METHODS OF ANESTHESIA AND ANALGESIA FOR AORTIC SURGERY

本次调查旨在评估替代方案的影响 术中麻醉与术后镇痛的联合应用 人类应激反应、选定的疾病和医疗费用 护理接受大血管手术的病人。 改善患者结局，减少对医疗资源的利用 已提出使用区域麻醉剂产生的资源 大手术中与单纯全身麻醉的技术比较 程序。报道这一发现的研究已经遭受了 方法论问题，包括使用非等价模式 术后疼痛缓解和未能确保优化的临床 两组均给予护理。目前还不清楚是否发现了这些好处 是由于术中或手术中的特殊情况 术后技术，或病人管理的未透露的方面。 要清楚地区分时间段和技术的影响，请删除 医生偏见，并在所有群体中提供类似的护理，我们建议 240例手术患者5年双盲临床试验 腹主动脉。受试者将被随机分成四组 两组接受区域补充全身麻醉或 手术中单独全身麻醉，静脉或 硬膜外病人术后自控镇痛。的具体目标 本研究旨在比较四组之间的差异：1)各项指标 人类应激反应，2)死亡率和发病率，以及3)恢复到 生理独立性和医疗费用。 围手术期医疗管理的所有方面都将由 协议。数据收集将包括：96小时连续Holter 监测；连续心电和体检；连续血样 心脏同工酶，去甲肾上腺素，肾上腺素；尿皮质醇； 生命体征分析；出院表复查及三个月和六个月 后续行动。这项提案的独特之处在于标准化了 整个围手术期的临床护理，包括所有四个 术中麻醉和术后镇痛相结合， 患者和治疗医生的盲法，以及对压力的评估 回应。 我们希望解决对质量和成本都很重要的问题 并有助于理解生理学 导致围手术期并发症的因素。一项意义重大的发现 不同组之间的差异将允许临床医生采用 兼顾安全和经济，发现没有区别 将允许根据偏好进行选择。

This investigation is designed to assess the impact of alternate combinations of intraoperative anesthesia and postoperative analgesia on the human stress response, selected morbidities, and the cost of medical care for patients undergoing major vascular surgery. Improvement in patient outcome and reduced utilization of medical resources have been suggested to result from using regional anesthetic techniques as compared to general anesthesia alone for large operative procedures. Studies that report this finding have suffered from methodologic problems including the use of non-equivalent modalities for postoperative pain relief and the failure to assure optimized clinical care in both groups. It remains unknown whether the benefits discovered are due to specific features of either the intraoperative or the postoperative technique, or to unrevealed aspects of patient management. To clearly separate the influence of time period and technique, remove physician bias, and provide comparable care in all groups we propose a five-year double blind clinical trial of 240 patients undergoing surgery of the abdominal aorta. Subjects will be randomized to one of four groups to receive either regional supplemented general anesthesia or general anesthesia alone during surgery, and either intravenous or epidural patient controlled analgesia after surgery. Specific aims of the study are to compare, between the four groups: 1) indices of the human stress response, 2) mortality and morbidity, and 3) return to physiologic independence and cost of medical care. All aspects of perioperative medical management will be specified by protocol. Data collection will include: 96 hours of continuous Holter monitoring; serial EKG's, and physical examinations; serial blood samples for cardiac isoenzymes, norepinephrine, epinephrine; urinary cortisols; vital sign analysis; discharge chart review and three and six month follow-up. Unique features of this proposal are the standardization of clinical care throughout the perioperative period, inclusion of all four combinations of intraoperative anesthesia and postoperative analgesia, patient and treating physicians blinded, and evaluation of the stress response. We hope to resolve issues of importance to both the quality and the cost of medical care and contribute to the understanding of physiologic factors which underlie perioperative morbidity. A finding of significant differences between groups will allow clinicians to adopt methods with due regard for both safety and economy while a finding of no difference will allow choice based on preference.