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Frailty Is Superior to Age for Predicting Readmission, Prolonged Length of Stay, and Wound Infection in Elective Otology Procedures. Otol Neurotol 2022; 43:937-943. [PMID: 35970157 DOI: 10.1097/mao.0000000000003636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the predictive ability of the 5-point modified frailty index relative to age in elective otology patients. STUDY DESIGN Retrospective database analysis. SETTING Multicenter, national database of surgical patients. PATIENTS We selected all elective surgical patients who received tympanoplasty, tympanomastoidectomy, mastoidectomy, revision mastoidectomy, and cochlear implant procedures from 2016 to 2019 from the National Surgical Quality Improvement database. INTERVENTIONS Therapeutic. MAIN OUTCOME MEASURES Readmission rates, discharge disposition, reoperation rates, and extended length of hospital stay. RESULTS Utilizing receiver operating characteristics with area under the curve (AUC) analysis, nonrobust status was determined to be a superior predictor relative to age of readmission (AUC = 0.628 [p < 0.001] versus AUC = 0.567 [p = 0.047], respectively) and open wound infection relative to age (AUC = 0.636 [p = 0.024] versus AUC = 0.619 [p = 0.048], respectively). Nonrobust otology patients were more likely to have dyspnea at rest and an American Society of Anesthesiology score higher than 2 before surgery (odds ratios, 13.304 [95% confidence interval, 2.947-60.056; p < 0.001] and 7.841 [95% confidence interval, 7.064-8.704; p < 0.001], respectively). CONCLUSION Nonrobust status was found to be a useful predictor of readmission and prolonged length of stay in patients undergoing elective otology procedures, which generally have low complication rate. Given the aging population and corresponding increase in otology disease, it is important to use age-independent risk stratification measures. Frailty may provide a useful risk stratification tool to select surgical candidates within the aging population.
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Walters B, Gaskell P, Muzaffar J, Iftikhar H, Monksfield P, Bance M. Cochlear implantation under local anesthetic: A systematic review and meta-analysis. Laryngoscope Investig Otolaryngol 2022; 7:226-236. [PMID: 35155802 PMCID: PMC8823255 DOI: 10.1002/lio2.720] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/17/2021] [Accepted: 12/11/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES As the population ages and implantation criteria are relaxed, more patients with complex comorbidities are becoming eligible for cochlear implantation (CI). These patients have higher risks associated with general anesthesia. This systematic review assesses outcomes and complications following CI under local anesthetic to examine utility for patients deemed not suitable or at high risk for general anesthesia. METHODS A systematic review and meta-analysis performed according to the 2020 PRISMA guidelines. Databases searched were MEDLINE, PubMed, EMBASE, CINAHL, Web of Science Core Collection, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials and ClinicalTrials.gov. There were no limitations on year of publication or language. RESULTS Then, 132 unique were identified. After screening abstracts and full texts for eligibility criteria a total of 18 articles were included. In the nine studies where audiological data were reported, all patients demonstrated improvement in audiological outcomes following implantation under local anesthetic (LA). Only minor complications of transient vertigo, wound infection, facial nerve paralysis, confusion, and tinnitus were reported but all were transient. Meta-analysis showed surgical time was significantly shorter under LA. CONCLUSIONS CI under LA is safe for patients with comorbidities which preclude them from general anesthesia, with minimal complications and an improved cost-effectiveness profile. However, larger scale, robust trials are required to assess this further.
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Affiliation(s)
- Ben Walters
- Royal Stoke University HospitalStoke On TrentUK
| | - Peter Gaskell
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital BirminghamBirminghamUK
| | - Jameel Muzaffar
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital BirminghamBirminghamUK
- Department of Clinical NeurosciencesUniversity of Cambridge, Addenbrooke's Health CampusCambridgeUK
| | - Haissan Iftikhar
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital BirminghamBirminghamUK
| | - Peter Monksfield
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital BirminghamBirminghamUK
| | - Manohar Bance
- Department of Clinical NeurosciencesUniversity of Cambridge, Addenbrooke's Health CampusCambridgeUK
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Cochlear implantation under local anesthesia and conscious sedation: an Italian experience. Eur Arch Otorhinolaryngol 2020; 278:3667-3672. [DOI: 10.1007/s00405-020-06419-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 10/03/2020] [Indexed: 10/23/2022]
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Yuan YJ, Zhou P, Xia F, Zhang XB, He SS, Guo DY, Xing YH, Zhao HW. Intranasal dexmedetomidine combined with local anesthesia for conscious sedation during breast lumpectomy: A prospective randomized trial. Oncol Lett 2020; 20:77. [PMID: 32863910 PMCID: PMC7436885 DOI: 10.3892/ol.2020.11938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 06/22/2020] [Indexed: 11/26/2022] Open
Abstract
Breast lumpectomy is usually performed under general or local anesthesia. To the best of our knowledge, whether conscious sedation with intranasal dexmedetomidine and local anesthesia is an effective anesthetic technique has not been studied. Thus, the present study aimed to investigate the effectiveness of conscious sedation with intranasal dexmedetomidine combined with local anesthesia in breast lumpectomy, and to identify its optimal dose. A prospective randomized, double-blinded, placebo-controlled, single-center study was designed, and patients undergoing breast lumpectomies were recruited based on the inclusion and exclusion criteria. All patients were randomly allocated to four groups: i) Local anesthesia with 0.9% intranasal saline (placebo); local anesthesia with ii) 1 µg.kg−1; iii) 1.5 µg.kg−1; or iv) 2 µg.kg−1 intranasal dexmedetomidine. The sedation status, pain relief, vital signs, adverse events, and satisfaction of patient and surgeon were recorded. Patients in the three dexmedetomidine groups were significantly more sedated and experienced less pain compared with the placebo group 45 min after intranasal dexmedetomidine administration and during 30 min in the post-anesthesia care unit. Patients in the 1.5 µg.kg−1 group were more sedated compared with the 1 µg.kg−1 group (without reaching statistical significance), whereas the 1.5 µg.kg−1 group exhibited a similar level of sedation 45 min after intranasal dexmedetomidine administration compared with the 2 µg.kg−1 group. In addition, patients in the 1 and 1.5 µg.kg−1 group experienced no adverse hemodynamic effects. Patient and surgeon satisfaction were greater in the 1.5 µg.kg−1 group compared with the 1 and 2 µg.kg−1 groups. Taken together, the results of the present study suggested that conscious sedation with intranasal dexmedetomidine and local anesthesia may be an effective anesthetic for breast lumpectomy surgery, and that the optimal dose for intranasal dexmedetomidine administration may be 1.5 µg.kg−1, as it resulted in good sedation and patient satisfaction without adverse effects.
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Affiliation(s)
- Ya-Jing Yuan
- Department of Anesthesia, Tianjin Medical University Cancer Institute & Hospital, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Centre for Cancer, Tianjin Clinical Research Center for Cancer, Tianjin 300060, P.R. China
| | - Peng Zhou
- Department of Anesthesia, Tianjin Medical University Cancer Institute & Hospital, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Centre for Cancer, Tianjin Clinical Research Center for Cancer, Tianjin 300060, P.R. China
| | - Fei Xia
- Department of Anesthesia, Tianjin Medical University Cancer Institute & Hospital, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Centre for Cancer, Tianjin Clinical Research Center for Cancer, Tianjin 300060, P.R. China
| | - Xiao-Bei Zhang
- Department of Anesthesia, Tianjin Medical University Cancer Institute & Hospital, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Centre for Cancer, Tianjin Clinical Research Center for Cancer, Tianjin 300060, P.R. China
| | - Shan-Shan He
- Department of Breast Reconstruction, Tianjin Medical University Cancer Institute & Hospital, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Centre for Cancer, Tianjin Clinical Research Center for Cancer, Tianjin 300060, P.R. China
| | - Dong-Yong Guo
- Department of Anesthesia, Tianjin Medical University Cancer Institute & Hospital, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Centre for Cancer, Tianjin Clinical Research Center for Cancer, Tianjin 300060, P.R. China
| | - Yu-Hong Xing
- Department of Anesthesia, Tianjin Medical University Cancer Institute & Hospital, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Centre for Cancer, Tianjin Clinical Research Center for Cancer, Tianjin 300060, P.R. China
| | - Hong-Wei Zhao
- Department of Anesthesia, Tianjin Medical University Cancer Institute & Hospital, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Centre for Cancer, Tianjin Clinical Research Center for Cancer, Tianjin 300060, P.R. China
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Connors JR, Deep NL, Huncke TK, Roland JT. Cochlear Implantation Under Local Anesthesia With Conscious Sedation in the Elderly: First 100 Cases. Laryngoscope 2020; 131:E946-E951. [PMID: 32663339 DOI: 10.1002/lary.28853] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/04/2020] [Accepted: 05/11/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To report the outcomes on a large series of elderly patients who underwent cochlear implantation (CI) surgery under local anesthesia with conscious sedation (LA-CS). METHODS Retrospective chart review on 100 consecutive elderly patients (> 65 years) who underwent CI with LA-CS at a tertiary care center between August 2013 and January 2020. An age-matched control group of 50 patients who underwent CI with general anesthesia (GA) are used for comparison. Outcomes measured included time in the operating room, time in the postanesthesia care unit (PACU), and rate of adverse events. RESULTS Cochlear implant surgery under LA-CS was successfully performed in 99 (99%) patients. One patient requiring conversion to GA intraoperatively. No patients in the LA-CS group experienced cardiopulmonary adverse events; however, three patients (6%) in the GA group experienced minor events including atrial fibrillation and/or demand ischemia. Overnight observation in the hospital due to postoperative medical concerns or prolonged wake-up from anesthesia was required in one patient (1%) from the LA-CS cohort and 12 patients (24%) from the GA cohort. Perioperative adverse events exclusive to the LA-CS group included severe intraoperative vertigo (8%), temporary facial nerve paresis (3%), and wound infection (1%). The average amount of time spent in the operating room was 37 minutes less for procedures performed under LA-CS compared to GA (P < .05). The average amount of time in recovery was similar for both groups (P > .05). CONCLUSION Cochlear implant surgery under LA-CS offers many benefits and is a safe, feasible, and cost-effective alternative to GA when performed by experienced CI surgeons. LEVEL OF EVIDENCE 3 Laryngoscope, 131:E946-E951, 2021.
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Affiliation(s)
- Joseph R Connors
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York, NY, USA
| | - Nicholas L Deep
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York, NY, USA
| | - T Kate Huncke
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Langone Health, New York, NY, USA
| | - J Thomas Roland
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York, NY, USA
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Shabashev S, Fouad Y, Huncke TK, Roland JT. Cochlear implantation under conscious sedation with local anesthesia; Safety, Efficacy, Costs, and Satisfaction. Cochlear Implants Int 2017; 18:297-303. [PMID: 28934019 DOI: 10.1080/14670100.2017.1376423] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To evaluate the safety, efficiency, cost effectiveness, and satisfaction of patients undergoing cochlear implantation under conscious sedation versus general anesthesia. STUDY DESIGN Retrospective case review of 20 patients who underwent cochlear implantation under conscious sedation which was compared to 20 age-matched patients where surgery was performed under general anesthesia. METHODS Perioperative times, length of stay, anesthesia drug costs, postoperative complications, and patient satisfaction were compared between the two groups. RESULTS Conscious sedation was associated with decreased drug costs, surgery time, and anesthesia time. Length of stay was significantly longer for patients undergoing general anesthesia. Patient satisfaction was superior with conscious sedation. Perioperative morbidity was not significantly different between the two groups. CONCLUSION Conscious sedation for cochlear implantation is a safe, efficient, and cost-effective alternative to general anesthesia. The efficacy of conscious sedation for cochlear implant surgery may expand the treatment of profound hearing loss to the elderly who are deemed too sick for general anesthesia or are fearful of the cognitive or medical consequences of general anesthesia.
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Affiliation(s)
- Samion Shabashev
- a NYU Department of Anesthesiology, Perioperative Care, and Pain Medicine , NYU Langone Medical Center , New York , NY , USA
| | - Yasser Fouad
- b Otlaryngology Department, Faculty of Medicine , Zagazig University , Zagazig , Egypt
| | - T Kate Huncke
- a NYU Department of Anesthesiology, Perioperative Care, and Pain Medicine , NYU Langone Medical Center , New York , NY , USA
| | - J Thomas Roland
- c Department of Otolaryngology-Head and Neck Surgery , NYU Langone Medical Center , New York , NY , USA
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Cochlear Implant Surgery in the Elderly: The Feasibility of a Modified Suprameatal Approach Under Local Anesthesia. Otol Neurotol 2017; 37:487-91. [PMID: 27093026 DOI: 10.1097/mao.0000000000001025] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Although cochlear implantation is a relatively safe procedure, there is some reticence to subject elderly people, especially those with significant comorbidity, to the risks of general anesthesia. The purpose of the study was to explore the feasibility of cochlear implant surgery under local anesthesia and sedation in elderly people. STUDY DESIGN Case report study (Clinical Capsule Report). SETTING Single tertiary academic referral center. PATIENTS Seven elderly subjects with severe or severe-to-profound sensorineural hearing impairment underwent cochlear implantation under local anesthesia and sedation. All subjects had significant comorbidities with an American Society of Anesthesiologists (ASA) classification 3 to 4 and explicitly expressed their concerns regarding general anesthesia. The subjects were implanted with 24 mm straight electrode array devices via a modified suprameatal approach. INTERVENTIONS Therapeutic. MAIN OUTCOME MEASURE The evaluation of a modified suprameatal approach for cochlear implant surgery under local anesthesia and sedation with respect to patient safety and compliance. RESULTS Cochlear implantation under local anesthesia and sedation was successful and well tolerated in all subjects. No intra- or postoperative complications occurred. Recovery was quick and all subjects were discharged on the first postoperative day. All subjects would opt again for the procedure under local anesthesia. CONCLUSION Cochlear implantation under local anesthesia and sedation was found to be feasible. The modified suprameatal approach lends itself for procedures under local anesthesia, because only minimal drilling is required. The application of this technique provides a safe alternative especially for the elderly with significant comorbidity and increased risks for general anesthesia.
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