Wendy Harrison

Risk factors for postoperative hemorrhage following tonsillectomy

To identify the main risk factors associated with postoperative hemorrhage following tonsillectomy.

Postoperative hemorrhage following adenoidectomy.

To examine postoperative hemorrhage following adenoidectomy.

A laboratory and clinical evaluation of single‐use instruments for tonsil and adenoid surgery

Objectives:  To compare the quality and consistency of single‐use adenotonsillectomy instruments available in the UK with reusable instruments and examine their performance in a clinical setting.

Surveillance and medical devices

Lenzer and Brownlee highlight the potential value for postmarketing surveillance,1 but this is true not only for “complex” or new devices. The UK government’s decision in 2001 to replace reusable tonsillectomy instruments with single use devices, because of the risk from variant Creutzfeldt-Jakob disease, is a lesson in point. These were not …

Is HELICS the Right Way? Lack of Chest Radiography Limits Ventilator-Associated Pneumonia Surveillance in Wales

Introduction: The reported incidence of ventilator-associated pneumonia (VAP) in Wales is low compared with surveillance data from other European regions. It is unclear whether this reflects success of the Welsh healthcare-associated infection prevention measures or limitations in the application of European VAP surveillance methods. Our primary aim was to investigate episodes of ventilator-associated respiratory tract infection (VARTI), to identify episodes that met established criteria for VAP, and to explore reasons why others did not, according to the Hospitals in Europe Link for Infection Control through Surveillance (HELICS) definitions. Materials and Methods: During two 14-day study periods 2012–2014, investigators reviewed all invasively ventilated patients in all 14 Welsh Intensive Care Units (ICUs). Episodes were identified in which the clinical team had commenced antibiotic therapy because of suspected VARTI. Probability of pneumonia was estimated using a modified Clinical Pulmonary Infection Score (mCPIS). Episodes meeting HELICS definitions of VAP were identified, and reasons for other episodes not meeting definitions examined. In the second period, each patient was also assessed with regards to the development of a ventilator-associated event (VAE), according to recent US definitions. Results: The study included 306 invasively ventilated patients; 282 were admitted to ICU for 48 h or more. 32 (11.3%) patients were commenced on antibiotics for suspected VARTI. Ten of these episodes met HELICS definitions of VAP, an incidence of 4.2 per 1000 intubation days. In 48% VARTI episodes, concurrent chest radiography was not performed, precluding the diagnosis of VAP. Mechanical ventilation (16.0 vs. 8.0 days; p = 0.01) and ICU stay (25.0 vs. 11.0 days; p = 0.01) were significantly longer in patients treated for VARTI compared to those not treated. There was no overlap between episodes of VARTI and of VAE. Discussion: HELICS VAP surveillance definitions identified less than one-third of cases in which antibiotics were commenced for suspected ventilator-associated RTI. Lack of chest radiography precluded nearly 50% cases from meeting the surveillance definition of VAP, and as a consequence we are almost certainly underestimating the incidence of VAP in Wales.

Ventilator-associated events … perhaps not the answer:

In the most recent issue of JICS, Dr Thomas has rightly argued that ventilator-associated pneumonia (VAP) can be difficult to diagnose and that efforts to limit ventilator-associated morbidity must extend beyond VAP prevention. We share his concerns but are unconvinced that adopting the US Centers for Disease Control and Prevention National Healthcare Safety Network’s (CDC NHSN) ventilator-associated event (VAE) surveillance system is currently the right approach for our population. In Wales, there has been a national surveillance programme to identify episodes of VAP since 2008, originally using the Hospitals in Europe Link for Infection Control through Surveillance definitions (HELICS, classified as PN 1 to 5, according to radiological, systemic, pulmonary and microbiological criteria). We recently investigated triggers for initiating antibiotic therapy for suspected ventilator-associated respiratory tract infection (VARTI) and the implications of variation in clinical practice for VAP surveillance. Among 282 invasively ventilated patients admitted to intensive care unit (ICU) for 48 h or more, 32 developed VARTI – the main features relating to sputum, inflammatory markers and radiography. Strikingly in less than 50% cases was chest radiography performed at time of diagnosis, precluding diagnosis of VAP according to HELICS although such episodes were associated with significantly prolonged mechanical ventilation and ICU stay. However, applying the new CDC NHSN definitions, we found no overlap between VAE and suspected VARTI. Other authors have also described potential limitations to VAE surveillance. A ventilator-associated complication (VAC) is identified when there is sustained increase in FiO2 or PEEP after a stable baseline of 48 h or more. However, many patients do not meet the definition of VAC because fluctuations in FiO2 and PEEP prevent them achieving a stable baseline. Preference for PEEP level or ventilator mode, such as APRV, may affect whether a patient qualifies for the diagnosis of VAC. Furthermore, the level of agreement between episodes of VAC and VAP has been questioned; patients developing a VAC have a range of pathology which might include VAP but alternatively may represent fluid overload or ARDS. Interventions required to prevent and treat heterogeneous pathology are likely to differ and it may be difficult to understand the contribution of different processes to outcomes associated with VAC. There are distinctions between the diagnostic needs of the clinician at the bedside and the surveillance administrator – and arguably there is risk of disengagement with a quality improvement programme that does not emphasise clinical discrimination. Furthermore, although VAE data are highly objective, in a paper-based clinical environment, the workload associated with screening should not be underestimated. Appreciating a wider burden of ICU-acquired respiratory infection, our approach has not been to dispense with HELICS definitions of VAP at this stage, but – acknowledging the variation in performance of chest X-ray and subjectivity in interpretation – to supplement with an additional category ‘PN0’ where there is pulmonary, systemic and microbiological evidence of VARTI but without radiographic evidence. We anticipate a potential value for the ICU clinician but also hope to standardise reporting across our region.

Re: Improvement in quality of life by adenotonsillectomy in children with adenotonsillar disease: Correspondence

Sir, I would like to thank for the comments of Dr Argiris. It is true that life quality perception differs according to cultural background. However, the questionnaire that we had used was translated and valididated for Turkish children. We do not have data regarding weight and height. We think that this kind of information is beyond the scope life quality. We did not propose surgery for the patients with mild symptoms. We only said that the children with milder symptoms benefit from the operation as the children having severe symptoms. In addition, as a drawback, we also said that it would be the best to compare these children undergoing surgery with a randomised control group composing of patients with mild symptoms but taking medical treatment instead of undergoing surgery. It is obvious that this kind of randomisation is nearly impossible because of serious ethical problems. Most parents will not be wilingful for randomisation. The airway obstruction classification in Table 1 was based on answers to questions related with airway and breathing in TAHS questionnaire. Actually, that section is only for information to readers. No comparision was made according to clinical indication for surgery. Any type of major complication including secondary hemorhage was not observed in any patient. We did not collect data about postoperative nausea, vomitting and pain. I agree with the author that a similiar study on different cultures would be interesting.