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Dean C, McCullough I, Papangelou A. An update on the perioperative management of postcraniotomy pain. Curr Opin Anaesthesiol 2024; 37:478-485. [PMID: 39011673 DOI: 10.1097/aco.0000000000001409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/17/2024]
Abstract
PURPOSE OF REVIEW Pain after craniotomy is often severe and undertreated. Providing adequate analgesia while avoiding medication adverse effects and physiological complications of pain remains a perioperative challenge. RECENT FINDINGS Multimodal pain management includes regional anesthesia and analgesic adjuncts. Strategies aim to reduce or eliminate opioids and the associated side effects. Many individual pharmacologic interventions have been studied with beneficial effects on acute pain following craniotomy. Evidence has been accumulating in support of scalp blockade, nonsteroidal anti-inflammatory drugs (NSAIDs), dexmedetomidine, paracetamol, and gabapentinoids. The strongest evidence supports scalp block in reducing postcraniotomy pain and opioid requirements. SUMMARY Improving analgesia following craniotomy continues to be a challenge that should be managed with multimodal medications and regional techniques. Additional studies are needed to identify the most effective regimen, balancing efficacy and adverse drug effects.
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MESH Headings
- Humans
- Pain, Postoperative/etiology
- Pain, Postoperative/prevention & control
- Pain, Postoperative/therapy
- Pain, Postoperative/diagnosis
- Pain, Postoperative/drug therapy
- Craniotomy/adverse effects
- Pain Management/methods
- Perioperative Care/methods
- Perioperative Care/standards
- Analgesics/administration & dosage
- Analgesics/therapeutic use
- Analgesics/adverse effects
- Anesthesia, Conduction/methods
- Anesthesia, Conduction/adverse effects
- Nerve Block/methods
- Nerve Block/adverse effects
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Anti-Inflammatory Agents, Non-Steroidal/administration & dosage
- Analgesics, Opioid/adverse effects
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/therapeutic use
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Affiliation(s)
- Cassandra Dean
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
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2
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Comparan HDM, Khaliq A, Frota LM, Pomar-Forero D, Ahmad B, Marnet E, Teixeira FJP, Thomas A, Patel P, Brunkal H, Singireddy S, Lucke-Wold B, Maciel CB, Busl KM. Cyclooxygenase 2 Inhibitors for Headache After Elective Cranial Neurosurgery: Results from a Systematic Review of Efficacy of Cyclooxygenase 2 Inhibitors for Headache After Acute Brain Injury. Neurocrit Care 2024:10.1007/s12028-024-02114-y. [PMID: 39266865 DOI: 10.1007/s12028-024-02114-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 08/22/2024] [Indexed: 09/14/2024]
Abstract
Headache management after acute brain injury (ABI) is challenging. Although opioids are commonly used, selective cyclooxygenase 2 inhibitors (COXIBs) may be promising alternatives. However, concerns about cardiovascular effects and bleeding risk have limited their use. We aimed at summarizing available data on efficacy of COXIBs for headache management following ABI. A systematic review was conducted through MEDLINE and Embase for articles published through September 2023 (PROSPERO identifier: CRD42022320453). No language filters were applied to the initial searches. Interventional or observational studies and systematic reviews assessing efficacy of COXIBs for headache in adults with ABI were eligible. Article selection was performed by two independent reviewers using DistillerSR. Descriptive statistics were used for data analysis, and meta-analysis was unfeasible because of study heterogeneity. Of 3190 articles identified, 6 studies met inclusion criteria: 4 randomized controlled trials and 2 retrospective cohort studies, all conducted in elective cranial neurosurgical patients (total N = 738) between 2006 and 2022. Five studies used COXIBs in the intervention group only. Of the six studies, four found a reduction in overall pain scores in the intervention group, whereas one showed improvement only at 6 h postoperatively, and one did not find significant differences. Pain scores decreased between 4 and 15%, the largest shift being from moderate to mild severity. Three studies found an overall opioid use reduction throughout hospitalization in the intervention group, whereas one reported a reduction at 12 h postoperatively only. Opioid consumption decreased between 9 and 90%. Two studies found a decrease in hospital length of stay by ~ 1 day in the intervention group. The one study reporting postoperative hemorrhage found a statistically nonsignificant 3% reduction in the intervention group. COXIBs may serve as opioid-sparing adjunctive analgesics for headache control after elective cranial surgery. Limited or no literature exists for other forms of ABI, and additional safety data remain to be elucidated.
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Affiliation(s)
- Hector David Meza Comparan
- Division of Neurocritical Care, Department of Neurology, College of Medicine, University of Florida, Gainesville, FL, 32611, USA
| | - Anum Khaliq
- Division of Neurocritical Care, Department of Neurology, College of Medicine, University of Florida, Gainesville, FL, 32611, USA
| | - Luciola Martins Frota
- Division of Neurocritical Care, Department of Neurology, College of Medicine, University of Florida, Gainesville, FL, 32611, USA
| | - Daniela Pomar-Forero
- Division of Neurocritical Care, Department of Neurology, College of Medicine, University of Florida, Gainesville, FL, 32611, USA
| | - Bakhtawar Ahmad
- Division of Neurocritical Care, Department of Neurology, College of Medicine, University of Florida, Gainesville, FL, 32611, USA
| | - Erica Marnet
- Department of Medicine, Bridgeport Hospital, Bridgeport, CT, 06610, USA
| | - Fernanda J P Teixeira
- Department of Neurology, University of Miami and Jackson Memorial Hospital, Miami, FL, 33130, USA
| | - Anita Thomas
- Division of Neurocritical Care, Department of Neurology, College of Medicine, University of Florida, Gainesville, FL, 32611, USA
| | - Priyank Patel
- Division of Neurocritical Care, Department of Neurology, College of Medicine, University of Florida, Gainesville, FL, 32611, USA
| | - Haley Brunkal
- Division of Neurocritical Care, Department of Neurology, College of Medicine, University of Florida, Gainesville, FL, 32611, USA
| | - Saanvi Singireddy
- Division of Neurocritical Care, Department of Neurology, College of Medicine, University of Florida, Gainesville, FL, 32611, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, 32611, USA
| | - Carolina B Maciel
- Division of Neurocritical Care, Department of Neurology, College of Medicine, University of Florida, Gainesville, FL, 32611, USA
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, 32611, USA
- Department of Neurology, Yale University School of Medicine, New Haven, CT, 06520, USA
- Department of Neurology, University of Utah, Salt Lake City, UT, 84132, USA
| | - Katharina M Busl
- Division of Neurocritical Care, Department of Neurology, College of Medicine, University of Florida, Gainesville, FL, 32611, USA.
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, 32611, USA.
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3
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Canelli RJ, Louca J, Gonzalez RM, Rendon LF, Hartman CR, Bilotta F. Trends in preoperative carbohydrate load practice: A systematic review. JPEN J Parenter Enteral Nutr 2024; 48:527-537. [PMID: 38676554 DOI: 10.1002/jpen.2633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/22/2024] [Accepted: 04/05/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND The preoperative carbohydrate load (PCL) is intended to improve surgical outcomes by reducing the catabolic state induced by overnight fasting. However, there is disagreement on the optimal PCL prescription, leaving local institutions without a standardized PCL recommendation. Results from studies that do not prescribe PCL in identical ways cannot be pooled to draw larger conclusions on outcomes affected by the PCL. The aim of this systematic review is to catalog prescribed PCL characteristics, including timing of ingestion, percentage of carbohydrate contribution, and volume, to ultimately standardize PCL practice. METHODS A comprehensive search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials were included if they studied at least one group of patients who were prescribed a PCL and the PCL was described with respect to timing of ingestion, carbohydrate contribution, and total volume. RESULTS A total of 67 studies with 6551 patients were included in this systematic review. Of the studies, 49.3% were prescribed PCL on the night before surgery and morning of surgery, whereas 47.8% were prescribed PCL on the morning of surgery alone. The mean prescribed carbohydrate concentration was 13.5% (±3.4). The total volume prescribed was 648.2 ml (±377). CONCLUSION Variation in PCL practices prevent meaningful data pooling and outcome analysis, highlighting the need for standardized PCL prescription. Efforts dedicated to the establishment of a gold standard PCL prescription are necessary so that studies can be pooled and analyzed with respect to meaningful clinical end points that impact surgical outcomes and patient satisfaction.
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Affiliation(s)
- Robert J Canelli
- Department of Anesthesiology, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Joseph Louca
- Department of Anesthesiology, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Rafael M Gonzalez
- Department of Anesthesiology, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
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Jolly S, Paliwal S, Gadepalli A, Chaudhary S, Bhagat H, Avitsian R. Designing Enhanced Recovery After Surgery Protocols in Neurosurgery: A Contemporary Narrative Review. J Neurosurg Anesthesiol 2024; 36:201-210. [PMID: 38011868 DOI: 10.1097/ana.0000000000000946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 10/16/2023] [Indexed: 11/29/2023]
Abstract
Enhanced Recovery After Surgery (ERAS) protocols have revolutionized the approach to perioperative care in various surgical specialties. They reduce complications, improve patient outcomes, and shorten hospital lengths of stay. Implementation of ERAS protocols for neurosurgical procedures has been relatively underexplored and underutilized due to the unique challenges and complexities of neurosurgery. This narrative review explores the barriers to, and pioneering strategies of, standardized procedure-specific ERAS protocols, and the importance of multidisciplinary collaboration in neurosurgery and neuroanesthsia, patient-centered approaches, and continuous quality improvement initiatives, to achieve better patient outcomes. It also discusses initiatives to guide future clinical practice, research, and guideline creation, to foster the development of tailored ERAS protocols in neurosurgery.
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Affiliation(s)
- Sagar Jolly
- Department of General Anesthesiology, Cleveland Clinic, OH
| | | | - Aditya Gadepalli
- Department of Anaesthetics and Intensive Care, Royal Free London NHS Foundation Trust, London, UK
| | - Sheena Chaudhary
- Department of Neuroanesthesia and Critical Care, Fortis Memorial Research Institute, Gurugram, HR, India
| | - Hemant Bhagat
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rafi Avitsian
- Department of General Anesthesiology, Cleveland Clinic, OH
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5
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Kulikov A, Gruenbaum SE, Quinones-Hinojosa A, Pugnaloni PP, Lubnin A, Bilotta F. Preoperative Risk Assessment Before Elective Craniotomy: Are Aspirin, Arrhythmias, Deep Venous Thromboses, and Hyperglycemia Contraindications to Surgery? World Neurosurg 2024; 186:68-77. [PMID: 38479642 DOI: 10.1016/j.wneu.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 04/18/2024]
Abstract
OBJECTIVE Perioperative risk assessment and stratification before craniotomy is necessary to identify and optimize modifiable risk factors. Due to the high costs of diagnostic testing and concerns for delaying surgery, some have questioned whether and when surgery delays are warranted and supported by the current body of literature. The objective of this scoping review was to evaluate the available evidence on the prognostic value of preoperative risk assessment before anesthesia for elective craniotomy. METHODS In this scoping review, we reviewed 156 papers that assess preoperative risk assessment before elective craniotomy, of which 27 papers were included in the final analysis. RESULTS There is little high-quality evidence to suggest significant risk reduction when 4 common preexisting abnormalities are present: preoperative chronic aspirin therapy, cardiac arrhythmias, deep vein thrombosis, or hyperglycemia. CONCLUSIONS The risk of delaying craniotomy should ultimately be weighed against the perceived risks associated the patient's comorbid conditions and should be considered on an individualized basis.
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Affiliation(s)
- Alexander Kulikov
- Department of Anesthesiology, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Shaun E Gruenbaum
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, Jacksonville, Florida.
| | | | - Pier Paolo Pugnaloni
- Department of Anesthesiology, Critical Care and Pain Medicine, Sapienza University of Rome, Rome, Italy
| | - Andrey Lubnin
- Department of Anesthesiology, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Federico Bilotta
- Department of Anesthesiology, Critical Care and Pain Medicine, Sapienza University of Rome, Rome, Italy
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6
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Fu Y, Wu T, Zhu J, Chen Y, Yang M. Improving operating room efficiency through evidence-based medical management. Minerva Gastroenterol (Torino) 2024; 70:261-263. [PMID: 37310374 DOI: 10.23736/s2724-5985.23.03468-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Yu Fu
- Medical Department, Wuxi 9th People's Hospital, Wuxi, China
| | - Tie Wu
- Medical Department, Wuxi 9th People's Hospital, Wuxi, China
| | - Jiandong Zhu
- Medical Department, Wuxi 9th People's Hospital, Wuxi, China
| | - Yue Chen
- Department of Gynecology and Obstetrics, Wuxi 9th People's Hospital, Wuxi, China
| | - Miao Yang
- Medical Department, Wuxi 9th People's Hospital, Wuxi, China -
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7
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Stieger A, Romero CS, Andereggen L, Heisenberg D, Urman RD, Luedi MM. Nerve Blocks for Craniotomy. Curr Pain Headache Rep 2024; 28:307-313. [PMID: 38472617 DOI: 10.1007/s11916-024-01236-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 03/14/2024]
Abstract
PURPOSE OF REVIEW Postcraniotomy headache (PCH) is a common adverse event and can lead to various complications and decreased quality of life. RECENT FINDINGS To reduce postcraniotomy pain and associated complications, a multimodal pain therapy including analgesics, analgesic adjuncts, and regional anesthesia is essential. The use of opioids should be minimized to facilitate prompt postoperative neurosurgical assessment. Here, we provide an update on the latest evidence regarding the role of scalp nerve blocks in the pain management of patients undergoing craniotomy procedure. Nerve blocks are effective in alleviating postoperative pain after craniotomy. Scalp blocks contribute to lower pain levels and less opioid consumption in the first 48 h following surgery. Moreover, there is a significant decrease in patients suffering from PONV among patients who receive scalp block.
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Affiliation(s)
- Andrea Stieger
- Department of Anaesthesiology, Rescue and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland.
| | - Carolina S Romero
- Department of Anaesthesiology and Critical Care, Hospital General, Universitario De Valencia, Valencia, Spain
- Research Methods Department, Universidad Europea de Valencia, Valencia, Spain
| | - Lukas Andereggen
- Department of Neurosurgery, Cantonal Hospital of Aarau, Aarau, Switzerland
- Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Daniel Heisenberg
- Department of Anaesthesiology, Rescue and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
| | - Richard D Urman
- Department of Anaesthesiology, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
| | - Markus M Luedi
- Department of Anaesthesiology, Rescue and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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8
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Kim SH, Choi SH, Moon J, Kim HD, Choi YS. Enhanced Recovery After Surgery for Craniotomies: A Systematic Review and Meta-analysis. J Neurosurg Anesthesiol 2024:00008506-990000000-00107. [PMID: 38651841 DOI: 10.1097/ana.0000000000000967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 03/15/2024] [Indexed: 04/25/2024]
Abstract
The efficacy of the enhanced recovery after surgery (ERAS) protocols in neurosurgery has not yet been established. We performed a systematic review and meta-analysis of randomized controlled trials to compare the effects of ERAS protocols and conventional perioperative care on postoperative outcomes in patients undergoing craniotomy. The primary outcome was postoperative length of hospital stay. Secondary outcomes included postoperative pain visual analog pain scores, incidence of postoperative nausea and vomiting (PONV), postoperative complications, all-cause reoperation, readmission after discharge, and mortality. A literature search up to August 10, 2023, was conducted using PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus databases. Five studies, including 871 patients, were identified for inclusion in this review. Compared with conventional perioperative care, ERAS protocols reduced the length of postoperative hospital stay (difference of medians, -1.52 days; 95% CI: -2.55 to -0.49); there was high heterogeneity across studies (I2, 74%). ERAS protocols were also associated with a lower risk of PONV (relative risk, 0.79; 95% CI: 0.69-0.90; I2, 99%) and postoperative pain with a visual analog scale score ≥4 at postoperative day 1 (relative risk, 0.37; 95% CI: 0.28-0.49; I2, 14%). Other outcomes, including postoperative complications, did not differ between ERAS and conventional care groups. ERAS protocols may be superior to conventional perioperative care in craniotomy patients in terms of lower length of hospital stay, lower incidence of PONV, and improved postoperative pain scores. Further randomized trials are required to identify the impact of ERAS protocols on the quality of recovery after craniotomy.
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Affiliation(s)
- Seung Hyun Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine
| | - Seung Ho Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine
| | - Jisu Moon
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Korea
| | - Hae Dong Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine
| | - Yong Seon Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine
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Comparan HDM, Khaliq A, Frota LM, Pomar-Forero D, Ahmad B, Marnet E, Teixeira FJP, Thomas A, Patel P, Brunkal H, Singireddy S, Lucke-Wold B, Maciel CB, Busl KM. Efficacy of Cyclooxygenase-2 Inhibitors for Headache in Acute Brain Injury: A Systematic Review. RESEARCH SQUARE 2024:rs.3.rs-4232407. [PMID: 38659820 PMCID: PMC11042422 DOI: 10.21203/rs.3.rs-4232407/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
Background Headache management after acute brain injury (ABI) is challenging. While opioids are commonly used, selective cyclooxygenase-2 inhibitors (COXIBs) may be promising alternatives. However, concerns about cardiovascular effects and bleeding risk have limited their use. We aimed at summarizing available data on efficacy of COXIBs for headache management following ABI. Methods A systematic review was conducted through MEDLINE and Embase for articles published through 09/2023 (PROSPERO CRD42022320453). No language filters were applied to the initial searches. Interventional or observational studies and systematic reviews assessing efficacy of COXIBs for headache in adults with ABI were eligible. Article selection was performed by two independent reviewers using Distiller SR®. Descriptive statistics were used for data analysis, while meta-analysis was unfeasible due to study heterogeneity. Results Of 3190 articles identified, six studies met inclusion criteria: four randomized controlled trials and two retrospective cohort studies, all conducted in neurosurgical patients (total n=738) between 2006-2022. Five studies used COXIBs in the intervention group only. Of the six studies, four found a reduction in overall pain scores in the intervention group, while one showed improvement only at 6 hours postoperative, and one did not find significant differences. Pain scores decreased between 4-15%, the largest shift being from moderate to mild severity. Three studies found an overall opioid use reduction throughout hospitalization in the intervention group, while one reported a reduction at 12 hours postoperative only. Opioid consumption decreased between 9-90%. Two studies found a decrease in hospital-length-of-stay by ~1 day in the intervention group. The one study reporting postoperative hemorrhage found a statistically non-significant 3% reduction in the intervention group. Conclusions In adults with ABI, COXIBs may serve as opioid-sparing adjunctive analgesics for headache control, with limited but pointed data to indicate efficacy in the post-neurosurgical setting. However, further safety data remains to be elucidated.
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Affiliation(s)
- Hector David Meza Comparan
- Department of Neurology, Division of Neurocritical Care, University of Florida, College of Medicine, Gainesville, FL 32611, USA
| | - Anum Khaliq
- Department of Neurology, Division of Neurocritical Care, University of Florida, College of Medicine, Gainesville, FL 32611, USA
| | - Luciola Martins Frota
- Department of Neurology, Division of Neurocritical Care, University of Florida, College of Medicine, Gainesville, FL 32611, USA
| | - Daniela Pomar-Forero
- Department of Neurology, Division of Neurocritical Care, University of Florida, College of Medicine, Gainesville, FL 32611, USA
| | - Bakhtawar Ahmad
- Department of Neurology, Division of Neurocritical Care, University of Florida, College of Medicine, Gainesville, FL 32611, USA
| | - Erica Marnet
- Department of Medicine, Bridgeport Hospital, Bridgeport, CT, USA 06610
| | - Fernanda J P Teixeira
- Department of Neurology, University of Miami/Jackson Memorial Hospital, FL, USA, 33130
| | - Anita Thomas
- Department of Neurology, Division of Neurocritical Care, University of Florida, College of Medicine, Gainesville, FL 32611, USA
| | - Priyank Patel
- Department of Neurology, Division of Neurocritical Care, University of Florida, College of Medicine, Gainesville, FL 32611, USA
| | - Haley Brunkal
- Department of Neurology, Division of Neurocritical Care, University of Florida, College of Medicine, Gainesville, FL 32611, USA
| | - Saanvi Singireddy
- Department of Neurology, Division of Neurocritical Care, University of Florida, College of Medicine, Gainesville, FL 32611, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, College of Medicine, Gainesville, FL 32611, USA
| | - Carolina B Maciel
- Department of Neurology, Division of Neurocritical Care, University of Florida, College of Medicine, Gainesville, FL 32611, USA; Department of Neurosurgery, University of Florida, College of Medicine, Gainesville, FL 32611, USA; Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA; Department of Neurology, University of Utah, Salt Lake City, UT 84132, USA
| | - Katharina M Busl
- Department of Neurology, Division of Neurocritical Care, University of Florida, College of Medicine, Gainesville, FL 32611, USA; Department of Neurosurgery, University of Florida, College of Medicine, Gainesville, FL 32611, USA
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10
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Li X, Jiang HY, Zhao YJ, Liu SZ, Pan LX. Early clinical efficacy analysis of enhanced recovery following surgery combined with interscalene brachial plexus block for arthroscopic rotator cuff repair. Medicine (Baltimore) 2023; 102:e35943. [PMID: 37960744 PMCID: PMC10637507 DOI: 10.1097/md.0000000000035943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 10/12/2023] [Indexed: 11/15/2023] Open
Abstract
To explore the early clinical value of enhanced recovery after surgery (ERAS) with interscalene brachial plexus block (ISB) for arthroscopic rotator cuff repair (ARCR). We enrolled 240 patients who underwent arthroscopic rotator cuff repair, randomly divided into 3 groups (n = 80 each). Groups A, B, and C underwent only surgery, surgery + ERAS, and ISB + surgery + ERAS, respectively. We analyzed the clinical data and postoperative indicators for the 3 patient groups. Group comparisons of clinical data and postoperative indicators revealed no significant differences in clinical characteristics (P > .05). Group C showed superior Visual Analog Scale scores at 0-6 and 6-24 hours postoperatively (P < .05), and the shortest length of hospital stay (LOS) (P < .05). At 6 weeks and 3 months postoperatively, Constant-Murley shoulder score and University of California-Los Angeles scores were better in Groups B and C than in Group A (P < .05). Joint swelling was more common in Group A than in Groups B and C (P < .05) but with no significant difference in the incidence of postoperative stiffness (P > .05). ERAS can relieve postoperative pain, shorten LOS, and help restore shoulder joint mobility, thereby reducing postoperative swelling. ISB + ERAS optimized pain control and allowed a shorter LOS, but had similar effects on early functional recovery and complications.
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Affiliation(s)
- Xiang Li
- Health Science Center, Ningbo University, Ningbo, China
- Department of Orthopedics and Sports Medicine, Li Huili Hospital Affiliated to Ningbo University, Ningbo, China
| | - Hong-yang Jiang
- Health Science Center, Ningbo University, Ningbo, China
- Department of Orthopedics and Sports Medicine, Li Huili Hospital Affiliated to Ningbo University, Ningbo, China
| | - Yong-jie Zhao
- Health Science Center, Ningbo University, Ningbo, China
- Department of Orthopedics and Sports Medicine, Li Huili Hospital Affiliated to Ningbo University, Ningbo, China
| | - Si-zhuo Liu
- Health Science Center, Ningbo University, Ningbo, China
- Department of Orthopedics and Sports Medicine, Li Huili Hospital Affiliated to Ningbo University, Ningbo, China
| | - Ling-xiao Pan
- Department of Orthopedics and Sports Medicine, Li Huili Hospital Affiliated to Ningbo University, Ningbo, China
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11
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Choi S, Choi YH, Lee HS, Shin KW, Kim YJ, Park HP, Cho WS, Oh H. Effects of Scalp Nerve Block on the Quality of Recovery after Minicraniotomy for Clipping of Unruptured Intracranial Aneurysms : A Randomized Controlled Trial. J Korean Neurosurg Soc 2023; 66:652-663. [PMID: 37042173 PMCID: PMC10641417 DOI: 10.3340/jkns.2023.0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/13/2023] [Accepted: 04/10/2023] [Indexed: 04/13/2023] Open
Abstract
OBJECTIVE This study compared the quality of recovery (QoR) after minicraniotomy for clipping of unruptured intracranial aneurysms (UIAs) between patients with and without scalp nerve block (SNB). METHODS Patients were randomly assigned to the SNB (SNB using ropivacaine with epinephrine, n=27) and control (SNB using normal saline, n=25) groups. SNB was performed at the end of surgery. To assess postoperative QoR, the QoR-40, a patient-reported questionnaire, was used. The QoR-40 scores were measured preoperatively, 1-3 days postoperatively, at hospital discharge, and 1 month postoperatively. Pain and intravenous patient-controlled analgesia (IV-PCA) consumption were evaluated 3, 6, 9, and 12 hours and 1-3 days postoperatively. RESULTS All QoR-40 scores, including those measured 1 day postoperatively (primary outcome measure; 155.0 [141.0-176.0] vs. 161.0 [140.5-179.5], p=0.464), did not significantly differ between the SNB and control groups. The SNB group had significantly less severe pain 3 (numeric rating scale [NRS]; 3.0 [2.0-4.0] vs. 5.0 [3.5-5.5], p=0.029), 9 (NRS; 3.0 [2.0-4.0] vs. 4.0 [3.0-5.0], p=0.048), and 12 (NRS; 3.0 [2.0-4.0] vs. 4.0 [3.0-5.0], p=0.035) hours postoperatively. The total amount of IV-PCA consumed was significantly less 3 hours postoperatively in the SNB group (2.0 [1.0-4.0] vs. 4.0 [2.0-5.0] mL, p=0.044). CONCLUSION After minicraniotomy for clipping of UIAs, SNB reduced pain and IV-PCA consumption in the early postoperative period but did not improve the QoR-40 scores.
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Affiliation(s)
- Seungeun Choi
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Young Hoon Choi
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hoo Seung Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Kyong Won Shin
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Yoon Jung Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hee-Pyoung Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Won-Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyongmin Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Yu C, Liu Y, Tang Z, Zhang H. Enhanced recovery after surgery in patients undergoing craniotomy: A meta-analysis. Brain Res 2023; 1816:148467. [PMID: 37348748 DOI: 10.1016/j.brainres.2023.148467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/12/2023] [Accepted: 06/15/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND AND OBJECTIVE Enhanced recovery after surgery (ERAS) is a multidisciplinary,and evidence-based perioperative care method. It is effective in shortening hospital stays and improving clinical outcomes. However, the application of ERAS in craniotomy lacks reliable evidence. The purpose of this study is to investigate the efficacy and safety of ERAS in craniotomy. METHODS Studies of ERAS in craniotomy were systematically searched in PubMed, Embase, Cochrane, and Web of Science. Primary outcomes (total hospital stay and postoperative hospital stay, hospitalization cost, percent of patients with moderate to severe pain) and secondary outcomes (readmission rate and incidence of complication) were compared between ERAS and traditional perioperative care. RESULT Of the 10 studies included in this meta-analysis, 6 were randomized-controlled trials (RCTs), 3 were cohort studies, and 1 was non-RCT. A total of 1275 patients were included, with 648 in the ERAS group and 627 in the control group. Compared with the control group, the ERAS group had a significantly shortened total length of stay (LOS) (MD = -2.437, 95% CI: -3.616, -1.077, P = 0.001) and postoperative LOS, reduced hospitalization cost (SMD = -0.631, 95% CI: -0.893, -0.369, P = 0.001), and lower percent of patients with moderate to severe pain. There was no significant difference in readmission rate between the two groups. Though, the ERAS group had a significantly lower risk of pneumonia than the control group. CONCLUSION ERAS is safe and effective for craniotomy as it shortens total and postoperative LOS, reduces hospitalization costs, decreases the percent of patients with moderate to severe pain.
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Affiliation(s)
- Chunyang Yu
- Beijing Tiantan Hospital, Capital Medical University, China
| | - Yuqing Liu
- Department of Rehabilitation Medicine, Peking University Third Hospital, China
| | - Zhiqing Tang
- School of Rehabilitation, Capital Medical University, China; Beijing Bo'ai Hospital, China Rehabilitation Research Center, China
| | - Hao Zhang
- School of Rehabilitation, Capital Medical University, China; Beijing Bo'ai Hospital, China Rehabilitation Research Center, China; University of Health and Rehabilitation Sciences, China; Cheeloo College of Medicine, Shandong University, China.
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Luo M, Zhao X, Deng M, Hu Y, Yang X, Mei Z, Meng L, Wang Y. Scalp Nerve Block, Local Anesthetic Infiltration, and Postoperative Pain After Craniotomy: A Systematic Review and Network Meta-analysis of Randomized Trials. J Neurosurg Anesthesiol 2023; 35:361-374. [PMID: 36040025 DOI: 10.1097/ana.0000000000000868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 07/27/2022] [Indexed: 11/25/2022]
Abstract
The most efficacious methods for controlling postoperative pain in craniotomy remain unknown. A systematic review and network meta-analysis were performed to compare the efficacies of different strategies of scalp nerve block (SNB), scalp infiltration (SI), and control in patients undergoing craniotomy. MEDLINE, Embase, and CENTRAL databases were searched for randomized controlled trials. The primary outcome was postoperative 24-hour pain score, and the secondary outcome was opioid consumption within the first 24 hour after surgery. The effect was estimated using the between-group mean difference and ranked using the surface under the cumulative ranking curve (SUCRA) score. Twenty-four randomized trials were identified for inclusion. SNB using ropivacaine reduced postoperative 24-hour pain score when compared with control (mean difference [95% credible interval], -2.04 [-3.13, -0.94]; low quality), and when compared with SI using ropivacaine (-1.77 [-3.04, -0.51]; low quality) or bupivacaine (-1.96 [-3.65, -0.22]; low quality). SNB using ropivacaine was likely the most efficacious method for pain control (SUCRA, 91%), and also reduced opioid consumption within the first postoperative 24 hours as compared with control (mean difference [95% credible interval], -11.91 [-22.42, -1.4]; low quality). SNB using bupivacaine, lidocaine, and epinephrine combined, and SNB using ropivacaine, were likely the most efficacious methods for opioid consumption reduction (SUCRA, 88% and 80%, respectively). In summary, different methods of SNB / SI seem to have different efficacies after craniotomy. SNB using ropivacaine may be superior to other methods for postcraniotomy pain control; however, the overall quality of evidence was low.
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Affiliation(s)
- Mengqiang Luo
- Department of Anesthesiology, Huashan Hospital, Fudan University
| | - Xu Zhao
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou
| | - Meng Deng
- Department of Anesthesiology, Huashan Hospital, Fudan University
| | - Yue Hu
- Department of Anesthesiology, Huashan Hospital, Fudan University
| | - Xiaoyu Yang
- Department of Anesthesiology, Huashan Hospital, Fudan University
| | - Zubing Mei
- Anorectal Disease Institute of Shuguang Hospital, Shanghai
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Lingzhong Meng
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yingwei Wang
- Department of Anesthesiology, Huashan Hospital, Fudan University
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14
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Rahman RK, Ginalis EE, Patel Y, San A, Kotrike S, Gajjar AA, Ghani H, Rahman MM. Enhanced recovery after surgery (ERAS) for craniotomies in the treatment of brain tumors: A systematic review. Neurochirurgie 2023; 69:101442. [PMID: 37062467 DOI: 10.1016/j.neuchi.2023.101442] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/30/2023] [Accepted: 04/08/2023] [Indexed: 04/18/2023]
Abstract
INTRODUCTION Postoperative complications after craniotomy for brain tumors include pain, nausea/vomiting, and infection. A standardized enhanced recovery after surgery (ERAS) protocol is not widely accepted for this common neurosurgical procedure. Few studies have explored its application. METHODS A literature search of PubMed, Cochrane, and Google Scholar databases was performed between January 1992 and March 2023. Original studies that implemented an ERAS protocol for patients that underwent craniotomy for brain tumors were included. The following variables were evaluated: hospital length of stay (LOS), postoperative pain, postoperative nausea and vomiting (PONV) prophylaxis, non-opioid analgesia, and quality of life (QOL). RESULTS Twelve studies with a total of 1309 patients met inclusion criteria, including ten randomized controlled trials, one nonrandomized controlled trial, and one quality control study. Most frequently assessed metrics included hospital LOS, PONV prophylaxis, and non-opioid analgesia. A significant reduction in postoperative LOS was observed in 7 studies with ERAS or ERAS components. ERAS was significantly associated with pain reduction on the visual analog scale and verbal numerical rating scale (n=8). Non-opioid analgesia in ERAS improved postoperative pain control (n=4) and decreased the duration of pain (n=1). Three of six studies found no difference in PONV in ERAS vs. control. No studies reported an increase in postoperative complications using ERAS vs. control. One study showed greater patient satisfaction at 30-day follow-up with improved QOL. CONCLUSION Implementing ERAS protocol may enhance outcomes and quality of life in patients with moderate evidence for improved recovery in those undergoing craniotomy for brain tumors.
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Affiliation(s)
- Raphia K Rahman
- Rowan University School of Osteopathic Medicine, Stratford, NJ, USA.
| | - Elizabeth E Ginalis
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Yash Patel
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Ali San
- Kansas City University College of Osteopathic Medicine, Kansas City, MO, USA
| | | | - Avi A Gajjar
- Department of Chemistry, Union College, Schenectady, NY, USA
| | - Hira Ghani
- New York Institute of Technology College of Osteopathic Medicine, Glen Head, NY, USA
| | - Md Moshiur Rahman
- Department of Neurosurgery, Holy Family Red Crescent Medical College, Dhaka, Bangladesh
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Duda T, Lannon M, Gandhi P, Martyniuk A, Farrokhyar F, Sharma S. Systematic Review and Meta-Analysis of Randomized Controlled Trials for Scalp Block in Craniotomy. Neurosurgery 2023; 93:4-23. [PMID: 36762905 DOI: 10.1227/neu.0000000000002381] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 12/04/2022] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND Scalp block is regional anesthetic injection along nerves innervating the cranium. Scalp blocks for craniotomy may decrease postoperative pain and opioid consumption. Benefits may extend beyond the anesthetic period. OBJECTIVE To analyze evidence for scalp block on postoperative pain and opioid use. METHODS This systematic review and meta-analysis, Prospective Register of Systematic Reviews registration (CRD42022308048), included Ovid Medical Literature Analysis and Retrieval System Online, Embase, and Cochrane Central Register of Controlled Trials inception through February 9, 2022. Only randomized controlled trials were included. We excluded studies not reporting either main outcome. Duplicate reviewers performed study selection, risk of bias assessment, data extraction, and evidence certainty Grading of Recommendations Assessment, Development, and Evaluation appraisal. Main outcomes were postoperative pain by visual analog scale within 72 hours and opioid consumption as morphine milligram equivalent (MME) within 48 hours. RESULTS Screening filtered 955 studies to 23 trials containing 1532 patients. Risk of bias was overall low. Scalp block reduced postoperative pain at 2 through 72 hours, visual analog scale mean differences of 0.79 to 1.40. Opioid requirements were reduced at 24 hours by 16.52 MME and 48 hours by 15.63 MME. CONCLUSION Scalp block reduces postoperative pain at 2 through 48 hours and may reduce pain at 72 hours. Scalp block likely reduces opioid consumption within 24 hours and may reduce opioid consumption to 48 hours. The clinical utility of these differences should be interpreted within the context of modest absolute reductions, overall care optimization, and patient populations. This is the first level 1A evidence to evaluate scalp block efficacy in craniotomy.
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Affiliation(s)
- Taylor Duda
- Division of Neurosurgery, Department of Surgery, Hamilton General Hospital, McMaster University, Ontario, Canada
- Department of Health, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Melissa Lannon
- Division of Neurosurgery, Department of Surgery, Hamilton General Hospital, McMaster University, Ontario, Canada
- Department of Health, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Pranjan Gandhi
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario
| | - Amanda Martyniuk
- Division of Neurosurgery, Department of Surgery, Hamilton General Hospital, McMaster University, Ontario, Canada
| | - Forough Farrokhyar
- Department of Health, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Sunjay Sharma
- Division of Neurosurgery, Department of Surgery, Hamilton General Hospital, McMaster University, Ontario, Canada
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Ali A, Gupta B, Johansen P, Santiago RB, Dabecco R, Mandel M, Adada B, Botero J, Roy M, Borghei-Razavi H. Enhanced recovery after surgery in patients with normal pressure hydrocephalus undergoing ventriculoperitoneal shunting procedures. Clin Neurol Neurosurg 2023; 230:107757. [PMID: 37196458 DOI: 10.1016/j.clineuro.2023.107757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/02/2023] [Accepted: 05/03/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVE Patients with idiopathic normal pressure hydrocephalus (iNPH) who undergo ventriculoperitoneal shunt (VPS) placement often belong to an older demographic, putting them at increased risk of postoperative delirium and related complications. Recent literature documenting the use of Enhanced Recovery After Surgery (ERAS) protocols in various disciplines of surgery has shown improved clinical outcomes, faster discharge, and lower readmission rates. Early return to a familiar environment (i.e., discharged home) is a well-known predictor of reduced postoperative delirium. However, ERAS protocols are uncommon in neurosurgery, especially intracranial procedures. We developed a novel ERAS protocol for patients with iNPH undergoing VPS placement to gain further insight regarding postoperative complications, specifically delirium. METHODS We studied 40 patients with iNPH with indications for VPS. Seventeen patients were selected at random to undergo the ERAS protocol, and twenty-three patients underwent the standard VPS protocol. The ERAS protocol consisted of measures to reduce infection, manage pain, minimize invasiveness, confirm procedural success with imaging, and shorten the length of stay. Pre-operative American Society of Anesthesiologists (ASA) grade was collected for each patient to indicate baseline risk. Rates of readmission and postoperative complications, including delirium and infection, were collected at 48 h, 2 weeks, and 4 weeks postoperatively. RESULTS There were no perioperative complications among the 40 patients. There was no postoperative delirium in any of the ERAS patients. Postoperative delirium was observed in 10 of 23 non-ERAS patients. There was no statistically significant difference between the ASA grade between the ERAS and non-ERAS groups. CONCLUSIONS We described a novel ERAS protocol for patients with iNPH receiving VPS focusing on an early discharge. Our data suggest that ERAS protocols in VPS patients might reduce the incidence of delirium without increasing the risk of infection or other postoperative complications.
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Affiliation(s)
- Assad Ali
- Dr. Kiran C. Patel College of Osteopathic Medicine Davie, FL, USA
| | - Bhavika Gupta
- Neurosurgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Phillip Johansen
- Florida Atlantic University School of Medicine Boca Raton, FL, USA
| | | | - Rocco Dabecco
- Neurosurgery, Cleveland Clinic Florida, Weston, FL, USA
| | | | - Badih Adada
- Neurosurgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Juan Botero
- Neurosurgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Mayank Roy
- Neurosurgery, Cleveland Clinic Florida, Weston, FL, USA
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Kaewborisutsakul A, Kitsiripant C, Kaewsridam S, Kaewborisutsakul WK, Churuangsuk C. The influence of enhanced recovery after surgery protocol adherence in patients undergoing elective neuro-oncological craniotomies. World Neurosurg X 2023; 19:100196. [PMID: 37181587 PMCID: PMC10173293 DOI: 10.1016/j.wnsx.2023.100196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 04/05/2023] [Accepted: 04/11/2023] [Indexed: 05/16/2023] Open
Abstract
Objectives Enhanced recovery after surgery (ERAS) protocols have reduced the length of hospital stay (LOS) and healthcare costs without increasing adverse outcomes. We describe the impact of adherence to an ERAS protocol for elective craniotomy among neuro-oncology patients at a single institution. Methods This retrospective study enrolled adult patients who underwent elective craniotomy and the ERAS protocol at our institute between January 2020 and April 2021. The patients were divided into high- and low-adherence groups depending on their adherence to ≥9 or <9 of the 16 items, respectively. Inferential statistics were used to compare group outcomes, and multivariable logistic regression analysis was used to examine factors related to delayed discharge (LOS>7 days). Results Among the 100 patients assessed, median adherence was 8 items (range, 4-16), and 55 and 45 patients were classified into the high- and low-adherence groups, respectively. Age, sex, comorbidities, brain pathology, and operative profiles were comparable at baseline. The high-adherence group showed significantly better outcomes, including shorter median LOS (8 days vs. 11 days; p = 0.002) and lower median hospital costs (131,657.5 baht vs. 152,974 baht; p = 0.005). The groups showed no differences in 30-day postoperative complications or Karnofsky performance status. In the multivariable analysis, high adherence to the ERAS protocol (>50%) was the only significant factor preventing delayed discharge (OR = 0.28; 95% CI = 0.10 to 0.78; p = 0.04). Conclusions High adherence to ERAS protocols showed a strong association with short hospital stays and cost reductions. Our ERAS protocol was feasible and safe for patients undergoing elective craniotomy for brain tumors.
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Affiliation(s)
- Anukoon Kaewborisutsakul
- Neurological Surgery Unit, Division of Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Chanatthee Kitsiripant
- Division of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
- Corresponding author. Division of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand.
| | - Sukanya Kaewsridam
- Division of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | | | - Chaitong Churuangsuk
- Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
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18
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Levy AS, Merenzon MA, Eatz T, Morell AA, Eichberg DG, Bloom MJ, Shah AH, Komotar RJ, Ivan ME. Development of an enhanced recovery protocol after laser ablation surgery protocol: a preliminary analysis. Neurooncol Pract 2023; 10:281-290. [PMID: 37188164 PMCID: PMC10180378 DOI: 10.1093/nop/npad007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background Enhanced recovery after surgery (ERAS) programs are a model of care that aim to improve patient outcomes, reduce complications, and facilitate recovery while reducing healthcare-associated costs and admission length. While such programs have been developed in other surgical subspecialties, there have yet to be guidelines published specifically for laser interstitial thermal therapy (LITT). Here we describe the first multidisciplinary ERAS preliminary protocol for LITT for the treatment of brain tumors. Methods Between the years 2013 and 2021, 184 adult patients consecutively treated with LITT at our single institution were retrospectively analyzed. During this time, a series of pre, intra, and postoperative adjustments were made to the admission course and surgical/anesthesia workflow with the goal of improving recovery and admission length. Results The mean age at surgery was 60.7 years with a median preoperative Karnofsky performance score of 90 ± 13. Lesions were most commonly metastases (50%) and high-grade gliomas (37%). The mean length of stay was 2.4 days, with the average patient being discharged 1.2 days after surgery. There was an overall readmission rate of 8.7% with a LITT-specific readmission rate of 2.2%. Three of 184 patients required repeat intervention in the perioperative period, and there was one perioperative mortality. Conclusions This preliminary study shows the proposed LITT ERAS protocol to be a safe means of discharging patients on postoperative day 1 while preserving outcomes. Although future prospective work is needed to validate this protocol, results show the ERAS approach to be promising for LITT.
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Affiliation(s)
- Adam S Levy
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, Florida, 33136, USA
| | - Martin A Merenzon
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, Florida, 33136, USA
| | - Tiffany Eatz
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, Florida, 33136, USA
| | - Alexis A Morell
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, Florida, 33136, USA
| | - Daniel G Eichberg
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, Florida, 33136, USA
| | - Marc J Bloom
- Department of Anesthesiology, University of Miami Health System, Miami, Florida, USA
| | - Ashish H Shah
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, Florida, 33136, USA
| | - Ricardo J Komotar
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, Florida, 33136, USA
- Sylvester Cancer Center, University of Miami Health System, Miami, Florida, USA
| | - Michael E Ivan
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, Florida, 33136, USA
- Sylvester Cancer Center, University of Miami Health System, Miami, Florida, USA
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Schmidt AQ, von Euw S, Roy JM, Skandalakis GP, Kazim SF, Schmidt MH, Bowers CA. Frailty predicts hospital acquired infections after brain tumor resection: Analysis of 27,947 patients' data from a prospective multicenter surgical registry. Clin Neurol Neurosurg 2023; 229:107724. [PMID: 37119655 DOI: 10.1016/j.clineuro.2023.107724] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 05/01/2023]
Abstract
BACKGROUND Hospital acquired infections (HAIs) present a significant source of economic burden in the United States. The role of frailty as a predictor of HAIs has not been illustrated among patients undergoing craniotomy for brain tumor resection (BTR). METHODS The American College of Surgery National Surgical Quality Improvement Program (ACS-NSQIP) database was queried from 2015 to 2019 to identify patients who underwent craniotomy for BTR. Patients were categorized as pre-frail, frail and severely frail using the 5-factor Modified Frailty Index (mFI-5). Demographics, clinical and laboratory parameters, and HAIs were assessed. A multivariate logistic regression model was created to predict the occurrence of HAIs using these variables. RESULTS A total of 27,947 patients were assessed. 1772 (6.3 %) of these patients developed an HAI after surgery. Severely frail patients were more likely to develop an HAI in comparison to pre-frail patients (OR = 2.48, 95 % CI = 1.65-3.74, p < 0.001 vs. OR = 1.43, 95 % CI = 1.18-1.72, p < 0.001). Ventilator dependence was the strongest predictor of developing an HAI (OR = 2.96, 95 % CI = 1.86-4.71, p < 0.001). CONCLUSION Baseline frailty, by virtue of its ability to predict HAIs, should be utilized in adopting measures to reduce the incidence of HAIs.
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Affiliation(s)
- Albert Q Schmidt
- Faculty of Science, University of Zurich, CH-8057, Switzerland; Faculty of Medicine, University of Zurich, CH-8057, Switzerland
| | - Salome von Euw
- Faculty of Science, University of Zurich, CH-8057, Switzerland; Faculty of Medicine, University of Zurich, CH-8057, Switzerland
| | - Joanna M Roy
- Topiwala National Medical College and B. Y. L. Nair Charitable Hospital, Mumbai, Maharashtra 400008, India
| | - Georgios P Skandalakis
- Department of Neurosurgery, Bowers' Neurosurgical Frailty and Outcomes Data Science Lab, University of New Mexico Hospital (UNMH), Albuquerque, NM 87131, USA
| | - Syed Faraz Kazim
- Department of Neurosurgery, Bowers' Neurosurgical Frailty and Outcomes Data Science Lab, University of New Mexico Hospital (UNMH), Albuquerque, NM 87131, USA
| | - Meic H Schmidt
- Department of Neurosurgery, Bowers' Neurosurgical Frailty and Outcomes Data Science Lab, University of New Mexico Hospital (UNMH), Albuquerque, NM 87131, USA
| | - Christian A Bowers
- Department of Neurosurgery, Bowers' Neurosurgical Frailty and Outcomes Data Science Lab, University of New Mexico Hospital (UNMH), Albuquerque, NM 87131, USA.
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20
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Phillips KR, Enriquez-Marulanda A, Mackel C, Ogbonna J, Moore JM, Vega RA, Alterman RL. Predictors of extended length of stay related to craniotomy for tumor resection. World Neurosurg X 2023; 19:100176. [PMID: 37123627 PMCID: PMC10139985 DOI: 10.1016/j.wnsx.2023.100176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Background Hospital length of stay (LOS) related to craniotomy for tumor resection (CTR) is a marker of neurosurgical quality of care. Limiting LOS benefits both patients and hospitals. This study examined which factors contribute to extended LOS (eLOS) at our academic center. Methods Retrospective medical record review of 139 consecutive CTRs performed between July 2020 and July 2021. Univariate and multivariable analyses determined which factors were associated with an eLOS (≥8 days). Results Median LOS was 6 days (IQR 3-9 days). Fifty-one subjects (36.7%) experienced an eLOS. Upon univariate analysis, potentially modifiable factors associated with eLOS included days to occupational therapy (OT), physical therapy (PT), and case management clearance (p < .001); and discharge disposition (p < .001). Multivariable analysis revealed that pre-operative anti-coagulant use (OR 10.74, 95% CI 2.64-43.63, p = .001), Medicare (OR 4.80, 95% CI 1.07-21.52, p = .04), ED admission (OR 26.21, 95% CI 5.17-132.99, p < .001), transfer to another service post-surgery (OR 30.00, 95% CI 1.56-577.35, p = .02), and time to post-operative imaging (OR 2.91, 95% CI 1.27-6.65, p = .01) were associated with eLOS. Extended LOS was not significantly associated with ED visits (p = .45) or unplanned readmissions within 30 days of surgery (p = .35), and both (p = .04; p = .04) were less likely following a short LOS (<5 days). Conclusion While some factors driving LOS related to CTR are uncontrollable, expedient pre- and post-operative management may reduce LOS without compromising care.
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Luo M, Zhao X, Tu M, Yang X, Deng M, Wang Y. The effectiveness of scalp nerve block on hemodynamic response in craniotomy: a systematic review and meta-analysis of randomized trials. Minerva Anestesiol 2023; 89:85-95. [PMID: 36448987 DOI: 10.23736/s0375-9393.22.16775-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
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.
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Affiliation(s)
- Mengqiang Luo
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xu Zhao
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Mengyun Tu
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaoyu Yang
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Meng Deng
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yingwei Wang
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China -
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22
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Wang Y, Xue YF, Zhao BF, Guo SC, Ji PG, Liu JH, Wang N, Chen F, Zhai YL, Wang Y, Xue YR, Gao GD, Qu Y, Wang L. Real-World Implementation of Neurosurgical Enhanced Recovery After Surgery Protocol for Gliomas in Patients Undergoing Elective Craniotomy. Front Oncol 2022; 12:860257. [PMID: 35686112 PMCID: PMC9171236 DOI: 10.3389/fonc.2022.860257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 04/11/2022] [Indexed: 11/14/2022] Open
Abstract
Objective To design a multidisciplinary enhanced recovery after surgery (ERAS) protocol for glioma patients undergoing elective craniotomy and evaluate its clinical efficacy and safety after implementation in a tertiary neurosurgical center in China. Methods ERAS protocol for glioma patients was developed and modified based on the best available evidence. Patients undergoing elective craniotomy for treatment of glioma between September 2019 to May 2021 were enrolled in a randomized clinical trial comparing a conventional neurosurgical perioperative care (control group) to an ERAS protocol (ERAS group). The primary outcome was postoperative hospital length of stay (LOS). Secondary outcomes were 30-day readmission rate, postoperative complications, duration of the drainage tube, time to first oral fluid intake, time to ambulation and functional recovery status. Results A total of 151 patients were enrolled (ERAS group: n = 80; control group: n = 71). Compared with the control group, postoperative LOS was significantly shorter in the ERAS group (median: 5 days vs. 7 days, p<0.0001). No 30-day readmission or reoperation occurred in either group. The time of first oral intake, urinary catheter removal within 24 h and early ambulation on postoperative day (POD) 1 were earlier and shorter in the ERAS group compared with the control group (p<0.001). No statistical difference was observed between the two groups in terms of surgical- and nonsurgical-related complications. Functional recovery in terms of Karnofsky Performance Status (KPS) scores both at discharge and 30-day follow-up was similar in the two groups. Moreover, no significant difference was found between the two groups in the Hospital Anxiety and Depression Scale (HADS) scores. Conclusion The implementation of the ERAS protocol for glioma patients offers significant benefits over conventional neurosurgical perioperative management, as it is associated with enhancing postoperative recovery, without additional perioperative complications and risks. Clinical Trial Registration Chinese Clinical Trial Registry (http://www.chictr.org.cn/showproj.aspx?proj=42016), identifier ChiCTR1900025108
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Affiliation(s)
- Yuan Wang
- Department of Neurosurgery, Tangdu Hospital, Airforce Medical University, Xi'an, China
| | - Ya-Fei Xue
- Department of Neurosurgery, Tangdu Hospital, Airforce Medical University, Xi'an, China
| | - Bin-Fang Zhao
- Department of Neurosurgery, Tangdu Hospital, Airforce Medical University, Xi'an, China
| | - Shao-Chun Guo
- Department of Neurosurgery, Tangdu Hospital, Airforce Medical University, Xi'an, China
| | - Pei-Gang Ji
- Department of Neurosurgery, Tangdu Hospital, Airforce Medical University, Xi'an, China
| | - Jing-Hui Liu
- Department of Neurosurgery, Tangdu Hospital, Airforce Medical University, Xi'an, China
| | - Na Wang
- Department of Neurosurgery, Tangdu Hospital, Airforce Medical University, Xi'an, China
| | - Fan Chen
- Department of Neurosurgery, Tangdu Hospital, Airforce Medical University, Xi'an, China
| | - Yu-Long Zhai
- Department of Neurosurgery, Tangdu Hospital, Airforce Medical University, Xi'an, China
| | - Yue Wang
- Department of Health Statistics, Airforce Medical University, Xi'an, China
| | - Yan-Rong Xue
- National Time Service Center, Chinese Academy of Sciences, Xi'an, China.,School of Optoelectronics, University of Chinese Academy of Sciences, Beijing, China
| | - Guo-Dong Gao
- Department of Neurosurgery, Tangdu Hospital, Airforce Medical University, Xi'an, China
| | - Yan Qu
- Department of Neurosurgery, Tangdu Hospital, Airforce Medical University, Xi'an, China
| | - Liang Wang
- Department of Neurosurgery, Tangdu Hospital, Airforce Medical University, Xi'an, China
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23
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Greisman JD, Olmsted ZT, Crorkin PJ, Dallimore CA, Zhigin V, Shlifer A, Bedi AD, Kim JK, Nelson P, Sy HL, Patel KV, Ellis JA, Boockvar J, Langer DJ, D'Amico RS. Enhanced Recovery After Surgery (ERAS) for Cranial Tumor Resection: A Review. World Neurosurg 2022; 163:104-122.e2. [PMID: 35381381 DOI: 10.1016/j.wneu.2022.03.118] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/25/2022] [Accepted: 03/26/2022] [Indexed: 11/15/2022]
Abstract
Enhanced Recovery After Surgery (ERAS) protocols describe a standardized method of preoperative, perioperative, and postoperative care to enhance outcomes and minimize complication risks surrounding elective surgical intervention. A growing body of evidence is being generated as we learn to apply principles of ERAS standardization to neurosurgical patients. First applied in spinal surgery, ERAS protocols have been extended to cranial neuro-oncological procedures. This review synthesizes recent findings to generate evidence-based guidelines to manage neurosurgical oncology patients with standardized systems and assess ability of these systems to coordinate multidisciplinary, patient-centric care efforts. Furthermore, we highlight the potential utility of multimedia, app-based communication platforms to facilitate patient education, autonomy, and team communication within each of the three settings.
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Affiliation(s)
- Jacob D Greisman
- Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY.
| | - Zachary T Olmsted
- Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY
| | - Patrick J Crorkin
- Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY
| | - Colin A Dallimore
- Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY
| | - Vadim Zhigin
- Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY
| | - Artur Shlifer
- Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY
| | - Anupama D Bedi
- Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY
| | - Jane K Kim
- Department of Anesthesiology, Lenox Hill Hospital/Northwell Health, New York, NY
| | - Priscilla Nelson
- Department of Anesthesiology, Lenox Hill Hospital/Northwell Health, New York, NY
| | - Heustein L Sy
- Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY
| | - Kiran V Patel
- Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY
| | - Jason A Ellis
- Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY
| | - John Boockvar
- Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY
| | - David J Langer
- Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY
| | - Randy S D'Amico
- Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY
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