RESUMEN
AIM: Rocuronium may be a good alternative to pancuronium in cardiac surgical patients. We evaluate the hemodynamic response to rocuronium and pancuronium administered to cardiac surgical patients. METHODS: A single-blind, randomized clinical trial was carried out at the National Institute of Cardiology in Mexico. Twenty-two patients older than 18 years, NYHA class III-IV, and scheduled to undergo an elective cardiovascular surgical procedure were enrolled. Patients were randomly allocated to receive an i.v. bolus dose of either pancuronium 100 microg/kg or rocuronium 600 microg/kg. Peripheral arterial (radial) and venous cannulations and insertion of a multi-lumen pulmonary artery flotation catheter through the right internal jugular vein were carried out under local anesthesia. Anesthetic induction with an i.v. bolus dose of fentanyl 700 microg and diazepam 20 mg was performed and thereafter the neuromuscular blocking agent was administered. Ventilation with O2 100% was performed until a TOF < or =5% was observed and tracheal intubation was performed. After intubation, patients were maintained with O2 10 mL/kg administered by means of a pulmonary ventilator at a pressure of 20-25 cm H2O. The basal, pre-laryngoscopy, post-intubation, and pre-operative recording of a set of cardiovascular parameters were obtained. RESULTS: No differences (P>0.05) in the hemodynamic response were observed between pancuronium and rocuronium nor during the different evaluation times in each group. CONCLUSIONS: Rocuronium can be a safe alternative to pancuronium for patients requiring cardiac surgical procedures.
Asunto(s)
Androstanoles , Procedimientos Quirúrgicos Cardíacos , Hemodinámica/efectos de los fármacos , Fármacos Neuromusculares no Despolarizantes , Pancuronio , Adulto , Androstanoles/economía , Anestesia General , Procedimientos Quirúrgicos Cardíacos/economía , Femenino , Humanos , Masculino , Fármacos Neuromusculares no Despolarizantes/economía , Pancuronio/economía , Rocuronio , Método Simple CiegoRESUMEN
STUDY OBJECTIVE: To determine whether placing price labels on the vial caps of muscle relaxants increases cost consciousness among anesthesiologists. DESIGN: Retrospective study. SETTING: University hospital departments of anesthesia and pharmacy. MEASUREMENTS AND MAIN RESULTS: We placed price labels on the vial caps of all muscle relaxants for a study period of 1 year. At the beginning of the investigation, we informed the anesthesiologists of the study, discussed the prices for different muscle relaxants, and encouraged utilizing less expensive muscle relaxants whenever possible without compromising patient care. The price labels on the vial caps served as visual reminders of the various costs of muscle relaxants during daily practice. We compared the total amount spent on each muscle relaxant during the period from October 1993 to September 1994 with the period from October 1994 to September 1995. The total number of surgical cases from October 1993 to September 1994 and from October 1994 to September 1995 was unchanged and equaled 20,389 and 20,358 cases, respectively. Expenditures for pancuronium increased 104.1%. Total expenditure decreased by 12.5%, with a net savings of $47,111. CONCLUSION: Expenditures for the less costly pancuronium increased while expenditures for vecuronium and atracurium decreased. Price labeling of muscle relaxants in conjunction with education reduces total pharmacy expenditure on muscle relaxants.
Asunto(s)
Anestesiología , Actitud del Personal de Salud , Costos de los Medicamentos , Etiquetado de Medicamentos , Fármacos Neuromusculares/economía , Androstanoles/economía , Servicio de Anestesia en Hospital/economía , Atracurio/economía , Control de Costos , Ahorro de Costo , Conocimientos, Actitudes y Práctica en Salud , Humanos , Capacitación en Servicio , Isoquinolinas/economía , Mivacurio , Fármacos Neuromusculares Despolarizantes/economía , Fármacos Neuromusculares no Despolarizantes/economía , Pancuronio/economía , Servicio de Farmacia en Hospital/economía , Estudios Retrospectivos , Rocuronio , Succinilcolina/economía , Tubocurarina/economía , Bromuro de Vecuronio/economíaRESUMEN
UNLABELLED: To test the hypothesis that the use of long-acting muscle relaxants is associated with prolonged postoperative recovery when compared with the use of shorter-acting relaxants, we undertook a retrospective study of 270 patients with induced paralysis recovering from general anesthesia. We calculated the mean recovery time associated with each muscle relaxant used. Regression analyses were performed to control for potential confounding of the results by length and type of surgery, as well as age and sex. Taking these into account, the adjusted difference in mean recovery time between patients receiving short- and intermediate-acting relaxants (mivacurium, atracurium, and vecuronium) versus those receiving long-acting relaxants (d-tubocurarine, pancuronium, and pancuronium and d-tubocurarine combination) was 30 min (95% confidence interval [CI] 8-53). The adjusted difference in mean recovery time between patients receiving vecuronium and those receiving pancuronium (i.e., the single most frequently used drug in each category) was 33 min (95% CI 1-66). Shortened recovery time accounted for an estimated average $37.95 decrease in recovery room charge per patient when vecuronium was used instead of pancuronium, versus a $22.84 increase in drug cost. Our data and analyses support the hypothesis that the use of long-acting muscle relaxants is associated with prolonged recovery after surgery and provide preliminary evidence that restricting the use of the more expensive, shorter-acting muscle relaxants may represent a false economy. IMPLICATIONS: In this retrospective study, the use of old-fashioned, inexpensive, long-acting paralyzing drugs was found to be associated with prolonged postoperative recovery. This has implications when deciding whether, as an economic measure, to restrict the use of the more expensive, shorter-acting paralyzing drugs, because prolonged recovery also has a price.
Asunto(s)
Periodo de Recuperación de la Anestesia , Fármacos Neuromusculares no Despolarizantes/economía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Anestesia General , Atracurio/administración & dosificación , Atracurio/economía , Niño , Preescolar , Ahorro de Costo , Costos de los Medicamentos , Femenino , Costos de Hospital , Humanos , Lactante , Isoquinolinas/administración & dosificación , Isoquinolinas/economía , Masculino , Persona de Mediana Edad , Mivacurio , Fármacos Neuromusculares no Despolarizantes/administración & dosificación , Pancuronio/administración & dosificación , Pancuronio/economía , Sala de Recuperación/economía , Sala de Recuperación/estadística & datos numéricos , Estudios Retrospectivos , Tubocurarina/administración & dosificación , Tubocurarina/economía , Bromuro de Vecuronio/administración & dosificación , Bromuro de Vecuronio/economíaAsunto(s)
Atracurio/farmacología , Enfermedad Crítica , Fármacos Neuromusculares no Despolarizantes/economía , Fármacos Neuromusculares no Despolarizantes/uso terapéutico , Taquifilaxis , Análisis Costo-Beneficio , Humanos , Isoquinolinas/economía , Isoquinolinas/uso terapéutico , Pancuronio/economía , Pancuronio/uso terapéuticoRESUMEN
When neuromuscular blockade becomes necessary in the intensive care unit, there are several options available in regard to both the drug and the mode of delivery (continuous versus intermittent administration). Despite extensive experience with intermediate acting drugs such as atracurium or vecuronium, these muscle relaxants are costly and may account for a significant portion of the pharmacy charges. We undertook an open label study to evaluate the efficacy and dosing requirements for a less costly drug, pancuronium. The study group included 25 patients ranging in age from 3 mo to 17 yr and in weight from 3.2 to 68 kg. If the patient had not previously received neuromuscular blocking agents (NMBAs), pancuronium was administered as a bolus dose of 0.1 mg/kg followed by a continuous infusion of 0.05 mg.kg-1.h-1. A nerve stimulator was applied to either the ulnar or peroneal nerve and a standard train-of-four (TOF) was monitored every 2 h. In patients that had previously received other NMBAs, no bolus dose of pancuronium was administered and the infusion was started at 0.05 mg.kg-1.h-1. The pancuronium infusion was increased or decreased by increments of 0.01 mg.kg-1.h-1 to maintain one to two twitches of the TOF. In patients that required an increase in the infusion rate, an additional bolus dose equivalent to the current hourly rate was administered and then followed by the increase in the infusion rate.(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Cuidados Críticos , Bloqueantes Neuromusculares/administración & dosificación , Pancuronio/administración & dosificación , Adolescente , Anticonvulsivantes/uso terapéutico , Niño , Preescolar , Costos de los Medicamentos , Estimulación Eléctrica , Femenino , Humanos , Lactante , Infusiones Intravenosas , Inyecciones Intravenosas , Masculino , Bloqueantes Neuromusculares/economía , Pancuronio/economía , Nervio Peroneo/efectos de los fármacos , Estudios Prospectivos , Nervio Cubital/efectos de los fármacosRESUMEN
The acceptance of new and increasingly expensive technologies is a major component of the rising costs of health care. While the practice of anesthesia has been relatively immune from the effects of cost containment, it is inevitable that practitioners will have to justify costly practices. Available pharmacoeconomic methods can be applied to the use of all anesthetic drugs, particularly neuromuscular blocking drugs. Cost-effectiveness analysis allows the practicing anesthesiologist to prioritize the use of neuromuscular blocking drugs to maximize their benefit while reducing unnecessary costs.
Asunto(s)
Anestesia/economía , Fármacos Neuromusculares no Despolarizantes/economía , Adulto , Control de Costos , Análisis Costo-Beneficio , Costos y Análisis de Costo , Toma de Decisiones , Costos de los Medicamentos , Femenino , Frecuencia Cardíaca/efectos de los fármacos , Humanos , Intubación Intratraqueal , Isoquinolinas/administración & dosificación , Isoquinolinas/economía , Masculino , Persona de Mediana Edad , Isquemia Miocárdica/fisiopatología , Isquemia Miocárdica/prevención & control , Fármacos Neuromusculares no Despolarizantes/administración & dosificación , Pancuronio/administración & dosificación , Pancuronio/economía , Pipecuronio/administración & dosificación , Pipecuronio/economía , Probabilidad , Factores de Riesgo , Bromuro de Vecuronio/administración & dosificación , Bromuro de Vecuronio/economíaRESUMEN
Nondepolarizing neuromuscular blocking agents (NNMBAs) are frequently administered to patients in the intensive care unit (ICU). We conducted a retrospective study of patients in intensive care who received infusions (> 48 hrs) of commonly used NNMBAs. The goals were to describe NNMBA use in our ICUs, determine patient characteristics, and assess the cost of the individual drugs. We found that atracurium was prescribed for 68% of study patients; 68% of the patients did not have renal, hepatic, or cardiovascular disease; dosages of NNMBAs varied; a statistically significant increase in dosage requirements over time occurred with atracurium; assessment of neuromuscular blockade was 100% subjective; and 41% and 17% of patients receiving atracurium and vecuronium, respectively, experienced prolonged neuromuscular weakness documented subjectively. As a result of this study, guidelines for agent selection were developed to facilitate cost effective use of NNMBA in our ICUs. Using these guidelines would potentially significantly decrease drug expenditures in this setting.
Asunto(s)
Fármacos Neuromusculares no Despolarizantes/uso terapéutico , Adulto , Anciano , Anciano de 80 o más Años , Atracurio/efectos adversos , Atracurio/economía , Atracurio/uso terapéutico , Preescolar , Ahorro de Costo , Costos de los Medicamentos , Revisión de la Utilización de Medicamentos , Femenino , Hospitales con 300 a 499 Camas , Humanos , Infusiones Intravenosas , Unidades de Cuidados Intensivos/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Minnesota , Pancuronio/efectos adversos , Pancuronio/economía , Pancuronio/uso terapéutico , Estudios Retrospectivos , Factores de Tiempo , Bromuro de Vecuronio/efectos adversos , Bromuro de Vecuronio/economía , Bromuro de Vecuronio/uso terapéuticoRESUMEN
We compared the pharmacodynamic effects and hospital costs of three long-acting neuromuscular blocking drugs in a prospective, randomized, double-blind manner. Each neuromuscular blocking drug was administered with fentanyl (50 micrograms/kg) for intravenous induction of anesthesia for coronary artery bypass surgery. Each patient received twice the 95% effective dose (ED95) of either pancuronium (0.14 mg/kg, n = 10), pipecuronium (0.10 mg/kg, n = 10), or doxacurium (0.05 mg/kg, n = 10). Hemodynamic measurements were recorded at baseline, 5 min after completion of anesthetic induction, immediately after endotracheal intubation, and 5 min after intubation. Only small hemodynamic differences between neuromuscular blocking drugs were observed. Doxacurium (but not pancuronium or pipecuronium) significantly decreased mean arterial blood pressure (from 94 +/- 4 mm Hg before induction to 83 +/- 3 mm Hg 5 min after intubation); nevertheless, there were no significant between-group differences at any time. Pancuronium increased heart rate (from 68 +/- 4 beats/min before induction to 76 +/- 5 beats/min 5 min after intubation); however, pancuronium differed significantly from doxacurium and pipecuronium only 5 min after induction and 5 min after intubation. Central venous pressure, pulmonary artery occlusion pressure, cardiac index, and systemic and pulmonary vascular resistance indices did not change. Electrocardiographic abnormalities were observed in two pipecuronium patients: ST segment depression in one and premature ventricular contractions in another. No other electrocardiographic changes were observed. There were no significant between-group differences in the need for hemodynamic interventions.(ABSTRACT TRUNCATED AT 250 WORDS)