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Biomedical subjects

J E Tetzlaff

Publications and source records attributed to J E Tetzlaff.

At least 19 recordsLinked to original sources
PubMed2001

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.

Brachial Plexus↗
PubMed2001

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.

Aged↗
PubMed2001

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.

Aspirin↗
PubMed2000

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.

Anesthetics, Local↗
PubMed2000

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.

Anesthesiology↗
PubMed2000

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.

Algorithms↗
PubMed1999

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.

Adult↗
PubMed1999

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.

Anesthesiology↗
PubMed1999

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.

Anesthesiology↗
PubMed1999

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.

Anesthesiology↗
PubMed1998

Ischaemic optic neuropathy after spinal fusion.

PURPOSE: We report a case of ischaemic optic neuropathy which occurred after prolonged spine surgery in the prone position in an obese, diabetic patient. CLINICAL FEATURES: The patient was a 44-yr-old, 123 kg, 183 cm man for decompressive laminectomy and instrumented fusion of the lumbar spine. Anaesthesia was induced with thiopentone, fentanyl and succinylcholine and maintained with nitrous oxide, oxygen, isoflurane and a fentanyl infusion. He was positioned prone on the Relton-Hall frame and had an uneventful intraoperative course. Estimated blood loss was 3,000 ml. He was taken to the surgical intensive care unit (SICU) and the trachea was extubated 3.5 hr later. He had no pulmonary or haemodynamic problems and went to a regular nursing floor in the morning. He was discharged home on postoperative day #5. He telephoned his surgeon on postoperative day #7 to say that his vision had been blurry since surgery. His visual acuity was decreased, and on examination, he had a bilateral papillary defect, optic swelling and a splinter haemorrhage in the right eye. Magnetic resonance imaging (MRI) scan of the head and orbits detected no other abnormality. Based on this examination, he was felt to have bilateral ischaemic optic neuropathy and treated conservatively. By postoperative day #47, his visual acuity was greatly improved and near normal. Careful review of possible contributing factors suggests that the cause of the ischaemic optic neuropathy was venous engorgement. CONCLUSION: This patient developed ischaemic optic neuropathy from a prolonged interval in the prone position of the Relton-Hall frame, which may be related to venous engorgement.

Adult↗
PubMed1998

Cauda equina syndrome after spinal anaesthesia in a patient with severe vascular disease.

PURPOSE: Spinal anaesthesia is selected for many lower extremity surgical procedures each year in the United States with a high degree of safety and efficacy. Even when adverse neurological outcomes have occurred, anatomical abnormality or coagulopathy have been implicated in the majority of cases. Epinephrine is used in high concentrations in many of these anaesthetics to increase the duration and intensity of the block. Although epinephrine is known to decrease spinal cord blood flow, its use in normal patients has not caused complications. We report a case where spinal anaesthesia with bupivacaine and epinephrine resulted in anterior spinal artery compromise and the development of a cauda equina syndrome postoperatively. CLINICAL FEATURES: A 57-yr-old man with severe coronary artery and peripheral vascular disease was scheduled for incision and drain of an abscess of the left thigh. He received an atraumatic dural puncture and injection of 12.5 mg bupivacaine with 0.2 ml 1:1000 epinephrine. During onset, he experienced a severe, painful sensation of the thighs which resolved with development of the block. Postoperatively, he was noted to have exacerbation of proximal muscle weakness and decreased perineal sensation and rectal tone. Subsequent EMG studies demonstrated proximal neuron loss consistent with cauda equina syndrome, presumed to be related to insufficiency of the anterior spinal artery. CONCLUSION: Routine use of epinephrine in spinal anaesthesia for patients with multi-organ vascular disease should be considered carefully because of the possibility of vascular insufficiency of the spinal cord which would be exaggerated by the vasoconstrictive effect of epinephrine.

Anesthesia, Spinal↗
PubMed1998

Massive bleeding during spine surgery in a patient with ankylosing spondylitis.

PURPOSE: Ankylosing spondylitis is associated with pathophysiology that has important anaesthetic implications. We report a case where the sequelae of ankylosing spondylitis may have been responsible for massive bleeding during emergency spine surgery. CLINICAL FEATURES: A 69 yr old man with long standing ankylosing spondylitis sustained a complex fracture of the lumbar spine in a fall, and was scheduled for stabilization of the spine. Under general anaesthesia, prone positioning was difficult because of the extreme spinal deformity. During exploration, dilatation of epidural veins was encountered and sustained haemorrhage was encountered throughout the surgical procedure. Estimated blood loss was 17,000 ml which was replaced with 31 units of packed red blood cells, 3200 ml of salvaged blood, 18 units of fresh frozen plasma, 26 units of platelets, 1,000 ml of albumin and 9,000 ml of crystalloid. CONCLUSIONS: Extreme deformity of the spine led to positioning difficulties that may have contributed to massive blood loss during complex spine surgery. Difficulties with placement in the prone position in-patients with advanced ankylosing spondylitis should be anticipated.

Aged↗
PubMed1998

Power spectral heart rate analysis demonstrates decreased activity of the sympathetic nervous system during low bupivacaine spinal anesthesia.

STUDY OBJECTIVE: To evaluate the onset of spinal anesthesia with power spectral heart rate analysis to determine the influence of the block on the autonomic nervous system. DESIGN: Prospective, clinical evaluation. SETTING: Tertiary-care teaching hospital. PATIENTS: 27 ASA physical status I and II patients scheduled for lower extremity orthopedic surgery and free of major cardiac disease or cardiac drugs with direct influence of heart rate (HR) or blood pressure (BP). INTERVENTIONS: Prior to anesthesia, a baseline power spectral heart rate reading was taken in the supine position. Spinal anesthesia was established in the sitting position with 15 mg of bupivacaine and 0.2 mg epinephrine introduced at the L3-L4 interspace with a 22-gauge Quincke needle. The patient was returned supine, and power spectral heart rate data were again collected at 5-minute intervals throughout the procedure. Level of the spinal block was checked at 5-minute intervals until 30 minutes and considered complete when two consecutive readings were unchanged. MEASUREMENTS AND MAIN RESULTS: Heart rate and BP were recorded at baseline and at five-minute intervals after injection. Power spectral heart rate data included low-frequency activity (LFa), high-frequency activity (HFa), and the ratio (LFa/HFa). Spinal level achieved was recorded by thoracic dermatome at complete onset. Heart rate and BP remained within 20% of control in all cases. Complete onset of the spinal block was present by 30 minutes in all cases. The average level of spinal anesthesia was T8. Compared with baseline, LFa activity decreased, HFa activity remained unchanged, and the ratio was decreased. During endoprosthesis insertion, 9 of 14 total hip patients had a transient ten-fold increase in LFa activity, without HFa change, and a corresponding increase in the ratio. CONCLUSIONS: Power spectral heart rate analysis during low thoracic bupivacaine spinal anesthesia is compatible with decreased sympathetic activity during stable hemodynamic intervals. Insertion of hip endoprosthesis resulted in a dramatic, transient increase in sympathetic activity, indicating that sympathetic activation was still possible despite the presence of surgical anesthesia from the subarachnoid block.

Anesthesia, Spinal↗