Head and Neck Medicine by Alexandros G.Sfakianakis: 01/11/17

Τετάρτη 11 Ιανουαρίου 2017

Thoracic Epidural Anesthesia and Prophylactic Three Times Daily Unfractionated Heparin Within an Enhanced Recovery After Surgery Pathway for Colorectal Surgery.

Background and Objectives: Venous thromboembolism (VTE) is a common cause of preventable harm. Perioperative thoracic epidural analgesia (TEA) presents a challenge to optimal VTE prophylaxis. Our primary aim was to characterize missed doses of VTE prophylaxis associated with epidural catheter placement and removal. Our secondary aim was to measure the effect of an enhanced recovery after surgery (ERAS) pathway on the rate of TEA-associated missed VTE prophylaxis. Methods: We retrospectively reviewed a prospectively collected database of 1264 colorectal surgery patients at a single academic center. Missed preoperative doses between TEA patients and non-TEA patients were compared. Missed postoperative unfractionated heparin (UFH) doses associated with epidural removal were compared before and after implementation of an ERAS program. Other data collected included demographic data, surgical indication, and thrombohemorrhagic complications. Results: Of the 445 TEA patients, 12.6% missed their preoperative heparin doses compared with 8.4% of patients without epidurals (P = 0.017). Of the TEA patients prescribed 3 times daily UFH, 22.5% missed one or more doses associated with epidural removal. The percent of patients missing at least one dose of UFH on epidural removal dropped from 28.1% before ERAS to 17.9% after the ERAS program (P = 0.023). Seven patients developed VTEs. There were zero epidural hematomas. Conclusions: Thoracic epidural analgesia was associated with a 1.5-fold increased risk of missed dose of preoperative VTE prophylaxis, which was not affected by implementation of an ERAS program. The implementation of an ERAS program reduced missed doses associated with epidural removal. This study highlights the challenge posed by providing VTE prophylaxis in the setting of perioperative neuraxial analgesia. Copyright (C) 2017 by American Society of Regional Anesthesia and Pain Medicine.

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Incidence of Local Anesthetic Systemic Toxicity in Orthopedic Patients Receiving Peripheral Nerve Blocks.

Background and Objectives: Peripheral nerve blocks are increasingly used. However, despite low complication rates, concerns regarding local anesthetic systemic toxicity remain. Although recent studies suggest that this severe complication has decreased considerably, there is a paucity of data about it on a national level. We sought to elucidate the incidence of local anesthetic systemic toxicity on a national level and therefore provide guidance toward the need for preparedness in daily anesthetic practice. Methods: We searched a large administrative database for patients who received peripheral nerve blocks for total joint arthroplasties from 2006 to 2014. Their discharge and billing data were analyzed for International Classification of Diseases, Ninth Revision, Clinical Modification codes coding for local anesthetic systemic toxicity or surrogate outcomes including cardiac arrest, seizures, and use of lipid emulsion on the day of surgery. Rates for these outcomes were determined cumulatively and over time. Results: We identified 238,473 patients who received a peripheral nerve block within the study period. The cumulative rate of outcomes among these patients in the study period was 0.18%. There was a significant decrease of overall outcome rates between 2006 and 2014. Use of lipid emulsion on the day of surgery increased significantly in total knee replacement from 0.02% 2006 to 0.26% in 2014. Conclusions: The incidence of local anesthetic systemic toxicity is low but should be considered clinically significant. Since it may cause substantial harm to the patient, appropriate resources and awareness to identify and treat local anesthetic systemic toxicity should be available wherever regional anesthesia is performed. Copyright (C) 2017 by American Society of Regional Anesthesia and Pain Medicine.

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"A Tale of Two Planes": Deep Versus Superficial Serratus Plane Block for Postmastectomy Pain Syndrome.

Introduction: Postmastectomy pain syndrome (PMPS) is a significant burden for breast cancer survivors. Although multiple therapies have been described, an evolving field of serratus anterior plane blocks has been described in this population. We describe the addition of the deep serratus anterior plane block (DSPB) for PMPS. Methods: Four patients with history of PMPS underwent DSPB for anterior chest wall pain. A retrospective review of these patients' outcomes was obtained through postprocedure interviews. Results: Three of the patients previously had a superficial serratus anterior plane block, which was not as efficacious as the DSPB. The fourth patient had a superficial serratus anterior plane that was difficult to separate with hydrodissection but had improved pain control with a DSPB. Conclusions: We illustrate 4 patients who have benefitted from a DSPB and describe indications that this block may be more efficacious than a superficial serratus plane block. Further study is recommended to understand the intercostal nerve branches within the lateral and anterior muscular chest wall planes. Copyright (C) 2017 by American Society of Regional Anesthesia and Pain Medicine.

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The reconstructive options for oropharyngeal defects in the transoral robotic surgery framework

Publication date: Available online 11 January 2017
Source:Oral Oncology
Author(s): Giuseppe Meccariello, Filippo Montevecchi, Rossella Sgarzani, Andrea De Vito, Giovanni D'Agostino, Riccardo Gobbi, Chiara Bellini, Claudio Vicini
Transoral robotic surgery (TORS) is a fascinating new technique that has been proved to be a safe and feasible for selected oropharyngeal cancers. Furthermore, TORS offers several advantages in the treatment of locoregionally advanced cancers. Nevertheless, the careful selection of patients is the keypoint for a successful application of this therapeutic modality. However, the reconstruction of large oropharyngeal defects is challenging due to the restoration of velopharyngeal competency and swallowing. Moreover, the absence of mandibular splitting increases the difficulties faced by reconstructive surgeons. The paradigm for oropharyngeal reconstruction has undergone changes reflecting the overall change in the trend of the treatment alternatives over the last few decades. The flap choice and harvesting should be tailored in order to obtain significant advantages both in terms of function and should be easy to inset. In this review, we analysed the strengths and weaknesses of the various flaps used in the TORS framework.

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Central nervous system vasculitis in adults: An update

Publication date: Available online 11 January 2017
Source:Autoimmunity Reviews
Author(s): Lívia Almeida Dutra, Alexandre Wagner Silva de Souza, Gabriela Grinberg-Dias, Orlando Graziani Povoas Barsottini, Simone Appenzeller
Primary central nervous system vasculitis (PCNSV) is a challenging diagnosis due to broad clinical manifestations and variable specificity and sensitivity of laboratory and imaging diagnostic tools. Differential diagnosis include reversible cerebral vasoconstriction syndrome (RCVS), secondary vasculitis of the CNS and other noninflammatory vasculopathies. Brain biopsy is essential for definitive diagnosis and to exclude mimickers. Recent data show data large-vessel PCNSV present worse prognosis when compared to small-vessel PCNSV. Herein we review diagnosis and management of PCNSV, secondary vasculitis of CNS and RCVS.

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Malignant transformation of a long-standing submental dermoid cyst to a carcinosarcoma: a case report

Submental dermoid cysts are uncommon midline cysts which occur due to entrapment of ectoderm between the second and third branchial arches during embryogenesis. Most dermoid cysts of the head and neck are beni...

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The see-saw of immune dysregulation association of diverse organ autoimmune conditions in a woman. Evolution over twenty-seven years

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