemiología , Femenino , Fracturas Óseas/epidemiología , Fracturas Óseas/etiología , Humanos , Lactante , Masculino , Auditoría Médica , Informática Médica , Persona de Mediana Edad , Osteoporosis/complicaciones , Proyectos de Investigación , Medición de Riesgo , Factores de RiesgoRESUMEN
BACKGROUND: The intubating laryngeal mask airway (ILMA) is designed to facilitate blind tracheal intubation. The effect of a muscle relaxant on the ability to perform tracheal intubation through the ILMA device has not been previously evaluated. This randomized, double-blind, placebo-controlled study was designed to evaluate rocuronium, 0.2 or 0.4 mg/kg administered intravenously, on the success rate and incidence of complications associated with ILMA-assisted tracheal intubation. METHODS: A total of 75 healthy patients were induced with propofol 2 mg/kg and fentanyl 1 microg/kg intravenously. After insertion of the ILMA device, patients were administered either saline, rocuronium 0.2 mg/kg, or rocuronium 0.4 mg/kg in a total volume of 5 ml. At 90 s after administration of the study drug, tracheal intubation was attempted using a disposable polyvinyl tube. If unsuccessful, a reusable silicone tube was tried. In addition to recording the time and number of attempts required to secure the airway, the incidence of complications during placement of the tracheal tube and removal of the ILMA were noted. RESULTS: Tracheal intubation was successful in 76-96% of the patients. The overall success rates and times required to secure the airway were similar in all three treatment groups. The high-dose rocuronium group experienced less patient movement (8 vs. 28 and 48%) and coughing (12 vs. 20 and 52%) than the low-dose rocuronium and saline groups, respectively. Use of rocuronium was also associated with a dose-related decrease in the requirement for supplemental bolus doses of propofol during intubation and removal of the ILMA device. CONCLUSIONS: Use of rocuronium did not significantly improve the success rate in performing tracheal intubation through the ILMA. However, it produced dose-related decreases in coughing and movement after tracheal intubation and reduced difficulties associated with removal of the ILMA device.
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Androstanoles/administración & dosificación , Anestesia por Inhalación , Anestésicos Intravenosos , Fentanilo , Intubación Intratraqueal/métodos , Máscaras Laríngeas , Fármacos Neuromusculares no Despolarizantes/administración & dosificación , Propofol , Adulto , Androstanoles/farmacología , Relación Dosis-Respuesta a Droga , Método Doble Ciego , Femenino , Hemodinámica/efectos de los fármacos , Humanos , Masculino , Fármacos Neuromusculares no Despolarizantes/farmacología , RocuronioRESUMEN
PURPOSE: The purpose of this study was to evaluate the effectiveness of ketorolac combined with local anesthetics for anorectal surgery. METHODS: From June 1998 through March 1999, 123 outpatients undergoing anorectal surgery were entered into a prospective, randomized, double-blinded study involving three treatment groups. All patients received intravenous sedation consisting of fentanyl and a propofol infusion, with a local anesthesia mixture of lidocaine, bupivacaine, and bicarbonate. Group A (41 patients) received placebo (saline) injections. Group B (41 patients) received 60 mg of intravenous ketorolac at the onset of the procedure, and Group C (41 patients) received 60 mg of ketorolac mixed with the local anesthetic. Data were analyzed using analysis of variance and chi-squared tests. RESULTS: All groups had similar demographic characteristics and operative procedures. Twenty-nine of the 123 patients were human immunodeficiency virus-positive. There was no difference in operative or anesthesia time. Anesthesia and fluids given were similar in across groups. A significantly higher percentage of Group A patients had pain (34 percent) and required additional oral analgesia (20 percent) in the Day Surgery Unit. Only 5 percent of Group B and Group C patients complained of pain, with oral analgesics given to 2 percent of Group B and none in Group C. Voiding difficulties were more common in Group A patients, one patient requiring catheterization. CONCLUSION: The addition of ketorolac (60 mg), either intravenous or injected with local anesthetics, reduces voiding problems and significantly decreases postoperative analgesic requirements in outpatients undergoing anorectal surgery.
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Procedimientos Quirúrgicos Ambulatorios , Antiinflamatorios no Esteroideos/uso terapéutico , Procedimientos Quirúrgicos del Sistema Digestivo , Ketorolaco/uso terapéutico , Adulto , Anestésicos Locales , Fístula del Sistema Digestivo/cirugía , Método Doble Ciego , Femenino , Hemorroides/cirugía , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
PURPOSE: To determine the incidence of post-discharge nausea and vomiting (PDNV) following outpatient laparoscopic procedures in women, and to assess the efficacy of the prophylactic administration of promethazine prior to discharge from hospital. METHODS: Ninety-five healthy women scheduled for ambulatory laparoscopic cholecystectomy or gynecological surgery completed this double blind, placebo controlled study. A standardized fentanyl-propofol-nitrous oxide-isoflurane anesthetic was used, and all patients received 0.5 mg droperidol i.v., intraoperatively. Subjects were randomized to receive 0.6 mg x kg(-1) promethazine or placebo i.m. prior to transfer from the post-anesthetic recovery (PAR) unit. The incidence and severity of nausea, pain, and drowsiness were documented using patient diaries at four time intervals during the first 24 hr postoperatively using four-point self-assessment scales. RESULTS: After discharge home, the overall incidence of nausea was 48%, moderate to severe nausea 30%, vomiting 17% and rescue antiemetic use 28%, with no difference between those receiving saline or promethazine. The need for antiemetics in the PAR was associated with subsequent PDNV, with those requiring PAR antiemetics being four times as likely to vomit after discharge (P = 0.008). CONCLUSION: Despite the prophylactic administration of 0.5 mg droperidol i.v., patients undergoing ambulatory laparoscopic surgery reported a high incidence of nausea after discharge. Patients requiring antiemetics in the PAR were at higher risk for PDNV. The incidence of nausea was not altered by prophylactic administration of 0.6 mg x kg(-1) promethazine i.m. before discharge.
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Procedimientos Quirúrgicos Ambulatorios , Antieméticos/uso terapéutico , Laparoscopía/efectos adversos , Náusea y Vómito Posoperatorios/prevención & control , Prometazina/uso terapéutico , Adulto , Colecistectomía/efectos adversos , Método Doble Ciego , Femenino , Procedimientos Quirúrgicos Ginecológicos , Humanos , Complicaciones Posoperatorias/inducido químicamente , Complicaciones Posoperatorias/psicología , Náusea y Vómito Posoperatorios/epidemiología , Estudios Prospectivos , Medición de RiesgoRESUMEN
BACKGROUND: The cuffed oropharyngeal airway is a modified Guedel-type oral airway with a cuff at its distal end. The objectives of this study were to compare the ability of the cuffed oropharyngeal airway and the laryngeal mask airway to provide positive-pressure ventilation during general anesthesia, and to assess their relative ease of use and ability to reduce total fresh gas flow rates. METHODS: In this prospective, randomized study, a cuffed oropharyngeal airway (n = 25) or a laryngeal mask airway (n = 25) device was inserted after induction of anesthesia intravenously using 2 mg/kg propofol. While anesthesia was maintained with sevoflurane and nitrous oxide, the leak pressure, leak fraction (the fractional difference between the inspired and expired tidal volume), minimum fresh gas flow rate, and need for airway manipulations were determined. The anesthesia provider who inserted the device completed an evaluation form at the end of the 15-min study period. RESULTS: Positive-pressure ventilation was established successfully on the first attempt in 92% of the patients when the cuffed oropharyngeal airway was used and in 88% of the patients when the laryngeal mask airway device was used. However, manipulations of the airway device were necessary more frequently (8 vs. 1 patient; P < 0.05) and the leak pressure was less (22 +/- 6 cm water vs. 26 +/- 5 cm water; P < 0.05) with the cuffed oropharyngeal airway than with the laryngeal mask airway. In addition, the leak fraction (0.19 +/- 0.18 vs. 0.31 +/- 0.22; P < 0.05) and the minimum fresh gas flow rate (1.3 +/- 1.5 vs. 2.4 +/- 2.5; P = 0.12) were less in the laryngeal mask airway group. CONCLUSIONS: Positive-pressure ventilation is possible with the laryngeal mask airway and cuffed oropharyngeal airway devices. Although the cuffed oropharyngeal airway can be inserted easily by inexperienced users with a high first-attempt success rate (> 90%), manipulations of the device may be required to maintain a patent airway. The laryngeal mask airway device allows positive-pressure ventilation at slightly greater peak inspiratory pressures.
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Anestesia General , Máscaras Laríngeas , Respiración con Presión Positiva , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Orofaringe , Propofol/farmacología , Estudios ProspectivosRESUMEN
BACKGROUND: Women awaiting needle-guided breast biopsy procedures may experience high anxiety levels. A randomized, double-blind, placebo-controlled study was designed to evaluate the ability of midazolam and diazepam (in a lipid emulsion [Dizac]) to improve patient comfort during needle localization and breast biopsy procedures. METHODS: Ninety women received two consecutive doses of a study medication, one before the mammographic needle localization and a second before entering the operating room. Patients were assigned randomly to receive saline, 2.0 ml intravenously, at the two time points; midazolam, 1.0 mg intravenously and 2.0 mg intravenously; or diazepam emulsion, 2.0 mg intravenously and 5.0 mg intravenously, respectively. Patients assessed their anxiety levels before the needle localization, before entering the operating room, and on arrival in the operating room. Patients completed a questionnaire evaluating their perioperative experience at the time of discharge. RESULTS: Patient satisfaction during needle localization was significantly improved in both benzodiazepine treatment groups (vs. saline). The incidence of moderate-to-severe discomfort during needle localization was lower in the midazolam (20%) and diazepam emulsion (6%) groups compared with the saline group (70%) (P<0.05). The preoperative visual analogue scale anxiety scores were similar in all three groups. In the operating room, however, anxiety scores were 55% and 68% lower after midazolam (21+/-19) and diazepam emulsion (15+/-14) compared with saline (46+/-28). Finally, there was no difference in the time to achieve home-readiness or actual discharge time among the three groups. CONCLUSIONS: Premedication with midazolam or diazepam emulsion improved patients' comfort during needle localization procedures and significantly reduced intraoperative anxiety levels before breast biopsy procedures without prolonging discharge times. Use of diazepam emulsion may be an effective alternative to midazolam in this population.
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Anestesia Local , Anestésicos Intravenosos/administración & dosificación , Ansiolíticos/administración & dosificación , Biopsia con Aguja , Mama/patología , Diazepam/administración & dosificación , Adolescente , Adulto , Anciano , Método Doble Ciego , Femenino , Humanos , Persona de Mediana Edad , Satisfacción del Paciente , Encuestas y CuestionariosRESUMEN
UNLABELLED: This study was designed to test the hypothesis that outpatients with higher electroencephalographic (EEG) Bispectral Index (BIS) values at the end of anesthesia achieve a modified Aldrete score of 10 and satisfy fast-track eligibility criteria more rapidly after ambulatory surgery. Sixty consenting women undergoing laparoscopic tubal ligation procedures were studied. After premedication with midazolam 2 mg IV, anesthesia was induced with propofol 2 mg/kg IV, fentanyl 1.5 microg/kg IV, and succinylcholine 1 mg/kg IV and was initially maintained with either desflurane 4% (n = 31) or a propofol infusion 100 microg kg(-1) min(-1) (n = 29), in combination with nitrous oxide 65% in oxygen. Subsequently, the inspired desflurane concentrations (2%-6%) and propofol infusion rates (50-150 microg.kg(-1) min(-1) were varied to maintain a clinically acceptable depth of anesthesia. The average BIS value during the 3-min interval immediately before the discontinuation of the maintenance anesthetics was recorded. Emergence times and modified Aldrete scores were assessed from the end of anesthesia until patients were considered fast-track-eligible. The BIS values at the end of anesthesia were significantly correlated with the time to reach fast-track eligibility in both the desflurane (r = -0.68) and propofol (r = -0.76) groups. We concluded that the EEG-BIS value at the end of anesthesia is useful in predicting fast-track eligibility after laparoscopic tubal ligation procedures with either a desflurane- or propofol-based anesthetic technique. IMPLICATIONS: In outpatients receiving either desflurane and propofol anesthesia for laparoscopic tubal ligation surgery, the times to achieve criteria for bypassing the recovery room (i.e., fast-tracking) correlated with the electroencephalographic-Bispectral Index values at the end of anesthesia.
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Procedimientos Quirúrgicos Ambulatorios , Periodo de Recuperación de la Anestesia , Anestesia General , Anestésicos por Inhalación , Anestésicos Intravenosos , Electroencefalografía , Isoflurano/análogos & derivados , Propofol , Adulto , Desflurano , Femenino , Humanos , Estudios ProspectivosRESUMEN
Fast-tracking in the ambulatory setting refers to the ability to transfer suitably recovered patients from the operating room directly to the Phase II (step-down) recovery area, bypassing the postanesthesia care unit. This article describes the concept of fast-tracking after ambulatory surgery and reviews anesthetic techniques that have helped to facilitate this process. The prevention and management of postoperative pain and nausea are also discussed.
RESUMEN
Impaired parasympathetic control of heart rate is associated with increased incidence of cardiac dysrhythmias and ischemia. Anticholinergic drugs suppress parasympathetic control and could be detrimental in the early postoperative period in high-risk patients. In this double-blind randomized trial, 30 ASA physical status I and II patients undergoing minor surgery received either atropine 20 micrograms/kg and neostigmine 50 micrograms/kg (Group A), glycopyrrolate 8 micrograms/kg and neostigmine 50 micrograms/kg (Group G), or placebo (Group P) for reversal of neuromuscular blockade. Two indices of parasympathetic modulation of heart rate, spontaneous baroreflex sensitivity, and high-frequency heart rate variability, were assessed. At 2 h after reversal, Group A showed persisting impairment of baroreflex sensitivity with respect to Group P (7.12 +/- 0.86 vs 12.71 +/- 1.38 ms/mm Hg, P = 0.022) as well as decreased high-frequency heart rate variability (280.8 +/- 30.1 vs 569.2 +/- 115.2 ms2/Hz, P = 0.015). Groups A and G showed a borderline decrease in normalized high-frequency variability at 2 h (P = 0.05 for Groups A and G versus Group P). Anticholinergic drugs with neostigmine cause impairment of parasympathetic control of heart rate which persists into the early postoperative period. The effects of glycopyrrolate appear to be of shorter duration; this drug may thus be preferable in patients at risk of cardiovascular complications.
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Atropina/administración & dosificación , Sistema Nervioso Autónomo/efectos de los fármacos , Glicopirrolato/administración & dosificación , Antagonistas Muscarínicos/administración & dosificación , Neostigmina/administración & dosificación , Bloqueo Neuromuscular , Adolescente , Adulto , Atropina/farmacología , Sistema Nervioso Autónomo/fisiología , Barorreflejo/efectos de los fármacos , Barorreflejo/fisiología , Método Doble Ciego , Femenino , Glicopirrolato/farmacología , Corazón/inervación , Frecuencia Cardíaca/efectos de los fármacos , Frecuencia Cardíaca/fisiología , Humanos , Masculino , Persona de Mediana Edad , Antagonistas Muscarínicos/farmacología , Neostigmina/farmacología , Parasimpaticomiméticos/administración & dosificación , Parasimpaticomiméticos/farmacología , Periodo PosoperatorioRESUMEN
Impaired parasympathetic control of heart rate is associated with increased incidence of cardiac dysrhythmias and ischemia. Anticholinergic drugs, commonly administered during reversal of neuromuscular blockade, suppress parasympathetic control in the early postoperative period. This could potentially be detrimental in patients at risk of cardiovascular complications. The duration of parasympathetic impairment by two anticholinergic drugs were compared in this double-blind randomized cross-over study. Fourteen healthy volunteers received a single intravenous injection of atropine 20 micrograms/kg or glycopyrrolate 8 micrograms/kg during two different study sessions. The methods of spontaneous baroreflex analysis and spectral analysis of heart rate variability generated indices of beat-by-beat parasympathetic modulation of heart rate. Both drugs resulted in a marked decrease in baroreflex sensitivity and high-frequency heart rate variability. The times to return to baseline values were approximately doubled after atropine compared to glycopyrrolate (177 +/- 22 vs 82 +/- 8 min for baroreflex sensitivity, 212 +/- 16 vs 111 +/- 14 min for high-frequency power, and 171 +/- 18 vs 95 +/- 18 min for high-frequency power normalized to total power; P < 0.01 for all variables). Atropine leads to more prolonged impairment of parasympathetic control than equipotent doses of glycopyrrolate, and its use may thus be less desirable in high-risk patients in the early postoperative period.