Adjuvant bupivacaine scalp block facilitates stabilization of hemodynamics in patients undergoing craniotomy with general anesthesia: a preliminary report

The effectiveness of scalp nerve block on hemodynamic response in craniotomy: a systematic review and meta-analysis of randomized trials

INTRODUCTION

Strategies that blunt noxious stimuli and stabilize hemodynamics may reduce perioperative cardiovascular complications and enhance recovery after craniotomy.

EVIDENCE ACQUISITION

Our systematic literature review and meta-analysis investigated whether scalp nerve block (SNB) reduces the acute hemodynamic response compared with non-SNB (scalp infiltration or control) in adult patients undergoing elective craniotomy. We searched MEDLINE, EMBASE, CENTRAL, and two Chinese databases for randomized trials. Primary outcomes included mean arterial pressure and heart rate during skull pin insertion and surgical incision in craniotomy. Secondary outcomes included incidence of hypertension and dosage of intraoperative analgesic opioids used. Random-effects models were used for meta-analyses.

EVIDENCE SYNTHESIS

SNB significantly reduced the mean arterial pressure (mean difference: -14.00 mmHg; 95% confidence interval [CI]: -19.71 to -8.28) and heart rate (mean difference: -11.55 beat/min; 95% CI: -19.31 to -3.80), when compared with non-SNB during skull pin insertion. A similar trend was observed during skin incisions (SNB vs. non-SNB, mean difference in mean arterial pressure: -9.46 mmHg; 95% CI: -14.53 to -4.38; mean difference in heart rate: -9.34 beat/min; 95% CI: -15.40 to -3.28). Subgroup analysis showed that, compared with scalp infiltration, SNB reduced mean arterial pressure and heart during pin insertion but not during skin incisions. SNB also reduced the incidence of intraoperative hypertension, but no difference was observed in intraoperative opioid consumption when compared with non-SNB.

CONCLUSIONS

SNB alleviated the craniotomy-associated hemodynamic response. SNB may be superior to scalp infiltration in maintaining hemodynamic stability during pin insertion. However, high-quality trials are still needed to provide more conclusive evidence.

REDUCE trial: the effects of perineural dexamethasone on scalp nerve blocks for relief of postcraniotomy pain-a study protocol for a randomized controlled trial

BACKGROUND

Pain is common in the first 2 days after major craniotomy. Inadequate analgesia may lead to an increased risk of postoperative complications. Most pain following craniotomy arises from the pericranial muscles and soft tissues of the scalp. Scalp nerve blocks with local anesthesia seem to provide effective, safe, however, transient postoperative analgesia which does not seem to meet the requirements of craniotomy. Currently, peripheral dexamethasone has been observed to significantly prolong the duration of analgesia of nerve blocks (e.g., saphenous nerve block, adductor canal block, thoracic paravertebral block, brachial plexus nerve block). On the contrary, a study reported that perineural dexamethasone did not appear to prolong the analgesic time after supratentorial craniotomy. However, all patients in this study were given 24 mg of oral or intravenous dexamethasone regularly for at least 7 days during the perioperative period, which possibly masked the role of single local low doses of perineural dexamethasone. Therefore, the analgesic effect of single dexamethasone for scalp nerve blocks without the background of perioperative glucocorticoid deserves further clarification.

METHODS

The REDUCE trial is a prospective, single-center, parallel-group randomized controlled trial involving a total of 156 adults scheduled for elective craniotomy with general anesthesia. Patients will be randomly divided among two groups: the control group (n = 78) will receive scalp nerve blocks with 0.5% bupivacaine, plus normal saline with epinephrine at 1:200,000; the DEX_4mg group (n = 78) will receive scalp nerve blocks with 0.5% bupivacaine, plus 4 mg dexamethasone with epinephrine at 1:200,000. The primary outcome will be the duration of analgesia, defined as the time between the performance of the block and the first analgesic request.

DISCUSSION

The REDUCE trial aims to further assess the analgesic effect of single dexamethasone as an adjuvant to scalp nerve blocks for relief of postcraniotomy pain without the background of perioperative glucocorticoid.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04648358 . Registered on November 30, 2020.

Efficacy of Dexmedetomidine Infusion Without Loading Dose on Hemodynamic Variables and Recovery Time During Craniotomy: A Randomized Double-blinded Controlled Study

Background

Maintaining hemodynamic stability during intracranial surgery is one of the most important tasks. There is no general agreement regarding which anesthetics are optimal for craniotomy. Propofol and short-acting opioids are usually used, but their use is not without side effects. Recently, dexmedetomidine has been considered a safe alternative in different surgeries.

Objectives

We aimed to assess the efficacy of 0.5 µg/kg/h dexmedetomidine infusion without loading dose as an adjunct to general anesthesia for craniotomy.

Methods

A prospective, randomized, double-blinded, parallel-group, placebo-controlled trial was conducted. Setting: Single university teaching hospital’s operating rooms and postoperative intensive care unit. Patients: A total of 50 patients scheduled for elective supratentorial craniotomy participated in this study. Interventions: Patients were randomly divided into either control group (group C) and Dexmedetomidine group (group D). Main outcome measure: Intraoperative hemodynamics measurements at specific timings.

Results

We found that dexmedetomidine had significantly maintained mean arterial blood pressure and heart rate (P-value < 0.001); with lower intraoperative fentanyl and propofol consumption in group D (132 ± 35 µg and 14 ± 30 mg, respectively) when compared to group C (260 ± 38 µg and 534 ± 66 mg, respectively). Finally, a lesser sedation level was noticed in the dexmedetomidine group, together with a significantly lesser recovery time of 10.3 ± 4 min.

Conclusions

Dexmedetomidine infusion without loading dose could be an efficacious and safe agent in achieving hemodynamic stability with intraoperative opioid-sparing effect and lesser recovery time.

Reduced Pain and Opioid Use in the Early Postoperative Period in Patients Undergoing a Frontotemporal Craniotomy under Regional vs General Anesthesia

INTRODUCTION

This study compares the postsurgical course of frontotemporal craniotomies conducted "awake" under regional anesthesia (RA) versus "asleep" under general anesthesia (GA) to investigate postoperative recovery, pain, opioid use, and anesthesia-related side effects.

METHODS

We retrospectively reviewed craniotomies for supratentorial, intra-axial tumors with frontotemporal exposure. Chronic opioid use and emergent cases were excluded. Primary outcomes included pain scores on a 0-10 numerical rating scale, opioid use as oral morphine milligram equivalence, first time to opioid use, nausea, and sedation on the Richmond Agitation and Sedation Scale (RASS). Secondary outcomes included postoperative seizures, Karnofsky Performance Scale (KPS) status, and hospital length of stay (LOS).

RESULTS

A total of 91 patients met inclusion criteria: 56 underwent a craniotomy under RA versus 35 under GA. Demographics and operative characteristics were similar between cohorts. A significant reduction in both postoperative pain and opioid use was observed among RA versus GA (first postoperative pain score 2 vs. 5, P < 0.01; postoperative day [POD] 0 median pain score 2.5 vs. 4, P < 0.01; POD 0 mean opioid in mg 14.49 vs. 24.43, P < 0.01). The time until patients requested opioids for pain after surgery was prolonged for RA versus GA [mean 7.23 vs. 3.42 hours, P < 0.01). Somnolence (RASS < 0) on POD 0 was significantly reduced among RA versus GA, with 23% versus 43%. Both cohorts had equivocal postsurgical outcomes such as seizures, KPS, and hospital LOS.

CONCLUSIONS

Frontotemporal craniotomy under RA during awake craniotomies provides better pain control, a reduction in opioid use, and less somnolence in the early postoperative period.

Influence of Levobupivacaine Regional Scalp Block on Hemodynamic Stability, Intra- and Postoperative Opioid Consumption in Supratentorial Craniotomies: A Randomized Controlled Trial

BACKGROUND

The anesthetic management of supratentorial craniotomy (CR) necessitates tight intraoperative hemodynamic control. This type of surgery may also be associated with substantial postoperative pain. We aimed at evaluating the influence of regional scalp block (SB) on hemodynamic stability during the noxious events of supratentorial craniotomies and total intravenous anesthesia, its influence on intraoperative anesthetic agents' consumption, and its effect on postoperative pain control.

METHODS

Sixty patients scheduled for elective CR were prospectively enrolled. Patient, anesthesiologist, and neurosurgeon were blind to the random performance of SB with either levobupivacaine 0.33% (intervention group [group SB], n = 30) or the same volume of saline (control group [group CO], placebo group, n = 30). General anesthesia was induced and maintained using target-controlled infusions of remifentanil and propofol that were adjusted according to hemodynamic parameters and state entropy of the electroencephalogram (SE), respectively. Mean arterial blood pressure (MAP), heart rate (HR), SE, and propofol and remifentanil effect-site concentrations (Ce) were recorded at the time of scalp block performance (Baseline), and 0, 1, 3, and 5 minutes after skull-pin fixation (SP), skin incision (SI), CR, and dura-mater incision (DM). Morphine consumption and postoperative pain intensity (0-10 visual analog scale [VAS]) were recorded 1, 3, 6, 24, and 48 hours after surgery. Propofol and remifentanil overall infusion rates were also recorded. Data were analyzed using 2-tailed Student unpaired t tests, 2-way mixed-design analysis of variance (ANOVA), and Tukey's honestly significant difference (HSD) tests for post hoc comparisons as appropriate.

RESULTS

Demographics and length of anesthetic procedure of group CO and SB were comparable. SP, SI, and CR were associated with a significantly higher MAP in group CO than in group SB, at least at one of the time points of recording surrounding those noxious events. This was not the case at DM. Similarly, HR was significantly higher in group CO than in group SB during SP and SI, at least at 1 of the points of recording, but not during CR and DM. Propofol and remifentanil Ce and overall infusion rates were significantly higher in group CO than in group SB, except for propofol Ce during SP. Postoperative pain VAS and cumulative morphine consumption were significantly higher in group CO than in group SB.

CONCLUSIONS

In supratentorial craniotomies, SB improves hemodynamic control during noxious events and provides adequate and prolonged postoperative pain control as compared to placebo.

Sphenopalatine ganglion block: Intranasal transmucosal approach for anterior scalp blockade - A prospective randomized comparative study

Background and Aims:

Peripheral nerve blocks in neurosurgical practice attenuate most stressful responses like pin insertion, skin, and dural incision. Scalp block is conventionally the blockade of choice. Further studies for less invasive techniques are required. Intranasal transmucosal block of the sphenopalatine ganglion has shown promising results in patients with chronic headache and facial pain. The primary objective of our study was to compare the gold standard scalp block and bilateral sphenopalatine ganglion block (nasal approach) for attenuation of hemodynamic response to pin insertion. Secondary objectives included hemodynamic response to skin and dural incision.

Material and Methods:

After IRB approval and informed consent, a prospective randomized comparative study was carried out on 50 adult patients undergoing elective supratentorial surgery. The hemodynamic response to pin insertion, skin incision, and dural incision was noted in both the groups. The data was analyzed with NCSS version 9.0 statistical software.

Results:

The HR and MAP were comparable between the groups. Following dural incision MAP was significantly lower at 1,2,3,4,5 and 10 min in group SPG whereas in group S it was significantly lower at 1 and 2min. (P = 0.02 at T1, P = 0.03 at T2).

Conclusions:

Concomitant use of bilateral SPG block with general anesthesia is an effective and safe alternative technique to scalp blockade for obtundation of hemodynamic responses due to noxious stimulus during craniotomy surgeries.

Regional Anesthesia in Neuroanesthesia Practice

Regional anesthesia has been an undervalued entity in neuroanesthetic practice. However, in the past few years, owing to the development of more advanced techniques, drugs and the prolific use of ultrasound guidance, the unrecognised potential of these modalities have been highlighted. These techniques confer the advantages of reduced requirements for local anesthetics, improved hemodynamic stability in the intraoperative period, better pain score postoperatively and reduced analgesic requirements in the postoperative period. Reduced analgesic requirement translates into lesser side effects associated with analgesic use. Furthermore, the transition from the traditional blind landmark-based techniques to the ultrasound guidance has increased the reliability and the safety profile. In this review, we highlight the commonly practised blocks in the neuroanesthesiologist's armamentarium and describe their characteristics, along with their individual particularities.

Effect of Scalp Nerve Block with Ropivacaine on Postoperative Pain in Patients Undergoing Craniotomy: A Randomized, Double Blinded Study

Scalp nerve block with ropivacaine has been shown to provide perioperative analgesia. However, the best concentration of ropivacaine is still unknown for optimal analgesic effects. We performed a prospective study to evaluate the effects of scalp nerve block with varied concentration of ropivacaine on postoperative pain and intraoperative hemodynamic variables in patients undergoing craniotomy under general anesthesia. Eighty-five patients were randomly assigned to receive scalp block with either 0.2% ropivacaine, 0.33% ropivacaine, 0.5% ropivacaine, or normal saline. Intraoperative hemodynamics and post-operative pain scores at 2, 4, 6, 24 hours postoperatively were recorded. We found that scalp blockage with 0.2% and 0.33% ropivacaine provided adequate postoperative pain relief up to 2 h, while administration of 0.5% ropivacaine had a longer duration of action (up to 4 hour after craniotomy). Scalp nerve block with varied concentration of ropivacaine blunted the increase of mean arterial pressure in response to noxious stimuli during incision, drilling, and sawing skull bone. 0.2% and 0.5% ropivacaine decreased heart rate response to incision and drilling. We concluded that scalp block using 0.5% ropivacaine obtain preferable postoperative analgesia compared to lower concentrations. And scalp block with ropivacaine also reduced hemodynamic fluctuations in craniotomy operations.

Intravenous Fentanyl 4 μg per kg Administered before Scalp Pin Application is Inferior to Scalp Block in Preventing Hemodynamic Changes

Background:

Application of scalp pins for craniotomy surgeries is a noxious stimulus, causing tachycardia and hypertension, resulting in increased cerebral blood flow and elevated intracranial pressure, hence measures to attenuate this will have beneficial role.

Aims:

The aim is to compare the effectiveness of scalp block (SB) to 4 μg.kg^-1 intravenous (i.v) fentanyl in attenuating hemodynamic response to scalp pin application in patients who underwent elective craniotomy under general anesthesia.

Settings and Design:

The study design involves prospective, randomized study conducted at Tertiary care center/hospital.

Subjects and Methods:

Forty-four American Society of Anesthesiologists physical status Classes l and II patients were randomly allocated into the following groups: Group-SB (n = 22) received SB using 0.25% injection bupivacaine and Group-F (n = 22) received 1 μg.kg^-1 i.v fentanyl. Patient's heart rate (HR) and mean arterial pressure (MAP) were recorded from the application of pins till 60 min and rescue analgesic/anesthetic agents and their dosage were noted. Statistical analysis was performed comparing HR and MAP changes to application of scalp pins.

Statistical Analysis:

Software developed by the Centre for Disease Control, Atlanta, namely Epidemiological Information Package 2010 was used to derive statistical variables.

Results:

Patients were comparable in age, gender, hypertension as comorbidity, baseline HR, and MAP. Significant rise in HR was noted in Group-F till 20^th min compared to Group-SB. MAP was high from application of pins till 60^th min in Group-F compared to Group-SB. Requirement of rescue analgesics/anesthetics was high in Group-F compared to Group-SB.

Conclusion:

SB effectively attenuates hemodynamic response to application of scalp pins in patients undergoing elective craniotomy and reduces requirement of rescue analgesic and/or anesthetics.

A comparison of effects of scalp nerve block and local anesthetic infiltration on inflammatory response, hemodynamic response, and postoperative pain in patients undergoing craniotomy for cerebral aneurysms: a randomized controlled trial

BACKGROUND

The purpose of this study was to compare the effects of scalp nerve block (SNB) and local anesthetic infiltration (LA) with 0.75% ropivacaine on postoperative inflammatory response, intraoperative hemodynamic response, and postoperative pain control in patients undergoing craniotomy.

METHODS

Fifty-seven patients were admitted for elective craniotomy for surgical clipping of a cerebral aneurysm. They were randomly divided into three groups: Group S (SNB with 15 mL of 0.75% ropivacaine), group I (LA with 15 mL of 0.75% ropivacaine) and group C (that only received routine intravenous analgesia). Pro-inflammatory cytokine levels in plasma for 72 h postoperatively, hemodynamic response to skin incision, and postoperative pain intensity were measured.

RESULTS

The SNB with 0.75% ropivacaine not only decreased IL-6 levels in plasma 6 h after craniotomy but also decreased plasma CRP levels and increased plasma IL-10 levels 12 and 24 h after surgery compared to LA and routine analgesia. There were significant increases in mean arterial pressure 2 and 5 mins after the incision and during dura opening in Groups I and C compared with Group S. Group S had lower postoperative pain intensity, longer duration before the first dose of oxycodone, less consumption of oxycodone and lower incidence of PONV through 48 h postoperatively than Groups I and C.

CONCLUSION

Preoperative SNB attenuated inflammatory response to craniotomy for cerebral aneurysms, blunted the hemodynamic response to scalp incision, and controlled postoperative pain better than LA or routine analgesia.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03073889 (PI:Xi Yang; date of registration:08/03/2017).

Description of a regional anaesthesia technique for the dorsal cranium in the dog: a cadaveric study

OBJECTIVE

To identify landmarks and to describe a technique for nerve blockade of the dorsal cranium in dogs.

STUDY DESIGN

Anatomic cadaveric study.

ANIMALS

A total of 39 dog cadavers, weighing 18.0 ± 9.7 kg (mean ± standard deviation).

METHODS

The study was performed in three parts. In the initial part, cadavers were dissected to determine the location of the frontal, zygomaticotemporal, and major occipital nerves, and to identify prominent landmarks for their blockade. In the second part, one technique was developed to block each of the frontal and zygomaticotemporal nerves, and two techniques, rostral and caudal, were developed to block the major occipital nerve. Injection solution was 0.05% methylene blue in 0.5% bupivacaine. In the third part, cadavers were used to test the techniques developed in the second part with 0.04 mL kg^-1 of the same injectate administered at each site (maximal volume 0.5 mL per site). The length of nerve stained was measured, with a length ≥6 mm considered successful. Confidence intervals were calculated using Fisher's exact test.

RESULTS

Success rates (95% confidence interval) for the frontal, zygomaticotemporal, and rostral and caudal locations for the major occipital nerve were 94% (80-99%), 91% (76-98%), 74% (58-86%) and 77% (59-89%), respectively. With a combination of both locations, the success rate for the major occipital nerve was 100% (90-100%).

CONCLUSION AND CLINICAL RELEVANCE

This study describes a simple regional anaesthesia technique using palpable anatomical landmarks that may provide analgesia for dogs undergoing craniotomy.

Selective Scalp Nerve Block: A Useful Technique With Tissue Expansion in Postburn Pediatric Alopecia

BACKGROUND

Scalp defects can be reconstructed either with skin graft, local flaps, free flaps, or tissue expansion. Tissue expanders have been proved to be fruitful in the pediatric population. Scalp expansion has proved to be useful in the reconstruction of posttraumatic and postburn alopecic defects. Selective nerve block can be added for attenuation of sympathetic stimulation and decrease surgical stress in cranial surgeries. In this study, a comparison was done between using selective nerve block and without selective nerve block in both stages of tissue expansion procedure.

PATIENTS AND METHODS

This study included 32 different children who underwent tissue expansions in the management of postburn alopecia. Pediatric patients presented with postburn alopecia of the scalp with mature scar were included in this work.

RESULTS

Postoperative analgesics were less in children who had received scalp block, whereas it was shorter in patients who did not receive any scalp block. Meperidine consumption was much more less in patients who received selective scalp nerve block. Pain score was markedly decreased in children who had received selective scalp nerve block in the immediate postoperative period. Children who received scalp block showed marked attenuation in the surgical stress responses with minimal changes in heart rate and mean arterial blood pressure after skin incision.

CONCLUSIONS

Scalp nerve block is considered an excellent choice for postoperative pain control with less need for opioid analgesia.

Effect of Local Ropivacaine on Hemodynamic Responses in Craniotomy Patients

BACKGROUND

Increased intracranial pressure (ICP) with hemodynamic is of major concern to anesthesiologists and surgeons in craniotomy surgery. Thus, the management of hemodynamic stability is essential in neuro-anesthesia. This study was performed to investigate the effect of local infiltration of 0.5% ropivacaine on hemodynamic responses in craniotomy patients.

MATERIAL AND METHODS

64 ASA class I -II patients, scheduled for elective craniotomies, were enrolled in this prospective randomized double blind placebo controlled study. These patients were randomly divided into the ropivacaine group, who were administered with 0.5% ropivacaine (n = 32), and the placebo group administered with 0.9% normal saline (NaCl) (n = 32). Anesthesia was induced with 3 µg/kg fentanyl, 5 mg/kg thiopental and 0.5 mg/kg atracurium, and was maintained with isoflurane (0.8-1 = MAC) in 50% N₂O, 1 mg/kg /30 minutes, 40% oxygen and 0.05 mg/kg /hour fentanyl. Five minutes prior to surgery, 10 mL of 0.5% ropivacaine was injected in the line of skin incision in the ropivacaine group, while 10 mL of normal saline was injected in placebo group. Thereafter, the systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial blood pressures (MABP), and heart rate (HR) were measured before infiltration into the incision area, 30 seconds, 3 minutes, 5, 10, and 30 minutes after infiltration into the scalp. For higher BP and HR, an adjunct 0.5 mcg/kg of fentanyl was prescribed and administered.

RESULTS

A significant difference was observed for SBP, DBP, MABP and HR, between the two groups at different times during craniotomy (p < 0.05). A significant decrease was observed for SBP, DBP, MABP and HR during craniotomy in 0.5% ropivacaine group as compared with placebo group (p < 0.05).

CONCLUSION

Local anesthetic of 0.05% ropivacaine scalp infiltration is effective in clinical usage of regional anesthesia for producing good quality anesthesia, it seems to be a significant choice for management of optimal hemodynamic profile, providing a better hemodynamic stability during craniotomy.

Effects of scalp block with bupivacaine versus levobupivacaine on haemodynamic response to head pinning and comparative efficacies in postoperative analgesia: A randomized controlled trial

Objective

This study was performed to determine the effects of scalp blocks with bupivacaine versus levobupivacaine on the haemodynamic response during craniotomy and the efficacies and analgesic requirements of these drugs postoperatively.

Methods

This randomized, prospective, placebo-controlled, double-blind study included 90 patients (age, 18–85 years; American Society of Anesthesiologists physical status, I or II). The patients were randomly divided into three groups: those who received 20 mL of 0.5% bupivacaine (Group B, n = 30), 20 mL of 0.5% levobupivacaine (Group L, n = 30), or saline as a placebo (Group C, n = 30). Scalp blocks were performed 5 min before head pinning. The primary outcome was the mean arterial pressure (MAP), and the secondary outcomes were the heart rate (HR), visual analogue scale (VAS) scores, and additional intraoperative and postoperative drug use. Postoperative pain was evaluated using a 10-cm VAS.

Results

During head pinning and incision, the MAP and HR were significantly higher in Group C. The additional drug requirement for intraoperative hypertension and tachycardia was significantly higher in Group C. There were no significant differences in MAP, HR, or VAS scores between Groups B and L.

Conclusion

Both bupivacaine and levobupivacaine can be effectively and safely used for scalp blocks to control haemodynamic responses and postoperative pain.

Effects of avoiding neuromuscular blocking agents during maintenance of anaesthesia on recovery characteristics in patients undergoing craniotomy for supratentorial lesions: A randomised controlled study

Background and Aims:

Neuromuscular blocking agents have been one of the cornerstones of anaesthesia. With the advent of newer surgical, anaesthetic and neurological monitoring techniques, their utility in neuroanaesthesia practice seems dispensable. The aim of this prospective, comparative, randomised study was to determine whether neuromuscular blocking agents are required in patients undergoing supratentorial surgery when balanced anaesthesia with desflurane, dexmedetomidine and scalp block is used.

Methods:

Sixty patients with the American Society of Anesthesiologists physical status I or II, aged between 18 and 60 years were included in the study. All patients received anaesthesia including desflurane, dexmedetomidine and scalp block. The patients were randomly allocated to receive no neuromuscular blocking agent (Group A) or atracurium infusion to keep train-of-four count 2 (Group B). The two groups were compared with respect to haemodynamic stability, brain relaxation scores and recovery characteristics. Haemodynamic parameters and time taken to achieve Aldrete score >9 and other secondary outcomes were analysed using Student's t-test. Non-parametric data were analysed using the Mann–Whitney test.

Results:

The mean arterial pressure was comparable between the groups. The intraoperative heart rate was comparable; however, in the post-operative period, it remained higher in Group B for 30 min after extubation (P = 0.02). The brain relaxation scores were comparable among the two groups (P = 0.27). Tracheal extubation time, time taken for orientation and time required to reach Aldrete score ≥9 were comparable among the two groups.

Conclusion:

The present study suggests that balanced anaesthesia using desflurane, dexmedetomidine and scalp block can preclude the use of neuromuscular blocking agents in patients undergoing supratentorial surgery under intense haemodynamic monitoring.

Which one is more effective for analgesia in infratentorial craniotomy? The scalp block or local anesthetic infiltration

OBJECTIVES

The most painful stages of craniotomy are the placement of the pin head holder and the skin incision. The primary aim of the present study is to compare the effects of the scalp block and the local anesthetic infiltration with bupivacaine 0.5% on the hemodynamic response during the pin head holder application and the skin incision in infratentorial craniotomies. The secondary aims are the effects on pain scores and morphine consumption during the postoperative 24h.

METHODS

This prospective, randomized and placebo controlled study included forty seven patients (ASA I, II and III). The scalp block was performed in the Group S, the local anesthetic infiltration was performed in the Group I and the control group (Group C) only received remifentanil as an analgesic during the intraoperative period. The hemodynamic response to the pin head holder application and the skin incision, as well as postoperative pain intensity, cumulative morphine consumption and opioid related side effects were compared.

RESULTS

The scalp block reduced the hemodynamic response to the pin head holder application and the skin incision in infratentorial craniotomies. The local anesthetic infiltration reduced the hemodynamic response to the skin incision. As well as both scalp block and local anesthetic infiltration reduced the cumulative morphine consumption in postoperative 24h. Moreover, the pain intensity was lower after scalp block in the early postoperative period.

CONCLUSION

The scalp block may provide better analgesia in infratentorial craniotomies than local anesthetic infiltration.

Perioperative Factors Contributing the Post-Craniotomy Pain: A Synthesis of Concepts

The perioperative management of post-craniotomy pain is controversial. Although the concept of pain control in non-neurosurgical fields has grown substantially, the understanding of neurosurgical pain and its causative factors in such a population is inconclusive. In fact, the organ that is the center of pain and its related mechanisms receives little attention to alleviate distress during neurosurgical procedures. In contrast to the old belief that pain following intracranial surgery is minimal, recent data suggest the exact opposite. Despite the evolution of various multimodal analgesic techniques for optimal pain control, the concern of post-craniotomy pain remains. This paradox could be due to the lack of thorough understanding of different perioperative factors that can influence the incidence and intensity of pain in post-craniotomy population. Therefore, this review aims to give an in-depth insight into the various aspects of pain and its related factors in adult neurosurgical patients.

[Should we continue to infiltrate the scalp with a local anesthetic for a craniotomy?]

Introduction

Le maintien de la stabilité hémodynamique est un objectif primordial de l'anesthésie pour craniotomie. Peu d’études ont prouvé l'efficacité de l'infiltration du scalp par un anesthésique local pour le maintien de la stabilité hémodynamique après l'incision. L'objectif de notre travail est d’évaluer l'influence de l'infiltration de la ligne d'incision du scalp par la lidocaïne à 0,5% adrénalinée sur les paramètres hémodynamiques après incision pour craniotomie supratentorielle.

Méthodes

Étude prospective en double aveugle réalisée au bloc opératoire de l'hôpital des spécialités de Rabat sur une période d'une année incluant 80 malades programmés pour craniotomie supratentorielle. Les malades étaient randomisés par tirage au sort en 2 groupes: Le groupe 1 était infiltré par 40 ml du sérum salé adrénaliné (1/200 000) et le groupe 2 était infiltré par 40 ml de la lidocaïne 0,5% adrénalinée (1/200 000). Le critère de jugement principal était la pression artérielle moyenne (PAM) après l'incision. L’étude statistique a fait appel aux tests t de student et l'U- mann-whitney. Une valeur de p <0.05 était considérée significative.

Résultats

L’étude a inclus 80 patients (40 hommes et 40 femmes). L’âge moyen était 42,33±14,76 ans. Le poids moyen était 71,58 ±10 kg. Le 3/4 des patients était ASA 1, seulement 25% étaient ASA2. La durée moyenne de la chirurgie était de 252,06±38,62 mn. Les deux groupes étaient comparables concernant l’âge, le sexe, le poids, la durée d'intervention, le type d'abord chirurgical, la dose totale du fentanyl reçue jusqu'a l'incision, ainsi que les paramètres hémodynamiques avant l'incision. Après l'incision la FC moyenne a augmenté dans les deux groupes: 80,53±7,72 bpm dans le groupe contrôle et 76,85±8,52 bpm dans le groupe lidocaïne. La différence d'augmentation de la FC entre les deux groupes était statistiquement significative (p = 0,047). L'augmentation de la PAM était également significativement plus élevée dans le groupe placebo (96,45± 3,53mmHg vs 94,75± 3,76mmHg) (p = 0,041). Nous n'avons pas noté de troubles de rythme ou d'hypertension artérielle par les solutions adrénalinées à 1/200000. Par contre, six cas d'hypotension artérielle ont été notés (3cas dans chaque groupe) après 2 minutes de l'infiltration et ayant répandu au remplissage par 500 ml de sérum salé 0,9%.

Conclusion

L'infiltration par la lidocaïne procure une stabilité hémodynamique (PAM et FC) statistiquement significative. Les autres études rapportées dans la littérature et avec un échantillon réduit ont permis de retrouver une différence significative concernant uniquement la PAM et non la fréquence cardiaque.

[Anesthesia for craniotomy in the conscious patient]

Craniotomy in the conscious patient (CPC) enables the neurological changes to be assessed during the mapping in epilepsy surgery, the location of the electrodes during deep brain stimulation surgery, and tumor resection in eloquent areas of the brain. CPC is a useful technique for radical surgery in order to minimize the damage to the functional areas of the brain. The anesthesiologist must ensure, adequate patient comfort, analgesia and ensure optimal collaboration. The appropriate selection of potential candidates for CPC should be made jointly with all professionals involved in the case. Knowledge of the different phases of CPC, coordination and communication among specialists, the right management of the pharmacology, and anesthetic techniques specific to CPC, along with the ability of psycho-emotional communication with the patient, determine the success of the procedure to be performed in the culture of patient safety. The aim of this review was to describe the anesthetic management, comprehensive considerations, and intraoperative neurophysiological tests for CPC.

Superficial temporal artery-middle cerebral artery bypass using local anesthesia and a sedative without endotracheal general anesthesia

OBJECT

Superficial temporal artery (STA)-middle cerebral artery (MCA) bypasses have continually evolved, and new strategies have been advocated for reducing anesthetic or surgical morbidity and mortality. Further simplifying, and decreasing the invasiveness of, STA-MCA bypass by performing this operation without endotracheal general anesthesia was believed to be feasible in certain subsets of patients.

METHODS

The authors performed STA-MCA bypass using local anesthesia with a sedative in 10 patients with hemodynamically compromised occlusive cerebrovascular disease, as well as multiple comorbidities, between February 2010 and September 2011. The technique is based on the preoperative identification of the point at which the donor and recipient vessels are in closest proximity. Preoperative use of CT angiography allowed the authors to identify the target point precisely and use a minimally invasive procedure. All patients received dexmedetomidine as the sole sedative agent, together with scalp-blocking local anesthesia, with an unsecured airway.

RESULTS

Successful STA-MCA bypass surgeries were achieved via a preselected minimally invasive approach in all cases. There was good hemodynamic stability throughout surgery. No airway or ventilation complications occurred, and no patients were converted to general anesthesia. Subjectively, patients tolerated the technique well with a high rate of satisfaction. There were no perioperative morbidities or deaths. Postoperative MR angiography confirmed a patent bypass in all patients. All patients remained symptom free and returned to normal daily life following the operation.

CONCLUSIONS

This initial experience confirms the feasibility of performing STA-MCA bypass without endotracheal general anesthesia. This novel technique produced a high degree of patient satisfaction.

Effects of propofol sedation during the early postoperative period in hemorrhagic stroke patients

BACKGROUND

The early postoperative period is a critical time for patients after receiving a decompressive craniotomy. Prompt detection and early management of postoperative recurrent/residual hemorrhagic complications may dramatically improve clinical outcomes.

METHODS

The present cohort retrospective study involved 135 patients who received decompressive craniotomy and intensive care unit (ICU) supervision as life-saving measures. The purpose of the study was to evaluate the effects of propofol sedation on the clinical outcome during the ICU stay. The patients' demographic data, hemodynamic variables, the dose of propofol used during the first 48 hours after surgery, residual/recurrent blood clot volume after surgery, and neurologic and clinical outcomes were reviewed. The propofol dosages used for sedation were further divided into three categories: < 0.66, 0.66-3.33 and > 3.33 mg/kg/hr, based on the doses infused during the first 12 hours after surgery.

RESULTS

Our results indicated that the patients of the propofol-sedated group had a significantly smaller amount of residual/recurrent blood clot (p < 0.05) than did those of the non-sedated group. The 30-day mortality rate was significantly lower in the propofol-sedated group (p < 0.05) than in the non-sedated group. Among the propofol-sedated patients, those who received a dose of 0.66-3.33 mg/kg/hr in the first 12 hours after surgery achieved significantly improved clinical and neurologic outcomes than those who received either more than 3.33 mg/kg/hr or less than 0.66 mg/kg/hr of propofol.

CONCLUSION

Our results support the use of propofol sedation during the early postoperative period after craniotomy in hemorrhagic stroke patients, because it improved both neurologic and clinical outcomes. However, early postoperative use of propofol sedation at larger dosages warrants special attention.

Effect of ropivacaine skull block on perioperative outcomes in patients with supratentorial brain tumors and comparison with remifentanil: a pilot study

Object

Skull blockade for craniotomy may result in the reduction of sympathetic stimulation associated with the application of head pins (“pinning”), improvement in intraoperative hemodynamic stability, and a decrease in intraoperative anesthetic requirements. Postoperative benefits may include a decrease in pain, in analgesic requirements, and in the incidence of nausea and vomiting. The authors examined the potential benefits of a skull block in patients in whom a maintenance anesthetic consisting of sevoflurane and a titratable remifentanil infusion was used. In other studies examining the ability of a skull block to improve perioperative outcomes, investigators have not used remifentanil.

Methods

Thirty patients presenting for resection of a supratentorial tumor were prospectively enrolled. Patients were randomized into 2 groups as follows: 14 patients (skull block group) received a skull block with 0.5% ropivacaine at least 15 minutes prior to pinning, whereas the remaining 16 patients (control group) did not.

Results

Patients in the skull block group did not have a significant increase in blood pressure or heart rate with placement of head pins, whereas patients in the control group did. Nevertheless, there was no difference in blood pressure variability between the groups. The mean intraoperative concentration of sevoflurane (1.0% in both groups, p = 0.703) and remifentanil (0.163 μg/kg/min compared with 0.205 μg/kg/min, p = 0.186) used was similar in both groups. During the postoperative period, there was no difference in the 1-, 2-, or 4-hour visual analog scale scores; in the need for postoperative narcotic analgesia (0.274 morphine equivalent mg/kg compared with 0.517 morphine equivalent mg/kg, p = 0.162); or in the incidence of nausea or vomiting.

Conclusions

Prospective analysis of perioperative skull blockade failed to demonstrate significant benefit in patients treated with a remifentanil infusion.