بررسی معیارها برای منابع انسانی علم و فن آوری (HRST) بر اساس تحلیل سلسله مراتبی فازی یکپارچه و رویکرد DEMATEL فازی

This study intends to use a combination of fuzzy Analytic Hierarchy Process (AHP) and fuzzy Decision-making Trial and Evaluation Laboratory (DEMATEL) method in human resource for science and technology (HRST). Specifically, this study first uses AHP to evaluate the weighting for each criterion and then use DEMATEL method to establish contextual relationships among those criteria. We find out Infrastructure might be more critical since it is a cause and will directly influence human resource for science and technology performance. For human resource for science and technology (HRST), improving Infrastructure might be a better choice for the long period of time. Moreover, Education, R&D Expenses and Immediate output are more important second-tier criteria than Value, Cooperation, Labor Market, Human Capital and Intermediate output. Therefore, the improvement should be started with Infrastructure, particularly on identification of the Education, R&D Expenses and Immediate output.

Adverse physiologic responses that occur during and after cardiac surgery include alterations in circulatory (tachycardia, hypertension, vasoconstriction), metabolic (increased catabolism), immunologic (impaired immune response), and hemostatic (platelet activation) systems.1 and 2 Together, these changes are referred to as the “stress response.” The stress response associated with cardiac surgery in neonates may be profound and is associated with increased morbidity and mortality.3 Anand and coworkers measured such responses during and after cardiac surgery in 15 neonates anesthetized with halothane and morphine. They found elevated plasma concentrations of epinephrine, norepinephrine, cortisol, glucagon, and beta endorphin in all patients, accompanied by hyperglycemia and lactic acidemia. The 4 deaths in the study group occurred in neonates with the greatest stress responses. Bromage and coworkers first demonstrated in 1971 that the stress response associated with major abdominal and thoracic surgery could be attenuated with epidural blockade.4 Since then, several investigators have shown that the use of regional anesthesia during and after cardiac surgery (ie, intraoperative anesthesia and postoperative analgesia) may decrease the stress response as well as morbidity and mortality.5, 6, 7, 8, 9, 10, 11 and 12 Although these adverse responses can be attenuated with intravenous opioids, regional anesthesia (intrathecal or epidural blockade) with opioids and/or local anesthetic agents appears to be more effective in inhibiting the stress response associated with surgery. For example, epidural fentanyl is more effective than intravenous fentanyl in reducing the stress response after thoracotomy in adults.13 Epidural morphine administration was shown to attenuate the adverse decrease in T3 (liothyronine) concentration in children undergoing open heart surgery compared with general anesthesia alone.10 Epidural anesthesia with bupivacaine suppresses the increase in serum catecholamines, glucose, and ACTH more effectively than intravenous fentanyl in infants.11 Epidural local anesthetics may be more efficacious than opioids in attenuating the stress response.12 Recently, attempts have been made to exploit the potency of high spinal anesthesia with local anesthetic agents to improve control of the perioperative neuroendocrine responses to cardiac surgery. A study performed in fetal lambs demonstrated that total spinal anesthesia administered via the cisterna magna completely blocked the stress response to surgical manipulation and cardiopulmonary bypass.14 This technique was associated with improved survival of the fetoplacental unit after bypass. A prospective, randomized study compared intrathecal anesthesia in adults using morphine and bupivacaine with conventional opioid anesthesia. The study demonstrated that the spinal anesthesia group had reduced stress responses with higher cardiac index, lower pulmonary vascular resistance, and reduced atrial β-receptor dysfunction after surgery.15 There have been few objective studies to evaluate the use of high spinal anesthesia in infants and children. Humphries recently evaluated the effects of this technique in infants and children under 3 years of age undergoing cardiac surgery with cardiopulmonary bypass. This group compared a high-dose bupivacaine technique delivered during and after surgery through a small spinal catheter with a conventional high-dose opioid technique in a prospective randomized trial of 60 patients.16 The authors were able to demonstrate virtual elimination of catecholamine responses with spinal anesthesia and improved plasma lactate in the perioperative period compared with opioid-based anesthesia. In addition, their data suggested that spinal anesthesia may moderate the rise in IL-6 after surgery compared with opioid anesthesia, either due to better preservation of splanchnic blood flow during bypass or by reducing the adverse sympathetic effects on the heart after cardioplegia and ischemia. Ultimately, the demonstration of reduced stress response associated with regional anesthesia becomes significant only if it is linked to improved outcome. It has been argued that complete elimination of the stress response per se may not lead to improved outcome and that the benefit of regional anesthetic techniques is due to enhanced recovery from surgery.2 The evidence from pediatric cardiac surgery units that have instituted fast-track programs appears to be that early extubation of children after surgery followed by early ambulation are the most important factors in outcome (eg, duration of ICU and hospital stay) irrespective of the degree of suppression of the stress response. Anesthetic techniques that are associated with decreased stress response may, however, have significant benefit in neonates undergoing major cardiac surgery.17 The recent demonstration that infants undergoing major cardiac surgery with high spinal anesthesia had lower postoperative lactate concentrations as well as ablation of stress response appears to support this view.16 Additional benefits that may be attributed to regional anesthesia include improved pulmonary function, greater circulatory stability, and reduced pain scores. Several randomized, controlled studies in adults have shown that patients receiving epidural analgesia have better pulmonary function after thoracic surgery than those treated with intravenous (IV) opioids. Thoracic epidural opioids are associated with improved pulmonary function following chest surgery compared with IV opioids.18 In a study comparing thoracic epidural bupivacaine with IV morphine for postoperative analgesia, the patients receiving epidural infusions had significantly greater FEV1 and FVC and were more cooperative with deep breathing maneuvers than those in the IV morphine group.19 Thoracic epidural anesthesia may also improve respiratory performance postoperatively by effecting an improvement in diaphragmatic function.20 Several studies in infants and children demonstrate reduced opioid requirements and improved analgesia following cardiac surgery with neuraxial anesthesia. Jones and coworkers reported the use of intrathecal morphine for postoperative analgesia in 56 children undergoing cardiac surgery.21 Following induction of anesthesia, patients received intrathecal morphine 0.02 or 0.03 mg/kg. Tracheal extubation was performed in all patients shortly after admission to the ICU following surgery. The duration of analgesia in both groups was similar, with two-thirds of patients requiring no supplemental analgesia for more than 18 hours. In a retrospective review of pain control in 91 children undergoing cardiac surgery, Shayevitz and coworkers compared lumbar epidural morphine infusions with intravenous opioid analgesia.22 In the epidural analgesia group, lumbar epidural catheters were placed following induction of anesthesia. Preservative-free morphine sulfate was administered in a bolus dose of 0.05 mg/kg followed by a continuous infusion of 0.03 to 0.04 mg/kg/hour during and after surgery. Children in the intravenous analgesia group received an initial IV dose of fentanyl 0.05 mg/kg followed by a continuous infusion of 0.018 mg/kg/hour during surgery. The fentanyl infusion was reduced to 0.006 mg/kg/hour postoperatively. Patients in the epidural analgesia group had significantly lower pain scores and received significantly less supplemental analgesia postoperatively than patients in the intravenous analgesia group. In a prospective, randomized, controlled study, Rosen and Rosen evaluated the efficacy of caudal epidural morphine compared with intravenous morphine in 32 children following cardiac surgery.23 Patients in the study group received a caudal injection of preservative-free morphine sulfate (0.075 mg/kg) in the OR following surgery but before awakening and tracheal extubation. Patients in the control group received intravenous morphine alone for postoperative analgesia. Supplemental doses of intravenous morphine were given to children in both groups as needed, before which pain scores were recorded. Children having received caudal morphine required significantly less intravenous morphine and had significantly lower pain scores postoperatively than patients in the control group. The mean duration of complete analgesia in children receiving caudal morphine was 6 hours (range 2-12 hours), but decreased analgesic requirements were noted for the entire 24-hour study period. Hammer and coworkers peformed a prospective, randomized, controlled trial in 45 infants and children undergoing open heart surgery to evaluate the effect of spinal anesthesia on postoperative opioid requirement.24 Patients in the spinal group received a combination of intrathecal tetracaine and morphine following tracheal intubation (Table 1). All patients’ tracheas were extubated in the operating room after the completion of surgery. Compared to control, patients in the spinal group received less fentanyl during the first 8 hour and 24 hour period following surgery.Beside having improved lung function and pain control, patients receiving epidural anesthesia have fewer opioid-related side effects than patients treated with intravenous opioids. Epidural anesthesia has been associated wtih more rapid return of bowel function following surgery compared with intravenous analgesia. In a review of 16 studies comparing epidural and systemic analgesia with regard to postoperative recovery of gastrointestinal function, all 8 studies with epidural catheter placement above T12 showed more rapid recovery of bowel function when epidural analgesia was used.25 The use of postoperative thoracic epidural analgesia with bupivacaine and morphine is associated with earlier return of gastrointestinal function and decreased hospital costs due to shortened hospital stay compared with IV morphine.26 A study comparing epidural versus intravenous fentanyl analgesia following thoracotomy also reported a lower incidence of nausea, shorter duration of ileus, and earlier hospital discharge in the epidural analgesia group.15

The use of epidural and spinal anesthesia in infants and children may attenuate the stress response and thereby decrease morbidity and mortality associated with cardiac surgery. In addition, the use of these regional anesthesia techniques during and after cardiac surgery may result in improved pulmonary function, greater circulatory stability, and better postoperative pain control compared with general anesthesia and postoperative intravenous opioid analgesia. To the extent that regional anesthesia may facilitate tracheal extubation in the operating room immediately following surgery, complications and the expense associated with mechanical ventilation in the postoperative period may be avoided. In those patients who undergo tracheal extubation in the ICU, cost savings may be achieved due to reductions in time of mechanical ventilation and ICU length of stay, as well as earlier resumption of a regular diet. The risks of epidural and spinal anesthesia in these patients include undesired side effects (nausea and vomiting, pruritus), hypotension, respiratory depression, and epidural hematoma formation. The incidence of side effects does not appear to exceed that associated with intravenous opioid analgesia. Hypotension, associated with local anesthetic spinal and epidural blockade in adult patients, is uncommon in infants and young children. Postoperative respiratory depression is greatly reduced by avoiding intraoperative opioids and using prudent doses of spinal and epidural opioids. The risk of epidural hematoma formation is small but finite. This risk can be minimized by employing reasonable safeguards. Appropriate precautions include selecting patients with normal coagulation function before needle placement, abandoning the regional anesthesia technique if needle placement is difficult, and delaying surgery in the event of return of blood via the needle or epidural catheter. The time interval between needle placement and heparin administration should be maximized, allowing for an interval of at least 60 minutes. Epidural and spinal catheters should be removed only after normal coagulation function has been restored. Future studies may provide additional information regarding the dose-response relationships of regional anesthetic agents in patients undergoing cardiac surgery. Modulation of the stress response in neonates, eg, using total spinal anesthesia, warrants further investigation. In addition, strategies to decrease the incidence of side effects (eg, prophylactic antiemetic therapy) may enhance the applicability of these techniques.