The use of throat packs in pediatric cleft lip/palate surgery: a retrospective study

Effect of fluticasone-impregnated throat packs on postoperative sore throat (POST) and hoarseness of voice: A randomized clinical trial

Background

Post-operative sore throat (POST) is one of the most common complaints post-endotracheal intubation and can be decreased through various interventions. This study aimed to determine the effect of fluticasone-impregnated versus saline throat packs on the occurrence and severity of POST and voice hoarseness.

Methods

This prospective, randomized, double-blinded trial was conducted on patients undergoing nasosinus surgeries at Kasturba Medical College and Hospital. Patients were randomized to groups based on a computer-generated table of random numbers post-intubation after placing a definite length of oropharyngeal packs into group F (fluticasone) who received four puffs of fluticasone furoate-soaked throat packs and group C (control) wherein normal saline-soaked throat packs were used. Determining the incidence of POST and voice hoarseness was the primary outcome; severity of POST and voice hoarseness, patient satisfaction scores at 24 hours post-surgery and adverse events were secondary outcomes.

Results

Overall, 86 patients were randomized and 43 patients were included in each group. Incidence of POST (%) and voice hoarseness (%) were 55.8, 55.6, 55.8, 53.4 and 30.2, 28, 28, 28 in group C. Incidence of POST (%) and voice hoarseness (%) were 37.2, 37.2, 37.2, 34.8 and 14, 14, 14,14 in group F at 1, 2, 6 and 24 hours, respectively, however, the p values were not found to be significant at any time interval. There was no significant difference in terms of severity of POST and voice hoarseness, patient satisfaction scores between the groups and there were no reported adverse events.

Conclusions

In patients undergoing nasosinus surgery under general anesthesia with endotracheal intubation, fluticasone furoate-impregnated throat packs failed to show any significant reduction in the incidence and severity of POST as well as hoarseness of voice, and even though it was not statistically significant, the fluticasone impregnated group had higher patient satisfaction scores.

Registration

CTRI ( CTRI/2020/09/027946; 22/09/2020).

Assessing the quality of reporting on quality improvement initiatives in plastic surgery: A systematic review

BACKGROUND

There has been a recent increase in the number and complexity of quality improvement studies in plastic surgery. To assist with the development of thorough quality improvement reporting practices, with the goal of improving the transferability of these initiatives, we conducted a systematic review of studies describing the implementation of quality improvement initiatives in plastic surgery. We used the SQUIRE 2.0 (Standards for Quality Improvement Reporting Excellence) guideline to appraise the quality of reporting of these initiatives.

METHODS

English-language articles published in Embase, MEDLINE, CINAHL, and the Cochrane databases were searched. Quantitative studies evaluating the implementation of quality improvement initiatives in plastic surgery were included. The primary endpoint of interest in this review was the distribution of studies per SQUIRE 2.0 criteria scores in proportions. Abstract screening, full-text screening, and data extraction were completed independently and in duplicate by the review team.

RESULTS

We screened 7046 studies, of which 103 full texts were assessed, and 50 met inclusion criteria. In our assessment, only 7 studies (14%) met all 18 SQUIRE 2.0 criteria. SQUIRE 2.0 criteria that were met most frequently were abstract, problem description, rationale, and specific aims. The lowest SQUIRE 2.0 scores appeared in funding, conclusion, and interpretation criteria.

CONCLUSIONS

Improvements in QI reporting in plastic surgery, especially in the realm of funding, costs, strategic trade-offs, project sustainability, and potential for spread to other contexts, will further advance the transferability of QI initiatives, which could lead to significant strides in improving patient care.

Effects of throat packs in upper airway surgery under intubation anesthesia: a randomized controlled trial

INTRODUCTION

Throat packs (TP) are used in upper airway surgery to avoid accumulation and aspiration of blood, foreign bodies, and fluids. But side effects such as sore throat and TP retention have been reported and challenge the standardized use of TP. The aim of this study is to compare benefits and side effects of TP versus no TP for upper airway procedures in intubation anesthesia.

MATERIAL AND METHODS

One hundred forty-eight patients with surgical interventions at the upper airway under intubation anesthesia were included. Of those, n = 74 each were treated without (A, control) and with (B) TP. Study group B was subdivided whether TP was placed by the surgeon (B1; n = 37) or by the anesthesiologist (B2; n = 37). TP-related side effects such as sore throat, foreign body sensation, hoarseness, dyspnea, difficulty of swallowing, nausea, retching, nausea, aspiration, and pneumonia as well as the influence of TP design and the applicant (surgeon or anesthetist) were analyzed.

RESULTS

A significantly increased rate of difficulty of swallowing (p = 0.045), intensity of sore throat (p = 0.04), and foreign body sensation (p = 0.024) was found in group B when compared to group A. There was no correlation between hoarseness, dyspnea, nausea, retching, and TP. No case of aspiration or pneumonia was seen but one TP was accidentally forgotten in the patient. B2 showed an increased frequency of difficulty swallowing, followed by A and B1. B1 led to the highest incidence of nausea followed by the A and B2.

CONCLUSION

The use of TP led to a high rate of side effects without showing the propagated advantages.

CLINICAL RELEVANCE

The use of TP must be considered critically and cannot generally be recommended without specific reasons, such as high aspiration risk.

Throat Packs in Cleft and Craniofacial Surgery

ABSTRACT

Throat packs are used in a wide range of surgical and dental procedures. Indications for use include; airway stabilization, reducing the risk of aspiration, and postoperative nausea and vomiting. Despite these perceived benefits, a retained throat pack can be fatal. This has been highlighted since the 1970s but as of yet no effective fail-safe mechanisms exist to prevent the potential tragic consequences of a retained throat pack.A multifaceted questionnaire was distributed at the annual Craniofacial Society of Great Britain and Ireland 2017 to identify current views and practices amongst cleft surgeons. The questionnaire contained seventeen questions related to throat pack use. The responses to the questions were collated and discussed in the context of the current literature.Twenty-four cleft surgeons completed the questionnaire; 67% always use a throat pack, with 84% not securing the throat pack in any way. Almost half (48%) had encountered a serious adverse incident secondary to the use of a throat pack.This survey and review of the literature highlight ongoing discrepancies and a lack of standardization on a national basis. Adverse incidents and fatalities are still occurring. Overwhelming evidence now confirms the lack of benefit regarding postoperative nausea and vomiting and the authors urge both surgeons and anesthetists to strongly consider the need for a throat pack in routine elective procedures.

The Throat Pack Debate: A Review of Current Practice in UK and Ireland Cleft Centers

INTRODUCTION

The use of throat packs during oropharyngeal surgery has long been a topic of debate among cleft surgeons. The advantage of inserting an absorbent tulle within the pharynx must be weighed against the risk of unintended retention postoperatively. Despite safety check mechanisms in place, retention may occur with potentially life-threatening consequences. We present a comprehensive review of throat pack use in all cleft units within the United Kingdom and Ireland.

METHODS

All 20 cleft surgery units in the United Kingdom and Ireland were surveyed on their use of throat packs in children aged 6 months to 2 years undergoing elective cleft palate surgery.

RESULTS

The response rate to the survey was 100%. Seventy-five percent of units currently use throat packs; in 40%, they are used in addition to cuffed endotracheal tubes (ETTs). Inclusion of the throat pack in the surgical swab count was perceived as the safest mechanism employed to avoid retention. 26.1% of respondents were aware of at least 1 incident of pack retention in their unit.

DISCUSSION/CONCLUSION

The reported UK and Irish experience demonstrates that three-quarters of units routinely use packs. Notably, a quarter of respondents to the survey have experience of an incident of throat pack retention. Nevertheless, the majority of respondents considered the perceived risk of retaining a pack to be low. The growing use of microcuffed ETTs in UK cleft units paired with a low incidence of perioperative complications when a throat pack is not introduced might prompt cleft surgeons to review routine pharyngeal packing.

Frequency of the requirement of inappropriate uncuffed tracheal tube size for pediatric patients: a retrospective observational analysis

BACKGROUND

The insertion of inappropriately sized uncuffed endotracheal tubes (ETTs) with a tight seal or presence of air leakage may be necessary in children. This study aimed to analyze the frequency of the requirement of inappropriately sized uncuffed ETT insertion, air leakage after the ETT was replaced with one of a larger size, and factors associated with air leakage after ETT replacement.

METHODS

Patients under 2 years of age who underwent oral surgery under general anesthesia with uncuffed ETTs between December 2013 and May 2015 were enrolled. The ETT size was selected at the discretion of the attending anesthesiologists. A leak test was performed after intubation. The ETT was replaced when considered necessary. Data regarding the leak pressure (P_Leak) and inspiratory and expiratory tidal volumes were extracted from anesthesia records. We considered a P_Leak of 10 < P_Leak ≤ 30 cmH₂O to be appropriate. The frequencies of the requirement of inappropriately sized ETTs, absence of leakage after ETT replacement, ETT size difference, and leak rate were calculated. A logistic regression was performed, with P_Leak, leak rate, and size difference included as explanatory variables and presence of leakage after replacement as the outcome variable.

RESULTS

Out of the 156 patients enrolled, 109 underwent ETT replacement, with the requirement of inappropriately sized ETTs being observed in 25 patients (23%). ETT replacement was performed in patients with P_Leak ≤ 10 cmH₂O; leakage was absent after replacement (P_Leak < 30 cmH₂O) in 52% of patients (25/48). In the multivariate logistic model, the leak rate before ETT replacement was significantly associated with the presence of leakage after replacement (p = 0.021).

CONCLUSIONS

Inappropriately sized ETTs were inserted in approximately 23% of the patients. The leak rate may be useful to guide ETT replacement.