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May 1998
Sedative/analgesic regimen in postoperative cardiac patients: An influence on hospital length of stay.
Trubiano PB, Geary V, Sheikh F, Mehta S, Lumb PD; Anesth Analg 1998; 86, SCA93.
[ see abstract below ]
There are many pressures on contemporary physicians to reduce hospital
length of stay as well as other easily measurable parameters. The creative tension between market forces and concerns for patient care has led to innovative approaches to a wide range of issues.
Of concern is the fact that frequently focus is on a single aspect, such
as drug costs, rather than on the entire picture. Pharmacies are
understandably concerned about their budgets, but one can spend
substantial time discussing the relative merits of using a less
expensive and less effective drug or a more expensive and more effective
one (e.g. metoclopramide vs. ondansetron for post-operative nausea and
vomiting).
One abstract presented at the recent IARS congress addresses the
relationship between sedation/analgesia in the early post-operative
period and length of hospital stay. One hundred twenty patients were
randomized to one of 4 drug groups after elective cardiac surgery. The
patients in the group receiving propofol and sufentanil were extubated
and discharged from the ICU earlier than those receiving
midazolam/sufentanil, midazolam/fentanyl or propofol/fentanyl. Patients
in the propofol/sufentanil group also had less nausea and shorter
hospital stays than those in the other 3 groups. The drug costs (I
assume for the sedative/analgesics, not other drugs such as
anti-emetics) in this group were substantially higher than drug costs in
the other groups, but the room charges were 15-30% lower. The drug
costs listed averaged 1-2% of the room charges.
A fatal flaw in this study, however, is that the authors made no effort
to document pain scores or to assess patient satisfaction with the
sedative/analgesia regimens. For patients facing cardiac surgery, fears
about inadequate pain and sedation management are high on their lists of
concerns. We can never let the safety and comfort of those under our
care be far from our thoughts; the constructive debate about fiscal
matters will have a far less beneficial outcome if we do not insist that
the entire scope of the issues be considered.
Another recent article of interest to those considering potential costs
of post-operative analgesic regimens is Steinbrook RA: Epidural
anesthesia and gastrointestinal motility. Anesth Analg 1998; 86:837-44.
Return to the Current Literature Review Front Page, or read the abstract:
ABSTRACT
Introduction: Dramatic changes in the health care market have forced physicians to scrutinize possible factors influencing hospital length of stay. In this study, postoperative sedation/analgesic regimens were compared for their effects on ICU stay and hospital length of stay of cardiac surgical patients.
Methods: 120 patients having elective cardiac surgery over a 2-month period were evenly allocated to 4 groups. Patients in each group were to receive a specific sedative/narcotic regimen initiated in the operating room and continued into the early post-operative period: Group 1- midazolam/sufentanil; Group 2- propofol/sufentanil; Group 3- midazolam/fentanyl; Group 4- propofol/fentanyl. Data was collected by an independent observer and ANOVA verified that no significant intra or inter group differences in age, sex, weight, procedure, surgeon, duration of surgery, duration of CPB, body temperature and total drug doses were present. The groups were compared by multiple regression analysis for significant differences in time to tracheal extubation time to ICU discharge, hospital length of stay, drug costs, and room charges.
Results:
| |
Group 1 |
Group 2 |
Group 3 |
Group 4 |
| Extubation (hrs) |
12.6 |
7.7 |
14.3 |
10.2 |
| ICU (d) |
1.6 |
1.1 |
1.8 |
1.2 |
| Floor (d) |
6.6 |
5.2 |
7.3 |
6.3 |
| Drug costs ($) |
95 |
126 |
73 |
75 |
| Room charges ($) |
7889 |
5957 |
8706 |
6982 |
| Nausea (%) |
18 |
8 |
23 |
11 |
Discussion: Patients in group 2 (propofol/sufentanil) were extubated and discharged from ICU earlier. They had less nausea and were sent home sooner than any of the other patients in the study group. This reduced hospital length of stay and resulted in significantly lower hospital charges. As specified anesthesiologists were assigned specific drug regime in this pilot study, a truly prospective randomized format is necessary to substantiate our conclusion.
Reference: Glass PSA: Pharmacokinetic and pharmacodynamic principles in providing �fast track� recovery. J Cardiothoracic Vasc Anesth 1995; 9:16-20.
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