Expert Consensus Statement on the Perioperative Management of Adult Patients Undergoing Head and Neck Surgery and Free Tissue Reconstruction From the Society for Head and Neck Anesthesia.

The perioperative care of adult patients undergoing free tissue transfer during head and neck surgical (microvascular) reconstruction is inconsistent across practitioners and institutions. The executive board of the Society for Head and Neck Anesthesia (SHANA) nominated specialized anesthesiologists and head and neck surgeons to an expert group, to develop expert consensus statements. The group conducted an extensive review of the literature to identify evidence and gaps and to prioritize quality improvement opportunities. This report of expert consensus statements aims to improve and standardize perioperative care in this setting. The Modified Delphi method was used to evaluate the degree of agreement with draft consensus statements. Additional discussion and collaboration was performed via video conference and electronic communication to refine expert opinions and to achieve consensus on key statements. Thirty-one statements were initially formulated, 14 statements met criteria for consensus, 9 were near consensus, and 8 did not reach criteria for consensus. The expert statements reaching consensus described considerations for preoperative assessment and optimization, airway management, perioperative monitoring, fluid management, blood management, tracheal extubation, and postoperative care. This group also examined the role for vasopressors, communication, and other quality improvement efforts. This report provides the priorities and perspectives of a group of clinical experts to help guide perioperative care and provides actionable guidance for and opportunities for improvement in the care of patients undergoing free tissue transfer for head and neck reconstruction. The lack of consensus for some areas likely reflects differing clinical experiences and a limited available evidence base.

Integrated Otolaryngology-Anesthesiology Clinical Skills and Simulation Rotation: A Novel 1-Month Intern Curriculum.

OBJECTIVES: Current Accreditation Council for Graduate Medical Education (ACGME) requirements allow PGY-1 otolaryngology-head and neck surgery (ORL-HNS) residents to spend 6 months on service, prompting reconsideration of educational best practices for the first-year resident experience. The aim of this study was to determine feasibility and value of a 1-month PGY-1 otolaryngology clinical skills rotation integrated with anesthesiology to complement clinical ORL-HNS rotations. METHODS: Our institution developed a 1-month rotation focusing on procedural simulation and airway management as a collaborative effort between ORL-HNS and anesthesiology. Logistics of curriculum design and implementation in the first 2 years are described. Learner outcome measures include pre- and postintervention Likert scale measures of knowledge and confidence. Statistical assessment of curriculum efficacy includes Wilcoxon sign rank test and effect size (Cohen's d). RESULTS: The described rotation was successfully implemented for 8 entering PGY-1 residents in the 2016-2017 and 2017-1018 academic years. Learners reported significant improvement in knowledge and confidence (5-point Likert scale, all P < .0001) in each of the following grouped domains following the intervention: anesthesia skills (pre 2.79, post 4.02), anesthesia knowledge (pre 2.31, post 3.50), anesthesia overall preparedness (pre 2.75, post 4.04), otolaryngology skills (pre 2.90, post 4.19), otolaryngology scenarios (pre 2.80, post 4.00), and otolaryngology overall preparedness (pre 2.38, post 3.75). Very large effect sizes (Cohen's d, range = 1.6-2.9) were observed. CONCLUSION: Changing rotation structure in ORL-HNS training programs provides an opportunity to develop novel rotations with high educational impact. Early outcome data suggest that the described clinical skills rotation is practically feasible and was perceived to have measurable value as part of the PGY-1 curriculum.

Preoperative ß-blockade and hypertension in the first hour of functional endoscopic sinus surgery.

OBJECTIVES/HYPOTHESIS: Local anesthetic with epinephrine is commonly injected into the nasal mucosa during functional endoscopic sinus surgery (FESS). Systemic absorption of epinephrine following local injection may occur, resulting in a mild sympathetic response. This study seeks to determine whether an exaggerated sympathetic response to epinephrine is demonstrated in patients undergoing FESS treated preoperatively with established pharmacologic beta (ß) adrenoceptor blockade. STUDY DESIGN: A retrospective analysis of adult patients undergoing FESS at a tertiary care university hospital. METHODS: The primary outcome was the occurrence of an exaggerated hypertensive response within the first hour of surgical time defined by a relative increase (>20%) in the first measured intraoperative systolic blood pressure (SBP) prior to induction of anesthesia, or a single SBP value above 200 mm Hg. A mixed effects logistic regression model was developed to identify independent predictors of an exaggerated hypertensive response and describe the variance in the outcome attributable to the surgeon and anesthesiologist. RESULTS: There were 2,051 patients identified. Independent predictors of an exaggerated intraoperative hypertensive event included: preoperative ß-blocker use (adjusted odds ratio [AOR]: 3.33), female gender (AOR: 1.92), body mass index (AOR: 1.03), lower baseline SBP (AOR: 0.93), and advanced age (AOR: 1.03). The C statistic for the model was 0.8881. CONCLUSIONS: Preoperative ß-blocker use is an independent predictor of an exaggerated hypertensive response within the first hour of operative time. An exaggerated hypertensive effect should be anticipated in patients presenting for FESS with established pharmacologic ß-blockade, and caution should be applied to use of epinephrine-containing solutions. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1496-1505, 2017.

Success of Intubation Rescue Techniques after Failed Direct Laryngoscopy in Adults: A Retrospective Comparative Analysis from the Multicenter Perioperative Outcomes Group.

BACKGROUND: Multiple attempts at tracheal intubation are associated with mortality, and successful rescue requires a structured plan. However, there remains a paucity of data to guide the choice of intubation rescue technique after failed initial direct laryngoscopy. The authors studied a large perioperative database to determine success rates for commonly used intubation rescue techniques. METHODS: Using a retrospective, observational, comparative design, the authors analyzed records from seven academic centers within the Multicenter Perioperative Outcomes Group between 2004 and 2013. The primary outcome was the comparative success rate for five commonly used techniques to achieve successful tracheal intubation after failed direct laryngoscopy: (1) video laryngoscopy, (2) flexible fiberoptic intubation, (3) supraglottic airway as part of an exchange technique, (4) optical stylet, and (5) lighted stylet. RESULTS: A total of 346,861 cases were identified that involved attempted tracheal intubation. A total of 1,009 anesthesia providers managed 1,427 cases of failed direct laryngoscopy followed by subsequent intubation attempts (n = 1,619) that employed one of the five studied intubation rescue techniques. The use of video laryngoscopy resulted in a significantly higher success rate (92%; 95% CI, 90 to 93) than other techniques: supraglottic airway conduit (78%; 95% CI, 68 to 86), flexible bronchoscopic intubation (78%; 95% CI, 71 to 83), lighted stylet (77%; 95% CI, 69 to 83), and optical stylet (67%; 95% CI, 35 to 88). Providers most frequently choose video laryngoscopy (predominantly GlideScope [Verathon, USA]) to rescue failed direct laryngoscopy (1,122/1,619; 69%), and its use has increased during the study period. CONCLUSIONS: Video laryngoscopy is associated with a high rescue intubation success rate and is more commonly used than other rescue techniques.

Airway laser procedures in children and the American Society of Anesthesiologists' Practice Advisory: a survey among pediatric anesthesiologists.

BACKGROUND AND OBJECTIVES: Recognizing the risk of fire during laser procedures involving the airway, the American Society of Anesthesiologists (ASA) developed recommendations designed to promote safe practice and reduce burn injuries. The aim of this study was to identify how reported anesthetic management of airway laser endoscopies in pediatric patients aligns with the ASA Practice Advisory (ASA-PA). METHODS: An online survey was created in an iterative process, pilot-tested, and distributed using the Society for Pediatric Anesthesia's (SPA) membership email list. Responses were analyzed using descriptive statistics. RESULTS: Responses from 322 respondents were included, 296 (92%) of whom participated in pediatric laser airway procedures. Fifty-nine respondents (20%) reported the use of an inspired fraction of oxygen (FiO2) of 90% or greater during laser activation in patients with a native airway, and 101 (34%) reported not waiting after the reduction of the FiO2 and laser activation in the airway. Sixty-four (36%) of respondents reporting the use of a non-laser-safe tube during laser airway cases did so due to a lack of availability of a laser specific tube or size limitations. Six respondents (2%) reported an airway fire during a laser procedure in a child under their care. CONCLUSIONS: Our results indicate that, in general, pediatric anesthesiologists do not adhere to the ASA-PA in several important aspects. Possible explanations might be knowledge deficiencies about the Practice Advisory or a perceived limited clinical applicability in the pediatric setting. Regardless, airway fires during laser airway surgeries in this population do occur, emphasizing the need for safe practice standards for both anesthesiologists and surgeons.

Lean management in academic surgery.

BACKGROUND: Lean is a management system designed to enhance productivity by eliminating waste. Surgical practice offers many opportunities for improving efficiency. Our objective was to determine whether systematic implementation of lean thinking in an academic otolaryngology operating room improves efficiency and profitability and preserves team morale and educational opportunities. STUDY DESIGN: In an 18-month prospective quasi-experimental study, a multidisciplinary task force systematically implemented lean thinking within an otolaryngology operating room of an academic health system. Operating room turnover time and turnaround time were measured during a baseline period; an observer-effect period in which workers were made aware that their efficiency was being measured but before implementing lean changes; and an intervention period after redesign principles had been used. The impact on teamwork, morale, and surgical resident education were measured during the baseline and intervention periods through validated surveys. A profit model was applied to estimate the financial implications of the study. RESULTS: There was no difference between the baseline and observer-effect periods of the study for turnover time (p = 0.98) or turnaround time (p = 0.20). During the intervention period, the mean turnover time and turnaround time were significantly shorter than during the baseline period (29 vs 38 minutes; p < 0.001 and 69 vs 89 minutes; p < 0.001, respectively). The composite morale score suggested improved morale after implementation (p = 0.011). Educational metrics were unchanged before and after implementation. The annual opportunity revenue for the involved operating room is $330,000; when extrapolated throughout the operating rooms, lean thinking could create 6,500 hours of capacity annually. CONCLUSIONS: Application of lean management techniques to a single operating room and surgical service improved operating room efficiency and morale, sustained resident education, and can provide considerable financial gains when scaled to an entire academic surgical suite.