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PubMedDate not supplied

Cerebrospinal fluid cytokine levels after surgery with spinal or general anesthesia.

BACKGROUND AND OBJECTIVES: Studies show that pain may cause neuroinflammatory changes in the spinal cord. These inflammatory changes could be caused by circulating factors such as plasma cytokines or could be a primary neuroimmune response of the central nervous system following peripheral nerve injury. To identify the possible effects of peripheral trauma and pain on the cytokine environment of the spinal cord, interleukin-6 (IL-6) and interleukin-10 (IL-10) concentrations in plasma and cerebrospinal fluid (CSF) were measured before and after hip replacement surgery. METHODS: The investigation used a prospective, observational design to measure cytokine levels in samples of plasma and CSF by enzyme-linked immunosorbent assay (ELISA). Samples were taken from surgical patients before and after surgery under general anesthesia or spinal anesthesia performed with or without a spinal catheter. Reference samples were also obtained from healthy control subjects. RESULTS: Both plasma and CSF levels of IL-6 increased substantially after major surgery with either general or spinal anesthesia. No significant correlation was observed between plasma IL-6 and CSF IL-6 levels, suggesting a central origin for increased CSF cytokine levels. IL-10 did not change in plasma or CSF after surgery. Plasma and CSF IL-6 and IL-10 cytokine levels were very low or undetectable in healthy controls. CONCLUSIONS: Major orthopedic surgery leads to elevated CSF levels of the proinflammatory cytokine, IL-6. The origin of increased CSF IL-6 may be central because there was no significant correlation with plasma levels.

Anesthesia, General↗

PubMedDate not supplied

Appropriateness of ambulance transportation to a suburban pediatric emergency department.

OBJECTIVE: To assess the appropriateness of ambulance use in patients presenting to a pediatric emergency department (ED), with regard to both medical necessity and insurance status. METHODS: The authors conducted a one-year retrospective chart analysis of all patients (age range 2 weeks to 19 years) who were transported via ambulance in 1994 to a suburban children's hospital ED. ED records of all patients who arrived by ambulance were abstracted for demographic data, type of insurance, chief complaint, medical interventions, discharge diagnosis, and disposition. Ambulance transportation was deemed unnecessary unless the medical record revealed any of the following criteria: 1) requiring cardiopulmonary resuscitation, 2) respiratory distress, 3) altered mental status or seizure, 4) immobilization, 5) inability to walk, 6) admission to intensive care, 7) ambulance recommended by medical personnel, 8) motor vehicle collision, or 9) parents not on scene. RESULTS: 43% of the ambulance patients were insured by Medicaid, compared with 29% of the overall ED population. Thus, Medicaid patients were significantly more likely to use ambulance transportation than were patients with commercial insurance (p<0.001). 28% of patients who arrived by ambulance were judged to have used the ambulance transportation unnecessarily. Of the unnecessary transports, 60% were insured by Medicaid. Thus, Medicaid patients were significantly more likely to have used ambulance transportation unnecessarily (p<0.001). The most common reason for appropriate ambulance use was seizure activity; the most common reason for inappropriate use was fever. CONCLUSION: Inappropriate use of ambulance transportation is common in this pediatric population, with Medicaid patients accounting for a significant majority of the misuse.

Adolescent↗