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Objectives: To determine the psychometric outcomes of patients participating in an extensive patient-centered verification process before receiving sedation for regional anesthesia., Design: Survey., Setting: Perioperative areas of university-affiliated hospital., Patients: Two hundred eligible patients scheduled for elective orthopedic surgery undergoing peripheral nerve blockade., Interventions: Postoperative survey evaluating patient perception, experience, and satisfaction with the anesthetic timeout before regional anesthesia., Measurements: Measures using numeric rating scales were obtained on patient perceptions of safety, confidence in anesthesia provider, anxiety, and positive sentiments during participation in block timeout. These variables were analyzed using logistic regression models to correlate with reported pain and satisfaction perioperatively., Main Results: One hundred seventy-five patients (93% enrollment) completed the study. More than 90% of patients reported agreeing strongly to feeling safe, confident, relaxed, and positive about their participation in the block timeout. These sentiments are associated with less reported perioperative pain and higher overall satisfaction., Conclusions: Patient perceptions of confidence and safety in regional anesthesia providers were enhanced by a preprocedural timeout process. These positive attitudes are associated with a superior perioperative experience and patient satisfaction., (Copyright © 2014 Elsevier Inc. All rights reserved.)

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.

When planning an anesthetic for patients undergoing orthopedic oncologic surgeries, numerous factors must be considered. Preoperative evaluation may elucidate significant co-morbidities or side effects secondary to chemotherapy or radiation, which can affect anesthetic choices. Procedures vary in length and complexity and pose challenges in both positioning and in planning to minimize blood loss. Many anesthetic techniques are available to provide both intraoperative anesthesia and postoperative analgesia, while the type of thromboprophylaxis and analgesic adjuvants that will be administered needs to be defined. This review focuses on approaches to use when caring for patients undergoing orthopedic oncologic procedures., (Copyright © 2010 Elsevier Inc. All rights reserved.)

A 61 year-old patient with a history of anxiety disorder presented with stridor after an uneventful laparotomy with a general anesthetic. Postoperative analgesia was withheld secondary to intermittent oxygen desaturation. She was unresponsive to standard therapies, including racemic epinephrine and albuterol nebulizers. An otolaryngology consultant performed fiberoptic laryngoscopy and paradoxical vocal cord movement was diagnosed. When fentanyl was subsequently administered to treat her pain, the stridor resolved., (Copyright 2010 Elsevier Inc. All rights reserved.)

Study Objective: To determine the safety and efficacy of regional anesthesia techniques when administered in the office-based setting., Design: Retrospective chart review., Setting: Free-standing orthopedic office with an operating room suite., Measurements: A total of 238 patients underwent 242 anesthetics. Types of anesthetics delivered were quantified. Regional anesthetics were further divided into specific nerve blocks. Times from anesthetic start to surgical start and from surgical end to anesthetic end were calculated. Adverse outcomes were ascertained and followed., Main Results: Of the 242 anesthetics administered, 123 were peripheral nerve blocks, two were neuraxial blocks, 140 were monitored anesthesia care cases, and 17 were general anesthetics (14 Laryngeal Mask Airway cases, two mask ventilation cases, and one endotracheal intubation). The average times from anesthesia start to surgery start were as follows: monitored anesthesia cases, 19+/-7 min (median, 20 min); regional anesthesia cases, 29+/-11 min (median, 30 min); and general anesthesia cases, 31+/-11 min (median, 30 min). The average time from surgery end to anesthesia end for monitored anesthesia cases was 9+/-3 min (median, 10 min); regional anesthesia, 9+/-3 min (median, 10 min); and general anesthesia, 12+/-4 min (median, 20 min). Two transient nerve injuries occurred, both of which resolved., Conclusions: On the basis of our experience, we believe that regional anesthesia can be delivered efficiently and safely for orthopedic procedures in the office-based environment, and we encourage its wider use.

Study Objective: To determine the current status and future plans of residency programs to train residents in office-based anesthesiology (OBA), which is rapidly emerging as an important specialty within the field of anesthesiology., Design: Survey questionnaire., Setting: University hospital., Measurements: A 14-question survey was sent to the 134 listed members of the Society of Academic Anesthesia Chairs/Association of Anesthesiology Program Directors to elicit the current status of educational endeavors and clinical exposure of anesthesiology residents to this type of practice., Main Results: There were 95 respondents (72%). Fifteen (15.8%) academic anesthesiology programs provide OBA services in the community and two (2.1%) of the academic programs provide clinical exposure to their residents., Conclusions: Residents are receiving minimal, if any, exposure to OBA during their training.

Study Objective: To elicit attendees' opinions and perceptions of problems-based learning and to asses the ability of this format to influence practitioner behavior., Design: Analysis of quality assurance material as part of the evaluation process of the Problem-Based Learning Discussion (PBLD) Committee of the American Society of Anesthesiologists (ASA)., Participants: Attendees of the 2002 PBLD Program and the annual meeting of the ASA, Orlando, FL., Measurements and Main Results: Exit and 6-months post-PBLD evaluations of individual PBLD sessions were offered to attendees of the program. A total of 742 evaluations were completed and collected at the conclusion of the individual sessions. Of the participants, 98.2% rated their sessions either good or excellent, 98.5% of whom enjoyed the interactive nature and 98% expressing a willingness to participate in future PBLD sessions. There were 221 questionnaires (17% response rate) completed after 6 months. Actual changes in practice were few, but attendees reported an increased ability to anticipate problems and/or complications and an increased knowledge and awareness about issues regarding patient care. 95.4% considered PBLD a worthwhile learning experience., Conclusions: PBLD remains a popular educational offering. Although 6 months may be too short an interval to gauge the ability of PBLD to change physician practices, attendees feel that it does confer increased knowledge and awareness about patient care issues.

Study Objective: To determine the number of interscalene blocks that are necessary for a resident in anesthesiology to complete so as to achieve autonomous success with that specific block., Design: Survey questionnaire of all CA1 and CA2 residents in the Department of Anesthesiology, Mount Sinai School of Medicine., Setting: University hospital., Measurements and Main Results: Seventeen CA-1 and CA-2 residents reported their experiences in performing interscalene blocks over an 8-month period. Data were collected regarding the number of previous attempts, technique, attending supervisor, patient weight, level of autonomy in the performance of the current block, and adequacy of the block for surgery. Eighty-two blocks were performed (1 to >15 per resident), supervised by 7 attending physicians, and 96.3% of blocks were reported as adequate for surgery. With an experience of seven to nine previous blocks, only 50% of residents were able to perform an interscalene block autonomously, whereas with >15 blocks, 87.5% reported autonomous success., Conclusions: Experience with only 40 unspecified peripheral nerve blocks, as currently required by the Residency Review Committee as of January 2001, may not provide adequate opportunity for an individual to develop expertise in regional anesthesia.

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.

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.

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.

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.

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.

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.