PubMed Health⌕ Search

Biomedical subjects

C A Stockall

Publications and source records attributed to C A Stockall.

5 recordsLinked to original sources
PubMed1999

Modified continuous femoral three-in-one block for postoperative pain after total knee arthroplasty.

UNLABELLED: We prospectively studied the continuous "modified" femoral three-in-one block for postoperative pain after total knee arthroplasty. Sixty-two patients undergoing elective knee arthroplasty under spinal anesthesia with bupivacaine (B) and fentanyl were randomized to receive 0.2% B, 0.1% B, or placebo at 10 mL/h for 48 h after an initial bolus of 30 mL of the same solution via the femoral block catheter. The catheters were inserted under the fascia iliaca using a "double pop" technique and a peripheral nerve stimulator and were advanced 15-20 cm cranially. Venous plasma levels of B, desbutylbupivacaine, and 4-hydroxy B were measured daily for 3 days. All patients received patient-controlled analgesia with morphine and indomethacin suppositories for 48 h. Using computed tomography, we evaluated the catheter location for 20 patients. The catheter tips, located superior to the upper third of the sacroiliac joint in the psoas sheath, were labeled as ideally located. The group receiving 0.2% B had a larger block success rate, smaller morphine consumption in the immediate postoperative period (15 vs 22 mg) and during the first postoperative day (9 vs 18 mg), and achieved a greater range of motion in the immediate postoperative period (91 degrees +/- 10 degrees vs 80 degrees + 13 degrees ). Visual analog scores for pain during both rest and activity were low but similar between the groups. Forty percent of the catheters evaluated were ideally located. Ideal location and use of 0.2% B resulted in 100% success of blockade of all three nerves. The S1 root was blocked in up to 76% of patients. The plasma levels of B, 4-hydroxy B, and desbutylbupivacaine were below the toxic range during the infusion. We conclude that continuous fascia iliaca block with 0.2% B results in opioid-sparing and improved range of motion during the immediate postoperative period. Larger doses of bupivacaine may safely be used in the immediate postoperative period if needed. IMPLICATIONS: Continuous fascia iliaca block with 0.2% bupivacaine reduces opioid requirements and improves range of motion in the immediate postoperative period compared with a placebo and 0.1% bupivacaine. Plasma levels are below the toxic range with this dose. Only 40% of the catheters are positioned in the ideal location. With the smaller dose of bupivacaine, the success rate with this block is small.

Aged↗
PubMed1998

New drugs in anaesthesia: can we afford them?

The most important challenge facing physicians today is the dilemma of providing high quality care in a fiscally responsible fashion. Cost can no longer be ignored. Pharmacoeconomics is a fundamental component of medical education. Economic issues should be an integral part of the drug development and clinical trials. While anaesthetists are concerned that the use of less expensive drugs may compromise patient outcome and satisfaction there is little evidence to support such concerns. This is a fertile area for intense future research. Pharmacoeconomics is a dynamic. The cost of drugs is not static, patterns of drug use shift rapidly and clinical practice is in a state of constant change. The answer to cost containment is not simply to cut, cap, delist or merely hope for the best, but rather to manage and modify practice while accommodating changing needs. Educational programmes, guidelines, department policies, system changes and financial incentives can be implemented to ensure consistent and enduring adherence to the principles of pharmacoeconomics and value based care. Some suggest that national societies should create guidelines for cost-beneficial practice. Others favour physician autonomy in drug selection. Changing physician behaviour is difficult. This change will occur gradually and will be the topic of many emotionally charged philosophical debates. There will be great reluctance to deny patients pharmacologically superior drugs based on cost alone, especially since drugs are such a small portion of the total costs. We must exercise caution to ensure that we don't become penny wise and pound foolish. Drug acquisition costs are only one element in a large and complex equation. Concentrating on acquisition drug cost may be dangerous, even naive if we fall prey to knowing the cost of everything but the value of nothing.

Anesthetics↗