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By: U. Mufassa, MD
Co-Director, Kaiser Permanente School of Medicine
Public reporting of outcomes associated with all aspects of care is now expected symptoms stomach flu purchase 100mg gabapentin otc, particularly in the United States medications jaundice cheap gabapentin 400 mg with amex. In some cases symptoms of mono generic gabapentin 800 mg without prescription, these large groups include other specialists medications you can give your cat 400mg gabapentin with amex, such as hospitalists, emergency department physicians, and interdisciplinary critical care providers. This multispecialty model allows the groups to coordinate care and offer broad services to hospitals and health systems. Alternative sources of revenue are required to ensure the scientific underpinnings of the specialty while partnering with the clinical enterprise to optimize patient care. While no single model is appropriate for every practice setting, whatever approach is used must not only address the financial viability of the practice but must also ensure that the anesthesiologists are valued and collaborative partners with other providers and the health system and that they ensure the delivery of safe, high-quality, and efficient care. At the same time, while this discussion identifies some of the current approaches to practice management, it is important to acknowledge the dynamic health care environment, both internationally and in the United States. Anesthesiologists have been leaders in patient safety and quality and have expanded their roles to include preoperative management, extended postoperative care, intensive care medicine, pain medicine, and in some countries sleep medicine and palliative care. In addition, a number of new opportunities have presented themselves as a result of changes in the delivery systems and the role of other providers in perioperative care. Implementing some of these new practice opportunities in perioperative management, such as the perioperative surgical home and other initiatives, will require considerable creativity and flexibility. New approaches to clinical care, staffing, and compensation must be implemented to achieve the goals of both patients and health systems. While some of these new opportunities are briefly discussed in this chapter, they are more comprehensively described in Chapter 3. This discussion will identify some of the critical business practices and ways to optimize the financial performance of anesthesia departments in the changing health care environment. Although the financial support for education and research is beyond the scope of this chapter, the discussion here will identify some ways in which the business models may need to be modified to address the needs of the academic departments and ensure the future scientific foundation for the specialty. It is essential that each practice build a business model that is financially viable and supports clinical needs within the health care system. At the same time, however, business practices and staffing models must be designed to optimize delivery of high-quality, safe care to the patient populations being served. Each practice must determine the model that most effectively and efficiently ensures the availability of well-trained anesthesia providers to its population. In addition, anesthesia providers across the spectrum of subspecialties, critical care anesthesiologists, and pain medicine physicians are required to support the needs of the health system or facility in which the practice works. The expanding role for anesthesiologists in preoperative management, pain medicine, critical care medicine, and ambulatory care provides new opportunities and requires different approaches to practice management (see Chapter 1). Some of the business practices described in this chapter apply to every practice setting whereas others are appropriate for select practices, such as in large urban or academic settings, or both. In addition, although this chapter defines some of the current business models, the dynamic health care environment mandates flexibility and entrepreneurship to take advantage of new technologies, such as telemedicine, and to manage the evolving needs of an increasingly complex patient population. Although these opportunities are discussed briefly in this chapter, they are more comprehensively described in Chapter 3. This variability is true for practices in all settings, including private practice, military medicine, and governmentsupported hospitals. In those countries with primarily publicly supported health care systems, physicians are often employed by the government directly or through a government-supported health authority, and care is provided within public hospitals, including military institutions. In some countries, there is a parallel private health care system and physicians may work outside the government system, providing care in the private sector, often while also spending the majority of the clinical time in the public sector, "moonlighting" in the private institutions to supplement income. In these parallel structures, the anesthesiologists and other physician practices are salaried within the government system and bill personally for care provided to patients in the private system. For many of these practice options, the business models are relatively straightforward. The government or health authority compensates the anesthesia providers based either on an annual budget or contract or on the basis of some assessment of work units. Compensation for care delivered outside of the public sector is often self-paid on a fee-for-service basis because in many cases there are limited health insurance options for patients receiving care in the private sector. Recently, in many countries, private insurance options have become more common, though the payment for services varies considerably based on the insurance options, costs, and other considerations. In the rapidly changing health care environment throughout the world, anesthesia practices are evolving and identifying new ways of caring for patients in the operating room and other inpatient and ambulatory settings. While many of these changes are now being implemented within the United States, many of the models of care being evaluated in the United States are based on delivery and financing models used in other countries. These models are largely dependent on the distribution of governmental health care systems or private practices within each country. For example, in France more than 60% of anesthesia services are provided by private practice, whereas in Scandinavia and the United Kingdom more than 90% is provided within governmental health care systems. In Germany and Sweden, payment for perioperative care is typically based on disease-related groups, that is, a single payment for all in-hospital care costs related to a specific disorder or surgical or diagnostic procedure. As a result, the business models used for internal cost allocation to anesthesia departments varies between countries and can vary within a country. In Germany, one third of anesthesia departments receive internal cost allocation payments based on a median national anesthesia cost estimation that is related to each specific disease-related group. The remaining two thirds of anesthesia departments in Germany generate their internal reimbursement based on a combined flat rate payment that includes payment for case load and time-that is, a combined formula with a flat rate for preanesthesia and postanesthesia visits, staffing, and maintenance, with additional payment for cases that are complex and that require intraoperative and postoperative time. While each of these payment distribution models is unique to the environment in which they have been implemented, they provide some important lessons, particularly to practices in the United States which are likely to have an increasing proportion of payments for clinical services be bundled. In the United Kingdom, more than 90% of anesthesia departments are primarily funded through the National Health Service. To the extent that the anesthesiologists broaden their clinical role to optimize perioperative management, they may (or may not) be successful in generating additional payment for these expanded services.
Most commonly medicine 003 buy generic gabapentin 300mg online, an opioid is combined with another drug more likely to provide hypnosis and amnesia medicine 750 dollars order gabapentin 600 mg overnight delivery. Alfentanil provides analgesia and hemodynamic stability while blunting responses to noxious stimuli medicine for depression cheap gabapentin 600mg on-line. Profound synergism also exists when more than two agents symptoms nausea headache fatigue order on line gabapentin, such as propofol, alfentanil, and midazolam, are combined. Investigators proposed that alfentanil concentrations as low as 85 ng/mL, when combined with a blood propofol concentration of 3. The optimal propofol concentration decreases in the order of fentanyl > alfentanil > sufentanil >> remifentanil. A shorter contextsensitive half-time allows the administration of greater amounts of opioid (and less propofol) during anesthesia without creating prolonged opioid effects. Drug infusions should be terminated 10 to 20 minutes before the end of anesthesia if N2O is employed. Otherwise, propofol infusions should be terminated 5 to 10 minutes before anticipated patient awakening. A multicenter evaluation demonstrated that, in patients undergoing elective inpatient surgical procedures, intravenous administration of remifentanil (1 g/kg followed by 1. High-dose opioid anesthesia was introduced as a stress-free anesthetic method for cardiac surgical procedures. High-dose opioid anesthesia was first performed with morphine; however, fentanyl and sufentanil were later recommended. Several factors have diminished the popularity of high-dose opioid anesthesia, even in cardiac anesthesia. These factors include the lack of evidence substantiating any significant outcome benefit associated with the use of large doses of opioids, the added drug costs, and the trend toward "fast track" approaches for cardiac patients that can be impeded with large doses of opioids. However, opioids, particularly when administered by continuous infusion, are still among the most effective anesthetic agents for patients undergoing cardiac or other extensive operations. In an attempt to decrease the costs of cardiac surgery, fast-track programs have become popular. Engoren and colleagues reported that the more expensive but shorteracting opioids, sufentanil and remifentanil, produced equally rapid extubation, similar stays, and similar costs when compared with fentanyl; these findings indicate that any of these opioids can be recommended for fasttrack cardiac surgery. Investigators indicated that fentanyl (25 to 50 g/kg) combined with isoflurane (0. Investigators also showed that high-dose fentanyl (50 g/kg) is not associated with a difference in the incidence of postoperative cognitive dysfunction at 3 or 12 months after coronary artery bypass surgery in older adults, whereas low-dose fentanyl (10 g/kg) leads to shorter postoperative ventilation times and may be associated with a greater incidence of postoperative cognitive dysfunction 1 week postoperatively. Large doses of alfentanil (150 g/kg) may be used with or without thiopental to induce anesthesia. However, some investigators claim that anesthesia cannot be reliably induced with alfentanil alone, at least in young and healthy adults. Continuous infusions of alfentanil (2 to 12 g/kg/minute) have been employed to maintain moderate to very high plasma alfentanil concentrations (<3000 ng/mL) during cardiac surgical procedures. Enthusiasm for high-dose alfentanil anesthesia techniques is limited by the amount (and cost) of drug required and by suggestions that alfentanil anesthesia for cardiac surgery is inadequate and is associated with more cardiovascular adverse effects compared with Fentanyl Many different techniques have been used to achieve anesthesia with fentanyl. These doses establish plasma fentanyl concentrations (10 to 30 ng/mL) that are often sufficient to provide stable hemodynamics throughout the induction and intubation sequence. Suppression of stress responses in the prebypass phase of open heart surgery in infants and young children by fentanyl combined with a low concentration (0. The values for the 2 g/kg group indicated by asterisks were significantly higher (P < 0. More modest doses of alfentanil have been successfully administered in combination with sedative-hypnotics such as propofol for cardiac anesthesia. Sufentanil Advantages of high-dose sufentanil include more rapid induction, better blunting or elimination of hypertensive episodes, and greater reduction in left ventricular stroke work, with higher cardiac outputs and more stable hemodynamics intraoperatively and postoperatively. Induction doses of sufentanil range from 2 to 20 g/kg administered as a bolus or infused over 2 to 10 minutes. Total doses of sufentanil administered in high-dose techniques usually range from 15 to 30 g/kg. During induction of anesthesia with sufentanil (3 g/kg), upper airway closure occurs at the level of the glottis or above. These investigators concluded that starting the remifentanil infusion rate higher than 1. Transdermal Therapeutic System Transdermal drug delivery generally requires high solubility in both water and oil, low molecular weight, high potency, and little or no skin irritation. Potential advantages of delivering fentanyl transdermally include no first-pass drug metabolism by the liver, improved patient compliance, convenience and comfort, and consistent analgesia. The pharmacokinetics of transdermally delivered fentanyl (50 g/hour) was compared in 10 young adult (25 to 38 years of age) and eight older adult (64 to 82 years of age) patients. Induction with remifentanil (2 g/kg) with propofol and maintenance with remifentanil at 0. Geisler and associates examined the efficacy and safety of high-dose remifentanil anesthesia in patients undergoing coronary artery bypass graft surgery. Times to awakening (green circles) and tracheal extubation (blue circles) in patients who underwent minimally invasive direct coronary artery bypass surgery after intravenous anesthesia with remifentanil and propofol or alfentanil and propofol.
Cardioselective -blockers have stronger affinity for 1-adrenergic receptors than for 2-adrenergic receptors 909 treatment buy gabapentin amex, and the predominant effects are therefore cardiac medicine of the wolf 100 mg gabapentin with mastercard. Cardioselective drugs include atenolol symptoms vitamin d deficiency 800 mg gabapentin with mastercard, betaxolol symptoms zoning out buy gabapentin 300mg online, bevantolol, esmolol, and metoprolol. These drugs may be preferable for patients with obstructive pulmonary disease, peripheral vascular disease, Raynaud phenomenon, and diabetes mellitus. Although previously a matter of controversy, a meta-analysis concluded that cardioselective -blockers can be given safely to patients with chronic obstructive pulmonary disease. These drugs primarily decrease arterial blood pressure and, to a lesser extent, heart rate and left ventricular function. When sympathetic activity is high, such as during exercise, these drugs behave more like conventional -blockers. In the late 1990s, two important studies established the value of perioperative blockade in patients at risk for coronary ischemia who were undergoing noncardiac operations (see Chapters 38 and 39). Patients were labeled as "at risk" if they fit into one of two categories: they were undergoing high-risk vascular surgery and had no evidence of inducible coronary ischemia, or they were undergoing a nonvascular procedure but had traditional risk factors for coronary artery disease (older age, high cholesterol, hypertension, cigarette smoking, family history of coronary disease, or diabetes). The second study enrolled patients with known ischemic disease demonstrated on preoperative stress echocardiography. These powerful demonstrations that blockade could decrease perioperative cardiac risk and improve survival out to 2 years led to tremendous political and administrative pressure to increase the use of -blockers perioperatively. Blockade was associated with a reduced mortality rate in only the 3% of patients who had three or more risk factors (based on the revised Cardiac Risk Index) for coronary ischemia. The safety of continuing long-term blockade perioperatively is well established, and initial concerns regarding interaction with general anesthesia have not been confirmed. Attempts to discontinue -blockers increase the risk for rebound tachycardia (with or without atrial fibrillation) and myocardial ischemia in patients with coronary disease. These drugs should be given up to the time of surgery, and intravenous forms in appropriate dosages should be used whenever gastrointestinal absorption may be in question. If -blockers have been omitted from the preoperative regimen, esmolol or labetalol may be used acutely to blunt tachycardia and hypertension. Cardioselective and nonselective -blockers are effective in blocking the chronotropic effects of endotracheal intubation and surgical stress. Propranolol was initially introduced for the treatment of myocardial ischemia in the 1960s, and -adrenergic blocking drugs remain an important part of drug therapy for myocardial ischemia (see Chapter 39). This class of drugs reduces oxygen demand by decreasing the heart rate and cardiac contractility. Although initially there was concern that 2-receptor blockade could worsen ischemia through unopposed mediated vasoconstriction, this phenomenon is rarely seen, even in patients with variant (Prinzmetal) angina. In usual clinical practice, the dose is increased until the heart rate is 60 to 80 beats/minute at rest and no tachycardia occurs with exercise. These effects have not turned out to be a significant concern in clinical practice. Early studies demonstrated a significant decrease in all-cause mortality for patients with heart failure who were treated with metoprolol or bisoprolol. Several large studies were stopped because the decrease in mortality in treated patients with moderate to severe heart failure was so pronounced. The mechanisms by which -antagonists treat hypertension are incompletely understood. Arterial blood pressure is specifically decreased in hypertensive patients because long-term treatment of normotensive individuals does not decrease blood pressure. However, this too is an incomplete explanation because labetalol is an effective antihypertensive despite its lack of effect on cardiac output. Generally, blockade is ineffective as monotherapy in hypertensive African American patients who are older than 60 years. These drugs can convert atrial arrhythmias to sinus rhythm,256 but blockade is primarily used to slow the ventricular response. Cardiac complications are a primary cause of morbidity in thyrotoxicosis (see Chapter 85). Blockade can suppress the tachycardia and rhythm disturbances, although very large doses may be required. Propranolol inhibits conversion of thyroxine to the active form triiodothyronine in the periphery. Timolol and betaxolol are -blocking drugs used topically in the eye to treat glaucoma. Even topical use of these agents has been associated with significant systemic effects of blockade. These drugs are also effective in the prophylaxis, but not the treatment, of migraine headaches and in controlling acute panic symptoms and essential tremor. Severe noncardiopulmonary reactions such as cutaneous reactions or anaphylaxis are rare. Diabetes mellitus is a relative contraindication to the long-term use of -antagonists because hypoglycemia in the presence of sympathetic blockade is not accompanied by warning signs such as tachycardia and tremor and because compensatory glycogenolysis is blunted. In addition to the potential worsening of peripheral perfusion by 2 blockade in patients with peripheral vascular disease, Raynaud phenomenon may be triggered in susceptible patients. To avoid worsening of hypertension, use in pheochromocytoma should be avoided unless receptors have previously been blocked.
Factors that affect the incidence of emergence reactions are age treatment quotes and sayings quality 600mg gabapentin, dose symptoms zoloft dose too high order gabapentin on line, gender useless id symptoms cheap gabapentin 600 mg on line, psychological susceptibility symptoms questions generic gabapentin 600 mg amex, and concurrent drugs. Pediatric patients do not report as high an incidence of unpleasant emergence reactions as do adult patients; men also report a less frequent incidence compared with women. Larger doses and rapid administration of large doses seem to predispose patients to a frequent incidence of adverse effects. Finally, certain personality types seem prone to the development of emergence reactions. Patients who score high in psychotism on the Eysenck Personality Inventory are prone to develop emergence reactions, and individuals who commonly dream at home are more likely to have postoperative dreams in the hospital after ketamine. Although numerous drugs have been used to reduce the incidence and severity of postoperative reactions to ketamine, the benzodiazepines seem to be the most effective group of drugs. When it is given to patients with reactive airway disease and bronchospasm, pulmonary compliance is improved. Ketamine is as effective as halothane or enflurane in preventing experimentally induced bronchospasm. The mechanism for this effect is probably a result of the sympathomimetic response to ketamine, but isolated bronchial smooth muscle studies showed that ketamine can directly antagonize the spasmogenic effects of carbachol and histamine. Because of its bronchodilating effect, administration of ketamine can treat status asthmaticus unresponsive to conventional therapy. A potential respiratory problem, especially in children, is the increased salivation that follows ketamine administration; this effect can be modulated by an anticholinergic drug such as atropine or glycopyrrolate (see also Chapter 93). Effects on the Cardiovascular System Ketamine increases arterial blood pressure, heart rate, and cardiac output in a biphasic manner. It has a direct cardiodepressant, negative inotropic effect next to an indirect stimulatory effect secondary to activation of the sympathetic system. Ketamine causes the systemic release of catecholamines, inhibition of the vagal nerve, inhibition of norepinephrine reuptake at peripheral nerves and nonneuronal tissues such as the myocardium, and norepinephrine release from sympathetic ganglia. Cardiovascular stimulation already occurs after smalldose ketamine infusion and is characterized by tachycardia, systemic and pulmonary hypertension, increases in cardiac output, and myocardial oxygen consumption. Whereas the cardiovascular stimulatory effects of ketamine generally are dominant, after termination of S-ketamine infusion, cardiovascular depression may become evident because cardiac output may decrease to less than preinfusion values. The increase in hemodynamic variables is associated with increased work and myocardial oxygen consumption. The healthy heart augments oxygen supply by increased cardiac output and decreased coronary vascular resistance, so that coronary blood flow is appropriate for the increased oxygen consumption. Patients with congenital heart disease have no significant changes in shunt directions or fraction, or systemic oxygenation, after ketamine induction of anesthesia (see also Chapter 94). Ketamine also causes the sympathoneuronal release of Effects on the Respiratory System Ketamine has minimal effects on the central respiratory drive as reflected by an unaltered response to carbon dioxide. In a -opioid knockout mouse model, however, at supraspinal sites S(+)-ketamine interacted with the -opioid receptor system. Ketamine depresses ventilatory Chapter 30: Intravenous Anesthetics 849 norepinephrine, which can be detected in venous blood. Blockade of this effect is possible with barbiturates, benzodiazepines, and droperidol. The centrally mediated sympathetic responses to ketamine usually override the direct depressant effects of ketamine. Some peripheral nervous system actions of ketamine play an undetermined role in the hemodynamic effects of the drug. Ketamine inhibits intraneuronal uptake of catecholamines by a cocainelike effect, and it inhibits extraneuronal norepinephrine uptake. Stimulation of the cardiovascular system is not always desirable, and certain pharmacologic methods have been used to block ketamine-induced tachycardia and systemic hypertension. Probably the most fruitful approach has been prior administration of benzodiazepines. Modest doses of diazepam, flunitrazepam, and midazolam all attenuate the hemodynamic effects of ketamine. It also is possible to decrease the tachycardia and hypertension caused by ketamine by using a continuous infusion technique with or without a benzodiazepine. Ketamine also is often used in patients with congenital heart disease, especially patients with a propensity for right-to-left shunting (see also Chapter 94). Ketamine has been successfully used in a patient susceptible to malignant hyperthermia. Ketamine combined with propofol or midazolam can be given by continuous infusion to produce satisfactory cardiac anesthesia for patients with valvular and ischemic heart disease. The combination of a benzodiazepine or of a benzodiazepine and sufentanil with ketamine attenuates or eliminates the unwanted tachycardia and hypertension and postoperative psychological derangements. With this technique, patients have minimal hemodynamic perturbations, profound analgesia, dependable amnesia, and an uneventful convalescence. The advantages of this combination are maintenance of stable hemodynamics and minimal ventilatory depression when allowing spontaneous ventilation. Nevertheless, ketamine has an important niche in the practice of anesthesiology when its unique sympathomimetic activity and bronchodilating capabilities are indicated during induction of anesthesia. It is used for premedication, sedation, induction, and maintenance of general anesthesia. Interest in the use of ketamine in small doses for preventive analgesia and for the treatment or prevention of opiate tolerance and hyperalgesia and in treatment of acute and chronic pain has increased. Pain Management Postoperative pain is a major concern of many patients, and it is inadequately treated in as many as 30% to 50% of all postoperative patients (see also Chapter 98). Multimodal analgesia combining various analgesic agents that act through different pathways is the way to manage postoperative pain.
