Staff Emeritus Retiree, Anesthesiology, Perioperative and Pain Medicine
Co-director, Division of Medical Acupuncture (2004 - Present)
Honors & Awards
Interdisciplinary Professor of the Year, Department of Gynecology and Obstetrics (1999)
Fellowship, University of Arizona, Integrative Medicine (2009)
Board Certification, American Board of Medical Acupuncture, Medical Acupuncture (2004)
Board Certification, American Board of Anesthesiology, Anesthesiology (1992)
Residency, Stanford University School of Medicine, Anesthesiology (1991)
Internship, Santa Clara Valley Medical Center, Transitional Internship (1988)
M.D., Baylor College of Medicine, Medicine (1987)
Current Research and Scholarly Interests
Clinical effectiveness of acupuncture in medical conditions, use of acupuncture in perioperative settings to reduce opiate and antiemetic use, use of acupuncture in pregnancy for the treatment of nausea, vomiting and other conditions, use of acupuncture in the treatment of the side effects in cancer patients.
A Pilot Study to Measure the Impact of Blended Learning on Intern Wellness and Burnout
LIPPINCOTT WILLIAMS & WILKINS. 2014
View details for Web of Science ID 000209827700053
- Resources for developing and integrating innovative curricula in complementary and alternative/integrative medicine MedEdPortal 2009
- Perioperative Acupuncture in Anesthesiologists Manual of Surgical Procedures 2008
- Latex allergy: Oh, what a surprise! Another reason why all anesthesia equipment should be latex-free ANESTHESIA AND ANALGESIA 2004; 99 (2): 629-629
The site of action of epidural fentanyl infusions in the presence of local anesthetics: A minimum local analgesic concentration infusion study in nulliparous labor
Annual Meeting of the Society-of-Obstetric-Anesthesiology-and-Perinatology
LIPPINCOTT WILLIAMS & WILKINS. 2003: 1439–45
We have previously demonstrated that continuous epidural infusions of fentanyl without local anesthetics elicit analgesia by a systemic mechanism. In this study, we examined the hypothesis that, in the presence of epidural bupivacaine, continuous infusions of epidural fentanyl elicit analgesia by a spinal mechanism. Forty-eight nulliparous women in active labor participated in this prospective, randomized, double-blinded study. Women received lumbar epidural analgesia with 20-30 mL bupivacaine 0.125% until pain free. Subjects were then randomized to either IV or epidural (EPI) fentanyl infusion groups. Each infusion delivered fentanyl 30 microg/h. All women received an epidural infusion of bupivacaine at a rate of 20 mL/h, the concentration of which was determined by the response of the previous woman in the same group to the analgesic regimen used. Unlike previous studies that assessed the minimum local analgesic concentration (MLAC) for bolus administration at the initiation of analgesia, this study assessed MLAC(infusion) for the maintenance of analgesia throughout the first stage of labor. MLAC(infusion) was determined using the up-down sequential analysis described by Dixon and Massey. The MLAC(infusion) of epidural bupivacaine was 0.063% (95% confidence interval, 0.058-0.068) and 0.019% (95% confidence interval, 0.000-0.038) in the IV and EPI groups respectively. A continuous infusion of fentanyl was more than three times as potent when administered by the epidural than by the IV route. This marked increase in potency for the epidural route is highly suggestive for a predominantly spinal mechanism of action for infused epidural fentanyl under the conditions of this study.This study determined the median effective concentration for epidural infusions of bupivacaine during labor analgesia. Coadministered epidural fentanyl infusions were more than three times more potent than IV fentanyl infusions, suggesting a predominantly spinal mechanism of opioid action under these study conditions.
View details for DOI 10.1213/01.ANE.0000081792.84877.A2
View details for Web of Science ID 000186143600038
View details for PubMedID 14570662
- The site of action of epidural fentanyl infusions in the presence of local anesthetics: a minimun local analgesic concentration infusion study in nulliparous labor Anethesia and Analgesia 2003; 97 (5): 1439-1445
A comparison of the 24-gauge Sprotte (R) and Gertie Marx (R) spinal needles for combined spinal-epidural analgesia during labor
2002; 97 (3): 574-577
Prior experience with the combined spinal-epidural technique (CSE) for labor analgesia demonstrated a high (up to 14%) failure rate because of failure to obtain cerebrospinal fluid (CSF) or lack of response to appropriate doses of intrathecal sufentanil. The current study was designed to test whether a longer needle with a shorter side port (Gertie Marx needle; 127 mm long) would eliminate failures to obtain CSF compared with the needle we had used previously (Sprotte needle; 120 mm long).Seventy-three parturients were randomly assigned to have a CSE performed with one of these two needles. After identifying the epidural space with an 18-gauge Touhy needle at the L2-L3 or L3-L4 interspace, the spinal needle was introduced through the Touhy needle until penetration of the dura was felt or until the needle was maximally inserted. If no CSF was obtained, the alternate needle was tried. After obtaining CSF, 10 microg sufentanil diluted in 1.8 ml saline was injected. Verbal pain scores (0-10) were obtained every 5 min for 30 min.Failure to obtain CSF occurred six times in the Sprotte group compared with none in the Gertie Marx group (P < 0.05). In all six failures in the Sprotte group, the Gertie Marx needle subsequently proved successful in obtaining CSF. There were no differences in pain scores between the groups.The extra length of the 127-mm Gertie Marx needle resulted in a higher success rate for obtaining CSF when used in the CSE technique. Side port design was not a factor influencing success in this clinical setting.
View details for Web of Science ID 000177766100008
View details for PubMedID 12218522
Pregnancy complicated by severe osteogenesis imperfecta: A report of two cases
ANESTHESIA AND ANALGESIA
2002; 94 (5): 1315-1317
This case report discusses the anesthetic management of two parturients with severe osteogenesis imperfecta who presented for cesarean delivery. Although the anesthetic management for milder forms of the disease has been previously reported, anesthetic options for cases of this severity have not.
View details for PubMedID 11973211
- Mask induction with sevoflurane in a parturient with severe tracheal stenosis ANESTHESIOLOGY 2001; 95 (2): 553-555
- Anesthesia for cesarean section in a pituitary dwarf ANESTHESIOLOGY 1998; 89 (1): 253-254
Intrathecal sufentanil for labor analgesia: Do sensory changes predict better analgesia and greater hypotension?
American-Society-of-Anesthesiologists Annual Meeting
LIPPINCOTT WILLIAMS & WILKINS. 1997: 346–51
Sensory changes and hypotension occur after intrathecal sufentanil (ITS) is given during labor. The goal of this study was to determine whether sensory changes are predictive of hemodynamic changes or duration of pain relief. We also examined whether sensory and hemodynamic changes relate to the concentration of ITS administered. Forty-five ASA physical status I and II women in active labor were randomly assigned to receive 10 micrograms ITS diluted in either 1, 2, or 3 mL of normal saline (15 in each group). An observer blinded to treatment recorded verbal pain scores, blood pressure, and sensory changes to light touch, pinprick, and cold at frequent intervals. Excellent analgesia was obtained in 42 of 45 patients. There were no differences among the groups with respect to the number of patients with sensory changes, the duration of analgesia or sensory changes, the quality of analgesia, or the severity of hypotension. The groups were therefore combined for further analyses. Among this combined group, the duration of analgesia was 99 +/- 7 min (mean +/- SE). Cold, pinprick, and light touch sensation were decreased in 66%, 50%, and 33% of patients, respectively. Motor block was absent in all patients. The duration and quality of analgesia were similar in subjects with and without sensory changes. Systolic blood pressure decreased 23 +/- 2 mm Hg (P < 0.05) during the first 30 min after ITS, and six patients were given ephedrine. The magnitude of blood pressure change was not affected by the diluent volume or the presence of sensory changes. Because sensory changes were not predictive of the duration or quality of analgesia or the degree of hemodynamic change, we conclude that analgesia with ITS is predominantly mediated via spinal cord opioid receptors rather than by a local anesthetic-type conduction blockade.
View details for Web of Science ID A1997WF15900019
View details for PubMedID 9024026
Failure of steroid supplementation to prevent operative hypotension in a patient receiving chronic steroid therapy
ANESTHESIA AND ANALGESIA
1996; 82 (6): 1294-1296
View details for PubMedID 8638809
Ketorolac and spinal morphine for postcesarean analgesia.
International journal of obstetric anesthesia
1996; 5 (1): 14-18
This study was designed to compare spinal morphine (SM), ketorolac (K), and a combination of the two drugs with respect to analgesic efficacy and side effects in postcesarean patients. Forty-eight parturients having bupivacaine spinal anesthesia for cesarean delivery randomly received in a double-blind manner either: SM: 0.1 mg or SM: 0.2 mg (but no K); SM: 0.1 mg plus K 60 mg intravenously (i.v.) one hour after spinal injection, and 30 mg i.v. every 6 h for three doses or i.v. K dosed as previously described (but no SM). Analgesia and side effects were evaluated during the first 20 h. Forty-eight women were studied. There were no significant differences in analgesia among the groups, although patients receiving SM: 0.1 mg tended to have less satisfactory intraoperative analgesia. Pruritus was common in all patients receiving SM whereas patients who received K had the lowest overall scores for severity of side effects. No serious complications occurred and all groups expressed similarly high satisfaction at the 24 h visit. We conclude that there is no advantage to combining SM and K, and that K provides satisfactory postcesarean analgesia with few side effects.
View details for PubMedID 15321377
SPINAL VERSUS EPIDURAL-ANESTHESIA FOR CESAREAN-SECTION - A COMPARISON OF TIME EFFICIENCY, COSTS, CHARGES, AND COMPLICATIONS
ANESTHESIA AND ANALGESIA
1995; 80 (4): 709-712
Spinal anesthesia recently has gained popularity for elective cesarean section. Our anesthesia service changed from epidural to spinal anesthesia for elective cesarean section in 1991. To evaluate the significance of this change in terms of time management, costs, charges, and complication rates, we retrospectively reviewed the charts of patients who had received epidural (n = 47) or spinal (n = 47) anesthesia for nonemergent cesarean section. Patients who received epidural anesthesia had significantly longer total operating room (OR) times than those who received spinal anesthesia (101 +/- 20 vs 83 +/- 16 min, [mean +/- SD] P < 0.001); this was caused by longer times spent in the OR until surgical incision (46 +/- 11 vs 29 +/- 6 min, P < 0.001). Length of time spent in the postanesthesia recovery unit was similar in both groups. Supplemental intraoperative intravenous (i.v.) analgesics and anxiolytics were required more often in the epidural group (38%) than in the spinal group (17%) (P < 0.05). Complications were noted in six patients with epidural anesthesia and none with spinal anesthesia (P < 0.05). Average per-patient charges were more for the epidural group than for the spinal group. Although direct cost differences between the groups were negligible, there were more substantial indirect costs differences. We conclude that spinal block may provide better and more cost effective anesthesia for uncomplicated, elective cesarean sections.
View details for Web of Science ID A1995QP46200010
View details for PubMedID 7893022
NALBUPHINE IS BETTER THAN NALOXONE FOR TREATMENT OF SIDE-EFFECTS AFTER EPIDURAL MORPHINE
ANESTHESIA AND ANALGESIA
1992; 75 (5): 747-752
This study compared naloxone and nalbuphine when administered for treatment of side effects after epidural morphine, 5 mg, given for postcesarean analgesia. Patients requesting treatment for pruritus or nausea randomly received, in a double-blind fashion, up to three intravenous doses of either naloxone 0.2 mg (group 1; n = 20) or nalbuphine 5 mg (group 2; n = 20). The incidence of vomiting, the severity of nausea and pruritus, and the degree of sedation and pain were assessed before and 30 min after each dose. The first dose of nalbuphine decreased the incidence of vomiting (P < 0.005) and the severity of nausea and pruritus (P < 0.01), whereas naloxone caused no significant changes. Sedation scores increased after nalbuphine (P < 0.05) and remained unchanged after naloxone, whereas pain scores increased after naloxone (P < 0.01) and were unchanged after nalbuphine. Eighteen patients in group 1 and 12 in group 2 received a second dose, and 8 and 4 patients, respectively, a third dose. Other than decreased pruritus after the second dose with both drugs, no further changes occurred. We conclude that nalbuphine is superior to naloxone for the treatment of side effects after epidural morphine. However, persistent symptoms may require supplemental therapy, as repeated doses proved less effective than the initial dose.
View details for Web of Science ID A1992JV69800016
View details for PubMedID 1416128
DIFFICULTY IN EXTUBATION - A CAUSE FOR CONCERN
1992; 47 (3): 229-230
Difficulties in removing the tracheal tube from the trachea are relatively uncommon. We report here a case of difficult extubation which was precipitated by pulling off the pilot balloon and valve assembly in order to deflate the cuff.
View details for Web of Science ID A1992HH73600012
View details for PubMedID 1566992