The Beneficial Role of Endotracheal Lidocaine in Mitigating Hemodynamic Responses During Elective Surgical Tracheostomy in Head and Neck Cancer Patients.

BACKGROUND: The effectiveness of endotracheal lidocaine administration to reduce sympathetic stimulus after tracheostomy is still uncertain. PURPOSE: This study aimed to compare the hemodynamic responses of patients undergoing tracheostomy with and without pre-tracheostomy administration of endotracheal lidocaine. STUDY DESIGN, SETTING AND SAMPLE: A prospective cohort study was conducted at a tertiary care cancer center in the United Kingdom. Patients who underwent tracheostomy as part of their head and neck cancer surgery were included. Exclusion criteria comprised tracheostomies involving special requirements and subjects with documented cardiac history or taking specific medications. PREDICTOR VARIABLE: The predictor variable was pre-tracheostomy anesthetic management defined as the administration of endotracheal 4 ml 4% lidocaine before tracheostomy coded as lidocaine used or not used. OUTCOME VARIABLE: The primary outcome measures in this study were the observed hemodynamic responses after tracheostomy, including heart rate, systolic blood pressure, and diastolic blood pressure. The secondary outcome measure in the two groups was the time it took for subjects to return to their pre-tracheostomy baseline hemodynamic parameters, measured in minutes. ANALYSES: Data analyses included χ2, t-test, analysis of variance, and multivariable regression models. P values < .05 were considered statistically significant. COVARIATES: The patients' age, sex, body mass index, smoking status, tracheostomy tube size, and tumor stage were evaluated. RESULTS: The sample included 50 consecutive patients, the majority of whom were male (55%) with a mean age of 62 years (standard deviation[SD] 12) and a mean body mass index of 28 (SD 4). Most patients had stage III or IV oral cancers (59%). Following surgical tracheostomy, the group that received endotracheal lidocaine demonstrated significantly less hemodynamic variability when compared with the control group. The case group exhibiting lower systolic blood pressure (117 [SD 10] vs 136 [SD 18]), diastolic blood pressure (62 [SD 4] vs 68 [SD 4]), and heart rate (72 [SD 4] vs 78 [SD 4]), with statistical significance (P < .05). However, there was no significant difference in the time taken for the two groups to return to their pre-tracheostomy baseline hemodynamic parameters. CONCLUSIONS AND RELEVANCE: This study demonstrates an association between the preadministration of 4% endotracheal lidocaine with an observed attenuation in hemodynamic response following surgical tracheostomy in head and neck cancer patients.

To What Extent Does Illicit Drug Use Predispose to Facial Injury? An Institutional Investigation for an Emergent Problem.

STUDY DESIGN: There are potential substantive linkages between illicit drug use and the occurrence of injury. OBJECTIVE: The purpose of our study was to determine the prevalence, class of illicit drugs abused, and demographics in relation to a cohort of patients who sustained facial injury. METHODS: The authors undertook a retrospective observational study of a prospectively accessioned cohort of patients who had sustained a facial injury and presented to the John Hunter Hospital (Newcastle, NSW, Australia). The primary predictor variable was the presentation of a facial injury and the secondary outcome variables included illicit drug use, alcohol use, and socioeconomic factors. The study was carried out over a 12-month period. A descriptive analysis was undertaken on the assembled data. RESULTS: Of the 465 patient medical records that were accessed for the study, 348 were male and 117 were female. Their average age was 42.6 years: 5.8% (n = 27) were under the influence of illicit drugs at the time of their presentation and 13.1% (n = 61) admitted to an intercurrent illicit drug habit. Those who were under the combined influence of alcohol and drugs comprised of 2.8% (n = 13). CONCLUSIONS: Our study found that illicit drug use plays a small, but nonetheless, demonstrable role in the presentation of maxillofacial trauma patients to an urban level I trauma center. Illicit drug users are an emergent sociodemographic group of patients who can sustain facial trauma and their presentation needs to be appropriately considered, assessed, and managed collectively.

Retrospective analysis of postoperative interventions in mandibular fractures: a shift towards outpatient day surgery care.

The management of fractured mandibles typically involves admission and operation at the time of presentation. While this should involve only a short stay in hospital these patients are surgically stable, and so priority is often given to more urgent cases. We retrospectively evaluated the postoperative medical requirements of patients who were operated on at Fiona Stanley Hospital, Perth, Western Australia between 1 January 2015 and 31 December 2016. Patients were excluded if they had had multiple facial fractures, multiple injuries, had fractures that were comminuted or in edentulous mandibles, and those who had been in hospital for preoperative medical investigations and care. We also excluded fractures in children aged 16 years and under. The results showed that of a total of 173 patients, 12 had had medical consultations during their hospital stay, and only four had required intervention. The mean (range) preoperative time was 37 (1 - 46) hours and that from operation to discharge 21.5 (2 - 93) hours. While traditional management involves emergency admission and open reduction and internal fixation as soon as possible, delays of up to five days were not associated with appreciably worse outcomes. This, together with the negligible requirements for medical management perioperatively, provides a strong argument for a selected group to be treated as outpatients.

Postoperative Bleeding Following Dental Extractions in Patients Anticoagulated With Warfarin.

PURPOSE: The practicing dentist must frequently advise on the risks involved with dental extractions in the patient taking an anticoagulant. This study assessed the risk of bleeding in a large heterogeneous cohort of patients on warfarin treated by practitioners in training (dental students and junior staff in a teaching hospital). MATERIALS AND METHODS: This was a retrospective case-and-control study of 439 patients on warfarin (1,022 extractions) and 439 matched controls (1,049 extractions). Patients with an international normalized ratio (INR) lower than 2.2 had no specific measures, those with an INR 2.2 to 4 received suturing and tranexamic acid mouthwash, and those with an INR higher than 4 did not undergo extraction. Bayesian methods were used to estimate posterior probabilities of bleeding. RESULTS: Of cases, 63% were men, 25% were older than 80 years, 40% had an INR lower than 2.2, and 9% had an INR higher than 3. Nine cases bled 0 to 10 days postoperatively, with 1 requiring admission and transfusion. Significant predictors of bleeding were INR and number of extractions (P < .001 for the 2 comparisons). There were no events of bleeding in controls or cases with an INR lower than 2.2 (95% credible interval [CrI] for difference, -0.7 to 1.6). The posterior mean of bleeding was 1% (CrI, 0.1-2.6) for an INR lower than 2.2, 2.3% (CrI, 0.9-4.5) for an INR of 2.2 to 3, and 8.4% (CrI, 3.5-15) for an INR higher than 3. CONCLUSION: Unselected patients taking an anticoagulant with an INR lower than 2.2 had a similar risk of bleeding as control patients. The risk was approximately 1 in 40 in those with an INR of 2.2 to 3, whereas the risk in patients with an INR higher than 3 was approximately 1 in 11.