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

Evidence for Practice

JANUARY 2006, VOL 83, NO 1

EVIDENCE

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Ultrasonic scalpel use;

effects of comorbidity; single wrap for sterile instrument packs; radiofrequency instruments Comparison of ultrasonic scalpel and electrocautery in tonsillectomy 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, microdebrider, 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,

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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 equalvariance 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

George Allen, RN

This information is intended for general use only. The clinical implications are specific to the abstracted article only. Individuals intending to put these findings into practice are strongly encouraged to review the original article to determine its applicability to their setting.

Evidence for Practice

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

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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. Findings. Three patients who received palliative procedures only were excluded from the analysis. None of the 117 patients died within one month after surgery; however, four patients (3.4%) died within months after diagnosis. Major complications occurred in 25 patients (21.4%). Most patients (ie, 70.9%) received an ACE-27 grade of zero or one, and 53% of the patients were classified as ASA class two. In the univariate analysis, ACE-27 grade (P = .01), ASA class (P = .001), tumor stage (P = .01), surgical procedure used for the primary tumor (P = .01), type of neck dissection (P = .02), and duration of anesthesia (P < .001) were significantly associated with major complications. Multivariate analysis revealed that • duration of anesthesia longer than 30 minutes (95% confidence interval [CI], odds ratio [OR] 7.8, 1.8-12.9); • ACE-27 grades one and AORN JOURNAL •

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two (OR 1.9, 0.6-6.8 and OR 4.6, 1.4-15.2 respectively); • and ASA class two and three (OR 2, 0.5-8.2 and OR 10, 2.2-45.1, respectively) remained significant. Clinical implications. This study found that duration of anesthesia and comorbidity as reflected by the ACE-27 grade and ASA classification were important predictors of major complications in head and neck surgery. Perioperative nurses should be aware that procedures to optimize the general conditions of patients with head and neck squamous cell carcinoma may reduce morbidity and, thus, reduce treatment-related costs.

Single versus double wrap for sterile instrument packs American Journal of Infection Control August 2005 Materials used for packing hospital-prepared sterile supplies are an important component in preventing contamination during the time between receipt of used supplies in the sterile processing area and eventual use. Woven and nonwoven products perform equally well in protecting sterile products from contamination during transport, storage, and handling. Given this equivalence, other variables such as handling, cost, and

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shelf life are important considerations. The recent introduction of a single-wrap product provides an opportunity to investigate these properties of wrapping materials. The single wrap is a new concept that offers the protection of double wrapping. Two sheets are thermally sealed along the sides, providing the convenience of a one-piece design. The objectives of this study were to examine the microbial barrier properties, cost, and ease of handling the new single wrap compared to the traditional double sequential wrap currently in use.3 Between February and July 2004, sterile processing department staff members at a women’s hospital in Queensland, Australia, used a parcel-wrap technique to prepare and steam sterilize 400 packs that each contained one safety pin, one gauzesquare, and one 3-cm piece of silicone tubing. Half of the packs were wrapped with an inner wrap of linen and an outer wrap of double wrap, and the remaining packs were wrapped with single wrap. Sterilized items were stored on shelves in four areas of the hospital, and items from the packs were randomly selected from each area, placed on a trolley, and moved to another area to simulate handling. Packs periodically were tested in the laboratory to evaluate shelf life. The time taken to wrap and unwrap the packs was determined by timing an experienced sterile process-

ing department staff member wrapping 50 packages (ie, 25 using each product) and a perioperative nurse opening the packs. Common statistical techniques including the chi-square and Student’s t tests were used to analyze the data. Findings. Fourteen packs containing 42 items were not included in the analysis because eight were control packs, and six were lost during the study. Bacteria was cultured from 20 (1.7%) of the 1,157 test items. Although not statistically significant, more of the double-wrapped items returned positive results compared to the singlewrapped items (P = .64). The average time to wrap test trays was significantly longer for double-wrapped compared to single-wrapped items (56.4 seconds versus 32.4 seconds, P ≤ .000). Additionally, unwrapping the double-wrapped packs was significantly slower than unwrapping single-wrapped packs (6.92 seconds versus 5.02 seconds, P = .000). Clinical implications. The results of this study suggest that wrapping and sterilizing items with single wrap carries no greater risk of bacterial contamination than using double wrap. Using single wrap could potentially lead to cost savings in both labor (ie, time needed to wrap items) and consumables (ie, linen and recycling costs). Perioperative managers should seriously consider evaluating this product in their facilities.

Evidence for Practice

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Radiofrequency versus monopolar electrosurgical excisions Otolaryngology—Head and Neck Surgery July 2005 Radiofrequency electrosurgical instruments that function in the radiofrequency energy spectrum range of 0.01 MHz to 300 MHz frequently are used to perform tonsillectomies. Such products include lasers, electrosurgery machines, and coblation systems (ie, specially designed hand pieces and wands for tonsil surgery). Although most radiofrequencybased surgical products, such as lasers and electrosurgical devices, use imprecise, heatdriven processes to remove or cut tissue, a coblation device operates at a lower temperature and gently dissolves targeted tissue, removing it by molecular disintegration while minimizing damage to surrounding healthy tissue. The purpose of this prospective, controlled, single-blinded study was to determine if tonsillectomy performed with coblation is less painful than tonsillectomy performed with a monopolar electrosurgery machine.4 Twenty-six adult patients who desired tonsillectomy because of obstructive hypertrophy or recurrent tonsillitis at an army medical center in

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Hawaii were enrolled in the study. Each patient had one tonsil removed with coblation and the other removed with the standard monopolar electrosurgical hand piece. The patients and postoperative staff members were unaware of which technique was used on which side. Data collected included the time in minutes to remove each tonsil, the estimated blood loss, and any electrocautery hemostasis needed during use of coblation. Additionally, the surgeons rated the difficulty of removing each tonsil on a 10point Likert-type scale with one being the easiest and 10 being the most difficult. Each patient was telephoned on postoperative days one, three, five, seven, 10, and 14 and asked about pain on each side via a predetermined script. Common statistical methods, including t test and analysis of variance, were used to analyze the data. Findings. Data were available for evaluation on 17 patients. There was no significant difference between the two methods in the mean time required to remove a tonsil and the mean difficulty of tonsillectomy. The mean estimated blood loss was significantly higher with use of coblation (P < .006, 15 degrees of freedom, coblation standard deviation [SD] 24.6, electrosurgery SD 9.4). Patients reported significantly less pain when coblation was used

(P < .036), and 12 of 14 patients preferred the coblation technique. Clinical implications. The results of this study revealed that use of coblation was significantly less painful, and patients preferred this method to use of electrosurgery. Perioperative nurses should be aware that no one definitive procedure has emerged for tonsillectomy. Consequently, they should be familiar with the various devices and equipment that may be used to remove tonsils in both adults and children. ❖ GEORGE ALLEN RN, PHD, CNOR, CIC DIRECTOR OF INFECTION CONTROL DOWNSTATE MEDICAL CENTER BROOKLYN, NY

NOTES 1. K L Potts, A Augenstein, J L Goldman, “A parallel group analysis of tonsillectomy using the harmonic scalpel vs electrocautery,” Archives of Otolaryngology—Head & Neck Surgery 131 (January 2005) 49-51. 2. M B Ferrier et al, “Comorbidity as a major risk factor for mortality and complications in head and neck surgery,” Archives of Otolaryngology—Head & Neck Surgery 131 (January 2005) 27-32. 3. J Webster et al, “Barrier properties and cost implications of a single versus a double wrap for storing sterile instrument packs,” American Journal of Infection Control 33 (August 2005) 348-352. 4. P D Littlefield, D J Hall, M R Holtel, “Radiofrequency excision versus monopolar electrosurgical excision for tonsillectomy,” Otolaryngology—Head and Neck Surgery 133 (July 2005) 51-54.