Spinal anesthesia for a cesarean delivery in a woman with type-2M von Willebrand disease: case report and mini-review.

Von Willebrand disease is the most common inherited bleeding disorder. No consensus exists about the use of neuraxial analgesia or anesthesia in patients with von Willebrand disease. We report on a 38-year-old multiparous woman who presented at 36 weeks' of gestation with spontaneous rupture of membranes for urgent cesarean delivery. Preoperative coagulation tests were normal except for prolonged platelet adhesion and aggregation tests. The cesarean delivery was performed under spinal anesthesia with hyperbaric bupivacaine, fentanyl and morphine sulfate. Desmopressin was administered immediately after delivery. No perioperative complications were observed.

Epidural analgesia in labor for a woman with an intrathecal baclofen pump.

A 28-year-old woman in active labor at 38 weeks of gestation requested epidural analgesia. She had previously received an intrathecal baclofen infusion pump to relieve the spasticity of cerebral palsy. She had right hemiparesis and cerebral palsy but was otherwise healthy. The patient had been seen one month before her expected delivery date by a staff anesthesiologist. A lumbar X-ray demonstrated the intrathecal catheter entering the L3-4 interspace and extending to the mid-thoracic region. For labor analgesia the epidural space was identified at L4-5 with the patient sitting, using a standard 17-gauge Tuohy needle. An epidural catheter was threaded to 5 cm and provided effective analgesia until delivery four hours later. There were no postnatal complications.

Interscalene brachial plexus anesthesia for shoulder surgery: report of a complicated intraoperative course.

We present a case of abrupt hemodynamic and mental status changes that occurred during shoulder surgery. During interscalene anesthesia for rotator cuff repair, there was abrupt onset of altered mental status and hemodynamic changes, which had a variety of possible contributing causes. Complete recovery occurred during care in the post-anesthesia care unit. A variety of physiologic changes can occurred during interscalene anaesthesia for shoulder surgery, which require prompt identification and management.

Diagnosis and management of transient neurologic symptoms following subarachnoid block with single-shot isobaric 2% lidocaine.

Hyperbaric 5% lidocaine has been used extensively for spinal anesthesia for the last 50 yr. The implication of lidocaine as specifically etiologic for transient neurologic symptoms (TNS) has led to increasing focus on lidocaine spinal anesthesia and reports of TNS with single-shot, hyperbaric lidocaine. We report the details of a case of TNS associated with single-shot, isobaric 2% lidocaine in a 69-year-old female, scheduled for outpatient hysteroscopy, dilatation and curettage, and endometrial biopsy while placed in the lithotomy position.

Hemoglobin and methemoglobin concentrations after large-dose infusions of diaspirin cross-linked hemoglobin.

UNLABELLED: Diaspirin cross-linked hemoglobin (DCLHb) solution is a purified human hemoglobin product chemically stabilized to deliver oxygen to tissues. We determined the peak plasma hemoglobin concentration and assessed changes in methemoglobin concentration after the infusion of 1 g/kg DCLHb in large blood loss surgical patients. This prospective, randomized study included 26 surgical patients who were either infused with up to three 250-mL units of 10% DCLHb or transfused with up to three units of packed red blood cells during the study infusion period. Serial plasma hemoglobin, plasma methemoglobin, and whole blood methemoglobin levels were measured before and at intervals up to 48 h after the study infusion period. Plasma hemoglobin and blood methemoglobin concentrations increased during the infusion of DCLHb. The plasma hemoglobin values in the DCLHb group continued to increase during each of the infusion periods to reach a peak plasma concentration of 1450 +/- 176 mg/dL. The fraction of whole blood methemoglobin increased from 0.84 +/- 0.77% at baseline to 4.08 +/- 1.36%. With a median DCLHb dose of 936 mg/kg (range 658-1500 mg/kg), the harmonic mean half-life was 10 h, and the increased whole blood methemoglobin reached a range not associated with complications. IMPLICATIONS: The dose of diaspirin cross-linked hemoglobin (DCLHb) (936 +/- 276 mg/kg) used in this study was one of the largest reported in humans to date. The DCLHb mean half-life was 10 h. The half-life observed was 2-4 times that found at smaller doses in previous studies. Whole blood methemoglobin fraction increased during DCLHb infusion but did not reach a range associated with complications.

Intraarticular morphine and bupivacaine reduces postoperative pain after rotator cuff repair.

BACKGROUND AND OBJECTIVES: To determine whether intraarticular injection of morphine, fentanyl, or sufentanil added to bupivacaine provided pain control after open rotator cuff repair. METHODS: These data were collected as a prospective, randomized, blinded observer study. All patients received a standard interscalene anesthetic with 1.4% mepivacaine with 1:200,000 epinephrine. At the conclusion of surgery, they received an intraarticular injection after the shoulder capsule was closed. Patients were randomized into 4 groups. All received 20 mL of 0.25% bupivacaine: group 1, plain; group 2, with 1 mg of morphine added; group 3, with 50 microg of fentanyl added; and group 4, with 10 microg of sufentanil added. Pain scores in the postanesthesia care unit were evaluated at 0, 30, 60, 90, 120, and 240 minutes and at 4-hour intervals postoperatively using a visual analogue scale. Breakthrough pain was managed with morphine, via patient controlled analgesia pump. RESULTS: Thirty-nine patients were entered into the study. Pain scores at 2 hours and beyond were lowest in group 2. Total morphine utilization was significantly lower for the first 24 hours in group 2. CONCLUSIONS: Intraarticular injection of the shoulder with 0.25% bupivacaine and 1 mg morphine at the conclusion of surgery provided pain control and diminished morphine used in the first 24 hours after open rotator cuff repair. Fentanyl and sufentanil did not improve the analgesia over that achieved with bupivacaine alone.

Redefining the preoperative evaluation process and the role of the anesthesiologist.

STUDY OBJECTIVE: To assess the effects of implementing an ambulatory and same-day surgery preoperative evaluation patient triage system over a 3-year period. DESIGN: Retrospective analysis of 63,941 ambulatory surgical patients presenting for elective surgery. SETTING: Tertiary care, academic medical institution. INTERVENTIONS: The following preoperative evaluation model components were implemented over a 3-year period: HealthQuest, which is an outpatient preoperative assessment computer program developed by the Department of General Anesthesiology; a general internal medicine clinic designated specifically for preoperative evaluation and medical optimization; disease specific algorithms for both preoperative patient assessment and management; and a preoperative anesthesia clinic that no longer performs preoperative medical optimization. MEASUREMENTS AND MAIN RESULTS: During the 3-year study period ambulatory and same-day surgical case volume increased 34.7%. A total of 50,967 patients used HealthQuest as part of their preoperative evaluation. Of these patients 22,744 (35.6%) did not need to see an anesthesiologist until the day of surgery as guided by both a computer-assigned HealthQuest score and surgical classification scheme. Also, 41,197 patients were evaluated in our anesthesia preoperative clinic with a cost per evaluation of $24.86, which increased only 0.9% per year. In addition, both patient interview time and patient dissatisfaction with the preoperative process decreased over the 3-year period. There were 20, 088 patient encounters in the general internal medicine clinic for patient medical evaluation and optimization. The average monthly preoperative surgical delay rate decreased 49% during the study period. Finally, significant monetary saving resulted due to decreased unnecessary laboratory testing. CONCLUSIONS: Efficient, cost-effective patient care can be provided by using this preoperative evaluation model. Some institutions may find portions of this preoperative model applicable to their current situation.

The pharmacology of local anesthetics.

The pharmacology of local anesthetics is an integration of the basic physiology of excitable cells and the mechanism by which local anesthetics are capable of interrupting conduction of neural messages. The common characteristics of the molecules with local anesthetic action have been identified and can explain the properties of the agents. These same chemical characteristics also explain toxicity of these agents and differences that exist between local anesthetics with similar structure.

Use of key words as an adjunctive learning tool improves learning during a perioperative medicine rotation for anesthesiology residents.

Designing a successful block rotation for anesthesiology residents requires not only an appropriate curriculum but also a set of teaching tools, which promote learning. Traditional clinical rotations in Anesthesiology residencies emphasize clinical teaching, supported by interaction with staff. Since Perioperative Medicine is a nontraditional subject for anesthesia residents, we introduced a syllabus and didactic curriculum to support clinical teaching. We hypothesized that the use of key words would enhance learning. Alternating groups of residents were assigned to receive key words, while control residents were expected to learn without key words. The key words were delivered in writing on the first day of the rotation and the syllabus was highlighted to identify the key words in the text. Pretests and posttests were administered to residents participating in the perioperative rotation. Learning was assessed by calculating the change in test scores. There was significantly more learning in the group given the key words. We conclude that key word designation improved learning in a rotation designed to teach perioperative medicine.

Use of Key Words as an Adjunctive Learning Tool Improves Learning During a Perioperative Medicine Rotation for Anesthesiology Residents.

Designing a successful block rotation for anesthesiology residents requires not only an appropriate curriculum but also a set of teaching tools, which promote learning. Traditional clinical rotations in Anesthesiology residencies emphasize clinical teaching, supported by interaction with staff. Since Perioperative Medicine is a non-traditional subject for anesthesia residents, we introduced a syllabus, and didactic curriculum to support clinical teaching. We hypothesized that the use of key words would enhance learning. Alternating groups of residents were assigned to receive key words, while control residents were expected to learn without key words. The key words were delivered in writing on the first day of the rotation and the syllabus was highlighted to identify the key words in the text. Pre and post-tests were administered to residents participating in the perioperative rotation. Learning was assessed by calculating the change in test scores. There was significantly more learning in the group given the key words. We conclude that key word designation improved learning in a rotation designed to teach perioperative medicine.

Autonomic dysfunction in end-stage liver disease manifested as defecation syncope: impact of orthotopic liver transplantation.

Patients with end-stage liver disease (ESLD) may be at increased risk for syncopal episodes based on their circulatory physiological state. Although a definitive cause for this is not known, several mechanisms have been proposed. In patients with ESLD, defecation syncope may result from a failure of short-term neurocirculatory adaptation to the Valsalva maneuver in the face of a hyperdynamic circulatory state and a decreased effective intravascular volume. We describe 2 patients with ESLD who had repeated episodes of defecation syncope before orthotopic liver transplantation (OLT). The most effective treatment of these syncopal episodes appears to be fluid administration and the use of a pressor agent, such as dopamine, to help maintain both an effective heart rate and intravascular volume. Correction of this altered circulatory physiological state through OLT prevented further syncopal episodes in both patients. A search of the literature failed to show previous reports associating ESLD and defecation syncope. Possible mechanisms favoring this association are reviewed.

Organization of a comprehensive anesthesiology oral practice examination program: planning, structure, startup, administration, growth, and evaluation.

STUDY OBJECTIVE: To describe the planning, structure, startup, administration, growth, and evaluation of a comprehensive oral practice examination (OPE) program. SETTING: Midwest U.S. anesthesiology residency training program. MEASUREMENTS AND MAIN RESULTS: Committee planning involved consideration of formal and frequency of administration, timing for best resident and faculty availability, communication, forms design, clerical support, record keeping, and quality monitoring. OPE format was deliberately constructed to resemble that used by the American Board of Anesthesiology (ABA) to enhance resident familiarity with ABA style oral examination. Quality improvement tools consisted of regular examiner and examinee inservice sessions, liaison with ABA associate examiners, and review of examinee exit questionnaires. A set of OPE databases was constructed to facilitate quality monitoring and educational research efforts. A semiannual administration schedule on three to four consecutive Mondays optimally accommodated resident rotations and faculty work schedules. Continued administration of the OPE program required ongoing construction of a pool of guided case-oriented questions, selection of appropriate questions based on examinee training exposure, examination calendar publication, and scheduling of recurring examiner and examinee activities. Important issues that required action by the governing committee were examination timing, conflict with clinical demands, use of OPE results, and procurement of training resources. The OPE program grew from 56 examinations in the first year to 120 exams by year 3. It was perceived positively by the majority of residents. There were 90.2% of exit questionnaires that acknowledged specific learning about oral examination technique, while only 0.3% indicated lack of meaningful information exchange. Fewer than 10% of responses indicated misleading questions or badgering by examiners. Resident preparedness increased with repeat OPE exposure. CONCLUSIONS: A comprehensive mock oral examination program was successfully planned, initiated, and developed. It is well accepted by residents and faculty. Its inception was associated with an increase in resident preparedness. Now in its tenth year of existence it continues to be an asset and essential component of our training program.

An introduction to the World Wide Web.

BACKGROUND AND OBJECTIVES: Anesthesiologists are increasingly utilizing the Internet for personal and professional purposes. Without guidance, the task of searching the Internet for information may be time-consuming and frustrating. This article includes a basic introduction to the Internet with suggestions and guidelines for accessing information resources. Future articles will address locating articles about human anatomy, regional anesthesia and pain medicine. EDITORS NOTE: This is the first in an informal series of articles demonstrating and describing information technology. The articles will include nontechnical information and will detail the experiences and wisdom obtained from experienced anesthesiologists. The series is geared toward the computer novice with interest in regional anesthesia and pain medicine. These articles are also available in full text on the American Society of Regional Anesthesia website (www.asra.com) with links to the websites in the article.

Continuing medical education and the anesthesiologist.

There are a large variety of scheduled activities and courses available to meet the continuing medical education (CME) needs of anesthesiologists. The presentation of CME material varies in format and delivery style. The reasons for attending CME activities include licensure requirements, participation in state and national societies, keeping current with technology, review of old subject material, participation as a lecturer, and other personal reasons. Funding occurs via personal funds, employer support, commercial support, or by research grants. External bodies, such as the American Council of Continuing Medical Education and the American Medical Association, have imposed guidelines in these areas. Methods to evaluate CME activities include retrospective needs analysis based on exit interviews, prospective needs assessment, focus groups, and complex systems such as the CRISIS criteria. Self-directed CME can be evaluated by data collection that identifies how quickly information is received and by the effect of this data on measurable outcome. In the future, CME will increasingly utilize simulators and multimedia computers. Multimedia can bring CME to the physician as opposed to the physician traveling to a CME site. Virtual reality and artificial intelligence are on the horizon and may interface well with the field of anesthesiology due to the technical nature of the discipline and the increasing use of computers and electronic data collection already occurring in clinical practice.

Consistency, inter-rater reliability, and validity of 441 consecutive mock oral examinations in anesthesiology: implications for use as a tool for assessment of residents.

BACKGROUND: Oral practice examinations (OPEs) are used extensively in many anesthesiology programs for various reasons, including assessment of clinical judgment. Yet oral examinations have been criticized for their subjectivity. The authors studied the reliability, consistency, and validity of their OPE program to determine if it was a useful assessment tool. METHODS: From 1989 through 1993, we prospectively studied 441 OPEs given to 190 residents. The examination format closely approximated that used by the American Board of Anesthesiology. Pass-fail grade and an overall numerical score were the OPE results of interest. Internal consistency and inter-rater reliability were determined using agreement measures. To assess their validity in describing competence, OPE results were correlated with in-training examination results and faculty evaluations. Furthermore, we analyzed the relationship of OPE with implicit indicators of resident preparation such as length of training. RESULTS: The internal consistency coefficient for the overall numerical score was 0.82, indicating good correlation among component scores. The interexaminer agreement was 0.68, indicating moderate or good agreement beyond that expected by chance. The actual agreement among examiners on pass-fail was 84%. Correlation of overall numerical score with in-training examination scores and faculty evaluations was moderate (r = 0.47 and 0.41, respectively; P < 0.01). OPE results were significantly (P < 0.01) associated with training duration, previous OPE experience, trainee preparedness, and trainee anxiety. CONCLUSION: Our results show the substantial internal consistency and reliability of OPE results at a single institution. The positive correlation of OPE scores with in-training examination scores, faculty evaluations, and other indicators of preparation suggest that OPEs are a reasonably valid tool for assessment of resident performance.

Preoperative intra-articular morphine and bupivacaine for pain control after outpatient arthroscopic anterior cruciate ligament reconstruction.

BACKGROUND AND OBJECTIVES: The purpose of this study was to determine whether intra-articular injection of bupivacaine, morphine, or a combination prior to surgery provided pain control after arthroscopic anterior cruciate ligament (ACL) reconstruction. METHODS: These data were collected as a two-stage prospective, randomized, blinded observer study. All patients received a standard general anesthetic, which included an intra-articular injection 20 minutes prior to incision. In phase I, three solutions were assigned randomly in a 60-mL volume. Group 1 was saline, group 2 was 0.25% bupivacaine, and group 3 was 0.25% bupivacaine with 1 mg morphine sulfate (MS). Phase II was identical to phase I in technique and had four groups. Group 1 was 0.25% bupivacaine, group 2 was 1 mg MS in saline, group 3 was 0.25% bupivacaine with 1 mg MS, and group 4 was 0.25% bupivacaine with 3 mg MS. All groups in phases I and II contained 1:200,000 epinephrine, freshly added. Pain scores were evaluated at 0, 30, 60, 90, 120, and 240 minutes postoperative using a visual analog scale. For pain scores of 5 or greater, 50 microg fentanyl was administered at 5-minute intervals until pain was controlled. After transition from phase I to phase II of the postanesthesia care unit (PACU), hydrocodone/acetaminophen tablets were used. RESULTS: Thirty patients were entered into phase I of the study. Both treatment groups (2 and 3) had significant (P < .05) pain reduction on arrival to the PACU. Group 3 had significantly (P < .05) reduced need for fentanyl during the PACU stay. Forty-nine patients entered phase II of the study. In phase II, group 3 had the lowest pain scores on arrival to the PACU. At 120 and 240 minutes, pain scores were lower in groups 3 and 4. Fentanyl and hydrocodone uses were significantly lower during the PACU stay in groups 3 and 4. CONCLUSIONS: Presurgical injection of a solution of 0.25 % bupivacaine, morphine, and epinephrine provided pain control and decreased opioid use in the PACU. Increasing the morphine dose did not improve the clinical result.