Cochlear Implant Surgery in the Elderly: The Feasibility of a Modified Suprameatal Approach Under Local Anesthesia.

OBJECTIVE: Although cochlear implantation is a relatively safe procedure, there is some reticence to subject elderly people, especially those with significant comorbidity, to the risks of general anesthesia. The purpose of the study was to explore the feasibility of cochlear implant surgery under local anesthesia and sedation in elderly people. STUDY DESIGN: Case report study (Clinical Capsule Report). SETTING: Single tertiary academic referral center. PATIENTS: Seven elderly subjects with severe or severe-to-profound sensorineural hearing impairment underwent cochlear implantation under local anesthesia and sedation. All subjects had significant comorbidities with an American Society of Anesthesiologists (ASA) classification 3 to 4 and explicitly expressed their concerns regarding general anesthesia. The subjects were implanted with 24 mm straight electrode array devices via a modified suprameatal approach. INTERVENTIONS: Therapeutic. MAIN OUTCOME MEASURE: The evaluation of a modified suprameatal approach for cochlear implant surgery under local anesthesia and sedation with respect to patient safety and compliance. RESULTS: Cochlear implantation under local anesthesia and sedation was successful and well tolerated in all subjects. No intra- or postoperative complications occurred. Recovery was quick and all subjects were discharged on the first postoperative day. All subjects would opt again for the procedure under local anesthesia. CONCLUSION: Cochlear implantation under local anesthesia and sedation was found to be feasible. The modified suprameatal approach lends itself for procedures under local anesthesia, because only minimal drilling is required. The application of this technique provides a safe alternative especially for the elderly with significant comorbidity and increased risks for general anesthesia.

[Exercise laryngoscopy: a new method for the differential diagnosis of dyspnea on exertion]. / Rasituslaryngoskopia: uusi menetelmä rasitushengenahdistuksen erotusdiagnostiikkaan.

Exertional dyspnea originating from the laryngeal level can be established with certainty only if the paradoxical vocal cord adduction is observed during dyspnea. We have developed a novel diagnostic method, exercise laryngoscopy, which involves observation of the larynx with a flexible endoscope applied via the nose during a bicycle ergometry test. It has been our aim to improve the differential diagnosis of dyspnea on exertion and thus also reduce unnecessary antiasthmatic medication. Exercise laryngoscopy allows examination in the out-patient clinics because the method is well tolerated.

Fiberoptic videolaryngoscopy during bicycle ergometry: a diagnostic tool for exercise-induced vocal cord dysfunction.

OBJECTIVES/HYPOTHESIS: Exercise-induced vocal cord dysfunction is difficult to diagnose because the paradoxical vocal cord adduction should be observed during exercise. Our goal was to develop and validate a new diagnostic method for exercise-induced vocal cord dysfunction by combining continuous fiberoptic laryngoscopy with a bicycle ergometry test. METHODS: Thirty consecutive patients referred to a laryngologist because of suspicion of exercise-induced vocal cord dysfunction and 15 healthy controls underwent the exercise test until dyspnea or exhaustion rated as 18-19/20 on the Borg scale. Laryngeal findings, electrocardiography, blood pressure, heart rate, and respiratory rate were monitored, and forced expiratory flow in the first second was measured before and after the exercise. The medical history was assessed by use of a structured questionnaire. RESULTS: Among the 30 patients, 27 (90%) performed the test successfully, as did all controls. Diagnostic signs of inspiratory stridor, supraglottic collapse, and vocal cord adduction appeared in five (19%) patients but in none of the controls. Of the 30 patients referred, the laryngologist considered 25 to be suspect. Of them, 9 (36%) showed signs diagnostic or highly suspect for exercise-induced vocal cord dysfunction. Of the 15 patients whose dyspnea could be induced during the test, nine (60%) were suspected of having exercise-induced vocal cord dysfunction. CONCLUSIONS: Fiberoptic videolaryngoscopy during bicycle ergometry was a well-tolerated and relatively easily established diagnostic tool that could induce dyspnea in more than one half the patients examined. If the symptom of dyspnea appeared, the most frequent diagnosis was exercise- induced vocal cord dysfunction.

Resource use and postoperative outcome: basic elements in benchmarking.

PURPOSE OF REVIEW: There is an increasing need to improve the economic efficiency in perioperative processes without compromising patient outcome. In perioperative care, optimization of resource use and costs are far from optimal and in this respect, there may be great differences between institutions. RECENT FINDINGS: Fast-track or enhanced recovery programs that use a multimodal approach have shown benefits in several surgical specialties, although the reports so far mainly come from single centers. Benchmarking with others is beneficial but requires case-mix adjustment. Methods to standardize patient populations, and to measure outcome and resource use, have been introduced in some surgical specialties, such as colorectal and cardiac surgery. There is a lot of evidence that centralization of surgical interventions results in improvements in risk-adjusted outcome and resource use. SUMMARY: There is a lot to do to achieve feasible quality indicators and methods for intrainstitutional and interinstitutional benchmarking. Using appropriate tools that are based on multicenter databases, resource use, outcome and effects of new treatment modalities could be more objectively estimated.

Case-mix-adjusted length of stay and mortality in 23 Finnish ICUs.

OBJECTIVES: To create a tool for benchmarking intensive care units (ICUs) with respect to case-mix adjusted length of stay (LOS) and to study the association between clinical and economic measures of ICU performance. DESIGN: Observational cohort study. SETTING: Twenty-three ICUs in Finland. PATIENTS: A total of 80,854 consecutive ICU admissions during 2000-2005, of which 63,304 met the inclusion criteria. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Linear regression was used to create a model that predicted ICU LOS. Simplified Acute Physiology Score (SAPS) II, age, disease categories according to Acute Physiology and Chronic Health Evaluation III, single highest Therapeutic Intervention Scoring System score collected during the ICU stay and presence of other ICUs in the hospital were included in the model. Probabilities of hospital death were calculated using SAPS II, age, and disease categories as covariates. In the validation sample, the created model accounted for 28% of variation in ICU LOS across individual admissions and 64% across ICUs. The expected ICU LOS was 2.53 +/- 2.24 days and the observed ICU LOS was 3.29 +/- 5.37 days, P < 0.001. There was no association between the mean observed - mean expected ICU LOS and standardized mortality ratios of the ICUs (Spearman correlation 0.091, P = 0.680). CONCLUSIONS: We developed a tool for the assessment of resource use in a large nationwide ICU database. It seems that there is no association between clinical and economic quality indicators.

Use of postanesthesia care unit for purposes other than postanesthesia observation.

Postanesthesia care units (PACUs) were originally developed to care for patients who needed monitoring until they recovered from anesthesia. As new treatment options are developing, however, the role of PACU is changing and the scope of PACU nurses is expanding. We performed a study to find out the proportion of patients who were admitted to the PACU for reasons other than postoperative observation and care and analyzed the resources, observation, and interventions these patients required in PACU facilities. These patients were a heterogeneous patient population who required variable monitoring, care, and nursing activities and, therefore, considerably increased the workload of PACU nurses. A small proportion of these patients suffered from problems that further increased the demand for special care.

Management of physiological variables in neuroanaesthesia: maintaining homeostasis during intracranial surgery.

PURPOSE OF REVIEW: The recent literature on the perioperative maintenance of cerebral homeostasis was reviewed. RECENT FINDINGS: Several studies focused on the regulation of cerebral blood flow in patients without intracranial disease; therefore, further studies in neurosurgical patients are needed. High intracranial pressure and brain swelling can be controlled by the choice of anaesthetic agents, and also by optimal positioning of the patient. The use of positive end-expiratory pressure may impair cerebral blood flow, but the effects of positive end-expiratory pressure seem to depend on the respiratory system compliance. The international multicenter study failed to show any benefit from intraoperative hypothermia in patients with subarachnoid hemorrhage; similarly, the results on corticosteroid therapy in head-injured patients are discouraging. Corticosteroid therapy has prompted studies on the control of blood glucose levels. While tight glycemic control has been recommended, it can have untoward effects manifested as cerebral metabolic stress. SUMMARY: From the clinical point of view, the recent research has added only little to the knowledge on the management of physiological parameters in neurosurgery. More adequately powered studies focusing in specific problems, and having a meaningful aim relative to outcome, are needed also in neuroanaesthesia.

Efficacy and costs of 3 anesthetic regimens in the prevention of postoperative nausea and vomiting.

STUDY OBJECTIVE: The aim of the study was to compare the antiemetic efficacy and costs associated with 3 different anesthesia regimens used in gynecologic laparoscopy. DESIGN: This was a randomized, controlled study. SETTING: The study was conducted at a university hospital. PATIENTS: We studied 150 ASA physical status I or II patients, undergoing elective gynecologic laparoscopy with general anesthesia. INTERVENTION: Patients were allocated into the following 3 groups: group P-preoperative placebo tablet, propofol induction, propofol-air/O2 maintenance; group I + O-preoperative 8-mg ondansetron tablet, thiopental induction, isoflurane-N2O maintenance; group I (control)-preoperative placebo tablet, thiopental induction, isoflurane-N2O maintenance. MEASUREMENTS: The frequency of postoperative nausea and vomiting (PONV), number needed to treat to prevent PONV, and the costs of the anesthetic drugs to prevent PONV in one additional patient were evaluated. MAIN RESULTS: The frequency of PONV within the 24-hour study period was lowest in group I + O (P, 38%; I + O, 33%; and I, 59%; P < 0.05 I + O vs I). The number needed to treat was 5 in group P and 4 in group I + O, compared with group I. The median costs of anesthetic drugs to prevent PONV in one additional patient were $65 in group P and dollar 68 in group I + O, compared with group I. CONCLUSIONS: We conclude that in gynecologic laparoscopy, propofol-air/O2 anesthesia alone, and isoflurane-N2O anesthesia combined with an oral 8-mg dose of ondansetron had similar efficacy and costs to prevent PONV. Isoflurane-N2O anesthesia without ondansetron was less expensive, but was also less efficacious.

Cervical spine surgery in patients with rheumatoid arthritis: longterm mortality and its determinants.

OBJECTIVE: Atlantoaxial subluxation (AAS) is a frequent manifestation of rheumatoid arthritis (RA). The instability of the craniocervical junction caused by AAS is a potentially fatal condition and may require surgical treatment. Systemic manifestations associated with RA may increase the risk of perioperative complications. We evaluated the longterm mortality and its determinants in RA patients with AAS after cervical spine surgery. METHODS: A retrospective study of consecutive patients treated at Kuopio University Hospital between 1994 and 1998. Preoperative risk factors, neurological impairment using the Ranawat classification, perioperative course, functional outcome, and survival status were evaluated. RESULTS: During the study period 86 rheumatoid patients with AAS underwent cervical spine surgery. The mean followup time was 7.5 years (range 5.0-9.8). During the followup, 32 patients (37%) died. The mean survival time after surgery was 7.2 years (95% CI 6.7-8.0). Seven patients experienced postoperative complications. Age, AAS other than horizontal, and occurrence of complications were independent predictors of mortality. In two-thirds of the patients there was relief or decrease of pain, and the functional capacity improved. Neurological deficits subsided in 53% of cases. CONCLUSION: Patients with RA should be actively studied for AAS or other cervical instability, even when cervical symptoms are minor. Attention should be paid to perioperative management of these patients. Surgical treatment may not decrease the mortality of patients with RA, but it may result in more symptom-free life-years.

Complications and postoperative care in patients undergoing treatment for unruptured intracranial aneurysms.

Endovascular treatment has become a feasible alternative in the management of aneurysmal subarachnoid hemorrhage. After endovascular or surgical treatment of patients with unruptured intracranial aneurysms (UIAs), little is known about the practices of observation or need for intensive care. We analyzed retrospectively perioperative complications that were associated with the procedure and postoperative care in patients undergoing management of UIAs. A total of 53 patients underwent endovascular treatment and 105 patients surgical treatment. Location of the aneurysm was the main determinant of the modality of treatment. In the endovascular group, 34 patients were conscious during the procedure and 19 were under general anesthesia. Six patients in the endovascular and 9 in the surgical group experienced complications during the procedure. After the procedure, complications were more common in the surgical group than in the endovascular group (11 versus 0 patients, P = 0.015). Six of the postoperative complications of surgically treated patients occurred in the intensive care unit. Two patients in the endovascular group and five in the surgical group had major neurologic deficits as a consequence of complications. One surgically treated patient died. Both endovascular and surgical treatment of UIAs carry risks that may result in severe neurologic impairment. Patients should be observed with equal vigilance with either treatment option. Surgical treatment is associated with emergencies that require prompt interventions postoperatively and therefore close observation in an ICU setting may be preferable in patients who have undergone surgical treatment of UIAs. Complications after uneventful endovascular procedures seem to be rare.

Resource use after subarachnoid hemorrhage: comparison between endovascular and surgical treatment.

OBJECTIVE: The aim of this study was to compare resource use after endovascular treatment and surgical clipping of ruptured intracranial aneurysms. METHODS: The study population consisted of patients with aneurysmal subarachnoid hemorrhage who were actively treated in Kuopio University Hospital. The baseline patients' characteristics were obtained from the institution's aneurysm registry. Variables indicating resource use in the intensive care unit (ICU) were obtained from the ICU patient data management system. The Therapeutic Intervention Scoring System was used to measure the intensity of treatment in the ICU. All care days in the ICU and in the hospital and all Therapeutic Intervention Scoring System points that were accumulated during the 12-month follow-up period were calculated. Outcomes were assessed according to the Glasgow Outcome Scale. RESULTS: The study population consisted of 68 patients who underwent endovascular treatment and 103 patients who had surgery. The median lengths of stay in the ICU (1.7 versus 1.8 d) and the hospital (14.0 versus 15.0 d), as well as the accumulated Therapeutic Intervention Scoring System points (56 versus 55), among patients who underwent endovascular or surgical treatment were similar (P = NS for all). The modality of treatment did not influence the number of ICU or hospital patient days or the intensity of ICU treatment, regardless of the patient's preoperative clinical status. CONCLUSION: The modality of treatment of patients with subarachnoid hemorrhage does not seem to affect resource use. Endovascular and surgical treatment are likely to require a similar amount of ICU resources in the year after initial treatment.

Supplemental oxygen does not reduce the incidence of postoperative nausea and vomiting after ambulatory gynecologic laparoscopy.

UNLABELLED: Supplemental 80% oxygen administration halves the incidence of postoperative nausea and vomiting (PONV) in inpatients. Whether it prevents PONV after ambulatory surgery is unknown. We tested the efficacy of supplemental 80% oxygen in decreasing the incidence of PONV after ambulatory gynecologic laparoscopy. One hundred patients were given a standardized sevoflurane anesthetic. They were randomly assigned to two groups: routine oxygen administration with 30% oxygen, balance nitrogen (Group A); and supplemental oxygen with 80% oxygen, balance nitrogen (Group B). Oxygen was administered during surgery and up to 1 h after surgery. The incidence of nausea and vomiting and the need for rescue antiemetics did not differ between the groups in the postanesthesia care unit, in the Phase II unit, or during the 24-h follow-up. The overall incidence of nausea and vomiting during the first postoperative 24 h was 62% in Group A and 55% in Group B (P = 0.486). There were no differences in the recovery profiles and patient satisfaction between the groups. In this study, supplemental oxygen did not prevent PONV in patients undergoing ambulatory gynecologic laparoscopy. IMPLICATIONS: Supplemental 80% oxygen administration during surgery and until 1 h after surgery compared with 30% oxygen administration did not prevent postoperative nausea and vomiting after ambulatory gynecologic laparoscopy.