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Cleere EF, Read C, Prunty S, Duggan E, O'Rourke J, Moore M, Vasquez P, Young O, Subramaniam T, Skinner L, Moran T, O'Duffy F, Hennessy A, Dias A, Sheahan P, Fitzgerald CWR, Kinsella J, Lennon P, Timon CVI, Woods RSR, Shine N, Curley GF, O'Neill JP. Airway decision making in major head and neck surgery: Irish multicenter, multidisciplinary recommendations. Head Neck 2024; 46:2363-2374. [PMID: 38984517 DOI: 10.1002/hed.27868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 06/21/2024] [Accepted: 06/30/2024] [Indexed: 07/11/2024] Open
Abstract
Major head and neck surgery poses a threat to perioperative airway patency. Adverse airway events are associated with significant morbidity, potentially leading to hypoxic brain injury and even death. Following a review of the literature, recommendations regarding airway management in head and neck surgery were developed with multicenter, multidisciplinary agreement among all Irish head and neck units. Immediate extubation is appropriate in many cases where there is a low risk of adverse airway events. Where a prolonged definitive airway is required, elective tracheostomy provides increased airway security postoperatively while delayed extubation may be appropriate in select cases to reduce postoperative morbidity. Local institutional protocols should be developed to care for a tracheostomy once inserted. We provide guidance on decision making surrounding airway management at time of head and neck surgery. All decisions should be agreed between the operating, anesthetic, and critical care teams.
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Affiliation(s)
- Eoin F Cleere
- Department of Otolaryngology - Head and Neck Surgery, Beaumont Hospital, Dublin, Ireland
| | - Christopher Read
- Department of Anaesthesia and Critical Care, Beaumont Hospital, Dublin, Ireland
| | - Sarah Prunty
- Department of Otolaryngology - Head and Neck Surgery, Beaumont Hospital, Dublin, Ireland
| | - Edel Duggan
- Department of Anaesthesia and Critical Care, Beaumont Hospital, Dublin, Ireland
| | - James O'Rourke
- Department of Anaesthesia and Critical Care, Beaumont Hospital, Dublin, Ireland
| | - Michael Moore
- Department of Anaesthesia and Critical Care, Beaumont Hospital, Dublin, Ireland
| | - Pedro Vasquez
- Department of Physiotherapy, Beaumont Hospital, Dublin, Ireland
| | - Orla Young
- Department of Otolaryngology - Head and Neck Surgery, Galway University Hospital, Galway, Ireland
| | - Thavakumar Subramaniam
- Department of Otolaryngology - Head and Neck Surgery, Galway University Hospital, Galway, Ireland
| | - Liam Skinner
- Department of Otolaryngology - Head and Neck Surgery, University Hospital Waterford, Waterford, Ireland
| | - Tom Moran
- Department of Otolaryngology - Head and Neck Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
- Department of Otolaryngology - Head and Neck Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - Fergal O'Duffy
- Department of Otolaryngology - Head and Neck Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
- Department of Otolaryngology - Head and Neck Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - Anthony Hennessy
- Department of Anaesthesiology, South Infirmary Victoria University Hospital, Cork, Ireland
| | - Andrew Dias
- Department of Otolaryngology - Head and Neck Surgery, South Infirmary Victoria University Hospital, Cork, Ireland
| | - Patrick Sheahan
- Department of Otolaryngology - Head and Neck Surgery, South Infirmary Victoria University Hospital, Cork, Ireland
- ENTO Research Unit, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Conall W R Fitzgerald
- Department of Otolaryngology - Head and Neck Surgery, St James's Hospital, Dublin, Ireland
| | - John Kinsella
- Department of Otolaryngology - Head and Neck Surgery, St James's Hospital, Dublin, Ireland
| | - Paul Lennon
- Department of Otolaryngology - Head and Neck Surgery, St James's Hospital, Dublin, Ireland
| | - Conrad V I Timon
- Department of Otolaryngology - Head and Neck Surgery, St James's Hospital, Dublin, Ireland
| | - Robbie S R Woods
- Department of Otolaryngology - Head and Neck Surgery, Beaumont Hospital, Dublin, Ireland
| | - Neville Shine
- Department of Otolaryngology - Head and Neck Surgery, Beaumont Hospital, Dublin, Ireland
| | - Gerard F Curley
- Department of Anaesthesia and Critical Care, Beaumont Hospital, Dublin, Ireland
- Department of Anaesthesia and Critical Care, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - James P O'Neill
- Department of Otolaryngology - Head and Neck Surgery, Beaumont Hospital, Dublin, Ireland
- Department of Otolaryngology - Head and Neck Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
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Sutthipongkiat E, Chumpathong S, Boonmak L, Panyamee S, Vorasanon K, Mangmeesri P. Emergency Tracheostomy: Complications, Anesthetic Techniques, and Outcomes. EAR, NOSE & THROAT JOURNAL 2024:1455613241238620. [PMID: 38462908 DOI: 10.1177/01455613241238620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024] Open
Abstract
Objectives: Acute upper airway obstruction is a critical medical condition that presents considerable challenges to anesthesiologists. This study aims to provide a formal report on the incidence and outcomes of perioperative complications, as well as the factors that influence unstable intraoperative hemodynamics. Methods: This retrospective study reviewed patients aged 18 years and older who underwent emergency tracheostomy between January 2013 and October 2021. Data on perioperative complications and outcomes within the first 24 hours and 7 days after surgery were subjected to analysis. Descriptive and multivariate analyses were used to examine the results. Results: A total of 253 patients were included in the study. The mean age was 61.5 ± 12.9 years. Malignancy was detected in 78.3% of the patients. General anesthesia was administered to 43.9% of the patients. The incidence of intraoperative complications was 51.8%, with hypotension and hypertension occurring in 30.4% and 22.5% of the cases, respectively. Desaturation and cardiac arrest were observed in 4.7% and 0.8% of the patients, respectively. The mortality rate at 7 days after surgery was 1.6%. Multivariate analysis revealed that monitored anesthesia care [adjusted odds ratio (OR) = 1.80; 95% confidence interval (CI): 1.08-3.00] and hypertensive patients (adjusted OR = 1.70, 95% CI: 1.01-2.86) were associated with unstable intraoperative hemodynamics. Conclusions: Cardiovascular instability represented the majority of the complications observed. Monitoring anesthesia care and hypertension were significant prognostic factors for unstable intraoperative hemodynamics. We recommend extensive communication between ear, nose, and throat surgeons and anesthesiologists to determine the appropriate choice of anesthesia.
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Affiliation(s)
- Ekanong Sutthipongkiat
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Saowapark Chumpathong
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Lapatrada Boonmak
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sriwimon Panyamee
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Khanittha Vorasanon
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Peerachatra Mangmeesri
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Erickson EL, Katta J, Sun S, Shan L, Lemeshow S, Schofield ML. Retrospective review of acute post-tracheostomy complications and contributing risk factors. Clin Otolaryngol 2024; 49:277-282. [PMID: 38095241 DOI: 10.1111/coa.14131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/01/2023] [Accepted: 11/18/2023] [Indexed: 02/16/2024]
Abstract
OBJECTIVE Tracheostomy is performed for various indications ranging from prolonged ventilation to airway obstruction. Many factors may play a role in the incidence of complications in the immediate post-operative period including patient-related factors. Chronic obstructive pulmonary disease and asthma are some of the most common pulmonary pathologies in the United States. The relationship between obstructive pulmonary diseases and acute post-tracheostomy complications has been incompletely studied. DESIGN A retrospective chart review was designed in order to answer these objectives. Medical records were reviewed for the technique used, complications, and contributing patient factors. Post-operative complications were defined as any tracheostomy-related adverse event occurring within 14 days. SETTING The study took place at an academic comprehensive cancer. PARTICIPANTS Inclusion criteria included patients from January 2017 through December 2018 who underwent a tracheostomy. Exclusion criteria included presence of stomaplasty, total laryngectomy, and tracheostomies performed at outside hospitals. MAIN OUTCOME MEASURES Patient factors examined included demographics, comorbidities, and body mass index with the primary outcome measured being the rate of tracheostomy complications. RESULTS The most common indication for tracheostomy among the 321 patients that met inclusion criteria was airway obstruction or a head and neck cancer surgical procedure. Obstructive sleep apnea was associated with acute complications in bivariate analysis (29.4% complications, p = .003). Chronic obstructive pulmonary disease and asthma were not associated with acute complications in bivariate analysis (11.6% complications, p = .302). Among the secondary outcomes measured, radiation was associated with early complications occurring in post-operative days 0-6 (1.1%, p = .029). CONCLUSION Patients with obstructive sleep apnea may have a higher risk of acute post-tracheostomy complications that might be due to the patient population at risk for obstructive sleep apnea. Patients with obstructive pulmonary pathologies such as asthma or chronic obstructive pulmonary disorder did not have an elevated risk of complications which is clinically significant when considering the utility of ventilation and tracheostomy in the management of acute respiratory failure secondary to these conditions.
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Affiliation(s)
| | - Juhi Katta
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Shuai Sun
- The Ohio State University Department of Public Health, Columbus, Ohio, USA
| | - Lingpeng Shan
- The Ohio State University Department of Public Health, Columbus, Ohio, USA
| | - Stanley Lemeshow
- The Ohio State University Department of Public Health, Columbus, Ohio, USA
| | - Minka L Schofield
- The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Pandian V, Ghazi TU, He MQ, Isak E, Saleem A, Semler LR, Capellari EC, Brenner MJ. Multidisciplinary Difficult Airway Team Characteristics, Airway Securement Success, and Clinical Outcomes: A Systematic Review. Ann Otol Rhinol Laryngol 2022:34894221123124. [DOI: 10.1177/00034894221123124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To investigate whether implementation of a multidisciplinary airway team was associated with improvement in (1) rate of successful airway securement at first attempt; (2) time to secure airway; and (3) overall complication rate in patients with a difficult airway, as compared with usual care. Data Sources: Ovid Medline, Embase, Scopus, Cochrane Central, and CINAHL databases. Review Methods: Systematic review of literature on inpatient multidisciplinary team management of difficult airways, including all studies performed in inpatient settings, excluding studies of ventilator weaning, flight/military medicine, EXIT procedures, and simulation or educational studies. DistillerSR was used for article screening and risk of a bias assessment to evaluate article quality. Data was extracted on study design, airway team composition, patient characteristics, and clinical outcomes including airway securement, complications, and mortality. Results: From 5323 studies screened, 19 studies met inclusion criteria with 4675 patients. Study designs included 12 quality improvement projects, 6 cohort studies, and 1 randomized controlled trial. Four studies evaluated effect of multidisciplinary difficult airway teams on airway securement; all reported higher first attempt success rate with team approach. Three studies reported time to secure the difficult airways, all reporting swifter airway securement with team approach. The most common difficult airway complications were hypoxia, esophageal intubation, hemodynamic instability, and aspiration. Team composition varied, including otolaryngologists, anesthesiologists, intensivists, nurses, and respiratory care practitioners. Conclusion: Multidisciplinary difficult airway teams are associated with improved clinical outcomes compared to unstructured emergency airway management; however, studies have significant heterogeneity in team composition, algorithms for airway securement, and outcomes reported. Further evidence is necessary to define the clinical efficacy, cost-effectiveness, and best practices relating to implementing difficult airway teams in inpatient settings.
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Affiliation(s)
- Vinciya Pandian
- Immersive Learning and Digital Innovations, Nursing Faculty, and Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, MD, USA
| | - Talha U. Ghazi
- Michigan State University College of Human Medicine, West Bloomfield, MI, USA
| | - Marielle Qiaoshu He
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
- US Navy Medical Corps, Washington, DC, USA
| | - Ergest Isak
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Abdulmalik Saleem
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Lindsay R. Semler
- INTEGRIS Health, Oklahoma City, OK, USA
- Johns Hopkins University, Baltimore, MD, USA
| | | | - Michael J. Brenner
- Department of Otolaryngology–Head & Neck Surgery, University of Michigan, Ann Arbor, MI, USA
- Global Tracheostomy Collaborative, Raleigh, NC, USA
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Mitton T, Atwood C, Kenee P, Wynings E, Tibbetts KM. Predictors of Mortality in Patients With COVID-19 Undergoing Tracheotomy. Ann Otol Rhinol Laryngol 2022:34894221115752. [PMID: 35923104 DOI: 10.1177/00034894221115752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To identify factors predictive of 30-day mortality following tracheotomy in patients with COVID-19. METHODS A retrospective chart review of patients with COVID-19 who underwent tracheotomy at a tertiary medical center between March 2020 and October 2021 was conducted. Univariate and multivariable analyses of factors correlated with 30-day post-tracheotomy mortality were performed. The outcomes of tracheotomies performed in the operating room and at bedside were compared with t-tests and multivariable analysis. RESULTS One hundred-twenty patients met inclusion criteria, with 48 female patients (40%). Mean age was 59.8 [12.6] years, and the 30-day mortality rate was 18.3%. On univariate analysis, age (odds ratio (OR) = 1.06; P = .015), FiO2 at the time of tracheotomy (OR = 1.06; P < .001), and bedside tracheotomy (OR = 3.21; P = .019) were associated with increased risk of 30-day mortality. After including control variables, increased FiO2 continued to predict increased odds of 30-day mortality (OR = 1.08; P = .02); specifically, patients with FiO2 > 65% were significantly more likely to pass within 30 days than those with FiO2 ≤ 40% (OR = 28.24; P < .001). There was a significant difference in the 30-day mortality rate of bedside tracheotomies (31%) and OR tracheotomies (12%; P = .02), but this association was eliminated on multivariable analysis (OR = 0.95; P = .96). CONCLUSION Intubated patients with COVID-19 undergoing tracheotomy with FiO2 > 65% have 25 times greater odds of 30-day mortality than those with FiO2 ≤ 40%. There were no differences in outcomes between bedside and OR tracheotomies.
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Affiliation(s)
- Tanner Mitton
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Carlyn Atwood
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Parker Kenee
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Erin Wynings
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kathleen M Tibbetts
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
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The Need to Routinely Convert Emergency Cricothyroidotomy to Tracheostomy: A Systematic Review and Meta-Analysis. J Am Coll Surg 2022; 234:947-952. [DOI: 10.1097/xcs.0000000000000114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Zheng Y, Yuan X, Zhang C, Liu R, Jin H, Hao H, Li F, Zhao Y, Yuan Y, Wang Z, Gao F. Efficacy and Safety of Tacrolimus Therapy for a Single Chinese Cohort With Very-Late-Onset Myasthenia Gravis. Front Neurol 2022; 13:843523. [PMID: 35432159 PMCID: PMC9007732 DOI: 10.3389/fneur.2022.843523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 02/15/2022] [Indexed: 11/28/2022] Open
Abstract
Background and Purpose Previous studies have found tacrolimus to be a favorable drug for treating different types of myasthenia gravis (MG), but few have focused on very-late-onset MG (VLOMG). This study evaluated the efficacy and safety of tacrolimus for VLOMG therapy. Methods This was a retrospective single-center cohort study of 70 patients with VLOMG (onset ≥65 years) who visited Peking University First Hospital in 2019. Participants were divided into the tacrolimus (Tac) group and the control group based on tacrolimus usage. We further divided the Tac group into patients treated without corticosteroids and with corticosteroids. Sociodemographic features, clinical profiles, and outcomes were compared between different therapies and further analyzed by multivariate regression. Details of tacrolimus treatment, comorbidities, and adverse drug reactions (ADRs) were described. Results Among 70 patients, the median (interquartile range) age at onset was 71 (68–77) years, and the follow-up duration was 27 (27-29) months. Most patients were types I (28%) and III (40%) according to the MG Foundation of America (MGFA) classification. In the Tac group, tacrolimus treatment was maintained for 36 (27-38) months. The dosage at the final evaluation was 1.0 (1.0–1.75) mg/day, and the last blood concentration test was 4.25 (2.85–5.7) ng/ml. A total of 43% reached remission, and 37% improved based on MGFA postintervention status (MGFA-PIS). For the 9 patients, newly diagnosed at enrollment within this group, MG activities of daily living (MG-ADL) decreased significantly from 3 (2-5) to 2 (1-2) (p = 0.041). Regarding the 13 patients, coadministering Wuzhi capsules the tacrolimus concentration increased from 2.75 (1.4–3.8) ng/ml to 5.95 (5.1–7.0) ng/ml (p = 0.012). No significant differences in outcomes were observed between tacrolimus treatment without and with corticosteroids or between the Tac group and the control group. A total of 93% had at least one comorbidity. ADRs related to tacrolimus emerged in 25% (9/36) of patients, most of which were not serious and reversible. Conclusions Tacrolimus is effective and safe in treating VLOMG. Tacrolimus monotherapy without corticosteroids can be used as an initial and maintenance treatment for VLOMG. Wuzhi capsules work well in elevating tacrolimus concentrations in this population.
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Affiliation(s)
- Yiming Zheng
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Xiaoqiu Yuan
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Caifeng Zhang
- Department of Neurology, Peking University First Hospital, Beijing, China
- North China University of Science and Technology Affiliated Hospital, Qinhuangdao, China
| | - Ran Liu
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Haiqiang Jin
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Hongjun Hao
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Fan Li
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Yawen Zhao
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Yun Yuan
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Zhaoxia Wang
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Feng Gao
- Department of Neurology, Peking University First Hospital, Beijing, China
- *Correspondence: Feng Gao
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Update on Tracheostomy and Upper Airway Considerations in the Head and Neck Cancer Patient. Surg Clin North Am 2022; 102:267-283. [DOI: 10.1016/j.suc.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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