Andrew J. Redmann

SURGEONS EXPECT PATIENTS TO BUY-IN TO POSTOPERATIVE LIFE SUPPORT PREOPERATIVELY: RESULTS OF A NATIONAL SURVEY

Objective:Evidence suggests that surgeons implicitly negotiate with their patients preoperatively about the use of life supporting treatments postoperatively as a condition for performing surgery. We sought to examine whether this surgical buy-in behavior is present among a large, nationally representative sample of surgeons who routinely perform high-risk operations. Design:Using findings from a qualitative study, we designed a survey to determine the prevalence of surgical buy-in and its consequences. Respondents were asked to consider their response to a patient at moderate risk for prolonged mechanical ventilation or dialysis who has a preoperative request to limit postoperative life- supporting treatment. We used bivariate and multivariate analysis to identify surgeon characteristics associated with 1) preoperatively creating an informal contract with the patient defining agreed upon limitations of postoperative life support and 2) declining to operate on such patients. Setting and Subjects:U.S. mail-based survey of 2,100 cardiothoracic, vascular, and neurosurgeons. Interventions:None. Measurements and Main Results:The adjusted response rate was 56%. Nearly two thirds of respondents (62%) reported they would create an informal contract with the patient describing agreed upon limitations of aggressive therapy and a similar number (60%) endorsed sometimes or always refusing to operate on a patient with preferences to limit life support. After adjusting for potentially confounding covariates, the odds of preoperatively contracting about life-supporting treatment were more than two-fold greater among surgeons who felt it was acceptable to withdraw life support on postoperative day 14 compared with those who believed it was not acceptable to withdraw life support on postoperative day 14 (odds ratio 2.1, 95% confidence intervals 1.3–3.2). Conclusions:Many surgeons will report contracting informally with patients preoperatively about the use of postoperative life support. Recognition of this process and its limitations may help to inform postoperative decision making.

Asystole From Direct Laryngoscopy: A Case Report and Literature Review

The rare and potentially fatal complication of asystole during direct laryngoscopy is linked to direct vagal stimulation. This case describes asystole in an 85-year-old female who underwent suspension microlaryngoscopy with tracheal dilation for subglottic stenosis. Quick recognition of this rare event with immediate cessation of laryngoscopy resulted in the return of normal sinus rhythm. This incident emphasizes the implications of continued vigilance during laryngoscopy and the importance of communication between the anesthesia and surgical staff to identify and treat this rare complication. The case was successfully concluded by premedication with an anticholinergic and by increasing the depth of anesthesia.

Posttonsillectomy Hemorrhage in a Pediatric Jehovah’s Witness and the Decision to Transfuse:

A 7-year-old male presented for adenotonsillectomy for chronic tonsillitis. The family was Spanish speaking and Jehovah’s Witness, and a specific request to avoid blood transfusions was made. Adenotonsillectomy was performed as an outpatient without event. On postoperative day (POD) 1, the patient presented to the emergency department (ED) with hematemesis. The patient was taken to the operating room (OR) for control of pharyngeal bleeding. Intraoperative blood loss was 400 mL, and he was transferred to the intensive care unit (ICU) intubated. Postoperative hemoglobin was 5.8 g/dL, with normal coagulation profiles. Hematology was consulted, and iron and transexamic acid were started. Discussion was made with the family and the Jehovah’s Witness liaison committee regarding recommendation for transfusion, which the family refused. On POD 2, the patient required an additional OR trip for hemorrhage control with a postoperative hemoglobin of 5.2 g/dL. The patient had another bleeding event on POD 5 and again went to the OR. Hemoglobin was 5.3 g/dL, and after difficulty controlling the hemorrhage, the anesthesiologist and the otolaryngologist jointly decided to administer 3 units of packed red blood cells to the child. The hemorrhage was controlled, and postoperatively, the child had a hemoglobin of 15.9 g/dL with no additional bleeding. The Cincinnati Children’s Hospital Medical Center IRB exempted this case report from review.

The effect of postoperative steroids on post-tonsillectomy pain and need for postoperative physician contact: Effect of Steroids on Post-Tonsillectomy Pain

Examine the effect of postoperative steroids on postoperative physician contacts and determine the hemorrhage rate for patients taking postoperative steroids.

Association of Reduced Delay in Care With a Dedicated Operating Room in Pediatric Otolaryngology

Importance Obtaining sufficient operating room time for inpatient consults requiring an operative intervention is a persistent challenge for otolaryngologists. Objective To examine the institution of an otolaryngology-specific operating room (OR) for unscheduled (add-on) cases for its association with time from initial consultation to surgery and, secondarily, to determine utilization of a dedicated block of time. Design, Setting, and Participants Retrospective review of medical records of a tertiary care pediatric hospital for patients treated between January 1, 2015, and March 31, 2016; analysis was concluded by June 2016. Included were all patients undergoing inpatient otolaryngology consultations who required nonemergency operative procedures. Interventions In August 2015, a once-weekly 5-hour block of OR time dedicated to inpatient otolaryngology consults was instituted. Prior to this, cases were placed on an add-on list shared between all surgical services. Main Outcomes and Measures It was hypothesized that institution of a dedicated block of OR time would decrease the time from initial consultation to operative intervention and would be utilized at a high rate. Operating room utilization was calculated by dividing scheduled OR time by actual OR time utilized. Time from initial consultation to OR intervention was compared before and after the institution of the dedicated OR block. Results A total of 316 inpatient add-on pediatric cases (including 108 patients from the intensive care unit [ICU]) were scheduled during the study period. The most common cases were microlaryngoscopy/bronchoscopy (79%) and tracheostomy (8%). Mean (SD) time between consultation and OR intervention was 7.8 (1.6) days prior to establishing the add-on OR and 4.4 (1.3) days after it was established (absolute difference of 3.4 days; 95% CI, 3.1-3.7 days). Mean (SD) time between consultation and OR intervention was 7.4 (5.0) days for ICU patients prior to intervention and 5.6 (3.0) days after intervention (absolute difference of 1.8 days; 95% CI, 1.6-2.0 days). Total utilization of the OR block time was 74%, and adjusted utilization was 86%. There was a 15% drop in the number of unscheduled add-on cases after the intervention (from 10 cases/mo to 8.5 cases/mo; absolute difference of 1.5 cases; 95% CI, 1.1-1.9 cases). Conclusions and Relevance Instituting a dedicated otolaryngology add-on OR was associated with significantly reduced time between initial consultation and operative care, by approximately 3 days, decreased the number of unscheduled add-on cases, and was utilized at a high level.

Airway inflammation and symptoms in children following liver and heart transplantation

To describe the upper airway endoscopic findings of children with upper airway symptoms after liver transplantation (LT) or heart transplantation (HT).