RESUMEN
BACKGROUND: Dexmedetomidine (DEX) is a highly selective alpha-2-receptor agonist, and its use has not been well studied in major microvascular reconstructive surgery of the head and neck. PURPOSE: The purpose is to measure the association between DEX and neck hematoma formation in subjects undergoing head and neck microvascular reconstructive surgery. STUDY DESIGN, SETTING, SAMPLE: The investigators implemented a retrospective cohort study on subjects undergoing microvascular head and neck reconstruction for benign and malignant pathology at the University of Alabama at Birmingham from 2014 to 2021. Patients with unresectable tumors were excluded. PREDICTOR VARIABLE: The predictor variable was the intraoperative use of DEX upon emergence from general anesthesia. Subjects received standard anesthetic drugs and DEX, while control subjects received only standard anesthetic drugs. MAIN OUTCOME VARIABLE(S): The primary outcome was postoperative neck hematoma formation necessitating a return to the operating theater. The secondary outcome was the length of stay (LOS). COVARIATES: The covariates were demographic, operative, and oral morphine equivalents of anesthesia drugs. ANALYSES: Bivariate analyses were performed using the Student's t-test and the χ2 test for continuous and categorical variables. Multivariate regression analyses were conducted to assess for associations between DEX and the outcomes adjusted for confounding variables when present. P values of < .05 were regarded as statistically significant. RESULTS: A total of 297 subjects (mean age, 59.6 years, and standard deviation [SD], 14.9) with 61.6% male received DEX, and 304 subjects (mean age, 58.9 years, and SD, 14.6) with 60.2% male served as controls (P > .5). A total of 11 postoperative neck hematoma occurred in the control group when compared to 2 in the DEX (relative risk = 5.4, 95% confidence interval [CI], 1.2 to 24, P = .02). The mean LOS was 7.7 (SD, 4.3) and 9.4 (SD, 8.1) for the DEX and control groups (95% CI, 0.7 to 2.8, P < .01). After adjusting for tobacco history, tracheostomy, and neck dissection, DEX (Beta coefficient (B) = -1.7, 95% CI -2.7 to -0.7, P < .01) and neck dissection (B = 2.2, 95% CI 1.0 to 3.4, P < .01) were statistically associated with LOS. CONCLUSION AND RELEVANCE: The use of intraoperative DEX upon emergence from general anesthesia was associated with lower postoperative neck hematoma formation and a shorter length of stay following microvascular head and neck reconstruction.
Asunto(s)
Dexmedetomidina , Hematoma , Cuello , Procedimientos de Cirugía Plástica , Humanos , Dexmedetomidina/uso terapéutico , Masculino , Hematoma/etiología , Estudios Retrospectivos , Femenino , Persona de Mediana Edad , Procedimientos de Cirugía Plástica/métodos , Cuello/cirugía , Cuello/irrigación sanguínea , Anciano , Neoplasias de Cabeza y Cuello/cirugía , Tiempo de Internación , Complicaciones Posoperatorias , Microcirugia/métodos , Periodo de Recuperación de la Anestesia , Adulto , Anestesia General , Agonistas de Receptores Adrenérgicos alfa 2/uso terapéuticoRESUMEN
OBJECTIVE: Currently there is variation in perioperative care of orthognathic surgery patients and limited clinical practice guidelines. The current orthognathic surgery practice patterns among US academic OMFS training centers have not been described. The purpose of this study is to describe the practice patterns among US academic OMFS training centers. DESIGN: The study design is cross-sectional. Data was collected through a survey of the sample. SETTING: OMFS programs in the US. PARTICIPANTS: Academic OMFS. 573 surgeons were contacted and 85 responses were received. MAIN OUTCOME MEASURE: Descriptive and bivariate statistics were reported. RESULTS: Respondents were 87% male and worked in full-time academic (80%), part-time academic (19%), or military settings (1%). Thirty-one percent have practiced for 30 years or more and then 29% with 11-20 years, 18% with 21-30 years, 12% with 6-10 years and 11% with 1-5 years. Twenty-six percent of respondents perform 20-40 orthognathic surgeries a year, 22% perform less than 20 surgeries a year, 21% perform 40-60 surgeries per year, and 19% perform more than 100 surgeries per year. Intraoperatively, 48% of surgeons request a mean arterial pressure of 60-64 mmHg, 25% utilize tranexamic acid (TXA), 85% report a blood loss of less than 400 milliliters, and 93% report a blood transfusion rate of <1%. CONCLUSION: There are variations in orthognathic surgery practice patterns with limited clinical practice guidelines. Only 13 of the 32 survey questions had a single response holding a simple majority. This study demonstrates the need for further research and evidence-based protocols and decision making.
RESUMEN
PURPOSE: Data on timing of oral intake (PO) after free flap reconstruction of the oral cavity have been limited. Recent studies have shown that early PO after free flap reconstruction does not lead to increased morbidity and has resulted in decreased hospital stay. The objective of this study is to assess postoperative complications associated with timing of PO after free flap reconstruction of the oral cavity and to define clinical predictors of postoperative complications. METHODS: This was a retrospective comparative cohort study and comprised of patients who underwent free flap reconstruction of the oral cavity between January 2014 and December 2019 in the Department of Oral and Maxillofacial Surgery at the University of Alabama at Birmingham. The predictor variable was timing of PO grouped into early (<5 days) and late (>5 days), postoperatively. The primary and secondary outcomes were postoperative complications and hospital length of stay (LOS), respectively. Covariates included age, gender, pathology, reconstruction site, flap type, tracheostomy, neck dissection, defect volume (cm3), skin paddle size (cm2), and gastrostomy tube (g-tube). Student's t-test, Chi-squared test, and binary logistic regression models were computed using odds ratios (ORs) with 95% confidence intervals (CIs). For all statistical tests, P values of < .05 were regarded as statistically significant. RESULTS: The sample consisted of 415 patients (253 males and 162 females), with a mean age of 58.8 years (range, 14.4-88.2 years). The majority had malignant pathology (68.9%) with defects involving the mandible (52.3%) and reconstructed with a radial forearm (43.6%), followed by fibula (39%), and osteocutaneous radial forearm (13%). Seventy one "early PO" and 344 "late PO" patients were analyzed. Early PO was associated with lower postoperative complications compared with the late PO group (RR = 0.847, 95% CI 0.747-0.960, P = .031) and shorter hospital LOS (6 vs 9 days, 95% CI 2.2459-3.720, P < .001). A regression model showed a 2% increase for postoperative complications with each unit (cm3) increase of defect volume (OR = 1.002, 95% CI 1.000-1.004, P = .035) and 2.286 times higher odds for postoperative complication in patients with a g-tube (95% CI 1.271-4.110, P = .006). CONCLUSIONS: Early PO after free flap reconstruction of the oral cavity was not associated with increased postoperative outcomes or delayed hospital course. Variables such as defect location, defect volume, and tracheostomy may increase the risk for postoperative complications and can help guide surgeons in deciding the optimal timing for PO postoperatively.