RESUMEN
BACKGROUND: Tranexamic acid is a synthetic antifibrinolytic drug. It has been widely available for over 40 years, but only recently has it started to be used routinely in many surgical disciplines. For ENT surgeons, epistaxis and post-tonsillectomy bleeding contribute a significant proportion of the morbidity and emergency workload in a general ENT department. Published evidence indicates a potentially helpful role for tranexamic acid in managing epistaxis. RESULTS AND CONCLUSION: To date, the benefits of tranexamic acid as a prophylactic treatment to reduce the rate and severity of post-tonsillectomy bleeding are less certain. Two recently published pilot studies looking at primary haemorrhage in children and secondary haemorrhage in adults following tonsillectomy suggest that further large, randomised trials should explore the efficacy of tranexamic acid in routine ENT surgery. There are potential reductions in patient morbidity and cost savings if tranexamic acid is found to be efficacious in larger trials.
Asunto(s)
Enfermedades Otorrinolaringológicas/cirugía , Procedimientos Quirúrgicos Otorrinolaringológicos , Hemorragia Posoperatoria/tratamiento farmacológico , Ácido Tranexámico/uso terapéutico , Antifibrinolíticos/uso terapéutico , HumanosRESUMEN
INTRODUCTION: Tranexamic acid has been used for many years to minimise blood loss during surgery and, more recently, to reduce morbidity after major trauma. While small studies have confirmed reduction in blood loss during tonsillectomy with its use, the rate of primary haemorrhage following tonsillectomy has not been reported. In the UK, less than 50% of children having a tonsillectomy are managed as day cases, partly because of concerns about bleeding during the initial 24 hours following surgery. METHODS: A retrospective review of clinical records between January 2007 and January 2013 produced 476 children between the ages of 3 and 16 years who underwent Coblation™ tonsillectomy, with or without adenoidectomy and/or insertion of ventilation tubes. All children were ASA (American Society of Anesthesiologists) grade 1 or 2 and anaesthetised using a standard day surgery protocol. Following induction of anaesthesia, all received intravenous tranexamic acid at a dose of 10-15 mg/kg. RESULTS: Two children (0.4%) had minor bleeding within two hours of surgery. Both returned to theatre for haemostasis and were discharged home later the same day with no further complications. The expected rate for primary haemorrhage in the UK using this technique for tonsillectomy is 1%. CONCLUSIONS: Perioperative tranexamic acid in a single, parenteral dose might reduce the incidence of primary haemorrhage following paediatric tonsillectomy, facilitating discharge on the day of surgery. The results from this observational study indicate a potential benefit and need for a large, prospective, multicentre, randomised controlled trial.
Asunto(s)
Antifibrinolíticos/uso terapéutico , Pérdida de Sangre Quirúrgica/prevención & control , Tonsilectomía/métodos , Ácido Tranexámico/uso terapéutico , Adolescente , Procedimientos Quirúrgicos Ambulatorios , Niño , Preescolar , Humanos , Infusiones Parenterales , Cuidados Intraoperatorios , Estudios Retrospectivos , Tonsilitis/cirugía , Resultado del TratamientoAsunto(s)
Analgésicos Opioides/efectos adversos , Codeína/efectos adversos , Dolor Postoperatorio/prevención & control , Tonsilectomía/mortalidad , Adolescente , Factores de Edad , Analgésicos Opioides/farmacología , Niño , Codeína/farmacología , Humanos , Dolor Postoperatorio/etiología , Pautas de la Práctica en Medicina/legislación & jurisprudencia , Tonsilectomía/efectos adversos , Estados UnidosRESUMEN
OBJECTIVE: To audit a protocol for elective, day-case, paediatric ENT surgery, previously reported as enabling an overall post-operative nausea and vomiting rate of 2 per cent and a discharge rate of 100 per cent on the day of surgery. METHOD: The audit included 91 children (45 boys and 46 girls) aged three to 14 years. Forty-seven children underwent tonsillectomy, 36 adenotonsillectomy and eight tonsillectomy with postnasal space examination; indications included recurrent tonsillitis, tonsillitis and nasal block, upper airway obstruction, and a combination of upper airway obstruction and recurrent tonsillitis. RESULTS: No post-operative nausea or vomiting was recorded in any of the children on the day of surgery, and no discharges were delayed. The reactionary haemorrhage rate was 1 per cent and the secondary haemorrhage rate 3.3 per cent. CONCLUSION: These findings have implications for the safe same-day discharge of children following tonsillectomy.
Asunto(s)
Procedimientos Quirúrgicos Ambulatorios/métodos , Anestesia General/métodos , Náusea y Vómito Posoperatorios/etiología , Tonsilectomía/métodos , Adenoidectomía/efectos adversos , Adenoidectomía/métodos , Adolescente , Procedimientos Quirúrgicos Ambulatorios/efectos adversos , Analgésicos/administración & dosificación , Analgésicos/uso terapéutico , Antieméticos/administración & dosificación , Antieméticos/uso terapéutico , Niño , Preescolar , Estudios de Cohortes , Dexametasona/administración & dosificación , Dexametasona/uso terapéutico , Quimioterapia Combinada , Femenino , Humanos , Masculino , Auditoría Médica , Ondansetrón/administración & dosificación , Ondansetrón/uso terapéutico , Dolor Postoperatorio/tratamiento farmacológico , Alta del Paciente , Hemorragia Posoperatoria/prevención & control , Náusea y Vómito Posoperatorios/prevención & control , Guías de Práctica Clínica como Asunto , Tonsilectomía/efectos adversos , Vómitos/etiología , Vómitos/prevención & controlAsunto(s)
Selección de Profesión , Competencia Clínica/normas , Otolaringología/legislación & jurisprudencia , Procedimientos Quirúrgicos Otorrinolaringológicos/legislación & jurisprudencia , Salud Pública/legislación & jurisprudencia , Orientación Vocacional/legislación & jurisprudencia , Humanos , Otolaringología/educación , Procedimientos Quirúrgicos Otorrinolaringológicos/educación , Reino UnidoRESUMEN
During 2008, ENT-UK received a number of professional enquiries from colleagues about the management of children with upper airway obstruction and uncomplicated obstructive sleep apnoea (OSA). These children with sleep-related breathing disorders (SRBDs) are usually referred to paediatricians and ENT surgeons. In some district general hospitals, (DGHs) where paediatric intensive care (PICU) facilities to ventilate children were not available, paediatrician and anaesthetist colleagues were expressing concern about children with a clinical diagnosis of OSA having routine tonsillectomy, with or without adenoidectomy. As BAPO President, I was asked by the ENT-UK President, Professor Richard Ramsden, to investigate the issues and rapidly develop a working consensus statement to support safe but local treatment of these children. The Royal Colleges of Anaesthetists and Paediatrics and Child Health and the Association of Paediatric Anaesthetists nominated expert members from both secondary and tertiary care to contribute and develop a consensus statement based on the limited evidence base available. Our terms of reference were to produce a statement that was brief, with a limited number of references, to inform decision-making at the present time. With patient safety as the first priority, the working party wished to support practice that facilitated referral to a tertiary centre of those children who could be expected, on clinical assessment alone, potentially to require PICU facilities. In contrast, the majority of children who could be safely managed in a secondary care setting should be managed closer to home in a DGH. BAPO, ENT-UK, APA, RCS-CSF and RCoA have endorsed the consensus statement; the RCPCH has no mechanism for endorsing consensus statements, but the RCPCH Clinical Effectiveness Committee reviewed the statement, concluding it was a 'concise, accurate and helpful document'. The consensus statement is an interim working tool, based on level-five evidence. It is intended as the starting point to catalyze further development towards a fully structured, evidence-based guideline; to this end, feedback and comment are welcomed. This and the constructive feedback from APA and RCPCH will be incorporated into a future guideline proposal.
Asunto(s)
Adenoidectomía/efectos adversos , Consenso , Síndromes de la Apnea del Sueño/cirugía , Tonsilectomía/efectos adversos , Preescolar , Humanos , Lactante , Selección de Paciente , Guías de Práctica Clínica como Asunto , Derivación y Consulta , Factores de Riesgo , Sociedades Médicas , Reino UnidoAsunto(s)
Adenoidectomía/métodos , Adenoidectomía/estadística & datos numéricos , Consenso , Conducta Cooperativa , Comunicación Interdisciplinaria , Síndromes de la Apnea del Sueño/epidemiología , Tonsilectomía/métodos , Tonsilectomía/estadística & datos numéricos , Anestesiología , Humanos , Lactante , Obesidad , Pediatría , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Reino UnidoAsunto(s)
Antiinflamatorios/uso terapéutico , Dexametasona/uso terapéutico , Complicaciones Posoperatorias , Hemorragia Posoperatoria/tratamiento farmacológico , Hemorragia Posoperatoria/etiología , Náusea y Vómito Posoperatorios/prevención & control , Tonsilectomía , Niño , Humanos , Factores de RiesgoRESUMEN
OBJECTIVE: To evaluate parental experience, satisfaction and outcomes following their child's tonsillectomy surgery. DESIGN: Structured postal questionnaire sent to the parents or guardians of 77 sequential children undergoing elective day-case tonsillectomy. SUBJECTS: Seventy-seven children with a mean age of 6.25 years (range three to 17 years) undergoing day-case tonsillectomy predominantly for recurrent acute tonsillitis, upper airway obstruction or a combination of these symptoms; 63.6 per cent of the parents or guardians of these children responded to the questionnaire. RESULTS: There was overall satisfaction with the operation, and positive health outcomes. CONCLUSIONS: Despite the current public health agenda to limit access to routine high volume operations such as childhood tonsillectomy on economic grounds, the users of this service rated the outcomes and benefits of the procedure highly.
Asunto(s)
Padres/psicología , Satisfacción del Paciente/estadística & datos numéricos , Tonsilectomía/psicología , Tonsilitis/cirugía , Adolescente , Niño , Preescolar , Femenino , Encuestas de Atención de la Salud , Conocimientos, Actitudes y Práctica en Salud , Humanos , Masculino , Pediatría/normas , Garantía de la Calidad de Atención de Salud , Encuestas y Cuestionarios , Resultado del TratamientoRESUMEN
Guidance from the Department of Health, published in 2000, stated that, 'as a matter of right', communications between clinicians would be copied to patients. In further guidance, the department indicated that, from April 2004, patients would receive copies of correspondence exchanged between healthcare professionals. There has been little research on this issue, and the few existing publications have come from the hospital psychiatric clinic setting. We examined the attitudes of 100 patients attending an ENT clinic as well as those of 100 parents of children attending a paediatric ENT clinic in a general hospital out-patient setting. At the end of consultations, patients or parents were invited to take part in the survey by completing a short questionnaire. Forty-three per cent of the adult patients and 44 per cent of the parents requested a copy of the clinic letter. These people were followed up by a telephone survey, three weeks after the copy of the clinic letter to the general practitioner was posted to the patient or parent. Eighty-one per cent of the patients and 77 per cent of the parents were successfully contacted for the follow-up telephone survey. Sixty per cent of the adults and 77 per cent of the parents reported that the copy of the clinic letter was helpful. There were no differences in responses between the adult patient and paediatric patient groups. In this study, less than half of both groups requested a copy of the ENT clinic letter to their general practitioner. To follow Department of Health guidance and copy the letter without patient consent is arguably contradictory to best practice and also to the concept of patient choice. There are significant financial implications in adopting the departmental guidance. We propose patients should be offered a copy of their clinic letter on request.
Asunto(s)
Actitud Frente a la Salud , Comunicación , Correspondencia como Asunto , Satisfacción del Paciente/estadística & datos numéricos , Adulto , Humanos , Relaciones Interprofesionales , Relaciones Médico-Paciente , Reino UnidoRESUMEN
Adenoidectomy is a common, routine paediatric operation for which the evidence base for effectiveness is lacking. While there is a broad evidence base of variable quality for other common children's ENT operations, most published data including adenoidectomy is combined with the effect of combined tonsillectomy or grommet surgery. For the common indications for adenoidectomy, does it work?
Asunto(s)
Adenoidectomía , Adenoidectomía/efectos adversos , Adenoidectomía/métodos , Niño , Preescolar , Humanos , Inmunocompetencia , Otitis Media con Derrame/cirugía , Sinusitis/cirugía , Apnea Obstructiva del Sueño/cirugíaAsunto(s)
Otitis Media con Derrame/diagnóstico , Otitis Media con Derrame/terapia , Pruebas de Impedancia Acústica , Audiometría de Tonos Puros/métodos , Preescolar , Trastornos de la Audición/diagnóstico , Trastornos de la Audición/etiología , Humanos , Masculino , Otitis Media con Derrame/complicaciones , Procedimientos Quirúrgicos Otológicos , Otoscopía , Resultado del TratamientoRESUMEN
OBJECTIVES: To gauge opinion among otolaryngologists about their wish to retain the title Mr, Miss, Ms or Mrs or to adopt the title of doctor. DESIGN: An e-mail questionnaire sent to all members of ENT-UK (The British Association of Otolaryngologists-Head and Neck Surgeons), who had registered an e-mail address with the ENT-UK secretariat. SETTING: The specialty group of otolaryngologists in the UK. PARTICIPANTS: 723 recipients of e-mails, who were members or fellows of a surgical Royal College and, by convention in the UK, entitled to adopt the title Mr, Miss, Ms or Mrs. RESULTS: 304 recipients of the e-mail questionnaire responded. 39% were not aware of any proposals to change the convention, addressing surgeons as 'doctor' in the future. Overall, 61.8% were in favour of retaining the current convention and retaining the title Mr or a female equivalent. Applying the null hypothesis that most surgeons would not like to change a title, the chi(2) test produced a highly significant P value of 0.0002. Of female respondents, however, only 43% supported retention of the current convention. Using Fisher's exact test to compare female and male respondents, the two-sided P value was highly significant at 0.006, with female respondents favouring the title of doctor. CONCLUSIONS: A large proportion of ENT surgeons in the UK responded to the questionnaire. They were unaware of proposals to change the current convention of address for surgeons. A significant number of those responding were in favour of retaining the current convention. The small proportion of female respondents indicated a preference for being addressed as 'doctor'.
Asunto(s)
Cuerpo Médico de Hospitales , Nombres , Otolaringología , Actitud del Personal de Salud , Femenino , Humanos , Masculino , Reino UnidoRESUMEN
More than 30% of all surgical activity for children in England and Wales is accounted for by routine ENT operations. There is known to be a high incidence of postoperative pain, nausea and vomiting following paediatric tonsillectomy with or without adenoidectomy. This prospective study examined the incidence of these complications in 100 children admitted for routine, elective day-case tonsillectomy, with or without adenoidectomy. The children were anaesthetised in accordance with our standard paediatric day-case protocol. The incidence of vomiting on the day of surgery was significantly less in the group anaesthetised in accordance with the protocol, compared to those in previously published studies. Postoperative pain was well controlled, with 88% of the children having minimal pain on the day of surgery, and reporting a pain score of 0-2. Modifying the anaesthetic care to a protocol designed to reduce postoperative pain, nausea and vomiting achieved measurable improvements in the recovery of this group following surgery. It has enabled us to evolve from a 100% inpatient stay for these operations to 98% day-case discharge rate, with minimal post anaesthetic or surgical morbidity. We describe the protocol and discuss the implications of implementing such a protocol for children undergoing these common operations.
Asunto(s)
Procedimientos Quirúrgicos Ambulatorios , Dolor Postoperatorio/prevención & control , Náusea y Vómito Posoperatorios/prevención & control , Tonsilectomía/métodos , Adenoidectomía , Adolescente , Distribución por Edad , Anestesia General/métodos , Peso Corporal , Niño , Preescolar , Protocolos Clínicos , Femenino , Humanos , Masculino , Dimensión del Dolor/métodos , Estudios ProspectivosAsunto(s)
Procedimientos Quirúrgicos Ambulatorios/normas , Hemorragia Posoperatoria/etiología , Tonsilectomía/normas , Procedimientos Quirúrgicos Ambulatorios/efectos adversos , Procedimientos Quirúrgicos Ambulatorios/estadística & datos numéricos , Inglaterra , Humanos , Factores de Tiempo , Tonsilectomía/efectos adversos , Tonsilectomía/estadística & datos numéricos , GalesAsunto(s)
Tonsilectomía/métodos , Adulto , Niño , Método Doble Ciego , Humanos , Complicaciones PosoperatoriasRESUMEN
Body temperature is an important clinical measurement. It can be estimated by sublingual, rectal, axillary or skin measurement. Pulmonary artery temperature measurement is the gold standard in the research setting, but is obviously inapplicable for routine clinical use. Infrared estimation of core temperature at the tympanic membrane has been proposed as an effective and accurate method. We investigate whether the common condition of childhood otitis media with effusion (OME) interferes with this mode of body temperature measurement. Ninety-five children undergoing grommet tube insertion were assessed preoperatively by axillary and transtympanic routes. The presence or absence of middle ear fluid was noted at the time of surgery. Analysis of the data showed no influence of OME on the measurement of body temperature by the transtympanic route compared with axillary measurement.