Ultrasonic scalpel use; effects of comorbidity; single wrap for sterile instrument packs; radiofrequency instruments

AORN Journal, Jan, 2006 by George Allen

Comparison of ultrasonic scalper and electrocautery in tonsiltectomy

Archives of Otolaryngology--Head & Neck Surgery January 2005

Tonsillectomy is a common childhood surgical procedure in which the tonsils and adenoids are removed because of chronic tonsillar infections or enlarged tonsils that have caused loud snoring, upper airway obstruction, or other sleep disorders. Numerous approaches are practiced for removal of tonsils, including the use of cold knife dissection, electrocautery, ultrasonic scalpel, radiofrequency ablation, carbon dioxide laser, micro-debrider, and bipolar radiofrequency ablation.

One of the more common methods for removing tonsils uses monopolar electrocautery current to burn the tonsillar tissue. In contrast, the ultrasonic scalpel uses ultrasonic energy that vibrates a blade at 55,000 cycles per second to remove the tonsils. The purpose of this retrospective study was to evaluate the efficiency and postoperative morbidity in tonsillectomy using conventional monopolar electrocautery versus tonsillectomy using the ultrasonic scalpel. (1)

Researchers reviewed the medical records of 605 consecutive patients who underwent adenotonsillectomy or tonsillectomy at a children's hospital in Louisville, Ky, between January 2001 and August 2003. Patients were grouped by surgical method (ie, electrocautery or ultrasonic scalpel). Data collected included age, weight, gender, indications for surgery, procedure duration, length of time in the postanesthesia care unit (PACU), the need for postoperative admission, the number of minutes of oxygen therapy required postoperatively, occurrence of postoperative hemorrhage, and pain scores in the immediate postoperative period as documented on the PACU nursing assessment sheet. Common statistical procedures including equal-variance t tests and chi-square tests were used to analyze the data.

Findings. The researchers found a significant difference between the two groups in mean age, mean weight, and indication for surgery. Compared to patients in the electrocautery group, patients in the ultrasonic scalpel group were younger, weighed less, and more often had obstructive symptoms as their primary surgical indication (P < .001). In patients seven years of age or younger, the rate of postoperative admission was significantly higher in the ultrasonic scalpel group (P < .005); however, there was no significant difference between the groups for patients older than seven years. Postoperative hemorrhage was significantly higher in the electrocautery group versus the ultrasonic scalpel group (ie, 13 of 313 patients versus two of 292 patients, respectively [P < .005]). No significant differences were found between the two groups in procedure duration, postoperative recovery time, minutes of oxygen therapy required, or pain scale scores.

Clinical implications. The results of this study indicated that tonsillectomy using an ultrasonic scalpel was as efficient as the conventional electrocautery method and that the rate of postoperative bleeding was significantly reduced when the ultrasonic scalpel method was used. Perioperative nurses should understand that several methods for removing the tonsils are available, and they must be ready to effectively participate in the procedure, including being prepared to provide hemostasis, regardless of the method the surgeon chooses.

Comorbidity as a risk factor in head and neck surgery

Archives of Otolaryngology--Head & Neck Surgery January 2005

Surgery is one of the treatment options for patients with head and neck squamous cell carcinoma; however, such surgery is associated with a substantial complication rate, and little is known about the risk factors for complications and mortality. It is postulated that reliable prediction of complications and mortality could lead to correction of contributing factors. One potential risk factor common to most patients with head and neck squamous cell carcinoma is comorbidity.

Although several comorbidity indices, including the Adult Comorbidity Evaluation 27 (ACE-27) index and the American Society of Anesthesiologist (ASA) risk classification system, are available, none are applied universally. The ACE-27 is a validated index especially designed for comorbidity measurements in patients with cancer; however, it is time consuming to administer. The ASA classification system, which is easier to use, is an index of perioperative risk that also can be used to evaluate comorbidity because it describes a patient's physical status before surgery. The objective of this retrospective study was to describe the effect of comorbidity on complications of surgery and mortality in patients with head and neck squamous cell carcinoma, identify risk factors for complications, and compare the comprehensive ACE-27 index with the concise ASA classification system. (2)

Researchers reviewed the medical records of 120 consecutive patients who were surgically treated for head and neck squamous cell carcinoma at a university medical center in the Netherlands between January 1999 and January 2001. The tumor sites, including sinus, lip, oral cavity, nasopharynx, oropharynx, hypopharynx, and larynx, were coded, and data including age at diagnosis, tumor stage, prior malignancies, and treatment were collected. Comorbidity and occurrence of major complications were determined. The ASA class assigned by the anesthesia care provider was categorized as one, two, three, or higher and the ACE-27 grades were categorized as zero, one, two, or higher. Information was gathered about the surgical procedure, type of neck dissection, type of reconstruction, duration of anesthesia, length of hospitalization, weight loss in the six-month period before diagnosis, and preoperative hemoglobin levels. Major complications were recorded from the start of anesthesia until hospital discharge. Medical and surgical complications were joined into a single variable identified as major complications. One-month and six-month mortality rates were calculated. Statistical techniques used to analyze the data included univariate and multivariate binary logistic backward selection analysis techniques.