Biomedical subjects

J E Tetzlaff

Publications and source records attributed to J E Tetzlaff.

51 records · Page 3Linked to original sources

PubMedDate not supplied

Influence of lumbar spine pathology on the incidence of paresthesia during spinal anesthesia.

BACKGROUND AND OBJECTIVES: Paresthesia occasionally occurs during dural puncture or injection of local anesthetic for spinal anesthesia. Although the incidence of neurologic complications after spinal anesthesia is extremely low, the significance of paresthesia is unknown. The influence of known lumbar spine pathology on the incidence of paresthesia during spinal anesthesia is studied. METHODS: Incidence of paresthesia with dural puncture (PP) or injection (PI) was studied in two groups of patients. Group 1 included patients for elective total joint replacement without known spine pathology or complaints. Group 2 included patients for elective lumbar spine surgery who received spinal anesthesia. RESULTS: Significantly more PP (20% vs 9%) and PI (16% vs 6%) occurred in the spine surgery group. There were no neurologic sequelae of spinal anesthesia. CONCLUSIONS: This information suggests that the incidence of paresthesia during the conduct of spinal anesthesia is higher in patients with lumbar spine pathology. Although there were no neurologic complications, the sample size is too small to exclude an increase in the neurologic risk of spinal anesthesia in patients with known intraspinal pathology.

Adrenergic Agonists↗

PubMedDate not supplied

An unusual cause of acute chest pain during epidural anesthesia.

BACKGROUND AND OBJECTIVES: Selective sympathetic denervation during epidural anesthesia results in a small, active gut. These changes can also result in selective activity in one segment of the gut that is absent in other segments. CASE REPORT: A 61-year-old male was scheduled for bilateral total knee replacement during epidural anesthesia. Following onset of the epidural block, he experienced severe left-sided chest pain. Surgery was canceled. A portable chest radiograph revealed a widened mediastinum, and he underwent angiography to rule out a dissecting thoracic aortic aneurysm. The left subclavian artery could not be visualized, and an MRI was obtained, which was normal. After his return to the intensive care unit, he had a large bowel movement and his chest pain resolved. CONCLUSION: Selective activity of the gastrointestinal tract during the onset of epidural anesthesia created a visceral pain, which effectively simulated pain with a cardiovascular origin.

Anesthesia, Epidural↗

PubMedDate not supplied

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.

Anesthesia, Conduction↗

PubMedDate not supplied

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.

Acetaminophen↗

PubMedDate not supplied

A survey of exposure to regional anesthesia techniques in American anesthesia residency training programs.

BACKGROUND AND OBJECTIVES: The American Board of Anesthesiologists and the Residency Review Committee for Anesthesiology do not keep records regarding the individual resident's cumulative exposure to specific peripheral nerve block techniques. Further, little is known about individual trainee confidence in performing regional anesthetic blocks. To improve training and anesthesia practice, such information is necessary. In this nationwide survey, we assessed residents' perceived cumulative regional anesthesia experience and their confidence level. METHODS: A survey was distributed to 42 U.S. residency programs in 22 states. Information collected included the resident's clinical anesthesia (CA) training level, estimated number of regional anesthetics performed, and the resident's confidence level in performing these techniques. Confidence was graded on a 3-point scale, as being very confident (1.0), somewhat confident (2.0), or not confident (3.0). We analyzed the estimated cumulative number and type of blocks performed in relation to training level and confidence level; differences were considered significant when P< .001. RESULTS: The response rate was 67.2% (736/1,096); 32% (n = 232) of responders were CA-3 residents. At all training levels, the number of blocks performed varied widely according to type of block, with spinal and epidural blocks being performed most often at all training levels and sciatic, retrobulbar, and femoral blocks being performed least (median = 0 each for CA-1, CA-2, and CA-3 residents). Confidence was high with frequently performed blocks (spinal and lumbar epidural) and low for those performed less than 10 times per resident. The CA-3 residents reported a cumulative experience with a median (interquartile range) of 100 (50-100) spinal anesthetics and 150 (100-200) lumbar epidural blocks with all residents being very confident. The CA-3 residents completed a median of 20 (10-30) axillary blocks but a median of less than 10 for each of these techniques: intravenous regional anesthesia, ankle, interscalene, femoral, sciatic, and retrobulbar. For interscalene block, 51% of CA-3 residents were not confident; for femoral, 62%; for sciatic, 75%; and for retrobulbar block, 91%, were not confident. CONCLUSIONS: Most CA-3 residents are confident in performing lumbar epidural and spinal anesthesia. However, many are not confident in performing the blocks with which they have the least exposure. Changes need to be made in the training processes so that residents can graduate with enough confidence to continue selecting less familiar blocks in postgraduate practice.

Anesthesia, Conduction↗

PubMedDate not supplied

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.

Analgesics, Opioid↗

PubMedDate not supplied

Asymptomatic profound oxyhemoglobin desaturation following interscalene block in a geriatric patient.

BACKGROUND AND OBJECTIVES: Interscalene block can be chosen for complete anesthesia for shoulder surgery. Phrenic nerve block occurs with almost all interscalene blocks, but is well tolerated in most patients. This may not be the case in selected geriatric patients. METHODS: The patient is a 90-year-old female with osteoarthritis of the left shoulder scheduled for total shoulder anthroplasty. Past medical history revealed hypertension, mild mitral valve insufficiency, and a remote episode of congestive heart failure. She underwent interscalene block with 40 mL of 1.4% mepivacaine, 1:200,000 epinephrine freshly added, alkalinized with sodium bicarbonate. RESULTS: The onset of the block was rapid and complete. The patient had minimal intravenous sedation (0.5 mg midazolam) and was resting comfortably with a respiratory rate of 12-14 breaths/min. Approximately 5 minutes after the injection of local anesthetic, the patient was noted to be alert, cyanotic, denying dyspnea, with an oxygen saturation of 75-85%. A chest radiograph revealed elevation of the ipsilateral hemidiaphragm and no pneumothorax or other pathology. Despite supplemental oxygen by face mask, desaturation persisted and general anesthesia was induced. On emergence from anesthesia, the patient had a complete interscalene block. Repeat chest radiograph after resolution of the block revealed return of hemidiaphragm position and no other pathology. The patient was extubated in the recovery room without difficulty. Following extubation the patient demonstrated stable respirations and normal oxyhemoglobin saturation. CONCLUSIONS: Ipsilateral phrenic nerve paralysis caused significant respiratory compromise in an elderly patient without known significant pulmonary disease.

Aged↗

PubMedDate not supplied

Preemptive analgesia: its role and efficacy in anterior cruciate ligament reconstruction.

As more outpatient orthopaedic surgical procedures are performed, postoperative pain control has gained importance. The benefits of preemptive analgesia, the use of analgesics or anesthetics or both before painful stimuli to prevent or reduce pain, have been widely published in the anesthesia and general surgery literature, but not in orthopaedic literature. We prospectively compared the effects, on postoperative pain and narcotic use, of intraarticular preoperative injections of 1) placebo with epinephrine, 2) bupivacaine with epinephrine, and 3) bupivacaine and morphine with epinephrine. Thirty patients (10 in each group) underwent arthroscopic anterior cruciate ligament reconstruction using patellar tendon autograft under general anesthesia. Pain was assessed with a 10-point visual analog scale pre- and postoperatively, and postoperative narcotic pain medication use was recorded. Postoperative pain was significantly greater in group 1 (placebo) than in the preemptive-treatment groups (groups 2 and 3), and in group 2 than in group 3. The differences became less apparent with time, and after 1 hour, no significant differences in pain scores existed between the groups. However, intravenous narcotic pain medication was administered in the recovery room to patients with pain scores greater than 5, equalizing pain scores. Group 3 used significantly less postoperative narcotic medication than group 1. Preemptive analgesia using intraarticular bupivacaine and morphine with epinephrine resulted in lower pain scores during the 1st hour after an arthroscopic anterior cruciate ligament reconstruction than did preemptive treatment with bupivacaine and epinephrine or placebo and epinephrine.

Adolescent↗

PubMedDate not supplied

Severe perioperative lactic acidosis: how clinically significant is it?

BACKGROUND: Lactic acidosis, generally defined as a plasma lactate concentration in excess of 5 mmol/L with a concomitant blood pH less than 7.25, is reported to have a direct association with mortality. OBJECTIVE: To report a case of unexplained perioperative lactic acidosis and to discuss the etiology, recognition, treatment, and importance of a transient rise in plasma lactate concentration. SUMMARY: Severe lactic acidosis developed in a 40-year-old man with Crohn's disease during major abdominal surgery. The plasma lactate concentration reached 16.9 mmol/L (normal range 1.5 to 2.2 mmol/L). This condition resolved within 14 hours without harm to the patient. CONCLUSIONS: When lactate accumulates in the perioperative period, the responsible condition is most often self-limiting. Reversible, subacute, marked lactic acidosis should not be assumed to predict mortality as it does in patients whose plasma lactate concentrations remain chronically elevated during severe systemic diseases such as sepsis.

Acidosis, Lactic↗

PubMedDate not supplied

Alkalinization of mepivacaine accelerates onset of interscalene block for shoulder surgery.

Reports evaluating the effect of alkalinization of mepivacaine on the onset of regional anesthesia have been controversial. The effect of alkalinization of mepivacaine on the onset of interscalene block has not been reported and is the subject of this study. Forty patients received an interscalene block by elicitation of paresthesia with 25-gauge, blunt level needle. Twenty patients received 40 ml 1.4% mepivacaine, which contained epinephrine (1:200,000). Another 20 patients received 40 ml 1.4% mepivacaine, epinephrine (1:200,000), and 4 mEq of NaHCO3. Time to onset of block was determined by awareness of cold, and loss of pain perception and motor function at the shoulder, elbow and hand. The duration of block for each observation was determined. The onset was significantly faster for all tested modalities in the pH-adjusted group. No statistically significant differences in the duration of either motor or sensory were found between the study and control groups.

Bicarbonates↗

PubMedDate not supplied

Alkalinization of mepivacaine improves the quality of motor block associated with interscalene brachial plexus anesthesia for shoulder surgery.

BACKGROUND AND OBJECTIVES: Interscalene block has produced appropriate anesthesia for shoulder surgery. Success is partly determined by the quality of motor block achieved. This study was designed to evaluate the influence of alkalinization of mepivacaine on the quality of motor block achieved with interscalene brachial plexus anesthesia. METHODS: The study design included a prospective, randomized trial of 2 groups of 20 patients each undergoing shoulder surgery by one surgeon with interscalene block. Both groups received interscalene block with 40 mL 1.4% mepivacaine, 1/200,000 epinephrine, using a 25-gauge, blunt-bevel needle and elicitation of paresthesia in the arm. One group had 1 mL sodium bicarbonate (1 mEq/mL) per 10 mL mepivacaine added and the other had an equal volume of saline. Average pH was determined for each solution in a nonclinical setting. Motor block was graded by a blinded observer after a standard 3-minute injection at 1 and 10 minutes after injection on a 0-5 standard neurologic scale. The surgeon, blinded to group selection, graded the quality of motor block as excellent, good, fair, or poor at preparation, incision, and 15 minutes postincision. RESULTS: Both groups were similar demographically. All blocks provided successful surgical anesthesia. Motor block quality was evaluated as better at all times in the study group (alkalinization) by both the blinded observer and the surgeon. CONCLUSIONS: Alkalinization of mepivacaine improves the quality of motor block after interscalene brachial plexus block for shoulder surgery.

Brachial Plexus↗

PubMedDate not supplied

Interscalene brachial plexus block for shoulder surgery.

BACKGROUND AND OBJECTIVES: To evaluate the efficacy of interscalene brachial plexus block as the primary anesthetic for shoulder surgery, the influence on blood loss, and the rate of complication. METHODS: Retrospective review of 676 reconstructive surgical procedures of the shoulder for anesthetic technique (regional or general), regional anesthetic technique (paresthesia versus nerve stimulator), local anesthetic agent selected, success rate, estimated blood loss by procedures, and complications. RESULTS: A total of 563 patients had interscalene anesthesia, exclusively, and 117 had general anesthesia. Mepivacaine, 1.4% with 1/200,000 epinephrine, was the most frequently used agent (480). Others included 0.5% bupivacaine (33) and 0.625% bupivacaine (50). Of 563 interscalene blocks attempted, 34 required general anesthesia to either initiate or complete the surgery (success rate, 94.1%) with 20 in the 0.5% bupivacaine group, 10 in the mepivacaine group, and 9 in the 0.65% bupivacaine group. For blood loss calculations, failed interscalene blocks were included with the general anesthesia group. Three surgical procedures were identified: total shoulder arthroplasty, acromioplasty with and without repair of the rotator cuff, and capsular advancement for recurrent shoulder dislocation. Comparing general and interscalene anesthesia, blood loss was less in the overall group and in the acromioplasty-rotator cuff group when interscalene block was compared to general anesthesia. There were four complications with two seizures and two subdural injections. CONCLUSIONS: Interscalene anesthesia is an effective anesthetic for elective shoulder surgery that may decrease intraoperative blood loss with a low complication rate.

Anesthesia, Conduction↗

PubMedDate not supplied

Subdural anesthesia as a complication of an interscalene brachial plexus block. Case report.

BACKGROUND AND OBJECTIVES: Interscalene brachial plexus block is performed in the groove between the anterior and middle scalene muscles at the level of C6, just over the transverse process. Injection occurs within 1-2 cm of the dural sleeve and could be misdirected into the epidural, subdural, or subarachnoid spaces. METHODS: Interscalene block was performed by elicitation of paresthesia with 40 mL 1.4% mepivacaine, 1/200,000 epinephrine. RESULTS: Initially, complete interscalene block was achieved that evolved into apnea, high motor, and sensory block; requiring induction of general anesthesia. CONCLUSIONS: The case represents a partial injection of local anesthetic intended for the interscalene brachial plexus into the subdural space. The diagnosis is based on the normal evolution of the block into full motor and sensory anesthesia of the ipsilateral brachial plexus that evolved into a patchy, sensory, and motor block involving many dermatomes outside the brachial plexus, with minimal sympathetic block, and evidence of a normal interscalene block on emergence from general anesthesia. Subdural injection must be considered when unusual motor and sensory block occurs after interscalene block, especially after a time interval too long for epidural or subarachnoid injection, or with minimal evidence of sympathetic block, after suspected high central block injection.

Adult↗

PubMedDate not supplied

Patient acceptance of interscalene block for shoulder surgery.

BACKGROUND AND OBJECTIVES: Regional anesthesia can be applied to shoulder surgery with an expected high success rate. To determine the level of patient satisfaction with regional anesthesia, we studied a group of patients who had undergone shoulder surgery more than once, with general anesthesia on one occasion and regional on another. METHODS: Twenty-five consecutive patients with prior shoulder surgery under general anesthesia (GA) willing to receive interscalene brachial plexus anesthesia (ISB) were identified. On postoperative day one, a questionnaire was administered. Data were evaluated with McNemar's test and chi-square analysis and considered significant at p < 0.05. RESULTS: There were no differences in sedation or patient preparation between GA and ISB. ISB was tolerable during placement, and no patients complained of being aware or inadequately sedated. With ISB, there was better recovery room pain control, less nausea, and less vomiting. Overall, the patients preferred ISB. CONCLUSIONS: Interscalene brachial plexus block is well accepted by patients for reconstructive shoulder surgery.

Anesthesia, Conduction↗

PubMedDate not supplied

Influence of baricity on the outcome of spinal anesthesia with bupivacaine for lumbar spine surgery.

BACKGROUND AND OBJECTIVES: Although the majority of elective lumbar spine surgical procedures are performed under general anesthesia, successful use of spinal and epidural anesthesia has been reported. This study was designed to evaluate the influence of baricity on the performance of spinal anesthesia for lumbar spine surgery. METHODS: The study was performed on 53 demographically similar American Society of Anesthesiologists status 1 and 2 patients who were randomly assigned to receive spinal anesthesia with 15 mg of bupivacaine along with 0.2 mg of epinephrine as either 3 ml 0.5% plain bupivacaine (I group) or 2 ml 0.75% bupivacaine (Sensorcaine Spinal, Astra, Westborough, MA) premixed in 8.25% glucose (H group). All blocks were placed with a 22-gauge Quincke needle (Becton Dickinson, Franklin Lakes, NJ) at the L3-L4 interspace with the patient in the sitting position. Subsequent data, collected by a blinded observer, included onset of motor and sensory anesthesia, highest sensory level achieved, maximum changes in heart rate and blood pressure, need for treatment of heart rate or blood pressure decreases, failed blocks, and need for supplemental local anesthetic injection to complete incision or wound closure. RESULTS: The time to onset for complete motor and sensory block was significantly longer in the I group. The maximum sensory level achieved was higher in the H group, and the maximum drop in blood pressure and number of interventions to treat heart rate and blood pressure were greater in the H group. There were two failed blocks, which were repeated successfully, in the H group. The need for local anesthetic infiltration of the wound with incision and closure was greater in the H group. CONCLUSIONS: Plain bupivacaine is superior to hyperbaric bupivacaine for spinal anesthesia for elective lumbar spine surgery.

Adult↗