Braun J-P, Walter M, Lein M, Roigas J, Schwilk B, Moshirzadeh M, Eveslage K, Rehberg-Klug B, Hansen D, Spies C
Klinik für Anästhesiologie und operative Intensivmedizin, Charité Universitätsmedizin, Campus Mitte, Schumannstrasse 20-21, 10117 Berlin.
Anaesthesist. 2005 Dec;54(12):1186-96. doi: 10.1007/s00101-005-0905-3.
In this study we investigated the anesthesiological module of a clinical pathway. We chose the pathway of "laparoscopic prostatectomy" as an example for time-consuming minimally invasive surgery and 40 patients were randomly assigned to 2 groups receiving either total intravenous anesthesia (TIVA) using propofol/ remifentanil or balanced minimal flow anesthesia using desflurane/ remifentanil. During this module the indicators of quality such as vigilance, pain, postoperative nausea and vomiting (PONV) and mobilization were measured. Costs were evaluated and analyzed by a bottom-up procedure.
There were no anesthesia-related deviations from clinical pathways and both forms of anesthesia management were equally well tolerated by the patients. No significant difference was observed regarding hemodynamic measurements or PONV. The patients in the desflurane/ remifentanil group recovered more rapidly (p=0.037) and had more pain. The amount of analgesic agents given immediately following anesthesia was significantly higher than in the TIVA group (p=0.017). The median anesthesia costs per minute for laparoscopic prostatectomy in the propofol group were 2.79 EUR (minimum cost 2.41 EUR, maximum cost 3.21 EUR) and in the desflurane group 2.68 EUR (minimum cost 2.45 EUR, maximum cost 3.39 EUR). The total anesthesia costs for both groups were within the proceeds matrix range for diagnosis-related groups (DRG). However, the cost analysis for medication was slightly higher than the proceeds matrix range for DRGs.
Both forms of anesthesia can be implemented for time-consuming surgical procedures and allow a cost-effective anesthesia management. Anesthesiological procedures must go hand-in-hand with the type of anesthesia selected. The prophylactic use of analgetics for desflurane/ remifentanil anesthesia should be given earlier and in higher doses than in propofol/ remifentanil anesthesia. The prophylactic use of antiemetics following laparoscopic procedures of long duration is indicated. Optimizing anesthesiological procedures could lead to a continuous improvement in the quality of therapeutic pathways.
在本研究中，我们调查了临床路径的麻醉模块。我们选择“腹腔镜前列腺切除术”路径作为耗时的微创手术示例，将40例患者随机分为两组，分别接受使用丙泊酚/瑞芬太尼的全静脉麻醉（TIVA）或使用地氟醚/瑞芬太尼的平衡低流量麻醉。在该模块期间，测量诸如警觉性、疼痛、术后恶心呕吐（PONV）和活动能力等质量指标。成本通过自下而上的程序进行评估和分析。
临床路径中未出现与麻醉相关的偏差，两种麻醉管理形式患者的耐受性均良好。在血流动力学测量或PONV方面未观察到显著差异。地氟醚/瑞芬太尼组患者恢复更快（p = 0.037）且疼痛更明显。麻醉后立即给予的镇痛药剂量显著高于TIVA组（p = 0.017）。丙泊酚组腹腔镜前列腺切除术每分钟的麻醉成本中位数为2.79欧元（最低成本2.41欧元，最高成本3.21欧元），地氟醚组为2.68欧元（最低成本2.45欧元，最高成本3.39欧元）。两组的总麻醉成本均在诊断相关组（DRG）的收益矩阵范围内。然而，药物成本分析略高于DRG的收益矩阵范围。
两种麻醉形式均可用于耗时的手术过程，并可实现具有成本效益的麻醉管理。麻醉程序必须与所选麻醉类型相匹配。与丙泊酚/瑞芬太尼麻醉相比，地氟醚/瑞芬太尼麻醉应更早、更高剂量地预防性使用镇痛药。对于长时间腹腔镜手术后预防性使用止吐药是必要的。优化麻醉程序可导致治疗路径质量的持续改善。
