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Management of Critically Ill Head and Neck Surgical Patients

  • Vineet Nayyar
Part of the Head and Neck Cancer Clinics book series (HNCC)

Abstract

Head and neck surgery has made tremendous advances during the past 50 years. These advances have led to increasing specialization and offering of complex surgical therapy to high-risk individuals, such that many head and neck patients now require critical care inputs as a key component of their care. The complex anatomy, rich vasculature and proximity to structures within a narrow space predispose patients to serious complications from infectious and non-infectious processes in the perioperative period. Yet, in spite of its importance, critical care literature on the topic has remained agonizingly sparse. The last substantial review was undertaken in 2003 [1].

Keywords

Intensive Care Unit Surgical Site Infection Intensive Care Unit Patient Obstructive Sleep Apnoea Extubation Failure 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Introduction

Head and neck surgery has made tremendous advances during the past 50 years. These advances have led to increasing specialization and offering of complex surgical therapy to high-risk individuals, such that many head and neck patients now require critical care inputs as a key component of their care. The complex anatomy, rich vasculature and proximity to structures within a narrow space predispose patients to serious complications from infectious and non-infectious processes in the perioperative period. Yet, in spite of its importance, critical care literature on the topic has remained agonizingly sparse. The last substantial review was undertaken in 2003 [1].

Issues of clinical importance identified in the 2003 review form the backbone of this chapter. Only two prototype disease processes (cancer and infection) have been highlighted in this chapter, as much of the published literature centres around these two themes. In a significant departure from the norm, this chapter avoids too narrow a focus on individual disease entities, but summarizes information relevant to the critically ill adult; it is, therefore, written from the perspective of an intensivist, and although comprehensive, it is not exhaustive. For an overview of the impact of comorbid conditions and disease entities, the reader is referred to two good reviews on the topic [1, 2].

Head and Neck Surgery: Overview

In different parts of the world, many surgical specialists undertake surgery of the head and neck region either alone or as part of a multidisciplinary team [3]. The latter includes general surgeons, oral and maxillofacial surgeons, plastic and reconstructive surgeons, and otorhinolaryngology and head and neck surgeons, each bringing their own perspective to the patient’s care and management.

Irrespective of the surgical specialty involved, patients with a head and neck problem usually undergo an extensive and often prolonged surgery that involves large fluid shifts, blood loss, and results in significant postoperative pain and inflammation. All these factors are considered important contributors to postoperative morbidity. These, coupled with pre-existing co-morbid medical conditions, such as advanced age and lifestyle choices, make postoperative complications not only more likely, but also considerably more serious.

Need for Intensive Care

Options for postoperative management depend on the country of practice, available healthcare resources, volume of cases, and expertise of nursing and medical staff [3]. The three main categories of head and neck patients that require admission to an intensive care unit (ICU) are; (i) the head and neck cancer (HNC) patient; (ii) the head and neck trauma patient; and (iii) the head and neck patient with medical complications [1].

HNC patients require intensive care for the following reasons:
  • Routine close observation and nursing care postoperatively

  • Treatment of complications after surgery, such as wound dehiscence, flap necrosis, airway compromise, bleeding or infection

  • Management of underlying medical conditions, such as chronic obstructive airways disease, ischaemic heart disease, renal failure or uncontrolled diabetes

  • Management of new medical conditions, e.g. myocardial infarction (MI), pulmonary embolism, respiratory failure, persistent hypotension, delirium or sepsis

  • Complications related to progression of disease, including airway obstruction, aspiration, respiratory distress caused by pleural effusions, or malnutrition

  • Complications related to chemotherapy or radiotherapy, such as mucositis, neutropenic sepsis, immune-compromised status or metabolic.

The risk of developing complications in HNC patients does not necessarily equate with the need for a critical-care bed. Not surprisingly, reports from Hong Kong [4], UK [5] and USA [6] have questioned the rationale for routinely admitting postoperative major HNC patients to the ICU, citing no advantage of this approach compared to postoperative observation in a specialist ward. While it is hard to ignore the evidence that the rate of complications remains unaffected, whether or not patients are admitted electively to the ICU, it is also difficult to extrapolate the findings of singlecentre studies [2]. Morton recommended caution, believing that decision making about postoperative care may not be as simple as an argument over observed complication rates reported from highly specialized centres [7]. It is conceivable that prompt recognition of adverse events in an ICU environment may guide proactive interventions early and might improve survival. Clearly, each healthcare facility must be able to establish whether such benefits outweigh the costs of a day’s observation in the ICU. To ensure that these benefits accrue to patients, favourable policies related to staffing and skill-mix in the ICU are essential, as they are important determinants of outcome among patients undergoing free flap reconstruction [9].

A stratification of postoperative cases on the basis of pre-existing conditions, the nature and extent of surgical procedures, and intraoperative complications has been proposed [8] but has not been adopted widely. Clearly, the type and site of surgery and duration of anaesthesia are some of the important determinants of the need for a critical-care bed. Although traditionally not thought to be risk factor, duration of time under anaesthesia appears to be predictive of postoperative surgical complications and length of hospital stay. In a retrospective study of 157 patients by Boruk et al., 10 patients were found to develop major complications in the postoperative period [10]. In this study, they estimated the odds of having a complication (major or minor) increased by 0.6 % with every minute of anaesthesia [10].

In view of the available evidence, it is reasonable to conclude that all patients with major head and neck problems do not require routine postoperative admission to the ICU. However, those who do, require a level of care consistent with the extensive nature of surgery, and co-morbid conditions that often accompany diseases of the head and neck. A decision to admit to the ICU requires close cooperation and active communication between the surgical team, the anaesthetist and the intensivist.

Co-morbid Conditions

The literature is expanding on factors associated with increased risk of mortality and postoperative complications [11, 12, 13]. Many of these factors can be identified before surgery, making them particularly important targets for preventative measures. With improved safety of operative techniques, the relative risk of complications associated with the surgery is substantially less compared to risk associated with pre-morbid conditions. Multiple studies have established the importance of frequently encountered patient factors [13, 14]. These include age, American Society of Anesthesiologist (ASA) physical status, and albumin. The odds of 30-day mortality double for every decade after 70 years of age; an increment in the ASA status roughly doubles postoperative death rate, and a drop in preoperative albumin level to <30 g/L is associated with an OR of 2.5 for 30-day mortality [13, 14].

Major co-morbidities identified in head and neck patients include hypertension, diabetes mellitus, cardiac disease, excessive alcohol intake, and a history of protracted and heavy smoking. These co-morbid conditions are believed to be a better predictor of patient outcome than staging of cancer [15]. Age is an important issue in head and neck surgery [1]. As expected, medical morbidity and mortality is increased in the elderly, but this is more so as a result of concurrent illness in patients rather than age alone. The impact of co-morbidity is greater in older than in younger patients, although it affects both. When complications occur, they are more severe in older patients and are associated with a higher mortality and costs [1].

Several instruments are available to quantify co-morbidity in patients planned for head and neck surgery. These include the adult co-morbidity evaluation 27 (ACE-27), Charlson index (CI) and cumulative illness rating scale. ACE-27 has been validated extensively in HNC for the purpose of predicting survival [16], complications [17], functional outcome [18], and quality of life [19]. CI too has been evaluated by several authors and has been found to be a significant predictor of postoperative complications among head and neck patients [20, 21]. In addition, ICU scoring systems (e.g. APACHE II) [22] have been used to predict immediate surgical complications, but have not been adopted widely. The Revised Cardiac Risk Index (RCRI), derived from using rigorous statistical methodology, is another useful measure that is robust, but guidelines on the action to undertake once the risk estimates are obtained are lacking [23]. Some head-to-head comparison [24] of disease-specific and general indices suggest that all these instruments have similar prognostic ability, whereas others have shown ACE-27 to be most successful in stratifying HNC patients with prognostic ability comparable to that of nodal staging [25].

Patients with HNC have a risk profile not dissimilar to those with vascular disease, which predisposes them to atherosclerotic disease and its complications. Some patients with pre-existing coronary artery disease and stents in situ need to discontinue antiplatelet therapy, exposing them to substantial risk of stent closure in the postoperative period. Although interest in and hope for revascularization was high 5 years ago, the weight of evidence subsequently has suggested no benefit of prophylactic revascularization in patients before major surgery [26].

The presence of chronic obstructive pulmonary disease (COPD) is associated with an increased risk of pneumonia and respiratory failure in the postoperative period [26]. The severity of the underlying lung disease and the magnitude of risk is roughly correlated. As many as 75–80 % of patients undergoing surgery for HNC have a history of smoking and a significant proportion have COPD [2]. Among these, 10 % have severe disease. Patients with undiagnosed obstructive sleep apnoea (OSA) are also likely to develop postoperative complications if the condition is not recognized and managed appropriately. Patients at risk can be identified preoperatively by the STOP-BANG questionnaire, which has been validated for use in head and neck patients [27]. Evidence is mounting to suggest a link between HNC treated with either primary surgical resection [28] or radiation therapy [29] and the development of OSA.

Postoperative Complications

The most dreaded complication after head and neck surgery is airway compromise and bleeding (or haematoma formation). However, the commonest complications post-surgery are either respiratory or cardiovascular.

Bhattacharya and Fried’s seminal work published in 2001 remains widely quoted even though nearly half of all patients included in their case series were postoperative after a thyroid or parathyroid operation [30]. Among 3309 patients undergoing a primary head and neck procedure, the authors reported an overall mortality of only 3.55 %. Death occurred in 12.6 % of those who experienced a complication compared with 1.71 % mortality in patients without a complication. Postoperative pneumonia was common, occurring in 3.26 % of patients and was associated with a mortality of 10.94 %. The majority of deaths occurred during the first 3 days after surgery, and among these, more patients died from medical rather than surgical complications. These data were similar to the findings reported earlier by Downey et al. [6], who retrospectively evaluated the need for an ICU after HNC surgery at a single, large, specialized cancer centre. Only 1.5 % of patients in this case series required ICU admission. Approximately two-thirds (29/43) of patients developed respiratory or cardiovascular complications; of these about 25 % died [6].

A recent analysis of patients admitted postoperatively to an ICU in the Netherlands has added to the knowledge base in this area [31]. In this large dataset of >28,000 patients admitted to the ICU postoperative after elective cancer surgery, 3.1 % (888 patients) were admitted after a major head and neck procedure. In this group, the commonest co-morbidity was COPD (~12 %) followed by diabetes mellitus (~9 %). The incidence of postoperative pneumonia was ~1 % and the rate of cardiac dysrhythmias was 1.5 %. Overall, the hospital mortality in this case series was 3.3 %, exceeded only by patients with colorectal malignancy, oesophageal surgery, and pancreatic (and/or biliary) surgery [31]. Postoperative pulmonary complications were the focus of a recent retrospective study of patients undergoing major head and neck surgery at a tertiary care centre in Canada [32]. In this case series, ~45 % developed one or more complications; the most common was postoperative respiratory failure. Development of pulmonary complication was associated with higher mortality (12.7 % vs. 1.7 %), and longer ICU and hospital length of stay (LOS).

The aforementioned studies have shaped our current understanding of the postoperative course of patients after head and neck surgery. Without doubt, patients who suffer medical complications do badly, but to identify them preoperatively remains a major challenge. The primary means of assessing risk is through history and a clinical examination. Needless to say, history must be elicited carefully.

Head and Neck Malignancy

HNC, or cancer of the upper aerodigetive tract, is an uncommon malignancy comprising only 3 % of all malignancies in the USA [33]. In many parts of the world, particularly France and India, HNC is a major cause of death. The most common pathology is that of a squamous cell carcinoma (SCC), comprising >90 % of all malignancies of the upper aerodigestive tract. Treatment includes radiotherapy and chemotherapy but surgery has been the mainstay of management for >30 years. Surgery as definitive treatment is preferred for oral cavity lesions whereas radiotherapy and/or chemotherapy are favoured for oropharyngeal or laryngeal disease, unless local spread is extensive.

Risk factors most commonly associated with HNC include smoking, alcohol consumption, human papillomavirus (HPV) infection and Epstein–Barr virus infection [34]. Among these, smoking and alcohol consumption are important in terms of additive risk for oral and oropharyngeal cancer.

Severe Soft Tissue Infections of Head and Neck

Infections of potential spaces of the head and neck may be associated with airway compromise, jugular septic thrombophlebitis, aspiration pneumonitis, lung abscess, mediastinitis or, in the worst case scenario, septic shock with multi-organ failure. An understanding of the anatomical boundaries, interconnections, clinical manifestation and microbiology are crucial to the management of these serious infections [35].

Submandibular Space Infections

In submandibular, lateral pharyngeal and retropharyngeal space infections, the portal of infection is the oral cavity and thus antibiotic therapy invariably is directed towards organisms commonly found in the mouth. Although severe infection in any deep spaces of the head and neck can affect airway patency, submandibular space infection is more commonly associated with a compromise of the airway. As a result, such patients require early airway involvement of the critical-care team and placement of a definitive airway. Not all patients require intubation, but if an initial course of close observation is pursued, it should be carried out in an environment in which frequent monitoring and airway intervention is possible [36].

Infections in the submandibular space are typically odontogenic in nature and arise from the spread of periapical abscesses of the mandibular molars, most typically the second or third molars where bone is the thinnest [35]. Other pathological processes that involve the submandibular space include sialadenitis, mandibular or lingual malignancy, laceration of mouth floor, lymphadenitis, and foreign bodies. The distinguishing feature of submandibular space infection is a rapidly spreading woody inflammation with or without overlying cellulitis. A striking aspect of the physical examination is the protruding tongue, which is forced outwards due to internal pressure and limitation imposed by fibres of the deep cervical fascia. At times, the whole floor of the oropharynx is elevated and tender to touch. Multivariate analysis has identified some independent risk factors associated with severe complications after submandibular space infections [37, 38]. These include anterior visceral space involvement, bilateral neck swelling, presence of diabetes mellitus, and other co-morbidities.

Over the past decade or so, the proportion of deep space infections arising from an odotogenic source has increased relative to other types of infections [39]. Odontogenic infections are associated with poor dental hygiene and low socioeconomic status. In a single-centre observational study, 144 patients with an odontogenic infection treated in a tertiary care ICU had indicies of socioeconomic disadvantage that were significantly worse than the rest of the ICU patients [40].

Lateral Pharyngeal Space Infections

Infections involving the lateral pharyngeal space can develop from a variety of sources but most commonly follow a pharyngitis or tonsillitis. Often, the infection yielding a portal of entry into the lateral pharyngeal space is minor or may even have resolved by the time symptoms of the deep space infection appear. The classical clinical signs are dysphagia, trismus and ipsilateral pain extending up to the jaw or pain referred to the ear. Complications of lateral pharyngeal space infection include laryngeal oedema, sudden death, carotid artery involvement or suppurative jugular vein thrombophlebitis (Lemierre syndrome) [41].

Retropharyngeal Space Infections

The retropharyngeal, danger and prevertebral spaces are a common pathway for extension of head and neck infections into the thorax. Although separated by fascial planes, these spaces are considered as a unit because of their anatomical proximity and their propensity for spread beyond the head and neck. Suppurative adenitis of deep cervical lymph nodes in children, trauma from oesophageal instrumentation, and foreign bodies are causes of retropharyngeal abscesses.

The most lethal complication of retropharyngeal and danger space infection is descending necrotizing mediastinitis. Infections, if untreated, can spread into the pleural, pericardial and the retroperitoneal space. Debridement and appropriate antibiotics are the foundations of treatment for mediastinitis, which even if treated effectively can be associated with a high mortality [41].

Infections of the prevertebral space are primarily haematogenous in nature and their microbiology is markedly different to other infections of the head and neck discussed so far. Complications arise from spread to the epidural space with cord compression, spread to the vertebrae or disc with mechanical instability of the spine, loculation of pus at distant sites, and ongoing bacteraemia. Initial coverage for Gram-positive organisms, including methicillin-resistant Staphylococcus aureus is recommended.

ICU Management: General

Anticipating, recognizing and treating complications is integral to operative success. Optimal management requires ongoing close cooperation between the surgical team and the critical-care team.

Patient Position

Nosocomial pneumonia is the most frequent problem in the postoperative period of patients undergoing a major head and neck procedure [30]. The recognized pathogenetic sequence is abnormal oropharyngeal colonization and subsequent aspiration. Bacterial colonization of the stomach and gastric reflux might also play a part in the pathogenesis of lung infection. Approximately 20 years ago, studies using radio-labelled gastric contents showed that reflux could be reduced and aspiration could be avoided by positioning patients in a semi-recumbent position [42, 43]. A subsequent clinical study indicated the risk of nosocomial pneumonia to be the highest among ventilated patients receiving enteral feeds in the supine position [44]. A recent meta-analysis of three randomized trials (337 patients) confirmed that the odds of developing clinically proven pneumonia were significantly lower among ventilated patients in the semi-recumbent 45° position compared to the supine position (OR 0.47; 95 % CI 0.27–0.82) [45].

Not surprisingly, an elevated head position (angle >30°) has become a standard of care for all mechanically ventilated patients in the ICU [46]. It stands to reason that the same concept can be extrapolated to prevent pneumonia in postoperative head and neck patients, although these patients have additional factors that contribute to nosocomial infections. The semi-recumbent position is one of the simplest and most cost-effective preventative measures in healthcare.

Analgesia and Sedation

Patient comfort and safety are two important priorities of analgesia and sedation in critically ill patients [47]. Analgesia and sedation are provided in the postoperative period by means of a pharmacological agent. Opioids are time-honoured, valuable and powerful analgesics for the management of moderate-to-severe postoperative pain. The efficacy of different opioids is similar as far as clinically relevant outcomes are concerned. However, evidence suggests that more sophisticated methods of administration, such as patient-controlled analgesia (PCA) may improve pulmonary outcome. The most commonly used opioids for intravenous (i.v.) PCA are morphine, fentanyl or hydromorphone. The common setting for administration of these drugs is summarized in Table 12.1. In general, the depth of analgesia should be adapted to the needs of individual patients. Management of patients is best guided by simple clinical scales [48, 49], although there is no consensus on how frequently pain and sedation scores should be evaluated. Whereas there is some agreement on what constitutes an acceptable level of pain relief, the same is not true of sedation. Recent data from clinical trials have shown that sedation of ICU patients with benzodiazepines might contribute to confusion or overt delirium [50, 51].
Table 12.1

Commonly used opioids in intravenous patient-controlled analgesia (PCA)

Drug

Demand dose

Lockout interval

Basal infusion ratea

Morphine

1–2 mg

5–10 min

<0.5 mg/h

Hydromorphone

0.25–0.5 mg

5–10 min

<0.4 mg/h

Fentanyl

10–50 mcg

5–10 min

<50 mcg/h

aBasal infusions are recommended only in opioid-tolerant patients

Patients receiving sedatives and opioids are also at risk of excessive sedation, respiratory depression, nausea and vomiting. These side-effects are likely to be most evident in elderly patients or those with renal or hepatic dysfunction, although large individual variations are known to occur. Opioids suppress hypoglossal activity, thereby diminishing the activity of genioglossus muscle during inspiration, while concomitantly decreasing the responsiveness of upper airway muscles to hypercapnia. Consequently, patients with known OSA have a higher frequency of apnoeic episodes postoperatively [52]. Patients with nasal obstruction, tonsillar or adenoidal hypertrophy, or those with upper airway surgery appear to have an increased risk of complications in the immediate perioperative period.

Postoperative delirium is a common complication of head and neck surgery because of the high prevalence of certain risk factors (e.g. age, cognitive decline, alcohol use). Patients who become agitated are at increased risk of self-harm [53, 54], increased length of ICU and hospital stay, increased costs, and a higher all-cause mortality. The relationship between delirium and increased mortality is independent of age, illness severity, and whether or not these patients receive mechanical ventilation in the ICU. The confusion assessment method for ICU (CAM-ICU) [55] is an objective scoring system for delirium, which complements the Richmond agitation–sedation scale [56] for use in ICU patients. A scoring system to identify patients at-risk of postoperative delirium is probably more useful but it has not been validated in head and neck surgery patients [57].

Given the high prevalence of alcohol consumption, it is prudent to screen all patients preoperatively for current alcohol intake using the standard CAGE questionnaire. In general, the severity of withdrawal symptoms is proportional to the duration and amount of alcohol intake, with patients who have experienced delirium tremens or seizures being at the highest risk. Symptom-triggered approach with early introduction of benzodiazepines is preferable at the onset of withdrawal symptoms. The α-2 agonists, clonidine and dexmetetomidine, have been used for alcohol withdrawal in the ICU. These agents have little effect on respiratory function but have several useful cardiovascular effects, including blunting of the tachycardic and hypertensive response of patients emerging from effects of prolonged alcohol intake. α-2 agonists have also been shown to reduce behavioural and autonomic responses after termination of conventional sedation and facilitate extubation [58]. In a separate study by Reade et al. [59] dexmetetomidine was compared with haloperidol for treating patients deemed otherwise ready, but were not extubated because of agitated delirium. Patients receiving dexmetetomidine went onto extubation earlier compared with those receiving haloperidol [59].

Venous Thromboembolism Prophylaxis

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are important causes of morbidity and mortality among surgical patients. Guidelines for thrombo-prophylaxis are well established and based on the results of several randomized trials [60]. In contradistinction to these guidelines, chemoprophylaxis is not recommended routinely for patients undergoing head and neck surgery, including HNC surgery [61]. The generally low incidence of perioperative DVT or PE (0.1–2.5 %) in head and neck surgery patients [62, 63, 64, 65] and the risk of bleeding or related complications means that chemoprophylaxis targeted to a high-risk group is a better strategy. Chemoprophylaxis for low-risk, ambulatory (or day care) patients is not justified and currently is not recommended.

Several patient-specific risk factors for venous thromboembolism (VTE) have been identified in surgical patients [26]. These can either be elicited from history or more formally in the form of a risk stratification scale [66]. Among patients with multiple risk factors who are undergoing a major procedure that is likely to result in prolonged immobilization, VTE prophylaxis is considered reasonable. A disproportionately high number of VTE events have been recorded among patients undergoing microvascular flaps, implying that this group of patients should also be managed as a high-risk group. The American College of Chest Physicians guidelines recommend the use of pneumatic compression devices, unfractionated heparin (UFH) or low-molecular weight heparin (LMWH) for prophylaxis [67]. If prophylaxis is used, it should commence within 2 h of completion of surgery to be effective [67]. For pneumatic compression to be effective, the compression device must be worn for at least 90 % of the duration of immobility [68].

A recent meta-analysis of clinical trials on ICU patients has confirmed a beneficial effect of chemoprophylaxis with UFH compared with placebo in reducing the risk of DVT, but more importantly, the statistical analysis showed a decreased risk of PE with the use of LMWH compared with UFH (RR 0.62; 95 % CI 0.39–1.00; p = 0.05) [69]. Although rates of major bleeding were not significantly different, it is worth noting that the effects of UFH can be easily quantified and reversed, if needed.

Nutrition

Nutrition has long been recognized as the second most important factor in predicting long-term prognosis in HNC. Whereas the National Institute for Health and Clinical Excellence (NICE) guidelines provide the best framework for a multidisciplinary approach to nutritional management of patients, the most comprehensive guidelines have been issued recently by the Clinical Oncological Society of Australia (COSA) [70]. COSA guidelines have provided a grade A recommendation for inclusion of a dietitian in the multidisciplinary team looking after HNC patients, and for dietary intervention during treatment to maintain or improve nutritional status. The European Society of Parenteral and Enteral Nutrition (ESPEN) guidelines on enteral nutrition (EN) recommend preoperative nutritional supplementation for 10–14 days prior to surgery in patients with BMI of <18.5 kg/m2, or those with weight loss of >10–15 % in past 6 months [71]. This is applicable to preoperative head and neck patients as well.

Standard polymeric fibre feeds are recommended for use postoperatively with an aim to deliver ≥30 kcal/kg/day. Postoperative tube feeds should commence within 24 h with consideration given to individual patients, depending on the extent of the surgical procedure performed and other priorities identified by the multidisciplinary team. This recommendation is supported by a recent meta-analysis, which showed that early EN (within 24 h) compared to standard care was associated with a significant reduction in mortality and rate of pneumonia among adult ICU patients [72]. The optimal method of tube feeding remains unclear. Evidence does not favour post-pyloric feeds over the standard nasogastric feeds [73].

The role of parenteral nutrition (PN) in critically ill adults has been clarified recently by two large multi-centre trials [74, 75]. Published in 2011, the EPaNIC trial did not find any benefit with the addition of PN to deliver calories up to a desired goal in patients who were already receiving some EN [74]. Therefore, sick ICU patients who tolerate some enteral feeds in the first 24–48 h may not derive any additional benefit from rapidly reaching a pre-specified but empirical nutritional target. A second trial (Early Parenteral Nutrition trial) was designed to study a small subset of ICU patients with relative contraindications for early EN (within 24 h of ICU admission) [75]. In this trial, early PN commenced on day 1 of ICU was compared with standard care; no difference was observed in 60-day mortality between the early PN group and standard care group in which nutritional therapy was started on day 3. Early PN resulted in significantly fewer days of invasive ventilation but no change in the ICU or LOS. In other words, starting PN within 24 h of admission in ICU patients who are not ready to be fed enterally is not associated with improvement in mortality. One salient finding of the early PN study was that the rate of central line infection in patients receiving PN was comparable to that in the EN arm of the study [74].

Diabetes is a common co-morbid condition among head and neck patients and is considered a risk factor for several postoperative complications, such as infections, cardiac and metabolic problems, and delirium. Although a review has focused on the postoperative care of the diabetic patient, it has not addressed the issue of diabetic patients undergoing head and neck surgery [76]. In general, targets for glycaemic control among the critically ill have been clarified recently by a large multi-centre, randomized trial NICE-SUGAR [77]. Contrary to the prevailing view at that time, the study showed an increased risk of mortality and adverse effects (hypoglycaemia) among patients randomized to the strict glycaemic control arm (4.5–6.0 mmol/L) [77]. Consequently, the currently recommended insulin therapy is targeted to achieve blood glucose levels of 6.0–10.0 mmol/L.

Antibiotic Prophylaxis

The efficacy of antibiotic prophylaxis for reducing surgical site infection (SSI) has been clearly established. Patients who receive prophylaxis within 1 h or 2 h before the surgical incision have lower rates of SSI compared with those who receive antibiotics sooner or later than this window [78, 79]. In general, antimicrobial selection for SSI prophylaxis is based on type of surgery, safety, bactericidal activity and cost.

Elective procedures of the head and neck are predominantly clean or clean-contaminated. Clean procedures include thyroidectomy and lymph node dissections. Clean-contaminated procedures include all surgeries involving an incision through the oral or pharyngeal mucosa. These range from parotidectomy, submandibular gland excision, tonsillectomy, adenoidectomy and rhinoplasty, to complex procedures, such as tumour debulking and mandibular fracture repair. The infection rate among patients undergoing complex head and neck procedures in the absence of antimicrobial prophylaxis is high (24–78 %); infection rates are markedly lower with prophylaxis (5–38 %) [80].

Most infections arising after clean-contaminated head and neck procedures are caused by microorganisms residing in the oral cavity. These include anaerobic bacteria, and therefore postoperative SSI are polymicrobial [81, 82]. The predominant oropharyngeal organisms include various streptococci (aerobic and anerobic), other anaerobes, including Bacteroides species (but not B. fragilis), Peptostreptococcus species, Fusobacterium species, Veillonella species and, rarely, Enterobacteriaceae, and Staphylococcus species.

Antimicrobial prophylaxis is not warranted for patients undergoing clean procedures of the head and neck [83, 84]. A single preoperative dose of cefazolin (or clindamycin in the setting of β-lactam allergy) is reasonable in the setting of prosthetic material placement, although data on the efficacy of this practice have not been clarified. Prophylaxis with antibiotics is recommended routinely for most other head and neck procedures [80], although randomized trials have not shown any benefit in the setting of adenoidectomy, tonsillectomy or septoplasty [85, 86]. A reasonable regimen for patients undergoing surgery includes a cephalosporin (cefazolin or cefuroxime) plus metronidazole or ampilcillin-sulbactam. Clindamycin is an alternative for patients with β-lactam allergy (Table 12.2).
Table 12.2

Antimicrobial prophylaxis for head and neck surgery patients

Type of surgery

Pathogens

Antimicrobial prophylaxis

Usual adult dose

Clean

 

None

 

Clean with placement of prosthesis

S. aureus, S. epidermidis, Strep. species

Cefazolin

<120 kg: 2 g i.v.

>120 kg: 3 g i.v.

 

OR cefuroxime

1.5 g i.v.

 

OR clindamycin

600–900 mg i.v.

Clean – contaminated

Anaerobes, enteric Gram-negative bacteria, S. aureus

Cefazolin

 
 

PLUS metronidazole

500 mg i.v.

 

OR cefuroxime

1.5 g i.v.

 

OR ampicillin- sulbactam

3 g i.v.

 

OR clindamycin

900 mg i.v.

In general, repeat antibiotic dosing after wound closure is not necessary. In a systematic review of controlled trials, no difference was seen in the rate of SSI with a single dose compared with multiple dose regimens given for less than or more than 24 h [87]. For cases in which perioperative antibiotic coverage is required beyond the period of surgery, the duration should be <24 h.

Errors in the selection and timing of prophylactic antibiotics remain a major concern. Among 34,133 patients undergoing major surgery in the USA, an antimicrobial was administered within 1 h before incision to only 56 % of patients, and antimicrobials were discontinued within 24 h of surgery in only 41 % of patients [88].

ICU Management: Specific

Patients with active head and neck pathology or those who have undergone surgical or radiation treatment for HNC are at increased risk of adverse airway events. These need to be recognized and managed appropriately.

Airway

A number of head and neck procedures involve the upper airway. When airway compromise is not an issue, most procedures are routine and largely uneventful [89]. All patients with airway compromise should be considered as having a potential difficult airway for which well-established guidelines now exist [90]. Unfortunately, there is no universal recipe for the management of the airway for head and neck procedures. Each procedure requires an appraisal of the urgency of the procedure, size and site of lesion, level of obstruction, and degree of airway compromise [89].

The recently published report of the Fourth National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society (DAS) identified serious airway complications occurring during anaesthesia in the ICU and in the emergency department [91]. In the presence of head and neck pathology and after maxillofacial or major neck surgery, a number of airway-related complications were encountered. Approximately 70 % were associated with obstructive lesions within the airway [91].

Early fibre-optic intubation by an experienced anaesthetist or tracheostomy by an experienced surgeon is a reasonable consideration in patients with a threatened airway. Patients with airway compromise are easily identified in the presence of tachypnoea and stridor, but should be recognized even in the presence of subtle signs, such as an inability to lie down flat in bed or silent breathing with adoption of the sniffing position while sitting upright. Routine endotracheal intubation in these patients is complicated by trismus, distorted anatomy, immobility of soft tissue structures, friability and bleeding, or in the worst case scenario, complete obstruction of the airway after anaesthetic induction. Awake fibre-optic techniques are suitable for oral cavity, oropharyngeal and tongue base lesions, but might be unsuitable for lesions in the larynx in which the fibrescope has to pass through the mass.

Inhaled induction techniques in which spontaneous ventilation is maintained have been used for potentially difficult airways. However, such an approach is not without its problems. A reduction in airflow, increased collapsibility of airway, increased work of breathing, and reduction in functional residual capacity can impair the onset and depth of anaesthesia and preclude placement of an endotracheal or nasotracheal tube, as required.

Following major head and neck surgery, the risk of upper airway obstruction remains high and the optimal postoperative airway management remains controversial. Bilateral neck dissections, use of bulky reconstruction flaps, resection of mandible, tongue or floor of mouth carry the greatest risk. It is uncertain if the risks of tracheostomy outweigh anticipated airway problems in the postoperative period. Cameron and colleagues used an old dataset to derive a clinical score to guide clinical decision-making that reliably identified the need for elective tracheostomy at the time of the initial procedure [92]. The score was validated in their sample of 148 major head and neck procedures and indicated a variable positive and negative predictive value, depending on the cut-off threshold used. The scoring system has since neither been refined nor applied widely, but remains a useful adjunct to clinical judgement.

Airway Devices

Humidity is important throughout the postoperative period to prevent drying of secretions and blockage of the airway, particularly in patients with a fresh tracheostomy or tracheostoma. Tracheostomy reduces the risk of glottic damage compared with long-term use of a tracheal tube, and is particularly important if slow resolution of oedema or inflammation is anticipated. Elective tracheostomy should be considered in patients with HNC in whom either the location or the extent of cancer precludes translaryngeal tube placement. Wherever possible, a tracheostomy tube with suction above the cuff should be considered. Two randomized trials [93, 94] and a meta-analysis [95] have shown that endotracheal tubes (ETT) equipped with subglottic suction significantly reduced the incidence of ventilator-associated pneumonia (VAP) in patients ventilated for ≤3 days without a corresponding increase in adverse events. A recently published randomized trial has extended these observations to a group of mechanically ventilated patients who required a tracheostomy in the ICU [96]. In this study involving only 18 patients, the researchers were able to show a significant reduction in the incidence of VAP (56 % vs. 11 %; p = 0.02) with the use of tracheostomy tubes with a suction port above the cuff [96].

Tracheostomy care has traditionally been provided by surgical teams that performed the procedure, but this has changed with the introduction of newer techniques [97] and with the growing recognition of the complex needs of tracheosomy patients. Tracheostomy insertion has implications for communication, swallowing, airway management and overall nursing care, thereby justifying the need for involvement of a multidisciplinary team. In 2009, Garrubba et al., conducted a systematic review of multidisciplinary care for ward-based tracheostomy patients [98]. They identified three studies and concluded that time to decannulation, LOS and adverse events were better with a tracheostomy team compared with the standard approach. A more recent, second systematic review also confirmed a reduction in total tracheostomy time after the introduction of tracheostomy teams [99].

Postoperative Care

Scheduled administration of steroids is a common practice. Steroids reduce inflammatory oedema but have no direct effect on oedema arising from mechanical trauma or venous obstruction. The evidence suggests that all steroids are equally efficacious, provided they are given in equivalent doses. When considered for use, steroids should be continued for ≥12 h [100]. Single-dose steroids given immediately before extubation are ineffective.

The perioperative use of β-blockers in naïve patients undergoing non-cardiac surgery is controversial since the publication of the POISE study [101]. In this large multicentre trial, patients >45 years of age randomized to receive metoprolol perioperatively had fewer MIs (4.2 % vs. 5.7 %; p = 0.05; NNT 67) but an increased rate of stroke and overall mortality. A metaanalysis of clinical trials on the same topic published within a month of the POISE study showed a reduction in the risk of non-fatal MIs in the postoperative period [102]. In fact, trials showing a beneficial effect of intervention were the ones that studied β-blockers in high-risk patients. Other studies showing benefit without any adverse events were ones that used a lower dose of β-blockers compared with the POISE study. These controversies notwithstanding, patients with an indication for β-blockers or those already on the drug derive a benefit, if they are continued on the drug throughout the surgical period [103].

Extubation in ICU

Many patients are transported to the ICU intubated and are extubated after what is deemed as a suitable period of observation. In 2012, the DAS—acknowledging the lack of large randomized trials of extubation practices—released a set of guidelines for the management of tracheal extubation on the basis of expert opinion [104].

Extubation in the ICU is an elective process even if intubation of the trachea was undertaken during an emergency. Planning for tracheal extubation is a critical component of a successful airway management strategy, particularly when dealing with patients with a difficult airway. This involves assessment of the airway and general risk factors. Extubation is considered ‘low risk’ if the airway anatomy was normal at induction and remained so until the end of surgery with no complications supervening. ‘At-risk’ extubation, on the other hand, is one in which an airway or a general risk factor has been identified. However, evaluating these risks in a patient whose airway is still protected is a more subtle task. While reliable anatomical predictors of inability to perform effective mask ventilation and intubation have been identified, the same is not true for answering the question, ‘Is it safe to remove the tube?’

Whereas oedema of the tongue and pharyngeal structures is easily visualized, laryngeal oedema is more difficult to assess and quantify, especially in the presence of an ETT. If the tube is small compared with the size of the airway, as is frequently the case with upper airway pathology, direct laryngoscopy to visualize the degree and anatomical distribution of oedema is helpful. However, the degree of inter-observer agreement is only modest [105]. A quantitative cuff leak test can be used along with laryngoscopy (direct or video-assisted) to increase the predictive value of assessment [106]. The discriminatory power of this test depends on the method and cut-off values chosen. Choice of a higher cut-off value minimizes the risk of false-negatives (presence of leak = negative test) may be valuable in patients in whom difficult tracheal intubation is expected. In a systematic review and a meta-analysis, Ochoa et al. [107] concluded that whereas a negative test is not necessarily reassuring, a positive cuff-leak test should alert the clinician about the risk of upper airway obstruction. This test has been validated only in patients who have received mechanical ventilation for 48 h rather than those ventilated overnight. The test itself requires measurement of expired tidal volumes after six complete respiratory cycles while on an assist-control mode or control mode of ventilation with the ETT cuff deflated. A leak volume of 10–25 % (~100–130 ml in a 70 kg adult) of the expired tidal volume before cuff deflation is considered safe for extubation.

With the exception of tube exchangers to guide and expedite reintubation, no other specific tool or procedure to increase safety at extubation has gained widespread acceptance or has been adopted in clinical algorithms [108]. Airway exchange catheters (AEC) are long, thin, hollow tubes made of semi-rigid polyurethane and are supplied with 15 mm connectors compatible with anaesthetic circuits and Luer lock connectors for use with jet ventilation. They can be inserted through the tracheal tube before extubation because they can be used as a guide over which a tracheal tube can be passed, should reintubation become necessary [109]. They can also be used to oxygenate patients’ lungs. In a recent review, Duggan et al. reported that oxygen insufflation might be associated with a significant risk of barotrauma [110]. The authors therefore concluded that priority be given to reintubation over attempting oxygenation and ventilation through the lumen of the catheter. To enhance safety, the recently published DAS guidelines suggest that an AEC should not be inserted beyond 25 cm, but this only applies to orally intubated, adult patients [104].

Extubation failure after a well-planned extubation is uncommon, but it is relatively more common in critically ill patients. In the presence of head and neck pathology and after maxillofacial or major neck surgery, the rate of tracheal reintubation has been reported to vary between 0.7 and 11 %. Conditions, such as obesity, OSA, rheumatoid arthritis and other cervical spine pathologies also carry a significant risk of extubation failure. This usually follows loss of upper airway patency because of oedema, soft tissue collapse, laryngospasm, bleeding, secretions, or collapse of upper airway structures. A few investigators have reported that ICU patients requiring reintubation for respiratory failure have a higher mortality (30–53 %) than patients reintubated because of airway obstruction (7–17 %), suggesting that weaning failure may carry a higher mortality compared with extubation failure [111]. One explanation to account for this difference is that patients who fail extubation because of airway obstruction are reintubated earlier than those who fail because of respiratory complications [108], and time to reintubation is a well known independent risk factor for mortality in this group [111].

In this context, it is reasonable to consider extubation in the operating theatre to ensure availability of equipment and, most importantly, availability of the surgical team, in case a surgical airway is required.

Conclusion

Care of the critically ill head and neck patient poses many challenges many of which arise as a result of the primary disorder, but increasingly because of associated co-morbidities and complications of treatment. Some, more often than not, complicate airway management, and pose a significant threat to life. These need to be recognized by the primary surgical team and the anaesthetist in a timely manner, and treated appropriately. A multidisciplinary approach is essential to achieve high quality care.

References

  1. 1.
    Garantziotis S, Kyrmizakis DE, Liolios AD. Critical care of the head and neck patient. Crit Care Clin. 2003;19:73–90.PubMedCrossRefGoogle Scholar
  2. 2.
    Bansal A, Miskoff J, Lis RJ. Otolaryngologic critical care. Crit Care Clin. 2003;19:55–72.PubMedCrossRefGoogle Scholar
  3. 3.
    Bradley PJ. Should all head and neck cancer patients be nursed in intensive therapy units following major surgery? Curr Opin Otolarygol Head Neck Surg. 2007;15:63–7.CrossRefGoogle Scholar
  4. 4.
    To EW, Tsang WM, Lai EC, et al. Retrospective study on the need of intensive care unit admission after major head and neck surgery. ANZ J Surg. 2002;72:11–4.PubMedCrossRefGoogle Scholar
  5. 5.
    Godden DR, Patel M, Baldwin A, et al. Need for intensive care after operations for head and neck cancer surgery. Br J Oral Maxillofac Surg. 1999;37:502–5.PubMedCrossRefGoogle Scholar
  6. 6.
    Downey RJ, Friedlander P, Groeger J, et al. Critical care for severely ill head and neck patient. Crit Care Med. 1999;27:95–7.PubMedCrossRefGoogle Scholar
  7. 7.
    Morton RP. The need for ITU admission after major head and neck surgery [Editorial]. ANZ J Surg. 2002;72:3–4.PubMedCrossRefGoogle Scholar
  8. 8.
    Sivagnanam T, Langton SG. Need for intensive care after operations for head and neck cancer surgery. Br J Oral Maxillofac Surg. 2001;39:77.PubMedCrossRefGoogle Scholar
  9. 9.
    Bhama PK, Davis GE, Bhrany AD, et al. The effects of intensive care unit staffing on patient outcomes following microvascular free flap reconstruction of the head and neck: a pilot study. JAMA Otolaryngol Head Neck Surg. 2013;139:37–42.PubMedCrossRefGoogle Scholar
  10. 10.
    Boruk M, Chernobilsky B, Rosenfeld R, et al. Age as a prognostic factor for complications of major head and neck surgery. Arch Otolaryngol Head Neck Surg. 2005;131:605–9.PubMedCrossRefGoogle Scholar
  11. 11.
    Pearse RM, Moreno RP, Bauer P, et al. Mortality after surgery in Europe: a 7-day cohort study. Lancet. 2012;380:1059–65.PubMedCentralPubMedCrossRefGoogle Scholar
  12. 12.
    Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med. 2009;361:1368–75.PubMedCrossRefGoogle Scholar
  13. 13.
    Story DA, Leslie K, Myles PS, et al. Complications and mortality in older surgical patients in Australia and New Zealand (the REASON Study): a multi-centre, prospective, observational study. Anaesthesia. 2010;65:1022–30.PubMedCrossRefGoogle Scholar
  14. 14.
    Khuri SF, Hendersen WG, DePalma RG, et al. Determinants of long term survival after major surgery and the adverse effect of postoperative complications. Ann Surg. 2005;242:326–41.PubMedCentralPubMedGoogle Scholar
  15. 15.
    Piccrillo JF. Importance of co-morbidity in head and neck cancer. Laryngoscope. 2000;110:593–602.CrossRefGoogle Scholar
  16. 16.
    Sabin SL, Rosenfeld RM, Sundaram K, et al. The impact of co-morbidity and age on survival with laryngeal cancer. Ear Nose Throat J. 1999;78:581–4.Google Scholar
  17. 17.
    Sanabria A, Carvalho AL, Melo RL, et al. Predictive factors for complications in elderly patients who underwent head and neck oncological surgery. Head Neck. 2008;30:170–7.PubMedCrossRefGoogle Scholar
  18. 18.
    Borggreven PA, Verdonck-de Leeuw I, Rinkel RN, et al. Swallowing after major surgery of the oral cavity or oropharynx: a prospective and longitudinal assessment of patients treated by microvascular soft tissue reconstruction. Head Neck. 2007;29:638–47.PubMedCrossRefGoogle Scholar
  19. 19.
    Le-Diery MW, Futran ND, McDowell JA, et al. Influences and predictors of long-term quality of life in head and neck cancer survivors. Arch Otolaryngol Head Neck Surg. 2009;135:380–4.CrossRefGoogle Scholar
  20. 20.
    Charlson ME, Pompei P, Alex KL, et al. A new method of classifying prognostic co-morbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–83.PubMedCrossRefGoogle Scholar
  21. 21.
    Singh B, Bhaya M, Stern J, et al. Validation of Charlson co-morbidity index in patients with head and neck cancer: a multi-institutional study. Laryngoscope. 1997;107:1469–75.PubMedCrossRefGoogle Scholar
  22. 22.
    Grant CA, Dempsey GA, Lowe D, et al. APACHE II scoring for the prediction of immediate surgical complications in head and neck cancer patients. Plast Reconstr Surg. 2007;119:1751–8.PubMedCrossRefGoogle Scholar
  23. 23.
    Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major non-cardiac surgery. Circulation. 1999;100:1043–9.PubMedCrossRefGoogle Scholar
  24. 24.
    Piccirillo JF, Spitznagel Jr EL, Vermani N, et al. Comparison of co-morbidity indicies for patients with head and neck cancer. Med Care. 2004;42:482–6.PubMedCrossRefGoogle Scholar
  25. 25.
    Paleri V, Wight RG, Silver CE, et al. Co-morbidity in head and neck cancer: a critical appraisal and recommendations for practice. Oral Oncol. 2010;46:712–9.PubMedCrossRefGoogle Scholar
  26. 26.
    Adler JS, Auerbach AD. Medical complications of head and neck surgery. In: Eisele DW, Smith RV, editors. Complications in head and neck surgery. 2nd ed. Philadelphia: Mosby Elsevier; 2009. p. 55–66.CrossRefGoogle Scholar
  27. 27.
    Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anaesthesiology. 2008;108:812–21.CrossRefGoogle Scholar
  28. 28.
    Payne RJ, Hier MP, Kost KM, et al. High prevalence of obstructive sleep apnea among patients with head and neck cancer. J Otolaryngol. 2005;34:304–11.PubMedCrossRefGoogle Scholar
  29. 29.
    Stern TP, Auckley D. Obstructive sleep apnea following treatment of head and neck cancer. Ear Nose Throat J. 2007;86:101–3.PubMedGoogle Scholar
  30. 30.
    Bhattacharya N, Fried MP. Benchmarks for mortality, morbidity and length of stay for head and neck surgery procedures. Arch Otolarygngol Head Neck Surg. 2001;127:127–32.CrossRefGoogle Scholar
  31. 31.
    Bos MM, Bakshi-Raiez F, Dekker JW, et al. Outcomes of intensive care unit admissions after elective cancer surgery. Eur J Surg Oncol. 2013;39:584–92.PubMedCrossRefGoogle Scholar
  32. 32.
    Petrar S, Bartlett C, Hart RD, et al. Pulmonary complications after major head and neck surgery: a retrospective cohort study. Laryngoscope. 2012;122:1057–61.PubMedCrossRefGoogle Scholar
  33. 33.
    Chen AY. Medical management of head and neck patients. In: Lubin MF, Smith III RB, Dodson TF, Spell NO, Walker HK, editors. Medical management of the surgical patient. 4th ed. Cambridge: Cambridge University Press; 2006. p. 767.CrossRefGoogle Scholar
  34. 34.
    Stenson KM, Brockstein BE, Ross ME. Epidemiology and risk factors for head and neck cancer. www.uptodate.com. Accessed 27 July 2013.
  35. 35.
    Reynolds SC, Chow AW. Severe soft tissue infections of the head and neck: a primer for critical care physicians. Lung. 2009;187:271–9.PubMedCrossRefGoogle Scholar
  36. 36.
    Ramadan HH, El-Soh AA. An update on otolaryngology in critical care. Am J Respir Crit Care Med. 2004;169:1273–7.PubMedCrossRefGoogle Scholar
  37. 37.
    Chen MK, Wen YS, Chang CC, et al. Predisposing factors of life threatening deep neck infections: logistic regressions analysis of 214 cases. J Otolaryngol. 1998;27:141–4.PubMedGoogle Scholar
  38. 38.
    Boscolo-Rizzo P, Da Mosto MC. Submandibular space infection: a potentially lethal infection. Int J Infect Dis. 2009;13:322–33.CrossRefGoogle Scholar
  39. 39.
    Vieira F, Allen SM, Stocks RM, et al. Deep neck infections. Otolarygngol Clin North Am. 2008;41:459–83.CrossRefGoogle Scholar
  40. 40.
    Salvi M, Gallagher JE, Nayyar V, et al. Intensive care admissions for odontogenic infections – a clinical and socio-economic marker of the need for dental care. Abstract, ANZICS ASM meeting, Adelaide; Oct 2012.Google Scholar
  41. 41.
    Reynolds SC, Chow AW. Life-threatening infections of the periphayngeal and deep fascial spaces of the head and neck. Infect Dis Clin North Am. 2007;21:557–76.PubMedCrossRefGoogle Scholar
  42. 42.
    Torres A, Serra-Battles J, Ros E, et al. Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position. Ann Intern Med. 1992;116:540–3.PubMedCrossRefGoogle Scholar
  43. 43.
    Centers for Disease Control and Prevention. Guidelines for prevention of nosocomial pneumonia. MMWR Morb Mortal Wkly Rep. 1997;46:1–79.Google Scholar
  44. 44.
    Drakulovic MB, Torres A, Bauer TT, et al. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet. 1999;354:1851–4.PubMedCrossRefGoogle Scholar
  45. 45.
    Alexiou VG, Ierodiakonou V, Dimopoulos G, et al. Impact of patient position on the incidence of ventilator associated pneumonia: a meta-analysis of randomised trials. J Crit Care. 2009;24:515–22.PubMedCrossRefGoogle Scholar
  46. 46.
    The American Thoracic Society and the Infectious Diseases Society of America Guidelines Committee. Guidelines for the management of adults with hospital-acquired, ventilator-acquired and healthcare-acquired pneumonia. Am J Respir Crit Care Med. 2005;171:388–416.CrossRefGoogle Scholar
  47. 47.
    Jacobi J, Fraser GL, Coursin DB, et al. Task force of the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM), American Society of Health-Systems Pharmacists (ASPH), American College of Chest Physicians: clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med. 2002;30:119–41.PubMedCrossRefGoogle Scholar
  48. 48.
    Kremer F, Atkinson JH, Ignelzi RJ. Measurement of pain: patient preference does not confound pain measurement. Pain. 1981;10:241–8.PubMedCrossRefGoogle Scholar
  49. 49.
    Palmer PP, Miller RD. Current and developing methods of patient controlled analgesia. Anesthesiol Clin. 2010;28:587–99.PubMedCrossRefGoogle Scholar
  50. 50.
    Pandharipande P, Shintani A, Peterson J, et al. Lorazepam is an independent risk factor for transitioning to delirium in intensive care units patients. Anesthesiology. 2006;104:21–6.PubMedCrossRefGoogle Scholar
  51. 51.
    Saito M, Terao Y, Fukusaki M, et al. Sequential use of midazolam and propofol for long-term sedation in postoperative mechanically ventilated patients. Anesth Analg. 2003;96:834–8.PubMedCrossRefGoogle Scholar
  52. 52.
    Memtsoudis SG, Besculides MC, Mazumdar M. A rude awakening – the perioperative sleep apnea epidemic. N Engl J Med. 2013;368:2352–3.PubMedCrossRefGoogle Scholar
  53. 53.
    Woods JC, Mion LC, Connor JT, et al. Severe agitation among ventilated medical intensive care unit patients: frequency, characteristics and outcomes. Intensive Care Med. 2004;20:1066–72.CrossRefGoogle Scholar
  54. 54.
    Thomason JW, Shintani A, Petersen JF, et al. Intensive care unit delirium is an independent predictor of longer hospital stay: a prospective analysis of 261 nonventilated patients. Crit Care. 2005;9:R375–81.PubMedCentralPubMedCrossRefGoogle Scholar
  55. 55.
    Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive care Unit (CAM-ICU). Crit Care Med. 2001;29:1370–9.PubMedCrossRefGoogle Scholar
  56. 56.
    Ely EW, Truman B, Shintani A, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation–Sedation Scale (RASS). JAMA. 2003;289:2983–91.PubMedCrossRefGoogle Scholar
  57. 57.
    Marcantonio ER, Goldman L, Magnione CM, et al. A clinical prediction rule for delirium after elective non-cardiac surgery. JAMA. 1994;271:134–9.PubMedCrossRefGoogle Scholar
  58. 58.
    Liatsi D, Tsapas B, Pampori S, et al. Respiratory, metabolic, and hemodynamic effects of clonidine in ventilated patients presenting with withdrawal syndrome. Intensive Care Med. 2009;35:275–81.PubMedCrossRefGoogle Scholar
  59. 59.
    Reade MC, O’Sullivan K, Bates S, et al. Dexmetetomidine vs haloperidol in delirious, agitated, intubated patients: a randomised open-label trial. Crit Care. 2009;13:R75.PubMedCentralPubMedCrossRefGoogle Scholar
  60. 60.
    McLeod AG, Geerts W. Venous thromboembolism prophylaxis in critically ill patients. Crit Care Clin. 2011;27:765–80.PubMedCrossRefGoogle Scholar
  61. 61.
    Prevention of venous thromboembolism (VTE) in patients admitted to Australian hospitals: Guideline summary. www.nhmrc.gov.au. Accessed 14 Aug 2013.
  62. 62.
    Jaggi R, Taylor SM, Trites J, et al. Review of thromboprophylaxis in otolarygngology head and neck surgery. J Otolaryngol Head Neck Surg. 2011;40:261–5.PubMedGoogle Scholar
  63. 63.
    Hennessey P, Semenov YR, Gourin CG. The effect of deep venous thrombosis on short-term outcomes and cost of care after head and neck cancer surgery. Laryngoscope. 2012;122:2199–204.PubMedCrossRefGoogle Scholar
  64. 64.
    Gavriel H, Thompson E, Kleid S, et al. Safety of thromboprophylaxis after oncologic head and neck surgery. Study of 1018 patients. Head Neck. 2013;35:1410–4.PubMedCrossRefGoogle Scholar
  65. 65.
    Garritano FG, Lehman EB, Andrews GA. Incidence of venous thromboembolism in otolaryngology head and neck surgery. JAMA Otolaryngol Head Neck Surg. 2012;139:21–7.CrossRefGoogle Scholar
  66. 66.
    Shuman AG, Hsou MH, Pannucci CJ, et al. Stratifying risk of venous thromboembolism in otolaryngology. Otolaryngol Head Neck Surg. 2011;146:719–24.CrossRefGoogle Scholar
  67. 67.
    Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest. 2004;126 Suppl 3:338S–400.PubMedCrossRefGoogle Scholar
  68. 68.
    Samamma CM, Albaladejo P, Benhamou D. Venous thromboembolism prevention in surgery and obstetrics: clinical practice guideline. Eur J Anaesthesiol. 2006;23:95–116.CrossRefGoogle Scholar
  69. 69.
    Alhazzani W, Lim W, Jaeschke RZ, et al. Heparin prophylaxis in medical-surgical critically ill patients: a systematic review and meta-analysis of randomised trials. Crit Care Med. 2013;41:2088–98.PubMedCrossRefGoogle Scholar
  70. 70.
    Evidence based practice guidelines for the nutritional management of adult patients with head and neck cancer. www.cosa.org.au. Accessed 17 Aug 2013.
  71. 71.
    Weimann A, Braga M, Harsanyi L, et al. ESPEN guidelines on enteral nutrition: surgery including organ transplantation. Clin Nutr. 2006;25:224–44.PubMedCrossRefGoogle Scholar
  72. 72.
    Doig GS, Heighes PT, Simpson F, et al. Early enteral nutrition, provided within 24 hours of injury or intensive care admission, significantly reduces mortality in critically ill patients: a meta-analysis of randomised controlled trials. Intensive Care Med. 2009;35:2018–27.PubMedCrossRefGoogle Scholar
  73. 73.
    Davies AR, Morrison SS, Bailey MJ, et al. A multi-centre, randomised trial comparing early nasojejunal with nasogastric nutrition in critical illness. Crit Care Med. 2012;40:2342–8.PubMedCrossRefGoogle Scholar
  74. 74.
    Casear MP, Mesotten D, Hermans G, et al. Early vs. late parenteral nutrition in critically ill adults. N Engl J Med. 2011;365:506–17.CrossRefGoogle Scholar
  75. 75.
    Doig DS, Simpson F, Sweetman EA, et al. Early parenteral nutrition in critically ill patients with short term relative contraindications to early enteral nutrition: a randomized, controlled trial. JAMA. 2013;309:2130–8.PubMedCrossRefGoogle Scholar
  76. 76.
    Hoogwerf BJ. Perioperative management of diabetes mellitus: how should we act on the limited evidence? Cleve Clin J Med. 2006;73 Suppl 1:S95–9.PubMedCrossRefGoogle Scholar
  77. 77.
    NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360:1283–97.CrossRefGoogle Scholar
  78. 78.
    Classen DC, Evans RS, Pestotnik SL, et al. The timing of prophylactic administration of antibiotics and the risk of surgical wound infection. N Engl J Med. 1992;326:281–6.PubMedCrossRefGoogle Scholar
  79. 79.
    Van Kasteren ME, Mannien J, Ott A, et al. Antibiotic prophylaxis and the risk of surgical site infections following total hip arthroplasty: timely administration is the most important factor. Clin Infect Dis. 2007;44:921–7.PubMedCrossRefGoogle Scholar
  80. 80.
    Simo R, French G. The use of prophylactic antibiotics in head and neck oncological surgery. Curr Opin Otolaryngol Head Neck Surg. 2006;14:55–61.PubMedCrossRefGoogle Scholar
  81. 81.
    Skitarelic N, Morovic M, Manestar D. Antibiotic prophylaxis in clean-contaminated head and neck oncological surgery. J Craniomaxillofac Surg. 2007;35:15–20.PubMedCrossRefGoogle Scholar
  82. 82.
    Brook I. Microbiology and principles of antimicrobial therapy for head and neck infections. Infect Dis Clin North Am. 2007;21:355–91.PubMedCrossRefGoogle Scholar
  83. 83.
    Anderson DJ, Sexton DJ. Antimicrobial prophylaxis for prevention of surgical site infection in adults. www.uptodate.com. Accessed 14 Aug 2013.
  84. 84.
    Avenia N, Sanguinetti A, Cirocchi R, et al. Antibiotic prophylaxis in thyroid surgery: a preliminary multi-centre Italian experience. Ann Surg Innov Res. 2009;3:10.PubMedCentralPubMedCrossRefGoogle Scholar
  85. 85.
    O’Reilly BJ, Black S, Fernandes J, et al. Is the routine use of antibiotics justified in adult tonsillectomy? J Larnygol Otol. 2003;117:382–5.Google Scholar
  86. 86.
    Caniello M, Passerotti GH, Goto EY, et al. Antibiotics in septoplasty: is it necessary? Braz J Otorhinolaryngol. 2005;71:734–8.PubMedCrossRefGoogle Scholar
  87. 87.
    McDonald M, Grabsch E, Marshall C, et al. Single versus multiple dose antimicrobial prophylaxis for major surgery: a systematic review. Aust NZ J Surg. 1998;68:388–96.CrossRefGoogle Scholar
  88. 88.
    Bratzler DW, Houck PM, Richards C, et al. Use of antimicrobial prophylaxis for major surgery: baseline results from the national surgical infection prevention project. Arch Surg. 2005;140:174–82.PubMedCrossRefGoogle Scholar
  89. 89.
    Feldman MA, Patel A. Anesthesia for eye, ear, nose and throat surgery. In: Miller RD, Eriksson LI, Fleisher LA, Weiner-Kronish JA, Young WL, editors. Miller’s anesthesia. 7th ed. Philadelphia: Churchill Livingstone; 2009. p. 2357–88.Google Scholar
  90. 90.
    American Society of Anesthesiologist Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report. Anesthesiology. 2003;98:1269–77.CrossRefGoogle Scholar
  91. 91.
    Cook TM, Woodall N, Frerk C. on behalf of the fourth national audit project. Major complications of airway management in the UK: results of the fourth national audit project of the Royal College of Anaesthetists and the Difficult Airway Society. Part I: Anaesthesia. Br J Anaesth. 2011;106:617–31.PubMedCrossRefGoogle Scholar
  92. 92.
    Cameron M, Corner A, Diba A, et al. Development of a tracheostomy scoring system to guide airway management after major head and neck surgery. Int J Oral Maxillofac Surg. 2009;38:846–9.PubMedCrossRefGoogle Scholar
  93. 93.
    Kollef MH, Skubas NJ, Sundt TM. A randomised clinical trial of continuous aspiration of subglottic secretions in cardiac surgery patients. Chest. 1999;116:1339–46.PubMedCrossRefGoogle Scholar
  94. 94.
    Shorr AF, O’Malley PG. Continuous subglottic suctioning for the prevention of ventilator associated pneumonia: potential economic implications. Chest. 2001;119:228–35.PubMedCrossRefGoogle Scholar
  95. 95.
    Muscedere J, Rewa O, McKechnie K, et al. Subglottic secretion drainage for the prevention of ventilator-associated pneumonia: a systematic review and meta-analysis. Crit Care Med. 2011;39:1985–91.PubMedCrossRefGoogle Scholar
  96. 96.
    Ledgerwood LG, Salgado MD, Black H, et al. Tracheostomy tubes with suction above the cuff reduce the rate of ventilator-associated pneumonia in intensive care unit patients. Ann Otol Rhinol Laryngol. 2013;122:3–8.PubMedCrossRefGoogle Scholar
  97. 97.
    Kornblith LZ, Burlew CC, Moore EE, et al. One thousand bedside percutaneous tracheostomies in the surgical intensive care unit: time to change the gold standard. J Am Coll Surg. 2011;212:163–70.PubMedCrossRefGoogle Scholar
  98. 98.
    Garrubba M, Turner T, Grieveson C. Multi-disciplinary care for tracheostomy patients: a systematic review. Crit Care. 2009;13:R177.PubMedCentralPubMedCrossRefGoogle Scholar
  99. 99.
    Speed L, Harding KE. Tracheostomy teams reduce total tracheostomy time and increase speaking valve use: a systematic review and meta-analysis. J Crit Care. 2013;28:216.e1–10.CrossRefGoogle Scholar
  100. 100.
    Francois B, Bellissant E, Gissot V, et al. 12-h pretreatment with methylprednisolone versus placebo for prevention of post-extubation laryngeal oedema: a randomised double blind trial. Lancet. 2007;369:1083–9.PubMedCrossRefGoogle Scholar
  101. 101.
    POISE Study Group. Effects of extended release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised trial. Lancet. 2008;371:1839–47.CrossRefGoogle Scholar
  102. 102.
    Bangalore S, Wetterslev J, Pranesh S, et al. Perioperative beta blockers in patients having non-cardiac surgery: a meta-analysis. Lancet. 2008;372:964–9.Google Scholar
  103. 103.
    Graber MA, Dachs R, Darby-Stewart A. Beta blockers and non-cardiac surgery: why POISE study alone should not change your practice. Am Fam Physician. 2010;81:717–9.PubMedGoogle Scholar
  104. 104.
    Popat M, Mitchell V, Dravid R, et al. Difficult Airway Society guidelines for the management of tracheal extubation. Anaesthesia. 2012;67:318–40.PubMedCrossRefGoogle Scholar
  105. 105.
    Pattersen JM, Hildreth A, Wilson JA. Measuring edema in irradiated head and neck cancer patients. Ann Otol Rhinol Laryngol. 2007;116:559–64.CrossRefGoogle Scholar
  106. 106.
    De Backker D. The cuff leak test: what are we measuring? Crit Care. 2005;9:31–3.CrossRefGoogle Scholar
  107. 107.
    Ochoa ME, Marin Mdel C, Frutos-Vivar F, et al. Cuff-leak test for the diagnosis of upper airway obstruction in adults: a systematic review and meta-analysis. Intensive Care Med. 2009;35:1171–9.PubMedCrossRefGoogle Scholar
  108. 108.
    Cavallone LF, Vannucci A. Extubation of the difficult airway and extubation failure. Anesth Analg. 2013;116:368–83.PubMedCrossRefGoogle Scholar
  109. 109.
    Mort TC. Continuous airway access for the difficult extubation: the efficacy of the airway exchange catheter. Anesth Analg. 2007;105:1357–62.PubMedCrossRefGoogle Scholar
  110. 110.
    Duggan LV, Law JA, Murphy MF. Brief review: supplementing oxygen through an airway exchange catheter – efficacy, complications and recommendations. Can J Anaesth. 2011;58:560–8.PubMedCrossRefGoogle Scholar
  111. 111.
    Epstein SK, Ciubotaru RL. Independent effects of etiology of failure and time to reintubation on outcome for patients failing extubation. Am J Respir Crit Care Med. 1998;158:489–933.PubMedCrossRefGoogle Scholar

Copyright information

© Faruque Riffat, Carsten E. Palme, Michael Veness, Rehan Kazi, Raghav C. Dwivedi 2015

Authors and Affiliations

  1. 1.Department Intensive Care UnitWestmead HospitalSydneyAustralia

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