Emergency Control of Large Aneurysmal Bleed During Endoscopic Sinus Surgery: A Case Report.

Functional endoscopic sinus surgery (FESS) is a commonly performed procedure for the treatment of chronic rhinosinusitis. It is most commonly performed as an outpatient procedure. Complications occur, including injury to the orbits, brain, and bleeding. Intraoperative injury to the internal carotid artery is rare and feared by otolaryngologists and skull base surgeons. Controlling this bleed is difficult and could be fatal. We report a case of intraoperative bleed of an internal carotid artery aneurysm during endoscopic sinus surgery. This case demonstrates that multidisciplinary coordination and prompt management can lead to a favorable outcome.

Transitioning From a Low-Dose-Rate to a High-Dose-Rate Prostate Brachytherapy Program: Comparing Initial Dosimetry and Improving Workflow Efficiency Through Targeted Interventions.

PURPOSE: We transitioned from a low-dose-rate (LDR) to a high-dose-rate (HDR) prostate brachytherapy program. The objective of this study was to describe our experience developing a prostate HDR program, compare the LDR and HDR dosimetry, and identify the impact of several targeted interventions in the HDR workflow to improve efficiency. METHODS AND MATERIALS: We performed a retrospective cohort study of patients treated with LDR or HDR prostate brachytherapy. We used iodine-125 seeds (145 Gy as monotherapy, and 110 Gy as a boost) and preoperative planning for LDR. For HDR, we used iridium-192 (13.5 Gy × 2 as monotherapy and 15 Gy × 1 as a boost) and computed tomography-based planning. Over the first 18 months, we implemented several targeted interventions into our HDR workflow to improve efficiency. To evaluate the progress of the HDR program, we used linear mixed-effects models to compare LDR and HDR dosimetry and identify changes in the implant procedure and treatment planning durations over time. RESULTS: The study cohort consisted of 122 patients (51 who received LDR and 71 HDR). The mean D90 was similar between patients who received LDR and HDR (P = .28). HDR mean V100 and V95 were higher (P < .0001), but mean V200 and V150 were lower (P < .0001). HDR rectum V100 and D1cc were lower (P < .0001). The HDR mean for the implant procedure duration was shorter (54 vs 60 minutes; P = .02). The HDR mean for the treatment planning duration dramatically improved with the implementation of targeted workflow interventions (3.7 hours for the first quartile to 2.0 hours for the final quartile; P < .0001). CONCLUSIONS: We successfully developed a prostate HDR brachytherapy program at our institution with comparable dosimetry to our historic LDR patients. We identified several targeted interventions that improved the efficiency of treatment planning. Our experience and workflow interventions may help other institutions develop similar HDR programs.

The safety and efficacy of intravenous ketorolac in patients undergoing primary endoscopic sinus surgery: a randomized, double-blinded clinical trial.

BACKGROUND: Ketorolac (KT) is an intravenous (IV) nonsteroidal anti-inflammatory drug (NSAID) for acute, moderate pain. KT is safe, but may be linked to increased risk of post-tonsillectomy hemorrhage. The safety and efficacy of KT following primary endoscopic sinus surgery (ESS) is unknown. METHODS: All patients underwent primary ESS and septoplasty. Patients randomly received either IVKT 30 mg or IV fentanyl (IVF) 25 µg postprocedure. Postoperative pain was recorded at 0, 30, and 60 minutes via visual analog scale (VAS), and patients received as needed fentanyl and hydrocodone/acetaminophen for additional pain. Postoperative bleeding questionnaires were completed on postoperative days 1 and 7 (POD 1 and POD 7). Preoperative and POD 7 hemoglobin was assessed. RESULTS: A total of 34 patients enrolled in the study over 1 year. Sixteen patients received IVKT and 18 patients received IVF. The average time of administration was 23 ± 6 minutes postprocedure. There were no significant differences in preoperative and postoperative hemoglobin levels between groups and bleeding assessments. There were no incidences of postoperative hemorrhage. There was no significant difference in pain VAS between the IVKT and IVF groups (3.5, 3.2, 2.1 vs 3.0, 4.4, 3.8 at 0, 30, and 60 minutes, respectively). There was no significant difference between the number of doses of supplemental analgesics for the IVKT and IVF groups (2.0 vs 3.4 doses IV; 1.0 vs 1.4 doses orally, respectively). CONCLUSION: In this study, IVKT was a safe analgesic in the setting of primary ESS. There was no increased risk of hemorrhage or acute blood-loss anemia. IVKT did not appear to offer statistically significant pain control over IVF.

Anesthetic and recovery profiles of lidocaine versus mepivacaine for spinal anesthesia in patients undergoing outpatient orthopedic arthroscopic procedures.

STUDY OBJECTIVE: To compare isobaric lidocaine and mepivacaine in outpatient arthroscopic surgery. DESIGN: Prospective, randomized, double-blinded study. SETTING: Ambulatory surgery center affiliated with an academic tertiary-care hospital. PATIENTS: 84 adult, ASA physical status 1, 2, and 3 ambulatory patients, age 18-70 years, undergoing arthroscopic knee surgery. INTERVENTION: Patients were randomized to receive a combination spinal-epidural anesthetic using 80 mg of either isobaric 2% mepivacaine or isobaric 2% lidocaine. Patients also received a femoral 3-in-1 block with 0.5% bupivacaine applied to the affected extremity. MEASUREMENTS: Demographic data and level and duration of the block were recorded. The use of supplemental epidural anesthesia was noted along with frequency of bradycardia, hypotension, and episodes of nausea and vomiting. Duration of block and times to ambulation and voiding were recorded. Delayed variables, including fatigue, difficulty urinating, back pain, and transient neurologic symptoms (TNS) were obtained. MAIN RESULTS: No demographic differences were noted between groups, and surgical duration was similar. Satisfactory anesthesia was achieved in all cases, with no differences noted in hypotension, bradycardia, nausea, or vomiting. Onset of sensory and motor block was similar. Duration of block before epidural supplementation was 94 ± 21 minutes with lidocaine versus 122 ± 23 minutes for mepivacaine (P < 0.011). Times to ambulation and voiding were longer in patients receiving mepivacaine but did not affect PACU stay. Twenty-four and 48-hour recovery was similar with no TNS symptoms reported. CONCLUSION: No major differences were noted between lidocaine and mepivacaine spinal anesthesia. Time to ambulation and voiding were longer in patients who received mepivacaine as was time to first dose of epidural catheter. Neither group had TNS symptoms. Lidocaine and mepivacaine are both appropriate spinal anesthetics for ambulatory orthopedic lower extremity procedures.