Describing our institution’s off-label use of gabapentin to treat irritability after superior cavopulmonary connection surgery and its impact on subsequent opiate and benzodiazepine requirements.

This is a single-center retrospective cohort study including infants who underwent superior cavopulmonary connection operation between 2011 and 2019.

Gabapentin was administered in 74 subjects (74/323, 22.9%) during the observation period, with a median (IQR) starting dose of 5.7 (3.3, 15.0) mg/kg/day and a maximum dose of 10.7 (5.5, 23.4) mg/kg/day. Infants who underwent surgery in 2015–19 were more likely to receive gabapentin compared with those who underwent surgery in 2011–14 (p < 0.0001). Infants prescribed gabapentin were younger at surgery (137 versus 146 days, p = 0.007) and had longer chest tube durations (1.8 versus 0.9 days, p < 0.001), as well as longer postoperative intensive care (5.8 versus 3.1 days, p < 0.0001) and hospital (11.5 versus 7.0 days, p < 0.0001) lengths of stays. The year of surgery was the only predisposing factor associated with gabapentin administration in multivariate analysis. In adjusted linear regression, infants prescribed gabapentin on postoperative day 0–4 (n = 64) had reduced benzodiazepine exposure in the following 3 days (−0.29 mg/kg, 95% CI −0.52 – −0.06, p = 0.01) compared with those not prescribed gabapentin, while no difference was seen in opioid exposure (p = 0.59).

Gabapentin was used with increasing frequency during the study period. There was a modest reduction in benzodiazepine requirements associated with gabapentin administration and no reduction in opioid requirements. A randomised controlled trial could better assess gabapentin’s benefits postoperatively in children with congenital heart disease.

There is variation in care and hospital length of stay following surgical repair of ventricular septal defects. The use of clinical pathways in a variety of paediatric care settings has been shown to reduce practice variability and overall length of stay without increasing the rate of adverse events.

A clinical pathway was created and used to guide care following surgical repair of ventricular septal defects. A retrospective review was done to compare patients two years prior and three years after the pathway was implemented.

There were 23 pre-pathway patients and 25 pathway patients. Demographic characteristics were similar between groups. Univariate analysis demonstrated a significantly shorter time to initiation of enteral intake in the pathway patients (median time to first enteral intake after cardiac ICU admission was 360 minutes in pre-pathway patients and 180 minutes in pathway patients, p < 0.01). Multivariate regression analyses demonstrated that the pathway use was independently associated with a decrease in time to first enteral intake (–203 minutes), hospital length of stay (–23.1 hours), and cardiac ICU length of stay (–20.5 hours). No adverse events were associated with the use of the pathway, including mortality, reintubation rate, acute kidney injury, increased bleeding from chest tube, or readmissions.

The use of the clinical pathway improved time to initiation of enteral intake and decreased length of hospital stay. Surgery-specific pathways may decrease variability in care while also improving quality metrics.

This study aimed to explore the utility of the eosinophil percentage in peripheral blood for guiding post-operative glucocorticoid therapy in patients with chronic rhinosinusitis with nasal polyps.

Forty-four patients with chronic rhinosinusitis with nasal polyps underwent functional endoscopic sinus surgery and were randomly divided into two groups. Patients in the standard treatment group used oral and nasal spray glucocorticoids. In the biomarker treatment group, patients with peripheral blood eosinophil percentage values less than 3.05 per cent did not receive glucocorticoid treatment, whereas patients with values 3.05 per cent or above were part of the standard treatment group. Visual Analogue Scale, Sino-Nasal Outcome Test-22 scores, endoscopic Lund–Kennedy scores, eosinophils, interleukin-5 and eosinophil cationic protein in peripheral blood, and nasal secretions were measured.

After functional endoscopic sinus surgery, the Visual Analogue Scale, Sino-Nasal Outcome Test-22 and Lund–Kennedy scores were significantly reduced in both groups; there were no significant differences in those indicators between the groups during the three follow-up visits.

Peripheral blood eosinophil percentage offers a potential biomarker to guide post-operative glucocorticoid therapy in patients with chronic rhinosinusitis with nasal polyps.

Tonsillectomy is a common surgical procedure in the UK. This study critically examined the current advice provided by UK hospitals to patients about post-operative care.

Post-tonsillectomy patient advice sheets were obtained from 110 UK National Health Service trusts and equivalent organisations. Their contents were analysed and compared with published literature to determine whether the advice being given to patients was evidence-based.

Post-tonsillectomy dietary and fluid intake advice varied between hospitals; although many recommended eating and drinking a normal diet (88 per cent), some recommended eating ‘hard’ (26 per cent) or ‘soft’ (8 per cent) foods. Non-evidence based advice given included avoiding fizzy drinks (21 per cent), fruit juices (9 per cent) and using chewing gum (51 per cent). Reported post-operative risks and safety-netting also varied.

Much of the advice in the available printed information appeared to be anecdotal and not based on, or was contrary to, published evidence. After review of the literature, an evidence-based post-tonsillectomy patient advice sheet was generated for dissemination.

Use of hydrocortisone to treat refractory haemodynamic instability in patients recovering from surgery for congenital heart disease is common practice at many centres. We aimed to determine whether there is a relationship between total serum cortisol concentrations and haemodynamic response to this therapy.

We retrospectively reviewed patients <21 years who underwent cardiac surgery from 2011 to 2013, received hydrocortisone within 72 hours postoperatively, and had total serum cortisol measurements contemporaneous with its administration. Favourable responders were defined as patients in whom, at 24 hours after hydrocortisone initiation, either (1) systolic blood pressure was increased or unchanged and vasoactive-inotrope score was decreased or (2) systolic blood pressure increased by ⩾10% of baseline and vasoactive-inotrope score was unchanged. Variables were compared using t-tests or Mann–Whitney U tests as appropriate.

In total, 24 patients were reviewed, with a median age of 1.4 months and range of 0.1–232 months. Among them, 14 (58%) patients responded favourably to hydrocortisone. At 24 hours, the median change in vasoactive-inotrope score was −18% in favourable responders and +31% in those who did not respond favourably, p=0.001. The mean pre-hydrocortisone total serum cortisol in favourable responders was 17.4±10.9 µg/dl compared with 46.1±44.7 µg/dl in those who did not respond favourably, p=0.03.

Total serum cortisol obtained before initiation of hydrocortisone was significantly lower in patients who responded favourably to this therapy. Total serum cortisol may therefore be helpful in identifying children recovering from cardiac surgery who may or may not haemodynamically improve with hydrocortisone.

Visual communication aids, such as handwriting or typing, are often used to communicate with deaf patients in the clinic. This study aimed to establish the feasibility of communicating through smartphone speech recognition software compared with writing or typing.

Thirty doctors and medical students were timed writing, typing and dictating a standard set of six sentences appropriate for a post-operative consultation, and the results were assessed for accuracy and legibility.

The mean time for smartphone dictation (17.8 seconds, 95 per cent confidence interval = 17.0–18.7) was significantly faster than writing (59.2 seconds, 95 per cent confidence interval = 56.6–61.7) or typing (44 seconds, 95 per cent confidence interval = 41.0–47.1) (p < 0.001). Speech recognition was slightly less accurate, but accuracy increased with time spent dictating.

Smartphone dictation is a feasible alternative to typing and handwriting. Slow speech may improve accuracy. Early clinical experience has been promising.

To review the literature on enhanced recovery programmes in head and neck surgery.

A systematic review was performed in May 2013.

Thirteen articles discussing enhanced recovery after laryngectomy, neck dissection, major ablative surgery and microvascular reconstruction were identified. Articles on general pre-operative preparation and post-operative care were also reviewed.

Considerable evidence is available supporting enhanced recovery in head and neck surgery that could be of benefit to patients and which surgeons should be aware of.

To develop a practical, efficient and predictive algorithm to manage potential or actual post-operative hypocalcaemia after complete thyroidectomy, using a single post-operative parathyroid hormone assay.

This paper reports a prospective study of 59 patients who underwent total or completion thyroidectomy over a period of 24 months. Parathyroid hormone levels were checked post-operatively on the day of surgery, and all patients were evaluated for hypocalcaemia both clinically and biochemically with serial corrected calcium measurements.

No patient with an early post-operative parathyroid hormone level of 23 ng/l or more (i.e. approximately twice the lower limit of the normal range) developed hypocalcaemia. All the patients who initially had post-operative hypocalcaemia but had an early parathyroid hormone level of 8 ng/l or more (i.e. approximately two-thirds of the lower limit of the normal range) had complete resolution of their hypocalcaemia within three months.

Early post-operative parathyroid hormone measurement can reliably predict patients at risk of post-thyroidectomy hypocalcaemia, and predict those patients expected to recover from temporary hypocalcaemia. A suggested post-operative management algorithm is presented.

To assess subjective preference using three nasal hygiene systems: Stérimar Original®, Emcur® and Sinus Rinse™.

We used a prospective, single-blind, randomised, crossover study to compare three nasal hygiene systems: Stérimar Original, Emcur and Sinus Rinse.

Eighteen adult volunteers were recruited and were asked to rate their experience over three days using three well-established nasal hygiene systems. A standard visual analogue scale was used to assess five criteria: (1) simplicity of instructions; (2) ease of use; (3) comfort; (4) perceived nasal clearance (effectiveness) and (5) single best overall system.

Stérimar Original was found to have the easiest instructions to understand compared to the other two systems. There was no significant difference between Stérimar Original and Sinus Rinse with regards to ease of use but they were both significantly easier to use than Emcur (p < 0.05). There was no statistically significant difference between the three systems when comparing the last three criteria. There was no alteration in preference when the cost of each treatment was disclosed to the subjects, and no significant side effects were reported.

The instructions accompanying Stérimar Original appeared to be the easiest to understand, while Stérimar Original and Sinus Rinse were easier to use than Emcur.

Voice rest is commonly recommended after vocal fold surgery, but there is a lack of evidence base and no standard protocol. The aim of this study was to establish common practice regarding voice rest following vocal fold surgery.

An online survey was circulated via e-mail invitation to members of the ENT UK Expert Panel between October and November 2011.

The survey revealed that 86.5 per cent of respondents agreed that ‘complete voice rest’ means no sound production at all, but there was variability in how ‘relative voice rest’ was defined. There was no dominant type of voice rest routinely recommended after surgery for laryngeal papillomatosis or intermediate pathologies. There was considerable variability in the duration of voice rest recommended, with no statistically significant, most popular response (except for malignant lesions). Surgeons with less than 10 years of experience were more likely to recommend fewer days of voice rest.

There is a lack of consistency in advice given to patients after vocal fold surgery, in terms of both type and length of voice rest. This may arise from an absence of robust evidence on which to base practice.

To compare the effects of routine nasal packing with polyvinyl acetal sponge (Merocel) versus no packing, after endoscopic sinus surgery for nasal polyposis.

This clinical, randomised, controlled trial was performed in an academic tertiary referral centre between 2008 and 2011. Sixty patients with resistant nasal polyposis underwent endoscopic sinus surgery, and were then randomly divided into two groups: packed and non-packed. The amount of bleeding and pain in each group during pack removal was documented.

There was no significant difference between the two groups in the outcome of surgery and complications. One patient in each group needed extra packing. In the packed group, the mean ± standard deviation pain score on pack removal was 61 ± 3 (using a visual analogue scale in which 0 = no pain and 100 = worst pain imaginable).

This study found no significant difference between polyvinyl acetal packed and non-packed groups, following endoscopic sinus surgery for nasal polyposis. This confirms the findings of similar studies, and supports the reconsideration of routine post-operative packing in selected cases.

Delayed sternal closure is used to prevent low cardiac output syndrome in selected newborns shortly after cardiac surgery for congenital cardiac defects. Sternal closure itself often causes haemodynamic and ventilatory instability that cannot be entirely assessed by standard monitoring means. Therefore, we used transpulmonary thermodilution technique for an exact evaluation of the haemodynamic changes.

Between April, 2006, and December, 2008, 23 neonates aged from 1 to 30 days, with a median of 7 days, and weighing from 1.9 to 4.2 kilograms, with a median of 3.25 kilograms, were studied after biventricular corrections. Residual intracardiac shunts were excluded by echocardiography. Haemodynamic and ventilatory parameters, along with those obtained by the transpulmonary thermodilution technique, were recorded before and immediately after the sternal closure, and then at 0.5, 1, 2, 6, 12, 24, and 48 hours.

Chest closure caused significant decrease in systolic arterial pressure from 80.04 ± 11.48 to 69.48 ± 9.63 mmHg (p < 0.001), cardiac index from [median (25th/75th centile)] 2.640 (2.355/2.950) to 2.070 (1.860/2.420) l/min/m2 (p < 0.001), stroke volume index from 18.50 (16.00/20.00) to 14.00 (11.00/17.00) ml/m2 (p < 0.001), and dynamic lung compliance from 2.45 (2.31/3.00) to 2.30 (2.14/2.77) ml/cmH2O (p = 0.007). Stroke volume variation increased from 14.00 (9.25/16.75) to 18.00 (15.00/21.00) % (p < 0.001). The oxygenation index transitorily increased from 2.50 (2.14/3.15) to 3.36 (2.63/4.29) (p < 0.001). Serum lactate decreased from 1.40 (1.12/2.27) to 1.0 (0.8/1.3)mmol/l, p < 0.001 in coincidence with a haemodynamic stabilisation at a later time after chest closure. Cardiopulmonary instability caused by the sternal closure necessitated therapeutic intervention in 18 of 23 patients (78.3%).

Delayed sternal closure causes a significant transitory decrease in stroke volume, cardiac output and arterial blood pressure. Also lung compliance and blood oxygenation are temporarily significantly compromised.

A variety of topical preparations are used for symptomatic relief following nasal surgery. The aim of this study was to compare the effect of two commonly used products on patient symptom scores following nasal surgery.

Randomised, single-blinded, comparative clinical trial.

A single, secondary otorhinolaryngology centre.

One hundred and twenty patients undergoing septoplasty or functional endoscopic sinus surgery as an isolated procedure between November 2003 and January 2006. Patients undergoing additional nasal procedures were excluded, as were those requiring additional post-operative medications other than standardised analgesia.

Following nasal surgery, patients were randomised to receive either xylometazoline hydrochloride 0.1 per cent nasal spray or a sterile physiological saline aerosol.

Visual analogue scale symptom scores for nasal obstruction, rhinorrhoea, pain, loss of sense of smell and bleeding were assessed at day 10 post-operatively.

Post-operative symptom scores were compared between treatment groups. Overall, median pain scores were significantly higher in the xylometazoline group (p = 0.03, chi-square test). When analysed by procedure, median pain scores were significantly higher in septoplasty patients using xylometazoline (p = 0.019, chi-square test).

There is no evidence to support the use of xylometazoline hydrochloride 0.1 per cent nasal spray over aerosolised physiological saline alone, following nasal surgery. Furthermore, there may be more pain associated with the post-operative use of xylometazoline.