Transversus abdominis plane block in renal allotransplant recipients: A retrospective chart review.

CONTEXT: The efficacy of the transversus abdominis plane (TAP) block appears to vary considerably, depending on the surgical procedure and block technique. AIMS: This study aims to add to the existing literature and provide a more clear understanding of the TAP blocks role as a postoperative analgesic technique, specifically in renal allotransplant recipients. SETTINGS AND DESIGN: A retrospective chart review was conducted by querying the intraoperative electronic medical record system of a 1200-bed tertiary academic hospital over a 5 months period, and reviewing anesthetic techniques, as well as postoperative morphine equivalent consumption. MATERIALS AND METHODS: Fifty renal allotransplant recipients were identified, 13 of whom received TAP blocks while 37 received no regional analgesic technique. All blocks were performed under ultrasound guidance, with 20 mL of 0.25% bupivacaine injected in the transversus abdominis fascial plane under direct visualization. The primary outcome was postoperative morphine equivalent consumption. STATISTICAL ANALYSIS USED: Morphine consumption was compared with the two-tailed Mann-Whitney U-test. Continuous variables of patient baseline characteristics were analyzed with unpaired t-test and categorical variables with Fischer Exact Test. A P < 0.05 was considered statistically significant. RESULTS: A statistically significant decrease in cumulative morphine consumption was found in the group that received the TAP block at 6 h (2.46 mg vs. 7.27 mg, P = 0.0010), 12 h (3.88 mg vs. 10.20 mg, P = 0.0005), 24 h (6.96 mg vs. 14.75 mg, P = 0.0013), and 48 h (11 mg vs. 20.13 mg, P = 0.0092). CONCLUSIONS: The TAP block is a beneficial postoperative analgesic, opiate-sparing technique in renal allotransplant recipients.

Intraneural injections and regional anesthesia: the known and the unknown.

Peripheral nerve injury is a rare complication of regional anesthesia. Intraneural injections were once considered harbingers of neural injury with practitioners focusing on their avoidance. With ultrasound guidance, it is now possible to visualize the difference between perineural (outside the nerve), intraneural (below the epineurium), and intrafascicular (within the perineurium) injections and to determine their association with postoperative neurological complications. We also now have a better understanding of the multifactorial nature of neurologic injury based on the nerve anatomy, site of needle insertion, bevel type, location of the needle tip, pressure achieved during injection, and underlying patient factors. Using ultrasound guidance during nerve blocks has revealed that not all intraneural injections result in injury, and its use will continue to provide insight into the mechanism of anesthetic-related nerve injury.

Complications of peripheral nerve blocks.

Complications of peripheral nerve blocks are fortunately rare, but can be devastating for both the patient and the anaesthesiologist. This review will concentrate on current knowledge about peripheral nerve injury secondary to nerve blocks, complications from continuous peripheral nerve catheter techniques, and local anaesthetic systemic toxicity.

Ultrasound-guided interscalene catheters performed under general anesthesia in a patient with Huntington's disease.

The placement of interscalene nerve blocks in adults under general anesthesia remains controversial. There have been reports of patients who suffered permanent losses of cervical spinal cord function during this practice; however, these cases employed long needles and paresthesia or nerve stimulator techniques with high stimulation currents. As a result, practitioners currently use short needles for interscalene block and value feedback from patients who are awake. Interscalene catheters, because they require large bores and occasionally longer needles, are unlikely to be used on anesthetized patients with traditional techniques. An ultrasound technique, however, may be able to change current thinking toward the placement of interscalene catheters under general anesthesia. Ultrasound permits direct visualization of the needle, nerves, and local anesthetic spread and may decrease the risk of catastrophic complications. As in children, in whom awake placement is extremely difficult or even impossible, certain adult patient populations may only be offered the advantages of a peripheral nerve catheter if it is placed after the induction of general anesthesia. We report the case of a patient with Huntington's disease who was only able to undergo a total shoulder arthroplasty following ultrasound-guided placement of a continuous interscalene block under general anesthesia.

Unintentional transfixation of a transverse cervical vein during placement of an interscalene brachial plexus catheter.

Cervical hematoma during placement of a catheter into the interscalene groove is a known complication of the procedure. I describe the occurrence of a hematoma while using a new system that is compatible with a nerve stimulator and offers the ability to aspirate during both needle placement and catheter insertion.

Evaluation, feedback, and remediation in anesthesiology residency training: a survey of 124 United States programs.

STUDY OBJECTIVE: To provide a review of evaluation, feedback, and remediation methods in United States residency programs during 1995 to 1996. The information gathered is to serve as a framework for discussions within and among programs regarding ways to enhance their current processes of evaluation, feedback, and remediation, and to serve as a baseline for future assessments. DESIGN, SETTING AND SUBJECTS: A three-page survey was mailed to program directors of each of the 145 anesthesiology programs listed in the Accreditation Council for Graduate Medical Education (ACGME/NRMP) Directory. MEASUREMENTS AND MAIN RESULTS: Quantitative and qualitative responses were sought about the resident evaluation process (including techniques of gathering information, frequency of evaluations, faculty compliance, and modes of offering feedback), departmental clinical competence committee, probation and remediation policies for problem residents, and the use of formal examinations. There was an 85.5% response rate. Frequency of evaluation of residents ranged from daily to quarterly: evaluations used both narrative comments and rating scales in 89% of institutions. Faculty compliance in the evaluation process was greater than 75% in 45.1% of programs. Only 25 (20.2%) programs offered formal training about resident evaluation to their faculty. Clinical competence committee meetings averaged five times annually. Ninety-five percent of committees were chaired by someone other than the department chairperson and 27% had resident members. A written policy regarding problem residents was used by 67.7% of programs, a formal probation policy by 82.2%. Standardized tests to provide feedback and guidance to residents existed in 48.3% of programs. CONCLUSIONS: There is a tremendous variety of techniques and methodologies employed among anesthesiology residency programs with regard to evaluation, feedback, and remediation, within the framework of the ACGME guidelines. Faculty training in the assessment of and feedback to residents is one area in which many programs can begin to strengthen their current procedures.

EVALUATION, FEEDBACK AND REMEDIATION IN ANESTHESIOLOGY RESIDENCY TRAINING: A SURVEY OF 124 UNITED STATES PROGRAMS.

PURPOSE: It was the purpose of this study to provide a review of evaluation, feedback and remediation methods in U.S. residency programs during 1995-96. The information gathered is to serve as a framework for discussions within and amongst programs regarding ways to enhance their current processes of evaluation, feedback and remediation, and to serve a baseline for future assessments. METHODS: A three-page survey was sent to the program director of each of the 145 anesthesiology programs listed in the ACGME/NRMP Directory. Information about the resident evaluation process (including techniques of gathering information, frequency of evaluations, faculty compliance, and modes of offering feedback), departmental clinical competence committee, probation and remediation policies for problem residents, and the use of formal examinations during residency was sought. RESULTS: There was an 86.1% response rate. Frequency of evaluation of residents ranged from daily through quarterly: evaluations used both narrative comments and rating scales in 89% of institutions. Faculty compliance in the evaluation process was greater than 75% in 45.1% of programs. Only 25 programs offered formal training about resident evaluation to their faculty. Clinical competence committee meetings average five times annually and 95% of committees are chaired by someone other than the Department Chairperson. 27% of them have resident members. 67.7% of programs have a written policy regarding problem residents, while 82.2% report having a formal probation policy. 48.3% programs use standardized tests to provide feedback and guidance to their residents. CONCLUSIONS: There is a tremendous variety of techniques and methodologies employed among anesthesiology residency programs with regard to evaluation, feedback, and remediation, within the framework of the ACGME guidelines. Providing faculty training in assessment of, and offering feedback to, residents is one area in which many programs can begin to strengthen their current procedures.

The ability of the Haemonetics 4 Cell Saver System to remove tissue factor from blood contaminated with amniotic fluid.

UNLABELLED: The purpose of this study was to determine whether functionally active tissue factor could be removed from blood contaminated with amniotic fluid (AF) after processing through a Haemonetics 4 Cell Saver System (Haemonetics Corporation, Braintree, MA). In Phase I, AF was collected from 29 women undergoing cesarean section. Nine experiments were performed. Forty-milliliter aliquots of pooled AF were mixed with 125 mL of packed red blood cells and processed in the Cell Saver. In Phase II, all the blood and AF lost at cesarean section was collected and processed through the Cell Saver. Pre- and postwash specimens were collected and analyzed for total tissue factor concentration and the concentration of functionally active tissue factor. In Phase I, total tissue factor concentration was reduced by 89%, and the concentration of active tissue factor was reduced to 0 after processing. In Phase II, no tissue factor was detected after processing through the Cell Saver. We have demonstrated the ability of the Haemonetics 4 Cell Saver System to remove tissue factor activity from blood contaminated with AF. IMPLICATIONS: Hemorrhage after childbirth may require massive transfusion. If the patient's own blood can be collected and given back to the patient, this may avoid the use of regular banked blood. Amniotic fluid, which may mix with blood lost after delivery, contains tissue factor, a substance that may activate the coagulation system and cause further bleeding. The authors found that the Haemonetics 4 Cell Saver System (Haemonetics Corporation, Braintree, MA), which collects and washes blood, can remove tissue factor from blood contaminated with amniotic fluid.

Intraoperative hemodilution is more cost-effective than preoperative autologous donation for patients undergoing procedures associated with a low risk for transfusion.

STUDY OBJECTIVE: To determine the utilization and cost of autologous blood that was donated preoperatively, and to compare it to the cost of employing intraoperative hemodilution to provide autologous blood for patients undergoing surgical procedures with a low risk for the need for transfusion. DESIGN: Retrospective chart review. SETTING: University medical center. PATIENTS: All ASA physical status I and II patients who underwent nononcologic gynecologic procedures and preoperatively donated autologous blood between July 1993 and June 1994. MEASUREMENTS AND MAIN RESULTS: The utilization and overall cost of predonated autologous blood was determined. The cost for employing intraoperative hemodilution and potential cost saving was then calculated. Of the 234 units of preoperatively donated autologous blood, 38 units were returned to patients who had an estimated blood loss of at least 500 ml, 32 units returned to patients who had an estimated blood loss less than 500 ml, and 164 units were wasted. No patient received allogeneic blood. The estimated total cost for all preoperatively donated autologous blood was $23,274.62. Employing hemodilution for those same patients would have cost $5,574.74, and resulted in a potential 75.6% savings. CONCLUSIONS: Inappropriate selection of patients for preoperative blood donation is costly. For those patients scheduled to undergo surgical procedures associated with a low probability for the need for blood transfusion, but who desire that autologous blood be available, hemodilution provides fresh whole blood, free from the possibility of processing or clerical errors, while decreasing blood bank utilization and affording substantial cost savings.

The effect of a propofol-based sedation technique on cumulative embryo scores, clinical pregnancy rates, and implantation rates in patients undergoing embryo transfers with donor oocytes.

STUDY OBJECTIVE: To determine the effect, if any, of a propofol-based sedation technique on the reproductive outcomes of patients undergoing embryo transfers with donor oocytes. These ova recipients form a unique subgroup, whose clinical outcomes are unrelated to direct anesthetic effects on their reproductive tracts. DESIGN: Retrospective chart review. SETTING: A 1200-bed university medical center. PATIENTS: 117 patients who received fresh embryo transfer cycles between January 1991 and December 1995. MEASUREMENTS AND MAIN RESULTS: The anesthesia records of 106 women who donated ova were reviewed for propofol usage during the transvaginal needle aspiration of the ova. The medical records of the 117 patients who received these donated embryos were reviewed for cumulative embryo scores, clinical pregnancy rates, and implantation rates. Fourteen patients received ova from women who were sedated with fentanyl and midazolam during ovum retrievals, while 103 patients received ova from women who had been given fentanyl, midazolam, and propofol in doses of 1.87 mg/kg to 8 mg/kg. The pregnancy rate among all patients who received ova from women who received propofol (44 of 103 = 42.7%) was 14.1% greater than those whose ovum donors did not receive propofol (4 of 14 = 28.6). 78.6% of both propofol and non propofol-exposed groups had cumulative embryo scores of greater than 50. Among patients who became pregnant, 52.3% of propofol-exposed and 50% of nonpropofol-exposed cases had greater than 20% implantation rates. CONCLUSION: There is no evidence from our data that the administration of propofol during the aspiration of ovarian follicles for oocyte donation had a negative impact on the oocytes as measured by cumulative embryo scores, probability of a clinical pregnancy, or implantation rate.

Information and concerns about obstetric anesthesia: a survey of 320 obstetric patients.

This study was undertaken to assess women's knowledge and concerns about obstetric anesthesia and to determine if they perceive a need for an anesthesia interview before the onset of labor. A 17 item questionnaire was distributed to 407 women on postpartum day one. The women were questioned about their knowledge, anxiety and concerns regarding obstetric anesthesia. The questionnaire was completed by 320 women, 57% of whom were Caucasian and 28% of whom had some postgraduate education. Most of the women (74%) had either a regional or general anesthetic for their delivery and 86% of the women admitted to having some anxiety about anesthesia. Although 82% of the women attempted to obtain information about anesthesia before labor, 28% did not feel adequately informed. The majority (59%) of the women would have wanted a preoperative visit with an anesthesiologist before labor. These results illustrate that most women are anxious about obstetric anesthesia and do not feel adequately prepared. Efforts at educating women about obstetric anesthesia would be welcomed by them and methods to accomplish this goal are discussed.

Choroidal lesions in patients with AIDS.

Seven cases of bilateral, scattered, yellow-white choroidal lesions have been seen in AIDS patients since January 1988. One resulted from presumed extension of cryptococcal meningitis into the optic nerve and choroid. All the remaining six patients had pneumocystis pneumonia at some time during the course of the disease and were receiving aerosolised pentamidine therapy. None died quickly of disseminated Pneumocystis carinii infection, unlike previously reported patients. Mycobacterial infection was also present in five of these six patients. The differential diagnosis of this entity in AIDS patients is discussed.

Ocular and periocular pain.

Periocular pain may result from local pathology or be referred from distant sites. Ophthalmic examination will detect most local disease, although a careful search may be needed to determine the cause of subtle entities. Painful ophthalmoplegia results from a variety of neoplasms and inflammations, often in the area of the cavernous sinus. Cluster headache should be differentiated from more sinister causes of painful Horner's syndrome. Systemic diseases that cause periocular pain and migraine and other classic headache syndromes that may present with eye pain alone are also discussed.

Eosinophilic granuloma of the cavernous sinus and orbital apex in an HIV-positive patient.

A 35-year-old HIV-positive woman with painful ophthalmoplegia, sensory loss extending to all branches of the trigeminal nerve, and progressive optic neuropathy was found to have eosinophilic granuloma of the cavernous sinus, superior orbital fissure, and orbital apex. There was no radiologic evidence of a lytic bone lesion within the skull or orbit and clinical evidence suggested a primary intracranial origin for this lesion. This is the first case of a cavernous sinus syndrome caused by eosinophilic granuloma and the first time HIV infection is reported in association with histiocytosis-X.

Intraocular pressure rise after argon laser trabeculoplasty.

Eighty-four eyes received 107 argon laser trabeculoplasty treatments at Beth Israel Medical Center between 1982 and 1984 for advanced primary and secondary glaucoma. The prelaser mean pressure was 20.25 mmHg. Pressures taken 1 1/2 hours postoperatively varied widely: the pressure rose after 47 treatments and fell or remained the same after 60. Significant increases in pressure occurred in 10 eyes, after 12 treatments; 42% of these had received burns of 0.8 watts or greater. Pressure changes were correlated with laser burn energy level. Both patients who had significant increases in pressure initially were retreated again--in the same eye--at another time had similar increases in postoperative pressure again, even with lower energy levels. Comparison with the results of previous reports highlights the advantages of limited treatment to the anterior trabeculum with low energy levels.

Magnetic resonance imaging of optic tract involvement in multiple sclerosis.

We studied two cases of optic tract involvement in multiple sclerosis with documentation by magnetic resonance imaging. In one, incongruous homonymous hemianopsia was accompanied by a decrease in visual acuity in one eye from chiasmal involvement. In the other, the involvement was restricted to the optic tract and the homonymous hemianoptic visual field defect was nearly congruous.