Respiratory Volume Monitoring in the Perioperative Setting Across Multiple Centers.

BACKGROUND: The prevalence of nuisance (technical) alarms is the leading cause of alarm fatigue resulting in decreased awareness and a reduction in effective care. The Joint Commission identified in their National Patient Safety goals alarm fatigue as a major safety issue. The introduction of noninvasive respiratory volume monitoring (RVM) has implications for effective perioperative respiratory status management. We evaluated this within the Kaiser Permanente health system. METHODS: This observational study was conducted at 4 hospitals in the Kaiser Permanente system. Standard data from RVM, pulse oximetry, and capnography were collected postoperatively in the post-anesthesia care unit (PACU) and/or on the general hospital floor. Device-specific alarm types, rates, and respective actions were recorded and analyzed by non-study staff. RESULTS: RVM was applied to 247 subjects (143 females, body mass index 32.3 ± 8.7 kg/m2, age 60.9 ± 13.9 y) providing 2,321 h. RVM alarms occurred 605 times (0.25 alarms/h); 64% were actionable and addressed, 17% were not addressed, 13% were self-resolved, and only 6% were nuisance. In a subgroup, RVM completed all 127 h of monitoring, whereas oximetry with capnography only completed 51 h with 12.9 alarms/h (73% nuisance). The overall RVM alarm rate was significantly lower than with either pulse oximeters or capnography monitors. We saw a nearly 1,000-fold reduction in nuisance alarms compared to capnography and a 20-50-fold reduction in nuisance alarms compared to pulse oximetry. CONCLUSIONS: Our study indicates that alarm fatigue due to nuisance alarms continues to be a clinical challenge in perioperative settings. Among the 3 common technologies for respiratory function monitoring, RVM had the lowest rate of overall technical alarms and the highest rate of compliance. Furthermore, with early interventions, none of the subjects monitored with RVM suffered any negative outcomes.

Anticoagulation and antiplatelet therapy in awake transcervical injection laryngoplasty.

OBJECTIVE: Vocal fold movement impairment (VFMI) due to neuronal injury occurs in 20% to 30% of surgeries in the region of the aortic arch. Early injection laryngoplasty can aid with postoperative pulmonary toilet in these high-risk cardiovascular patients. The purpose of this study is to determine whether continuing antiplatelet and anticoagulation therapy during awake transcervical injection laryngoplasty surgery is safe, and if there is any increase in bleeding complications in these patients. METHODS: This is a retrospective review of patients undergoing awake injection laryngoplasty surgery for VFMI between 2013 and 2016 at a tertiary academic center specializing in aortic and mediastinal diseases. Records were reviewed for patients regarding baseline antiplatelet or anticoagulation therapy, and whether these medications were stopped or continued preoperatively. The primary outcome was bleeding complications. RESULTS: Of the 95 surgeries reviewed, 44 (46%) were performed for patients on antiplatelet therapy, and 71 (75%) for patients on anticoagulation therapy. None of the patients on antiplatelet therapy had their treatment discontinued. Of the patients on anticoagulation, 13 (16.4%) had their therapy held prior to surgery. There was no observed difference in bleeding complications between patients who were continued on antiplatelet or anticoagulation treatment versus those whose therapy was withheld. CONCLUSION: These results suggest that patients undergoing awake transcervical injection laryngoplasty for VFMI can be maintained on antiplatelet or anticoagulation therapy without increased risk of bleeding. Further larger studies are needed to confirm these findings. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1850-1854, 2017.

Outcomes of serial dilation for high-grade radiation-related esophageal strictures in head and neck cancer patients.

OBJECTIVES/HYPOTHESIS: Dysphagia and esophageal stricture are frequent consequences of treatment for head and neck cancer. This study examines the effectiveness of the anterograde-retrograde rendezvous procedure and serial dilations in reestablishing esophageal patency to allow return to oral diet and gastrostomy tube removal in a cohort of patients with complete or near-complete esophageal stricture following nonsurgical cancer treatment. STUDY DESIGN: Retrospective review of patients treated with radiation therapy with or without concurrent chemotherapy presented with complete or near-complete esophageal stricture. Patients underwent serial dilations using combined anterograde-retrograde dilation (rendezvous) techniques. METHODS: Medical records of patients having undergone treatment between 2006 and 2012 were reviewed, and semistructured interviews were also conducted to determine current swallowing function and actual patient experience. The primary outcome was swallowing improvement that allowed for return to oral diet and/or gastrostomy tube removal. Outcomes were compared between patients with complete and near-complete (<5 mm in diameter) strictures and univariate analysis performed to identify associations between patient, cancer, and treatment characteristics on odds of gastrostomy tube removal. RESULTS: Twenty-four patients (median age 59.5 years, 63% male, 91% Caucasian) underwent treatment. Fifty percent of patients had complete occlusion of the esophageal lumen. The majority of patients (92%) underwent either anterograde (54%) or combined antero-retrograde (38%) approach. Following a median (interquartile range) of 9 (6-20) dilation sessions, 42% of patients were able to return to an oral diet and/or had their gastrostomy tube removed. This outcome was independent of whether the stricture was complete or near complete (P = .67). Of patients who had their gastrostomy tubes removed, only 33.3% had ever smoked, compared to 92.3% of those whose tubes were not discharged (P = .007). CONCLUSIONS: Recannulation is possible even in cases of complete or near-complete stricture. Several factors appear to impact the likelihood of successful outcome, but in this study, only patients with a history of smoking had a significantly lower likelihood of return to full oral diet.

Antiplatelet and anticoagulation therapy in microlaryngeal surgery.

OBJECTIVES/HYPOTHESIS: Indications for antiplatelet and anticoagulation use are expanding. There is no evidence to direct therapeutic management in patients undergoing microlaryngeal surgeries. Our aim was to compare bleeding complications between microlaryngeal surgeries performed for patients preoperatively taken off and maintained on antiplatelet and/or anticoagulation therapy. STUDY DESIGN: Retrospective cohort study. METHODS: Patients undergoing microlaryngeal surgeries (2008-2009) on baseline antiplatelet and/or anticoagulation therapy were identified. Records were reviewed to determine whether therapy was stopped preoperatively. The primary outcome, bleeding complication, was compared between those taken off and maintained on therapy. Patient characteristics, surgical data, and outcomes were assessed. RESULTS: Of 287 microlaryngeal surgeries, 26% were performed for patients on antiplatelet (23%) and/or anticoagulation (3%) therapy. There was no difference in bleeding complications between patients' naïve to and on baseline antiplatelet or anticoagulation therapy [naïve: 3.8% vs. on: 5.3%, P = 0.58] and no thromboembolic events. Among surgeries performed for patients on baseline antiplatelet therapy, 35% preoperatively stopped therapy. No observed difference in bleeding complications was observed between those taken off or maintained on therapy [off: 8.0% vs. on: 4.9%, P = 0.63]. Of 3% of surgeries performed for patients on warfarin, no bleeding complications occurred, even among the 8/10 with therapeutic international normalized ratios. CONCLUSIONS: Perioperative management decisions regarding antiplatelet and anticoagulation therapy are becoming more common. Results suggest that antiplatelet therapy can be maintained during microlaryngeal surgery without increasing bleeding risk. Further prospective research is required to confirm findings and rigorously investigate the safety of continuing warfarin and other anticoagulation therapy in these surgeries. LEVEL OF EVIDENCE: 4.