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Study Objective: To identify factors that may influence the implementation of acute pain management guidelines in hospital settings., Design: Two questionnaire surveys., Setting: Healthcare Association of New York State, Albany, NY., Measurement: The surveys were administered to 220 hospitals in New York State regarding their acute pain management practices and resources available. One survey was addressed to each hospital's chief executive officer (CEO) and the second survey was addressed to the clinical director of the Department of Anesthesiology or Acute Pain Service. The barriers and incentives to guideline implementation identified by CEOs were analyzed using factor analysis. Logistic regression was employed to determine predictors of guideline implementation by linking the CEOs' survey data with the clinical directors' report of guideline usage., Main Results: According to clinical directors, only 27% of the responding hospitals were using a published pain management practice guideline. Factors predictive of guideline implementation include resource availability and belief in the benefits of using guidelines to improve quality of care or to achieve economic/legal advantages. Guideline implementation, however, does not necessarily include applying all key elements recommended by the federal Agency for Healthcare Research and Quality (formerly Agency for Health Care Policy and Research) guideline. For example, a collaborative, interdisciplinary approach to pain control was used in only 42% of the hospitals, and underutilization of nonpharmacologic therapies to control pain was widespread. Resource availability, particularly staff with expertise in pain management and existence of a formal quality assurance program to monitor pain management, was significantly predictive of compliance with key guideline elements., Conclusions: Resource availability significantly influences the implementation of pain management practice guidelines in hospital settings. Implementation is often incomplete because various factors affect the feasibility of individual guideline elements and may explain the varying results that guidelines have had on clinical practices.

We have determined if alfentanil could obtund the haemodynamic instability commonly seen at induction of anaesthesia with ketamine. Five groups of ASA I and II patients received ketamine 1 mg kg-1 i.v., preceded by saline (group 1) or alfentanil 10, 20, 30 or 40 micrograms kg-1 (groups 2-5, respectively). Heart rate (HR), mean arterial pressure (AP), postoperative patient complaints and dysphoria were noted. All groups showed increases (P < 0.05) in both HR and AP after administration of ketamine, which were progressively smaller as the dose of alfentanil increased. After tracheal intubation, all groups showed further increases in HR and AP, with groups 3-5 (alfentanil 20-40 micrograms kg-1) showing significant obtundation (P < 0.05) of these increases compared with group 1. No patient in any group reported postoperative dysphoria or dissatisfaction with their anaesthetic. Ketamine 1 mg kg-1 with alfentanil 20-40 micrograms kg-1 provided statistically significant obtundation of the haemodynamic instability that is common with ketamine alone.

Study Objective: To examine three commonly used anesthetic induction regimens (thiopental sodium, ketamine, and thiopental plus fentanyl) and one newly described regimen (ketamine plus fentanyl) with respect to hemodynamic stability and patient satisfaction., Design: Randomized, double-blind study., Setting: University-affiliated Veterans Administration Hospital., Patients: Forty-eight ASA physical status I and II patients (47 males, 1 female) scheduled for surgery requiring general anesthesia., Interventions: Patients were randomized to one of four groups to receive intravenous injections of thiopental 5 mg/kg (Group 1), ketamine 1.5 mg/kg (Group 2), thiopental 3 mg/kg plus fentanyl 4 to 6 micrograms/kg (Group 3), or ketamine 0.5 mg/kg plus fentanyl 4 to 6 micrograms/kg (Group 4) for induction of anesthesia., Measurements and Main Results: Heart rate (HR) and mean arterial pressure (MAP) were measured during anesthetic induction. Evaluation of patient satisfaction/dissatisfaction and pleasantness/unpleasantness by the Anesthesia Experience Rating (AER) was carried out the day following surgery. Groups 3 and 4 showed the least increase from their baseline values in both HR and MAP after tracheal intubation, but only Group 4 exhibited no statistically significant change in hemodynamic parameters after induction but before intubation (p < 0.05). AER showed a higher level of pleasantness in Group 3 as compared with Group 2 (p < 0.03) and higher levels of satisfaction in Groups 3 (p < 0.03) and 4 (p < 0.02) as compared with Group 2., Conclusion: The combination of ketamine plus fentanyl provides superior hemodynamic stability with excellent patient satisfaction.

Administration of vecuronium by infusion is an increasingly common technique, both in the operating room and in the intensive care unit (ICU), for patients requiring prolonged neuromuscular blockade and mechanical ventilation. The major advantage of vecuronium over older neuromuscular blocking agents is its rapid excretion and intermediate duration of action. Prior to the current case report, the longest reported continuous paralysis after the cessation of a vecuronium infusion was 90 hours. A case of an 81-year-old patient with renal failure and subclinical chronic cirrhosis of the liver, who remained paralyzed for 13 days following a vecuronium infusion, is described. Intensive monitoring of neuromuscular function is recommended whenever muscle relaxants are administered by continuous infusion.

The Grieshaber Air System was designed to maintain intraocular pressure during ophthalmologic surgery. It also has been used to maintain pressure in leaking endotracheal tube cuffs. It is a very useful device, especially if the intubation is difficult or the patient's position precludes replacement of the endotracheal tube. Two patients are presented in whom the system was used to maintain endotracheal tube cuff pressure.