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Biomedical subjects

M J Tessler

Publications and source records attributed to M J Tessler.

At least 19 recordsLinked to original sources
PubMed1999

Patient flow in the Post Anesthesia Care Unit: an observational study.

PURPOSE: Anesthesiologists are constantly striving for improvement in health care delivery. We assessed the patient flow in the Post Anesthesia Care Unit (PACU) to determine if patients are being transported out of the PACU when ready. METHODS: A University student recorded the flow of 336 patients who recovered in our Post Anesthesia Care Unit. The corresponding nursing and orderly complements were recorded. If a delay arose between the time the patient was deemed fit for discharge by the PACU nurse and the time the patient was transported from the PACU, the student determined the duration and cause(s) of the delay. RESULTS: The number of patients, nurses, and orderlies increased from three to twelve, three to seven, and one to two respectively throughout the elective working day. Seventy-six per cent of patients studied were delayed in transport from the PACU, with 26% of patients waiting 30 min. The average delay in discharge for patients increased during the day from 0 to 65 +/- 54 min from the time of fit for discharge, as determined by the PACU nurse, until transport. Five causes were identified as contributing to the delay: orderly too busy (41%), awaiting Anesthesia assessment (36%), Post Anesthesia Care Unit nurse too busy (15%), receiving floor not ready (6%), and patient awaiting radiographic interpretation (2%). CONCLUSION: Our study has shown that system errors unnecessarily prolongs the stay of patients in the PACU.

Anesthesia Recovery Period↗
PubMed1998

Anesthesiologists and the time interval between cases in cardiac surgery.

STUDY OBJECTIVE: To determine whether an association exists between individual anesthesiologists and nonpatient care time in the operating room (OR). DESIGN: Retrospective chart review. SETTING: Cardiac surgery operating theatre in a University Hospital. PATIENTS: 312 elective coronary artery bypass procedures over 2 years. MEASUREMENTS AND MAIN RESULTS: The time interval between cases, as defined by the time between the first patient out and the second patient in, was compared. Six anesthesiologists, labelled 1 to 6, were involved in the 156 data points analyzed. The mean (+/- SD) time interval between cases, in minutes, for anesthesiologists 1 to 6 were, respectively: 24 +/- 9, 25 +/- 8, 27 +/- 8, 29 +/- 5, 30 +/- 4, 31 +/- 7. The difference among the anesthesiologists' mean time interval between cases was significant (p < 0.01). The mean time interval between cases was significantly different between anesthesiologists 1 and 6 (p < 0.01) and between anesthesiologists 2 and 6 (p < 0.05). CONCLUSION: The impact of a shorter time interval between cases on OR efficiency remains unknown. Further education and investigation of this issue are warranted.

Analysis of Variance↗
PubMed1997

Videotape feedback in teaching laryngoscopy.

PURPOSE: To evaluate if videotape feedback provides educational insights for students learning laryngoscopy that they would not otherwise perceive. METHODS: Twenty-six medical students were videotaped while performing laryngoscopy for oral intubation. Before and after reviewing their performance on the videotape, they answered a standardized questionnaire assessing the adequacy of positioning, head movement during laryngoscopy, degrees of neck flexion and head extension, time elapsed, and whether the laryngoscope contacted the upper lip or teeth. After the review, they were asked if being videotaped was distracting, whether it provided new instructional insights and, if so, which was most important. RESULTS: Only 4% of students felt that initial head and neck positioning was suboptimal and this increased to 38% after videotape review (P = 0.029). The perceived inadequacy of positioning seemed related to initial overestimation of head extension (34.0 +/- 15 degrees) compared with that seen on videotape (21.5 +/- 13.5 degrees, P = 0.003). The estimated duration of laryngoscopy was underestimated (55 +/- 32 sec vs. 75 +/- 29 sec, P = .024) before videotape review. Although 26.9% (7/26) of students admitted feeling distracted by the video camera, all felt the experience had educational value. CONCLUSION: Videotape feedback changed students' perception of how they performed laryngoscopy. In particular, head extension was overestimated and duration of laryngoscopy underestimated.

Anesthesiology↗
PubMed1997

A "zero tolerance for overtime" increases surgical per case costs.

PURPOSE: One technique which some hospitals have used in an attempt to control Operating Room costs is a "zero tolerance for overtime" policy. We used a case cost analysis to determine if this policy was always cost effective. METHOD: A case cost analysis was designed based on a "test case" which would start late in the day. The case would last for three hours of which 1 1/2 hr would be during regular hours, and 1 1/2 hr would incur overtime. Costs were analysed using a "patient pays," "society pays," and "hospital pays" analysis. Costs were based on figures determined from the SMBD-Jewish General Hospital budget, Québec Health Insurance fees, and Government of Canada statistics. RESULTS: Regardless of who pays, in this case scenario it was more cost effective to proceed than to postpone surgery. Costs of proceeding with the surgery in the "patient pays," "society pays," and "hospital pays" models were $1,832.00, $1,227.40, and $1,215.00 respectively. The costs of postponing the surgery in the same three models were $1,937.00, $1,336.80, and $1,436.00. CONCLUSION: A "zero tolerance for overtime" policy may be too rigid to be consistently cost effective.

Anesthesiology↗
PubMed1996

Changes in PCO2 with acute changes in cardiac index.

PURPOSE: A direct relationship between cardiac index (CI) and end-tidal PCO2 (PETCO2) shortly after decreased CI was reported, but arterial PCO2 was not measured. Our purpose was to supply the missing information on the immediate effects of alterations in CI on PaCO2, PETCO2 and thus on Pa-PETCO2. METHODS: We measured CI, Pa and PETCO2 and calculated the difference in 20 patients scheduled for elective heart surgery just before and immediately after the sternotomy. The measurements were made using standard methods: thermodilution for CI, infra-red and blood gas analysis for PET and PaCO2 respectively. The results were analyzed by linear regression. RESULTS: Very significant, direct and immediate changes in PET and PaCO2 with changes in CI were noted. The ratios were 3.8 and 4.2 mmHg L-1 respectively. The calculated values of r were 0.75 (P < 0.001) for PETCO2 and 0.64 (P < 0.005) for PaCO2. The magnitude of individual change in PCO2 varied considerably such that the alterations in Pa-PETCO2 were also variable, without any correlation with the direction or magnitude of change in CI. CONCLUSION: Our results explain the reported wide variations in Pa-PETCO2 that accompany perturbations of cardiac output. Our observations pertain to the unsteady state only. The results suggest that PETCO2 can be used to estimate changes in CI with a reasonable degree of confidence.

Adult↗
PubMed1996

Misleading end-tidal CO2 tensions.

PURPOSE: The aim of this study was to determine if the literature supported the assumption that the values and changes in end-tidal PCO2 (PETCO2) during anaesthesia accurately reflect the values and changes in arterial PCO2 (PaCO2) is tenable. METHODS: The information was obtained by (a) a Medline literature search and the appropriate references quoted in the list generated; (b) appropriate abstracts in recent issues of the annual meeting supplements of Anesth Analg, Anesthesiology, Br J Anaesth and Can J Anaesth. We specifically sought information obtained during major operations, in sick patients, and reports of serial measurements. The information obtained is summarized in graphic form, with a discussion of the mechanisms and clinical implications. RESULTS: (1) Patients with systemic disease, or when placed in the lateral position, or with haemodynamic instability have an increased Pa-PETCO2 gradient. The values during surgery are probably due to marked alterations of ventilation: perfusion relationships. (2) In a number of reports, the gradient varied widely during the procedure. (3) The gradient may be reduced due to an alteration of the configuration of the alveolar plateau. (4) The magnitude and direction of change in PaCO2 and PETCO2 can be disproportionate and in the opposite direction. CONCLUSION: End-tidal PCO2 is often not indicative of PaCO2. Also, changes in PETCO2 do not always accurately indicate the direction and extent of the change in PaCO2.

Anesthesia↗
PubMed1996

Late operating room starts: experience with an education trial.

PURPOSE: This study was undertaken to determine if late starts of first cases in the Operating theatres at the SMBD-Jewish General Hospital remained a problem after identification of the causes of late starts and remedial actions being taken. METHODS: Hospital approval was obtained. A retrospective chart audit analyzed a two week period (10 days with 90 elective surgical cases) in October 1993. The time of entry by the first patient into each Operating Room (OR) was transcribed from the nursing records from each OR. A late start was defined as patient entry into the OR after 0745 hr. This audit revealed 77.8% of patients scheduled' for surgery at 0745 entered the OR late with a cumulative time lost of 1101 min. The reasons for this inefficiency were identified by a follow-up assessment in April 1995 as a result of this audit. Corrective measures included presentation of inpatients for the first case, reorganization of transport personnel schedules to facilitate arrival of patients to the OR, alteration of patient verification procedures prior to entry to the OR, and education of nursing, anaesthesia, and surgical personnel of the scope of the problem of late OR starts. All attending surgeons were notified either by letter or by discussion at departmental rounds. These measures were in effect by July 1995. A second audit, using the same methodology as the first, evaluated a two week period (10 days with 87 elective surgical cases) in October 1995. RESULTS: The second audit showed 65.5% of patients (average of 9 operating rooms daily) scheduled for surgery at 0745 entered the OR late with 601 min lost. The average delay for late starting cases decreased from 15.73 +/- 4.56 to 10.54 +/- 3.92 min (P < 0.05). CONCLUSION: Late OR starts are common and only modest improvements can be achieved without cooperation from anaesthetists and surgeons to arrive on time.

Education↗
PubMed1996

Acute ventilatory complications during laparoscopic upper abdominal surgery.

PURPOSE: This article examines and summarizes the published reports dealing with subcutaneous emphysema, pneumothorax and carbon dioxide (CO2) embolism during laparoscopic upper abdominal surgery. The purpose is to describe the expected clinical picture, the differential diagnosis and the management of these complications. SOURCE: The information was obtained from a Medline literature search and the annual meeting supplements of Anesthesiology, Anesth Analg, Br J Anaesth and Can J Anaesth. PRINCIPAL FINDINGS: An abrupt increase in PETCO2 is the first sign of subcutaneous emphysema and of pneumothorax. Desaturation and increased airway pressure occur with pneumothorax, but not with subcutaneous emphysema alone. Desaturation and increased airway pressure also occur with bronchial intubation. The preliminary diagnosis is made by verifying the position of the tube, examination of the patient for swelling and crepitus and auscultation for air entry. Chest radiography and paracentesis confirm the diagnosis of pneumothorax, which frequently occurs with subcutaneous emphysema but is rarely of the tension type. Pulmonary embolism due to CO2 during LUAS has not been reported, but the available data suggest that small, haemodynamically inconsequential CO2 embolism occurs without change in PETCO2. Massive embolism is possible and will markedly decrease PETCO2, arterial O2 saturation (SpO2) and blood pressure. CONCLUSION: The immediate recognition of the three complications requires continuous monitoring of PETCO2, arterial saturation, airway pressure, and an index of pulmonary compliance.

Abdomen↗
PubMed1995

Upper airway involvement in Parkinson's disease resulting in postoperative respiratory failure.

A 71-yr-old man with a six-year history of Parkinson's disease (PD), Type II diabetes mellitus, myocardial infarction, and remote 20 pack-year smoking history, underwent an anterior resection of the rectum for carcinoma. Sixty hours later, the patient suffered a respiratory arrest; his antiparkinsonian medications had not been resumed. Preoperative flow-volume loops showed the characteristic saw-tooth pattern of PD indicating dysfunction of the striated muscle of the upper airway. Although postoperative respiratory distress was managed as lower airway obstruction, at the time of intubation there were no signs of lower airway pathology. Upper airway dysfunction and obstruction secondary to PD is thought to have been a contributing factor to the postoperative respiratory distress and failure. This case is presented to draw attention to the risk of upper airway dysfunction in Parkinson's Disease, especially with the withdrawal of antiparkinsonian medications.

Aged↗
PubMed1995

A retrospective comparison of spinal and general anesthesia for vaginal hysterectomy: a time analysis.

The authors sought to compare time efficiency of spinal versus general anesthesia. The charts of 106 consecutive patients who had undergone a vaginal hysterectomy were analyzed. This analysis divided the patients into three groups: Group 1, spinal anesthesia; Group 2, general anesthesia; Group 3, spinal anesthesia with subsequent general anesthesia. The perioperative time course was divided into six intervals from entry into the operating room to discharge from the postanesthesia care unit (PACU). Total time was calculated by adding the six intervals. There were 85 patients in Group 1, 17 patients in Group 2, and 4 patients in Group 3. The mean times for surgical readiness once the anesthesiologist was present for Group 1, Group 2, and Group 3 were 21.4 +/- 7.3, 21.4 +/- 6.0, and 25.0 +/- 5.8 min, respectively. The total time for the three groups was 278.3 +/- 72.0, 245.9 +/- 23.1, and 295.0 +/- 101.2 min, respectively (P < 0.01 Group 1 vs Group 2). The difference in total time between Groups 1 and 2 was accounted for mainly by the stay in the PACU. This study concludes that there is no difference in the efficiency of operating room time use between spinal and general anesthesia.

Aged↗
PubMed1994

Light intensity and area of illumination provided by various laryngoscope blades.

Several brands of laryngoscopes and commonly used blades are evaluated for differences in direct light intensity and area of illumination. The purpose of this study was to determine which laryngoscope/blade combination provided the best lighting conditions for tracheal intubation. The direct light intensity was assessed by directing various laryngoscope/blade combinations towards a multifunction exposure meter (Flash Meter III, Minolta Corp.). Light intensity expressed in Lux was calculated using the formula: lux = 2.5 x 2 exposure index. The area of illumination provided by the laryngoscopes was assessed by taking photographs when the laryngoscope blade tips were touching a wall. The widest diameter of bright illumination in the photograph was measured in centimeters (cm). The direct light intensity ranged from 0.4-5.5 x 10(3)lux. The field of illumination ranged from 3.2 to 8.8 cm. When fitted on regular size handles, blades with incandescent bulbs provided more intense light than blades using fibreoptic light sources (P = 0.0078). For blades using incandescent light, the use of a short handle laryngoscope resulted in a decrease in light intensity (P = 0.0117). The results of this study suggest that blades using incandescent light provide greater light intensity than blades using fibreoptics.

Equipment Design↗
PubMed1994

Spinal anaesthesia for patients with previous lower limb amputations.

Phantom limb pain has been reported as a transient phenomenon in patients with lower limb amputations during subsequent spinal anaesthesia. In order to determine its incidence and to define any predisposing factors we prospectively studied 23 spinal anaesthetics in 17 patients with previous lower limb amputation. Only one patient developed clinically significant phantom limb pain and we were unable to define any predisposing factors. Given the low incidence of recurrent phantom limb with spinal anaesthesia, its transient nature, and the fact that it can be treated if it occurs, we conclude that spinal anaesthesia is not contraindicated in patients with previous lower limb amputation.

Aged↗
PubMed1994

A comparison of simple identification tests to distinguish cerebrospinal fluid from local anaesthetic solution.

Local anaesthetic solution is sometimes used to enlarge the epidural space in preparation for the insertion of an indwelling epidural catheter and during subsequent checking a small volume of fluid may be aspirated. Twelve anaesthetists were asked to distinguish 0.1 ml plain bupivacaine 0.25% from 0.1 ml simulated cerebrospinal fluid (CSF) solution. The distinction was based on differences in the physicochemical properties of the two test solutions, namely, temperature, presence of glucose, pH, and turbidity when mixed with thiopentone. Temperature difference resulted in correct identification of the two solutions in 75% of cases, the presence of glucose in 92%, pH in 83%, and turbidity in 25% of cases. No single test resulted in correct identification by all the anaesthetists. We suggest that more than one physicochemical test is required to identify correctly the nature of the small volume of liquid which may be aspirated from an epidural catheter.

Anesthesia, Epidural↗
PubMed1994

Can anesthesia ventilators provide high-frequency ventilation?

We measured the tidal volumes (VT) delivered by two anesthesia ventilators (the Narkomed 2B and the Ohmeda 7800) to a model lung at frequencies of 60 breaths/min and 99-100 breaths/min under two conditions of compliance and resistance designed to mimic mild and severe adult respiratory distress syndrome (ARDS) (mild ARDS = S1 and severe ARDS = S2). The VT produced were measured with a pneumotachometer at the ventilator outflow and distal to the anesthesia circuit. With the Narkomed 2B, the VT measured at the entrance to the model lung decreased from 216 mL to 129 mL in S1, and from 152 mL to 88 mL in S2 as the ventilatory frequency increased from 60 to 99 breaths/min. With the Ohmeda 7800, the VT decreased from 213 mL to 118 mL in S1, and from 134 mL to 73 mL in S2 when the frequency was changed from 60 to 100 breaths/min. Since the delivered VT are similar to those previously reported to maintain adequate ventilation at these rates using standard high-frequency ventilation (HFV), it may be possible to use these newer anesthesia ventilators for this purpose.

Anesthesia↗
PubMed1993

Postdural puncture headache: a randomized prospective comparison of the 24 gauge Sprotte and the 27 gauge Quincke needles in young patients.

This study was designed to compare the frequency of postdural puncture headaches (PDPH) using the 24 gauge Sprotte and the 27 gauge Quincke spinal needles in a population of patients less than 45 yr of age undergoing spinal anaesthesia for non-obstetrical surgery. Patients were randomly assigned to receive spinal anaesthesia with either the 24 gauge Sprotte spinal needle (n = 46) or the 27 gauge Quincke spinal needle (n = 47). Patients were interviewed on either postoperative day one or two and on postoperative day three. A PDPH was defined as a headache involving the occipital or frontal areas that is made worse when assuming either the sitting or standing position. Ninety-three patients were included in the analysis of data. The overall incidence of PDPH was 14% (13 of 93), and no difference was found between the Sprotte (15.2%) and Quincke (12.8%) needles. The distribution of the PDPHs by severity was not different between the two groups. None of the 13 patients with PDPHs required on epidural blood patch for relief of symptoms. Both the Sprotte needle and the Quincke needles were judged as easy to use and both required the same number of attempts in order to locate cerebrospinal fluid (first attempt successful: 73.9% versus 66%). Neither patient satisfaction nor the acceptability of spinal anaesthesia for a future procedure was adversely affected by the occurrence of a PDPH. The results of this study suggest that the risk of PDPH after spinal anaesthesia in young patients is similar using either the 24 gauge Sprotte or the 27 gauge Quincke spinal needle.

Adult↗