BACKGROUND: Outpatient tympanomastoidectomy is common in many medical centers. However, failure of same-day discharge is often the result of postoperative nausea and vomiting (PONV). Many times this leads to hospital admission after tympanomastoidectomy, and it is often difficult to predict before surgery whether PONV will be an issue that impedes same-day discharge. OBJECTIVE: To determine the clinical factors correlated with the incidence of PONV requiring hospital admission after chronic ear surgery by hypothesizing that the complexity of a particular case, as measured using a 10-point scale, is predictive of surgical time or failure of same-day hospital discharge. STUDY DESIGN: Retrospective medical chart review of 103 patients having mastoidectomy with tympanoplasty for chronic otitis media over a 2-year period. METHODS: We recorded patient age, clinical data, surgical times, types of agents used for induction and maintenance of anesthesia, use of prophylactic antiemetic drugs, types and doses of analgesic agents, and PONV. Univariate and multivariate logistic regression analyses were performed to determine which variables were associated with PONV that required hospital admission. RESULTS: One third of patients studied were safely discharged from the hospital the day of surgery, and 92% were discharged within 23 hours. The most common cause for observation admission to the hospital was PONV. The only variable in multivariate analysis that significantly correlated with PONV mandating hospital admission after tympanomastoid surgery was a history of motion sickness or PONV (odds ratio, 5.21; P =.02). Although severity of disease did not correlate with length of hospital stay, it directly correlated with length of surgery. CONCLUSIONS: A history of PONV or motion sickness is predictive of PONV and length of hospital stay. Routine planning for a 23-hour overnight observation stay seems warranted for all patients undergoing tympanomastoidectomy, despite severity of disease.

OBJECTIVE: To evaluate the efficacy of triple-lumen central venous catheters coated with a combination product of chlorhexidine and silver sulfadiazine (CSS) in reducing the incidence of local catheter infection and catheter-related bacteremia. DESIGN: Randomized, controlled trial. SETTING: The surgical intensive care units in a university hospital. PATIENTS: All patients who needed central venous catheterization were randomized to receive either an uncoated triple-lumen catheter (n = 157) or a catheter coated with CSS (n = 151). MAIN OUTCOME MEASURE: Catheters were removed when no longer needed or suspected as a cause of infection. The tip and a 5-cm segment of the intradermal portion of the catheter were cultured semiquantitatively. Blood cultures were obtained when clinically indicated. The remaining segment of catheters coated with CSS were cut and incubated on an agar plate with strains of Staphylococcus aureus and Enterococcus. Zone of inhibition was determined 24 hours later. Data were analyzed by survival and logistic multivariate regression methods. RESULTS: Catheters coated with CSS were effective in reducing the rate of significant bacterial growth on either the tip or intradermal segment (40%) compared with control catheters (52%; P = .04). However, there was no difference in the incidence of catheter-related bacteremia (3.8% [uncoated] vs 3.3% [coated]; P = .81). In vitro activity of catheters with CSS against S aureus was evident up to 25 days but activity against Enterococcus dissipated more quickly over time and was absent by day 4. The most common colonizing organisms were coagulase-negative staphylococcus and enterococcus. Variables that were associated with a significant amount of growth on the tip or intradermal segment were a duration of catheterization of longer than 7 days, jugular insertion site, and the absence of a CSS coating. The use of a guidewire when the catheter was removed was associated with a lower risk of significant bacterial growth. CONCLUSIONS: The use of CSS reduces the incidence of significant bacterial growth on either the tip or intradermal segments of coated triple-lumen catheters but has no effect on the incidence of catheter-related bacteremia. In this patient population, catheters coated with CSS provide no additional benefit over uncoated catheters.

Regional anesthesia is frequently administered to elderly patients and those with known cardiovascular disease in the hope of minimizing the cardiovascular complications associated with general anesthesia. Drug interactions between local anesthetics used in regional techniques and calcium channel blockers have been described. To date, however, potentially life-threatening dysrhythmias associated with brachial plexus blockade using the supraclavicular approach have not been reported. We now describe such a case.