[The profit of the anesthetic work in Tsukuba Medical Center Hospital]

Recently, it has been reported that many hospitals in Japan are facing financial difficulties. In order to study profit and loss of anesthetic work, we calculated costs and fees of 78 anesthetic cases experienced in Tsukuba Medical Center hospital in April, 1993, using our original formula. We compared the profit per hour among 4 groups; the local anesthesia with subcutaneous injection, the general anesthesia alone, the general anesthesia with epidural anesthesia or brachial plexus block, and the epidural and/or spinal anesthesia. Furthermore we compared elective cases with emergency surgery in each group. The profits of the anesthetic work were about -120000 yen for a month. There were two factors which influenced the profits of the hospital, one was whether we selected the general anesthesia or not, and the other was the length of the anesthetic time. The loss in the emergency surgery with the epidural and/or spinal anesthesia was greater than the elective surgery with the same anesthesia. However, in the other anesthesia groups, there were no differences between elective and emergency surgery.

Efficacy of an epidural test dose in adult patients anesthetized with isoflurane: lidocaine containing 15 micrograms epinephrine reliably increases arterial blood pressure, but not heart rate

When continuous epidural anesthesia is combined with general anesthesia, the only objective sign of intravascular migration of the epidural catheter are the increments of heart rate (HR) or arterial blood pressure after a local anesthetic test dose containing epinephrine. However, the efficacy of a simulated intravenous (IV) test dose in adult patients under general anesthesia has not been determined. Thirty adult patients were randomly assigned to one of two groups, each of which was anesthetized with 1% end-tidal isoflurane and nitrous oxide after endotracheal intubation. The epinephrine group (n = 15) was given 3 mL of 1.5% lidocaine with epinephrine (1:200,000) IV to simulate an IV administered epidural test dose. The saline group (n = 15) was identical to epinephrine group, but received 3 mL of normal saline IV. HR and arterial blood pressure were measured at 20-s intervals for 4 min after IV injection. In the epinephrine group, significant increases in HR compared with the baseline value were observed from 40 to 80 s after the IV test dose with a mean maximum HR increase of 24 +/- 2 bpm (mean +/- SEM) occurring at 48 +/- 3 s. However, 5 of 15 patients in the epinephrine group developed HR increments smaller than 20 bpm (sensitivity 67%). Since HRs were essentially unchanged in the saline group, specificity, positive predictive value (+PV), and negative predictive value (-PV) were 100%, 100%, and 75%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Toe skin temperature as a guide to epidural anaesthesia dosing

To determine the time for additional epidural anaesthesia, skin temperature of the big toe was evaluated in 50 patients undergoing mastectomy. Epidural catheters were placed at or near the T5-6 intervertebral space and 12 ml, lidocaine 1.5% with 1:200,000 epinephrine were injected. When the skin temperature, which had increased following epidural anaesthesia, decreased by 0.3 degrees C without an increase of systolic arterial blood pressure (ABP) of more than 20%, 8 ml lidocaine 1.5% were injected. If the skin temperature increased, the monitor was judged to have been useful. When ABP increased > 20% without a decrease of skin temperature, the monitor was judged not to have been useful. Monitoring of toe skin temperature was useful in 39 patients (78%) in estimating the time for the first additional dose of epidural anaesthetic. First, second and third intervals between injection were 96.5 +/- 21.0 (n = 39), 69.7 +/- 14.2 (n = 35) and 50.1 +/- 12.2 min (n = 7), respectively. We conclude that, when epidural puncture is performed at upper thoracic levels, toe skin temperature can be a useful monitor to judge the time for additional anaesthetic.

Minimum effective combination dose of epidural morphine and fentanyl for posthysterectomy analgesia: a randomized, prospective, double-blind study

Recent studies have produced conflicting results regarding whether the addition of epidural fentanyl improves postoperative analgesia from epidural morphine. Therefore, we prospectively determined the dose-response relationship and the minimum effective combination dose of epidural morphine and fentanyl (fentanyl given after morphine) for posthysterectomy analgesia. We studied 120 patients undergoing radical abdominal hysterectomy. All patients had epidural lidocaine 1.5% with epinephrine (1:200,000) for surgical anesthesia followed by light general anesthesia with endotracheal intubation. They were assigned randomly into six groups according to the combination of each narcotic dose: morphine 2 mg, morphine 2 mg/fentanyl 50 micrograms, morphine 2 mg/fentanyl 100 micrograms, morphine 4 mg, morphine 4 mg/fentanyl 50 micrograms, and morphine 4 mg/fentanyl 100 micrograms. Morphine and fentanyl were given epidurally in a double-blind manner approximately 60 and 15 min, respectively, before the completion of surgery. For 2 mg of morphine, the addition of 50 or 100 micrograms of fentanyl improved pain relief during the first 6 h postoperatively (P < 0.05), provided longer duration of analgesia (P < 0.05), and required less analgesic supplement (P < 0.05), but did not alter the incidence of side effects. For 4 mg of morphine, the same conclusion was drawn, except that vomiting occurred more frequently with addition of 100 micrograms of fentanyl (P < 0.05). Among fentanyl groups, there was no significant difference in pain scores, duration of analgesia, and analgesic requirements. Therefore, we conclude that epidural fentanyl given after morphine improves early postoperative analgesia from epidural morphine, and the minimum effective combination dose is morphine 2 mg/fentanyl 50 micrograms for posthysterectomy surgery analgesia.

[The usefulness of a pulse oximeter on the postanesthesia round]

In our hospital, a patient must be transported to one of several types of wards according to the degree of severity of illness (PPC-system). Severely ill patients are surveyed in ICU and HCU with various kinds of monitors. On the contrary, for the patients outside the ICU and HCU wards, the number of monitors is not enough even during postoperative periods. Therefore, we studied the occurrence of hypoxic state of patients with a portable pulse oximeter on postanesthesia round. We surveyed 843 patients during 4 months, and found 79 hypoxemic patients. The number of hypoxemic patients was greater not only after longer operations and anesthesia, but also in obese patients (P < 0.05) as reported previously. Interestingly, we also found more hypoxemic patients in common wards than in ICU and HCU wards. In conclusion, a portable pulse oximeter is a useful equipment in ordinary wards during postanesthesia round.