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Zhang Q, Xu J, Huang Q, Gong T, Li J, Cui Y. Risk factors for delayed extubation after pediatric perineal anaplasty in patients less than 1 year of age: a retrospective study. BMC Pediatr 2024; 24:307. [PMID: 38711038 DOI: 10.1186/s12887-024-04781-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 04/22/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND Anorectal malformation is a common congenital problem occurring in 1 in 5,000 births and has a spectrum of anatomical presentations, requiring individualized surgical treatments for normal growth. Delayed extubation or reintubation may result in a longer intensive care unit (ICU) stay and hospital stay, increased mortality, prolonged duration of mechanical ventilation, increased tracheostomy rate, and higher hospital costs. Extensive studies have focused on the role of risk factors in early extubation during major infant surgery such as Cardiac surgery, neurosurgery, and liver surgery. However, no study has mentioned the influencing factors of delayed extubation in neonates and infants undergoing angioplasty surgery. MATERIALS AND METHODS We performed a retrospective study of neonates and infants who underwent anorectal malformation surgery between June 2018 and June 2022. The principal goal of this study was to observe the incidence of delayed extubation in pediatric anorectal malformation surgery. The secondary goals were to identify the factors associated with delayed extubation in these infants. RESULTS We collected data describing 123 patients who had anorectal malformations from 2019 to 2022. It shows that 74(60.2%) in the normal intubation group and 49(39.8%) in the longer extubation. In the final model, anesthesia methods were independently associated with delayed extubation (P < 0.05). CONCLUSION We found that the anesthesia method was independently associated with early extubation in neonates and infants who accepted pediatric anorectal malformation surgery.
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Affiliation(s)
- Qianqian Zhang
- Department of Anesthesiology, The Affiliated Hospital, School of Medicine, UESTC Chengdu Women's & Children's Central Hospital, Chengdu, 610091, China
| | - Jing Xu
- Department of Anesthesiology, The Affiliated Hospital, School of Medicine, UESTC Chengdu Women's & Children's Central Hospital, Chengdu, 610091, China
| | - Qinghua Huang
- Department of Anesthesiology, The Affiliated Hospital, School of Medicine, UESTC Chengdu Women's & Children's Central Hospital, Chengdu, 610091, China
| | - Tianqing Gong
- Department of Anesthesiology, The Affiliated Hospital, School of Medicine, UESTC Chengdu Women's & Children's Central Hospital, Chengdu, 610091, China
| | - Jia Li
- Department of Anesthesiology, The Affiliated Hospital, School of Medicine, UESTC Chengdu Women's & Children's Central Hospital, Chengdu, 610091, China
| | - Yu Cui
- Department of Anesthesiology, The Affiliated Hospital, School of Medicine, UESTC Chengdu Women's & Children's Central Hospital, Chengdu, 610091, China.
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Jiang M, Zhang X, Zhang Y, Liu Y, Geng R, Liu H, Sun Y, Wang B. The Effects of Perioperative Probiotics on Postoperative Gastrointestinal Function in Patients with Brain Tumors: A Randomized, Placebo-Controlled Study. Nutr Cancer 2023; 75:1132-1142. [PMID: 37139872 DOI: 10.1080/01635581.2023.2178929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
The incidence of postoperative gastrointestinal dysfunction among neurosurgical patients is as high as 80%. Probiotics help to maintain gastrointestinal barrier defense, provide competitive adherence to mucus and epithelial cells, and regulate gastrointestinal motility. Therefore, the purpose of this study was to investigate whether probiotics enhance gastrointestinal health after craniotomy in patients with brain tumors. This study was a 15-day, prospective, randomized, double-blind, placebo-controlled trial for patients being treated with elective craniotomy for brain tumors. Participants were randomly divided into the probiotics group (4 g probiotics, twice daily) and placebo group. The primary outcome was the time of first stool after surgery. The secondary outcomes included assessments of the gastrointestinal function, changes in gastrointestinal permeability and clinical outcomes. We enrolled a total of 200 participants (probiotics: 100; placebo: 100) and followed the principles of intention-to-treat analysis. The time of first stool and flatus were significantly shorter in the probiotics group compared to the placebo group (P < 0.001, respectively). No significant trends were observed for any other of the secondary outcome variables. Our findings suggest that probiotics can improve the gastrointestinal mobility of patients received craniotomy, and this improvement cannot be explained by changes in gastrointestinal permeability.
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Affiliation(s)
- Mengyang Jiang
- Department of Anesthesiology, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Xiaoyu Zhang
- Department of Anesthesiology, Sanbo Brain Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Clinical Epidemiology, School of Public Health, Capital Medical University, Beijing, China
| | - Yiqiang Zhang
- Department of Anesthesiology, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Yang Liu
- Department of Anesthesiology, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Ran Geng
- Zhongke Yikang Biological Technology Company, Beijing, China
| | - Haixia Liu
- Zhongke Yikang Biological Technology Company, Beijing, China
| | - Yongxing Sun
- Department of Anesthesiology, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Baoguo Wang
- Department of Anesthesiology, Sanbo Brain Hospital, Capital Medical University, Beijing, China
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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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Hurtado P, Tercero J, Garcia-Orellana M, Enseñat J, Reyes L, Cabedo G, Rios J, Carrero E, de Riva N, Fontanals J, Gracia I, Belda I, Lopez AM, Fabregas N, Valero R. Hemodynamic Response, Coughing and Incidence of Cerebrospinal Fluid Leakage on Awakening with an Endotracheal Tube or Laryngeal Mask Airway in Place after Transsphenoidal Pituitary Surgery: A Randomized Clinical Trial. J Clin Med 2021; 10:2874. [PMID: 34203476 PMCID: PMC8269347 DOI: 10.3390/jcm10132874] [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: 05/28/2021] [Revised: 06/23/2021] [Accepted: 06/25/2021] [Indexed: 11/16/2022] Open
Abstract
We aimed to compare systemic and cerebral hemodynamics and coughing during emergence after pituitary surgery after endotracheal tube (ETT) extubation or after replacing ETT with a laryngeal mask airway (LMA). Patients were randomized to awaken with an ETT in place or after replacing it with an LMA. We recorded mean arterial pressure (MAP), heart rate, middle cerebral artery (MCA) flow velocity, regional cerebral oxygen saturation (SrO2), cardiac index, plasma norepinephrine, need for vasoactive drugs, coughing during emergence, and postoperative cerebrospinal fluid (CSF) leakage. The primary endpoint was postoperative MAP; secondary endpoints were SrO2 and coughing incidence. Forty-five patients were included. MAP was lower during emergence than at baseline in both groups. There were no significant between-group differences in blood pressure, nor in the number of patients that required antihypertensive drugs during emergence (ETT: 8 patients (34.8%) vs. LMA: 3 patients (14.3%); p = 0.116). MCA flow velocity was higher in the ETT group (e.g., mean (95% CI) at 15 min, 103.2 (96.3-110.1) vs. 89.6 (82.6-96.5) cm·s-1; p = 0.003). SrO2, cardiac index, and norepinephrine levels were similar. Coughing was more frequent in the ETT group (81% vs. 15%; p < 0.001). CSF leakage occurred in three patients (13%) in the ETT group. Placing an LMA before removing an ETT during emergence after pituitary surgery favors a safer cerebral hemodynamic profile and reduces coughing. This strategy may lower the risk for CSF leakage.
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Affiliation(s)
- Paola Hurtado
- Department of Anesthesiology, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (P.H.); (J.T.); (M.G.-O.); (G.C.); (E.C.); (N.d.R.); (J.F.); (I.G.); (I.B.); (A.M.L.); (N.F.)
| | - Javier Tercero
- Department of Anesthesiology, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (P.H.); (J.T.); (M.G.-O.); (G.C.); (E.C.); (N.d.R.); (J.F.); (I.G.); (I.B.); (A.M.L.); (N.F.)
| | - Marta Garcia-Orellana
- Department of Anesthesiology, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (P.H.); (J.T.); (M.G.-O.); (G.C.); (E.C.); (N.d.R.); (J.F.); (I.G.); (I.B.); (A.M.L.); (N.F.)
| | - Joaquim Enseñat
- Department of Neurosurgery, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (J.E.); (L.R.)
| | - Luis Reyes
- Department of Neurosurgery, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (J.E.); (L.R.)
| | - Gemma Cabedo
- Department of Anesthesiology, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (P.H.); (J.T.); (M.G.-O.); (G.C.); (E.C.); (N.d.R.); (J.F.); (I.G.); (I.B.); (A.M.L.); (N.F.)
| | - Jose Rios
- Biostatistics and Data Management Platform, Hospital Clínic de Barcelona, University of Barcelona, Barcelona,08036, Spain;
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Enrique Carrero
- Department of Anesthesiology, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (P.H.); (J.T.); (M.G.-O.); (G.C.); (E.C.); (N.d.R.); (J.F.); (I.G.); (I.B.); (A.M.L.); (N.F.)
| | - Nicolas de Riva
- Department of Anesthesiology, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (P.H.); (J.T.); (M.G.-O.); (G.C.); (E.C.); (N.d.R.); (J.F.); (I.G.); (I.B.); (A.M.L.); (N.F.)
| | - Jaume Fontanals
- Department of Anesthesiology, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (P.H.); (J.T.); (M.G.-O.); (G.C.); (E.C.); (N.d.R.); (J.F.); (I.G.); (I.B.); (A.M.L.); (N.F.)
| | - Isabel Gracia
- Department of Anesthesiology, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (P.H.); (J.T.); (M.G.-O.); (G.C.); (E.C.); (N.d.R.); (J.F.); (I.G.); (I.B.); (A.M.L.); (N.F.)
| | - Isabel Belda
- Department of Anesthesiology, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (P.H.); (J.T.); (M.G.-O.); (G.C.); (E.C.); (N.d.R.); (J.F.); (I.G.); (I.B.); (A.M.L.); (N.F.)
| | - Ana M. Lopez
- Department of Anesthesiology, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (P.H.); (J.T.); (M.G.-O.); (G.C.); (E.C.); (N.d.R.); (J.F.); (I.G.); (I.B.); (A.M.L.); (N.F.)
| | - Neus Fabregas
- Department of Anesthesiology, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (P.H.); (J.T.); (M.G.-O.); (G.C.); (E.C.); (N.d.R.); (J.F.); (I.G.); (I.B.); (A.M.L.); (N.F.)
| | - Ricard Valero
- Department of Anesthesiology, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain; (P.H.); (J.T.); (M.G.-O.); (G.C.); (E.C.); (N.d.R.); (J.F.); (I.G.); (I.B.); (A.M.L.); (N.F.)
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), 08036 Barcelona, Spain
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Lepski G, Reis B, de Oliveira A, Neville I. Recursive partitioning analysis of factors determining infection after intracranial tumor surgery. Clin Neurol Neurosurg 2021; 205:106599. [PMID: 33901746 DOI: 10.1016/j.clineuro.2021.106599] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 03/11/2021] [Accepted: 03/14/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Several factors are commonly associated with the occurrence of post-operative infection after craniotomy. However, the risk factors associated with tumor surgery have been less intensively investigated. The aim of the present study was to analyze the risk factors for infection and categorize patients according to risk rate. METHODS In this study, we retrospectively evaluated 987 adult patients consecutively submitted to craniotomy for tumor resection. The primary outcome was the occurrence of infection within 30 days after surgery. The following independent variables were assessed: age, gender, surgery duration, length of hospital stay prior to surgery, reoperation, body mass index, serum albumin, hemoglobin, lactic dehydrogenase, smoking, diabetes, corticoid use, preoperative chemotherapy, previous irradiation, elective or urgent indication for surgery, supra or infratentorial lesion location, and tumor histology. We performed a recursive partitioning analysis to assess the relative importance of these variables in predicting infection. RESULTS The model returned a 3-level classification: 1. CSF-leakage (relative contribution 70%), 2. Emergency surgery indication (18%), and 3. Tumor histology (8%). Additionally, partitioning clustered together 3 risk groups: 1. CSF-leakage group (probability of infection 72.5%), 2. No CSF-leakage and urgent surgery (mean probability 18.1%); and 3. no CSF-leakage and no urgent surgery (3.4%). The misclassification rate was 4.5%, the overall specificity and sensitivity were 99.6% and 75.5%, respectively, and the area under the ROC-curve was 0.6908. CONCLUSION Our analysis indicates that technical and treatment-related factors are significantly more relevant than patient- or disease-related factors in determining the risk of postoperative infection.
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Affiliation(s)
- Guilherme Lepski
- Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, LIM26, São Paulo, Brazil; Department of Neurosurgery, University Eberhard Karls, Tübingen, Germany.
| | - Bruno Reis
- Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, LIM26, São Paulo, Brazil
| | - Adilson de Oliveira
- Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, LIM26, São Paulo, Brazil
| | - Iuri Neville
- Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, LIM26, São Paulo, Brazil
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Lončar-Stojiljković D, Maksimović Ž, Đurić M. Esmolol as an adjunct to general balanced anaesthesia in neurosurgery. SCRIPTA MEDICA 2021. [DOI: 10.5937/scriptamed52-35617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Background/Aim: In surgery, and especially in the neurosurgical operations, maintenance of cardiovascular stability during and in the phase of the immediate postoperative recovery is of vital importance. The aim of this study was to investigate the effects of continuous esmolol infusion on the values of cardiovascular parameters and quality of the emergence from anaesthesia in neurosurgical patients. Methods: A total of 40 patients of both sexes scheduled for elective supratentorial surgery were randomly assigned to two groups. Esmolol group received intravenous (iv) infusion of esmolol dissolved in 5 % glucose solution (during the first 5 min at a rate of 0.3 mg/kg/min and thereafter at a rate of 0.1 mg/kg/min), while the ones from the control group received a 5 % glucose solution without esmolol at the same volume and rate. Cardiovascular parameters were registered at critical phases of anaesthesia and operation (induction, intubation, placement of Mayfield frame, craniotomy, skull closure, extubation). Recovery after anaesthesia was assessed based on times of eye opening on command, spontaneous eye opening and regaining of full orientation. Results: Values of systolic blood pressure and heart rate were significantly lower in the esmolol than in the control group of patients. Although the durations of anaesthesia did not differ, patients from the esmolol group required significantly less opioids and isoflurane and recovered after the anaesthesia significantly faster than the patients in the control group. Conclusion: Ultrashort-acting beta-adrenergic receptor antagonist esmolol, administered as a continuous iv infusion, assures better cardiovascular stability and smoother emergence from the balanced inhalation general anaesthesia than the control glucose infusion in elective neurosurgical patients.
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Khozenko A, Lamperti M, Velly L, Simeone P, Tufegdzic B. Role of anaesthesia in neurosurgical enhanced recovery programmes. Best Pract Res Clin Anaesthesiol 2020; 35:241-253. [PMID: 34030808 DOI: 10.1016/j.bpa.2020.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 10/29/2020] [Accepted: 11/02/2020] [Indexed: 12/12/2022]
Abstract
The application of Enhanced Recovery After Surgery (ERAS) in neurosurgical practice is a relatively new concept. A limited number of studies involving ERAS protocols within neurosurgery, specifically for elective craniotomy, have been published, contrary to the ERAS spine surgery pathways that are now promoted by numerous national and international dedicated surgical societies and hospitals. In this review, we want to present the patient surgical journey from an anaesthesia perspective through the key components that can be included in the ERAS pathways for neurosurgical procedures, both craniotomies and major spine surgery.
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Affiliation(s)
- Andrey Khozenko
- Anaesthesiology Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, PO box 112412, Abu Dhabi, United Arab Emirates
| | - Massimo Lamperti
- Anaesthesiology Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, PO box 112412, Abu Dhabi, United Arab Emirates.
| | - Lionel Velly
- Aix Marseille Univ, AP-HM, Department of Anesthesiology and Critical Care Medicine, University Hospital Timone, 264 rue saint Pierre, 13005, CEDEX 5, Marseille, France.
| | - Pierre Simeone
- Aix Marseille Univ, AP-HM, Department of Anesthesiology and Critical Care Medicine, University Hospital Timone, 264 rue saint Pierre, 13005, CEDEX 5, Marseille, France.
| | - Boris Tufegdzic
- Anaesthesiology Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, PO box 112412, Abu Dhabi, United Arab Emirates.
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The Activation of Phosphatidylserine/CD36/TGF- β1 Pathway prior to Surgical Brain Injury Attenuates Neuroinflammation in Rats. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2020; 2020:4921562. [PMID: 32849998 PMCID: PMC7441426 DOI: 10.1155/2020/4921562] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 07/23/2020] [Indexed: 12/12/2022]
Abstract
Neuroinflammation plays an important pathological role in experimental surgical brain injury (SBI). Apoptotic associated with phosphatidylserine (PS) externalization promotes anti-inflammatory mediator TGF-β1 release. In the present study, we investigated the anti-neuroinflammation effect of PS liposome or isoflurane pretreatment via PS/CD36/TGF-β1 signaling in a rat model of SBI. A total of 120 male Sprague-Dawley rats (weighing 280-330 gms) were used. SBI was induced by partial right frontal lobe corticotomy. Intranasal PS liposome or isoflurane inhalation was administered prior to SBI induction. CD36 small interfering RNA (siRNA) was administered intracerebroventricularly. Recombinant Annexin V protein (rAnnexin V) was delivered intranasally. Post-SBI assessments included neurological tests, brain water content, Western blot, and immunohistochemistry. Endogenous CD36 protein levels but not TGF-β1 was significantly increased within peri-resection brain tissues over 72 h after SBI. SBI rats were associated with increased brain water content surrounding corticotomy and neurological deficits. PS liposome pretreatment significantly reduced brain water content and improved some neurological deficits at 24 hours and 72 hours after SBI. PS liposome increased CD36 and TGF-β1 protein levels, but decreased IL-1β and TNFα protein levels in peri-resection brain tissues at 24 hours after SBI. CD36 siRNA or rAnnexin V partially countered the protective effect of PS liposome. Isoflurane pretreatment produced similar antineuroinflammation and neurological benefits in SBI rats partially by upregulating CD36/Lyn/TGF-β1 signaling. Collectively, our findings suggest that the activation of PS/CD36/TGF-β1 pathway by PS liposome or isoflurane prior to SBI could attenuate neuroinflammation and improve neurological outcomes in rats. PS liposome or isoflurane pretreatment may serve as an effective preventive strategy to minimize the brain injury caused by neurosurgical procedures in patients.
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9
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de Almeida CC, Boone MD, Laviv Y, Kasper BS, Chen CC, Kasper EM. The Utility of Routine Intensive Care Admission for Patients Undergoing Intracranial Neurosurgical Procedures: A Systematic Review. Neurocrit Care 2019; 28:35-42. [PMID: 28808901 DOI: 10.1007/s12028-017-0433-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Patients who have undergone intracranial neurosurgical procedures have traditionally been admitted to an intensive care unit (ICU) for close postoperative neurological observation. The purpose of this study was to systematically review the evidence for routine ICU admission in patients undergoing intracranial neurosurgical procedures and to evaluate the safety of alternative postoperative pathways. METHODS We were interested in identifying studies that examined selected patients who presented for elective, non-emergent intracranial surgery whose postoperative outcomes were compared as a function of ICU versus non-ICU admission. A systematic review was performed in July 2016 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist of the Medline database. The search strategy was created based on the following key words: "craniotomy," "neurosurgical procedure," and "intensive care unit." RESULTS The nine articles that satisfied the inclusion criteria yielded a total of 2227 patients. Of these patients, 879 were observed in a non-ICU setting. The most frequent diagnoses were supratentorial brain tumors, followed by patients with cerebrovascular diseases and infratentorial brain tumors. Three percent (30/879) of the patients originally assigned to floor or intermediate care status were transferred to the ICU. The most frequently observed neurological complications leading to ICU transfer were delayed postoperative neurological recovery, seizures, worsening of neurological deficits, hemiparesis, and cranial nerves deficits. CONCLUSION Our systematic review demonstrates that routine postoperative ICU admission may not benefit carefully selected patients who have undergone elective intracranial neurosurgical procedures. In addition, limiting routine ICU admission may result in significant cost savings.
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Affiliation(s)
- Cesar Cimonari de Almeida
- Department of Surgery, Division of Neurosurgery, Beth Israel Deaconess Medical Center, Lowry Medical Building 3B, 02215, Boston, MA, USA
| | - M Dustin Boone
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Yosef Laviv
- Department of Surgery, Division of Neurosurgery, Beth Israel Deaconess Medical Center, Lowry Medical Building 3B, 02215, Boston, MA, USA
| | | | - Clark C Chen
- Department of Neurosurgery, University of California San Diego, San Diego, CA, USA
| | - Ekkehard M Kasper
- Department of Surgery, Division of Neurosurgery, Beth Israel Deaconess Medical Center, Lowry Medical Building 3B, 02215, Boston, MA, USA
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10
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Huang HW, Yan LM, Yang YL, He X, Sun XM, Wang YM, Zhang GB, Zhou JX. Bi-frontal pneumocephalus is an independent risk factor for early postoperative agitation in adult patients admitted to intensive care unit after elective craniotomy for brain tumor: A prospective cohort study. PLoS One 2018; 13:e0201064. [PMID: 30024979 PMCID: PMC6053234 DOI: 10.1371/journal.pone.0201064] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 06/07/2018] [Indexed: 12/18/2022] Open
Abstract
Postoperative agitation frequently occurs after general anesthesia and may be associated with serious consequences. However, studies in neurosurgical patients have been inadequate. We aimed to investigate the incidence and risk factors for early postoperative agitation in patients after craniotomy, specifically focusing on the association between postoperative pneumocephalus and agitation. Adult intensive care unit admitted patients after elective craniotomy under general anesthesia were consecutively enrolled. Patients were assessed using the Sedation-Agitation Scale during the first 24 hours after operation. The patients were divided into two groups based on their maximal Sedation-Agitation Scale: the agitation (Sedation-Agitation Scale ≥ 5) and non-agitation groups (Sedation-Agitation Scale ≤ 4). Preoperative baseline data, intraoperative and intensive care unit admission data were recorded and analyzed. Each patient's computed tomography scan obtained within six hours after operation was retrospectively reviewed. Modified Rankin Scale and hospital length of stay after the surgery were also collected. Of the 400 enrolled patients, agitation occurred in 13.0% (95% confidential interval: 9.7-16.3%). Body mass index, total intravenous anesthesia, intraoperative fluid intake, intraoperative bleeding and transfusion, consciousness after operation, endotracheal intubation kept at intensive care unit admission and mechanical ventilation, hyperglycemia without a history of diabetes, self-reported pain and postoperative bi-frontal pneumocephalus were used to build a multivariable model. Bi-frontal pneumocephalus and delayed extubation after the operation were identified as independent risk factors for postoperative agitation. After adjustment for confounding, postoperative agitation was independently associated with worse neurologic outcome (odd ratio: 5.4, 95% confidential interval: 1.1-28.9, P = 0.048). Our results showed that early postoperative agitation was prevalent among post-craniotomy patients and was associated with adverse outcomes. Improvements in clinical strategies relevant to bi-frontal pneumocephalus should be considered. TRIAL REGISTRATION ClinicalTrials.gov (NCT02318199).
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Affiliation(s)
- Hua-Wei Huang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Li-Mei Yan
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Critical Care Medicine, Inner Mongolia People’s Hospital, Hohhot, Inner Mongolia, China
| | - Yan-Lin Yang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuan He
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiu-Mei Sun
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yu-Mei Wang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guo-Bin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- * E-mail:
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The Prophylactic Use of Remifentanil for Delayed Extubation After Elective Intracranial Operations: a Prospective, Randomized, Double-Blinded Trial. J Neurosurg Anesthesiol 2018; 29:281-290. [PMID: 27152427 DOI: 10.1097/ana.0000000000000311] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Endotracheal extubation is a painful and stressful procedure. The authors hypothesized that the prophylactic use of remifentanil would attenuate the pain intensity and stress responses resulting from extubation in neurosurgical patients. MATERIALS AND METHODS In this prospective, randomized, double-blinded, controlled trial, 160 patients with planned delay extubation after elective intracranial operation were randomized 1:1 to receive either remifentanil or normal saline (control) before their extubation. The dose regime of remifentanil was a bolus of 0.5 μg/kg over 1 minute, followed by a continuous infusion of 0.05 μg/kg/min for 20 minutes. The primary outcome was the incidence of severe pain during the periextubation period. Secondary outcomes included changes in the pain intensity and vital signs, failing to pass an extubation evaluation after the study drug infusion, severe adverse events, postextubation complications, and clinical outcomes. RESULTS Two patients in the remifentanil group did not pass the extubation evaluation. The incidence of severe pain during the periextubation period was significantly lower in the remifentanil group compared with the control group (25.0% vs. 41.3%, P=0.029). Compared with the control group, the visual analog scale in the remifentanil group was significantly lower after the bolus of remifentanil (12±18 vs. 25±27, P=0.001) and immediately after extubation (19±25 vs. 34±30, P=0.001). There were no significant differences in the vital signs immediately after extubation between the 2 groups (P>0.05). CONCLUSIONS The prophylactic use of remifentanil decreases the incidence of severe pain. Our preliminary findings merit a larger trial to clarify the effect of the prophylactic use of remifentanil on clinical outcomes and adverse events.
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12
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Supratentorial Masses: Anesthetic Considerations. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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13
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Bertrand HG, Sandersen C, Flecknell PA. The use of desflurane for neurosurgical procedures in rhesus macaque ( Macaca mulatta). Lab Anim 2017; 52:292-299. [PMID: 29132231 DOI: 10.1177/0023677217740169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Volatile agents are widely used to anaesthetise laboratory non-human primates as they allow a rapid induction and recovery as well as an easy adjustment of the anaesthesia plan. Desflurane is currently the volatile agent with the lowest solubility in blood, and hence enables the most rapid onset of anaesthesia and most rapid recovery. This study aimed to investigate the suitability of desflurane for maintenance of general anaesthesia in rhesus macaques undergoing elective experimental neurosurgery. Fourteen primates (five males and nine females) were sedated with ketamine (10 mg kg-1) and anaesthesia was induced with propofol (usually 8 mg kg-1 IV). Anaesthesia was maintained with desflurane (5.9 ± 0.8 %) and alfentanil (0.2-0.5 µg kg-1 min-1 IV). Animals were mechanically ventilated. Meloxicam (0.3 mg kg-1) and methylprednisolone infusion (5.4 mg kg-1 h-1) were also administered. All the primates were successfully anaesthetised and no severe complications related to the procedure or the anaesthesia regimen occurred. No major differences in physiological parameters and recovery times between the male and female groups were found. Emergence from anaesthesia was rapid (male 5.2 ± 2.4 min; female 4.1 ± 1.7 min) but its quality was assessed as equivalent to two other volatile anaesthetics, isoflurane and sevoflurane. These had previously been assessed for neuroanaesthesia in rhesus macaques. In conclusion, this study demonstrated that desflurane was suitable for maintenance of general anaesthesia for elective experimental neurosurgical procedures in rhesus macaque. However the vasodilatory action of the desflurane may limit its use in cases of severe intracranial hypertension or systemic hypotension.
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Affiliation(s)
- Henri Gmj Bertrand
- 1 Comparative Biology Centre, Newcastle University, UK.,2 Faculty of Veterinary Medicine, University of Liege, Belgium
| | | | - Paul A Flecknell
- 1 Comparative Biology Centre, Newcastle University, UK.,4 Institute of Neurosciences, Newcastle University, UK
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Vieitez V, Álvarez Gómez de Segura I, López Rámis V, Santella M, Ezquerra LJ. Total intravenous anaesthesia in a goat undergoing craniectomy. BMC Vet Res 2017; 13:287. [PMID: 28915921 PMCID: PMC5603036 DOI: 10.1186/s12917-017-1205-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 09/07/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Cerebral coenurosis is a disease of the central nervous system in sheep and goats, and is usually fatal unless surgical relief is provided. Information regarding neuroanaesthesia in veterinary medicine in goats is scant. CASE PRESENTATION We describe anaesthetic management of an intact female goat (2 years; 16 kg) presented for craniectomy. The goat was sedated with xylazine (0.05 mg kg-1, i.m.) and morphine (0.05 mg kg-1, i.m.). General anaesthesia was induced 20 min later with propofol and maintained with a constant rate infusion of propofol (0.2 mg kg-1 min-1). A cuffed endotracheal tube was placed and connected to a rebreathing (circle) system and mechanical ventilation with 100% oxygen was initiated. A bolus of lidocaine (1 mg kg-1), midazolam (0.25 mg kg-1) and fentanyl 2.5 μg kg-1 was delivered via the intravenous route followed immediately by a constant rate infusion of lidocaine (50 μg kg-1 min-1), midazolam (0.15 mg kg-1 h-1) and fentanyl (6 μg kg-1 h-1) administered via the intravenous route throughout surgery. Craniectomy was undertaken and the goat recovered uneventfully. CONCLUSION Total intravenous anaesthesia with propofol, lidocaine, fentanyl and midazolam could be an acceptable option for anaesthesia during intracranial surgery in goats.
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Affiliation(s)
- Verónica Vieitez
- Veterinary Teaching Hospital, University of Extremadura, Avda, Universidad s/n, 10003 Cáceres, Spain
| | - Ignacio Álvarez Gómez de Segura
- Department of Animal Medicine and Surgery, Veterinary Faculty, University Complutense of Madrid, Avda. Puerta de Hierro, 28040 Madrid, Spain
| | - Víctor López Rámis
- Veterinary Teaching Hospital, University of Extremadura, Avda, Universidad s/n, 10003 Cáceres, Spain
| | - Massimo Santella
- Veterinary Teaching Hospital, University of Extremadura, Avda, Universidad s/n, 10003 Cáceres, Spain
| | - Luis Javier Ezquerra
- Veterinary Teaching Hospital, University of Extremadura, Avda, Universidad s/n, 10003 Cáceres, Spain
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Use of Dexmedetomidine for Prophylactic Analgesia and Sedation in Patients With Delayed Extubation After Craniotomy: A Randomized Controlled Trial. J Neurosurg Anesthesiol 2017; 29:132-139. [PMID: 26641648 PMCID: PMC5351758 DOI: 10.1097/ana.0000000000000260] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background: We conducted a randomized trial to evaluate the efficacy and safety of dexmedetomidine for prophylactic analgesia and sedation in patients with delayed extubation after craniotomy. Methods: From June 2012 to July 2014, 150 patients with delayed extubation after craniotomy were randomized 1:1 and were assigned to the dexmedetomidine group that received a continuous infusion of 0.6 μg/kg/h (10 μg/mL) or the control group that received a maintenance infusion of 0.9% sodium chloride for injection. The mean percentage of time under optimal sedation (SAS3-4), the percentage of patients who required rescue with propofol/fentanyl, and the total dose of propofol/fentanyl required throughout the course of drug infusion, as well as VAS, HR, MAP, and SpO2 were recorded. Results: The percentage of time under optimal sedation was significantly higher in the dexmedetomidine group than in the control group (98.4%±6.7% vs. 93.0%±16.2%, P=0.008). The VAS was significantly lower in the dexmedetomidine group than in the control group (1.0 vs. 4.0, P=0.000). The HR and mean BP were significantly lower in the dexmedetomidine group than in the control group at all 3 time points (before endotracheal suctioning, immediately after extubation, and 30 min after extubation). No significant difference in SpO2 was observed between the 2 groups. For hemodynamic adverse events, patients in the dexmedetomidine group were more likely to develop bradycardia (5.3% vs. 0%, P=0.043) but had a lower likelihood of tachycardia (2.7% vs. 18.7%, P=0.002). Conclusions: Dexmedetomidine may be an effective prophylactic agent to induce sedation and analgesia in patients with delayed extubation after craniotomy. The use of dexmedetomidine (0.6 μg/kg/h) infusion does not produce respiratory depression, but may increase the incidence of bradycardia.
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16
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Recombinant Slit2 Reduces Surgical Brain Injury Induced Blood Brain Barrier Disruption via Robo4 Dependent Rac1 Activation in a Rodent Model. Sci Rep 2017; 7:746. [PMID: 28389649 PMCID: PMC5429690 DOI: 10.1038/s41598-017-00827-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 03/14/2017] [Indexed: 12/25/2022] Open
Abstract
Brain tissue surrounding surgical resection site can be injured inadvertently due to procedures such as incision, retractor stretch, and electrocauterization when performing neurosurgical procedures, which is termed as surgical brain injury (SBI). Blood brain barrier (BBB) disruption due to SBI can exacerbate brain edema in the post-operative period. Previous studies showed that Slit2 exhibited vascular anti-permeability effects outside the brain. However, BBB protective effects of Slit2 following SBI has not been evaluated. The objective of this study was to evaluate whether recombinant Slit2 via its receptor roundabout4 (Robo4) and the adaptor protein, Paxillin were involved in reducing BBB permeability in SBI rat model. Our results showed that endogenous Slit2 increased in the surrounding peri-resection brain tissue post-SBI, Robo4 remained unchanged and Paxillin showed a decreasing trend. Recombinant Slit2 administered 1 h before injury increased BBB junction proteins, reduced BBB permeability, and decreased neurodeficits 24 h post-SBI. Furthermore, recombinant Slit2 administration increased Rac1 activity which was reversed by Robo4 and Paxillin siRNA. Our findings suggest that recombinant Slit2 reduced SBI-induced BBB permeability, possibly by stabilizing BBB tight junction via Robo4 mediated Rac1 activation. Slit2 may be beneficial for BBB protection during elective neurosurgeries.
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17
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Martín N, Valero R, Hurtado P, Gracia I, Fernández C, Rumià J, Valldeoriola F, Carrero EJ, Tercero FJ, de Riva N, Fàbregas N. Experience with “Fast track” postoperative care after deep brain stimulation surgery. Neurocirugia (Astur) 2016; 27:263-268. [DOI: 10.1016/j.neucir.2016.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 02/15/2016] [Accepted: 02/16/2016] [Indexed: 12/11/2022]
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18
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Lonjaret L, Guyonnet M, Berard E, Vironneau M, Peres F, Sacrista S, Ferrier A, Ramonda V, Vuillaume C, Roux FE, Fourcade O, Geeraerts T. Postoperative complications after craniotomy for brain tumor surgery. Anaesth Crit Care Pain Med 2016; 36:213-218. [PMID: 27717899 DOI: 10.1016/j.accpm.2016.06.012] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 06/21/2016] [Accepted: 06/23/2016] [Indexed: 01/22/2023]
Abstract
INTRODUCTION After elective craniotomy for brain tumour surgery, patients are usually admitted to an intensive care unit (ICU) for monitoring. Our goal was to evaluate the incidence and timing of neurologic and non-neurologic postoperative complications after brain tumour surgery, to determine factors associated with neurologic events and to evaluate the timing and causes of ICU readmission. PATIENTS AND METHODS This prospective, observational and analytic study enrolled 188 patients admitted to the ICU after brain tumour surgery. All postoperative clinical events during the first 24hours were noted and classified. Readmission causes and timing were also analysed. RESULTS Twenty-one (11%) of the patients were kept sedated after surgery; the remaining 167 patients were studied. Thirty one percent of the patients presented at least one complication (25% with postoperative nausea and vomiting (PONV), 16% with neurologic complications). The occurrence of neurological complications was significantly associated with the absence of preoperative motor deficit and the presence of higher intraoperative bleeding. Seven patients (4%) were readmitted to the ICU after discharge; 43% (n=3) of them had a posterior fossa surgery. CONCLUSION Postoperative complications, especially PONV, are frequent after brain tumour surgery. Moreover, 16% of patients presented a neurological complication, probably justifying the ICU postoperative stay for early detection. The absence of preoperative motor deficit and intraoperative bleeding seems to predict postoperative neurologic complications. Finally, patients may present complications after ICU discharge, especially patients with fossa posterior surgery, suggesting that ICU hospitalization may be longer in this type of surgery.
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Affiliation(s)
- Laurent Lonjaret
- Department of Anesthesiology and Intensive Care, University Hospital of Toulouse, University Toulouse 3-Paul-Sabatier, Toulouse, France.
| | - Marine Guyonnet
- Department of Anesthesiology and Intensive Care, University Hospital of Toulouse, University Toulouse 3-Paul-Sabatier, Toulouse, France.
| | - Emilie Berard
- Department of Epidemiology, HealthEconomics and public health, UMR-1027 Inserm, Toulouse University Hospital, Toulouse, France.
| | - Marc Vironneau
- Department of Anesthesiology and Intensive Care, University Hospital of Toulouse, University Toulouse 3-Paul-Sabatier, Toulouse, France.
| | - Françoise Peres
- Department of Anesthesiology and Intensive Care, University Hospital of Toulouse, University Toulouse 3-Paul-Sabatier, Toulouse, France.
| | - Sandrine Sacrista
- Department of Anesthesiology and Intensive Care, University Hospital of Toulouse, University Toulouse 3-Paul-Sabatier, Toulouse, France.
| | - Anne Ferrier
- Department of Anesthesiology and Intensive Care, University Hospital of Toulouse, University Toulouse 3-Paul-Sabatier, Toulouse, France.
| | - Véronique Ramonda
- Department of Anesthesiology and Intensive Care, University Hospital of Toulouse, University Toulouse 3-Paul-Sabatier, Toulouse, France.
| | - Corine Vuillaume
- Department of Anesthesiology and Intensive Care, University Hospital of Toulouse, University Toulouse 3-Paul-Sabatier, Toulouse, France.
| | - Franck-Emmanuel Roux
- Department of Neurosurgery, University Hospital of Toulouse, University Toulouse 3-Paul-Sabatier, Toulouse, France.
| | - Olivier Fourcade
- Department of Anesthesiology and Intensive Care, University Hospital of Toulouse, University Toulouse 3-Paul-Sabatier, Toulouse, France.
| | - Thomas Geeraerts
- Department of Anesthesiology and Intensive Care, University Hospital of Toulouse, University Toulouse 3-Paul-Sabatier, Toulouse, France.
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Gökçek E, Kaydu A, Akdemir MS, Akil F, Akıncı IO. Early postoperative recovery after intracranial surgical procedures. Comparison of the effects of sevoflurane and desflurane. Acta Cir Bras 2016; 31:638-644. [DOI: 10.1590/s0102-865020160090000010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 08/23/2016] [Indexed: 12/26/2022] Open
Affiliation(s)
- Erhan Gökçek
- Diyarbakır Selahaddini Eyyubi State Hospital, Turkey
| | - Ayhan Kaydu
- Diyarbakır Selahaddini Eyyubi State Hospital, Turkey
| | | | - Ferit Akil
- Diyarbakır Selahaddini Eyyubi State Hospital, Turkey
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Schär RT, Fiechter M, Z'Graggen WJ, Söll N, Krejci V, Wiest R, Raabe A, Beck J. No Routine Postoperative Head CT following Elective Craniotomy--A Paradigm Shift? PLoS One 2016; 11:e0153499. [PMID: 27077906 PMCID: PMC4831779 DOI: 10.1371/journal.pone.0153499] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 03/29/2016] [Indexed: 12/16/2022] Open
Abstract
Introduction Patient management following elective cranial surgery often includes routine postoperative computed tomography (CT). We analyzed whether a regime of early extubation and close neurological monitoring without routine CT is safe, and compared the rate of postoperative emergency neurosurgical intervention with published data. Methods Four hundred ninety-two patients were prospectively analyzed; 360 had supra- and 132 had infratentorial lesions. Extubation within one hour after skin closure was aimed for in all cases. CT was performed within 48 hours only in cases of unexpected neurological findings. Results Four-hundred sixty-nine of the 492 patients (95.3%) were extubated within one hour, 20 (4.1%) within 3 hours, and three (0.6%) within 3 to 10 hours. Emergency CT within 48 hours was performed for 43/492 (8.7%) cases. Rate of recraniotomy within 48 hours for patients with postoperative hemorrhage was 0.8% (n = 4), and 0.8% (n = 4) required placement of an external ventricular drain (EVD). Of 469 patients extubated within one hour, 3 required recraniotomy and 2 required EVD placements. Of 23 patients with delayed extubation, 1 recraniotomy and 2 EVDs were required. Failure to extubate within one hour was associated with a significantly higher risk of surgical intervention within 48 hours (rate 13.0%, p = 0.004, odds ratio 13.9, 95% confidence interval [3.11–62.37]). Discussion Early extubation combined with close neurological monitoring is safe and omits the need for routine postoperative CT. Patients not extubated within one hour do need early CT, since they had a significantly increased risk of requiring emergency neurosurgical intervention. Trial Registration ClinicalTrials.gov NCT01987648
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Affiliation(s)
- Ralph T. Schär
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Fiechter
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Werner J. Z'Graggen
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicole Söll
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Vladimir Krejci
- Department of Anesthesiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Roland Wiest
- Department of Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jürgen Beck
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- * E-mail:
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ProSeal Laryngeal Mask Airway Attenuates Systemic and Cerebral Hemodynamic Response During Awakening of Neurosurgical Patients: A Randomized Clinical Trial. J Neurosurg Anesthesiol 2016; 27:194-202. [PMID: 25121397 DOI: 10.1097/ana.0000000000000108] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Extubation and emergence from anesthesia may lead to systemic and cerebral hemodynamic changes that endanger neurosurgical patients. We aimed to compare systemic and cerebral hemodynamic variables and cough incidence in neurosurgery patients emerging from general anesthesia with the standard procedure (endotracheal tube [ETT] extubation) or after replacement of the ETT with a laryngeal mask airway (LMA). MATERIALS AND METHODS Forty-two patients undergoing supratentorial craniotomy under general anesthesia were included in a randomized open-label parallel trial. Patients were randomized (sealed envelopes labeled with software-generated randomized numbers) to awaken with the ETT in place or after its replacement with a ProSeal LMA. We recorded mean arterial pressure as the primary endpoint and heart rate, middle cerebral artery flow velocity, regional cerebral oxygen saturation, norepinephrine plasma concentrations, and coughing. RESULTS No differences were found between groups at baseline. All hemodynamic variables increased significantly from baseline in both groups during emergence. The ETT group had significantly higher mean arterial pressure (11.9 mm Hg; 95% confidence interval [CI], 2.1-21.8 mm Hg) (P=0.017), heart rate (7.2 beats/min; 95% CI, 0.7-13.7 beats/min) (P=0.03), and rate-pressure product (1045.4; 95% CI, 440.8-1650) (P=0.001). Antihypertensive medication was administered to more ETT-group patients than LMA-group patients (9 [42.9%] vs. 3 [14.3%] patients, respectively; P=0.04). The percent increase in regional cerebral oxygen saturation was greater in the ETT group by 26.1% (95% CI, 9.1%-43.2%) (P=0.002), but no between-group differences were found in MCA flow velocity. Norepinephrine plasma concentrations rose in both groups between baseline and the end of emergence: LMA: from 87.5±7.1 to 125.6±17.3 pg/mL; and ETT: from 118.1±14.1 to 158.1±24.7 pg/mL (P=0.007). The differences between groups were not significant. The incidence of cough was higher in the ETT group (87.5%) than in the LMA group (9.5%) (P<0.001). CONCLUSIONS Replacing the ETT with the LMA before neurosurgical patients emerge from anesthesia results in a more favorable hemodynamic profile, less cerebral hyperemia, and a lower incidence of cough.
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Awakening properties of isoflurane, sevoflurane, and desflurane in pediatric patients after craniotomy for supratentorial tumours. J Neurosurg Anesthesiol 2016; 27:1-6. [PMID: 24633212 DOI: 10.1097/ana.0000000000000058] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND The aim of this prospective, comparative, randomized study was to compare the inhalational anesthetics isoflurane, sevoflurane, and desflurane in pediatric patients undergoing craniotomy for excision of supratentorial tumors. We assessed early postoperative recovery outcome, intraoperative hemodynamics, and degree of brain swelling, as well as postoperative vomiting and shivering. METHODS Sixty patients scheduled for supratentorial brain tumor excision, were randomly allocated into 1 of 3 groups (20 patients each); isoflurane, sevoflurane, and desflurane group. After IV induction of anesthesia, maintenance was achieved using the inhalational anesthetic according to the allocated group. Tracheal extubation time was the primary endpoint. The secondary endpoints included: emergence time and the interval time needed to reach Aldrete score ≥9, intraoperative degree of brain swelling, intraoperative heart rate and mean arterial blood pressure, as well as postoperative vomiting and shivering. RESULTS The mean emergence time, extubation time, and the interval required to reach Aldrete score 9 were significantly shorter in the desflurane and sevoflurane groups than the isoflurane group. No statistically significant changes in the 3 groups regarding intraoperative brain swelling, hemodynamics, and postoperative shivering or vomiting were noted. CONCLUSIONS Desflurane and sevoflurane can be used to facilitate early emergence from anesthesia in neurosurgical pediatric patients. Emergence times are shorter with desflurane or sevoflurane than with isoflurane. The patients who received desflurane or sevoflurane have similar intraoperative and postoperative incidence of adverse effects compared with those who received isoflurane. Thus, desflurane and sevoflurane can be considered as suitable for emergence in pediatric neurosurgical anesthesia.
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Sherchan P, Huang L, Wang Y, Akyol O, Tang J, Zhang JH. Recombinant Slit2 attenuates neuroinflammation after surgical brain injury by inhibiting peripheral immune cell infiltration via Robo1-srGAP1 pathway in a rat model. Neurobiol Dis 2016; 85:164-173. [PMID: 26550694 PMCID: PMC4688150 DOI: 10.1016/j.nbd.2015.11.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 10/29/2015] [Accepted: 11/05/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND PURPOSE Peripheral immune cell infiltration to the brain tissue at the perisurgical site can promote neuroinflammation after surgical brain injury (SBI). Slit2, an extracellular matrix protein, has been reported to reduce leukocyte migration. This study evaluated the effect of recombinant Slit2 and the role of its receptor roundabout1 (Robo1) and its downstream mediator Slit-Robo GTPase activating protein 1 (srGAP1)-Cdc42 on peripheral immune cell infiltration after SBI in a rat model. METHODS One hundred and fifty-three adult male Sprague-Dawley rats (280-350 g) were used. Partial resection of right frontal lobe was performed to induce SBI. Slit2 siRNA was administered by intracerebroventricular injection 24h before SBI. Recombinant Slit2 was injected intraperitoneally 1h before SBI. Recombinant Robo1 used as a decoy receptor was co-administered with recombinant Slit2. srGAP1 siRNA was administered by intracerebroventricular injection 24h before SBI. Post-assessments included brain water content measurement, neurological tests, ELISA, Western blot, immunohistochemistry, and Cdc42 activity assay. RESULTS Endogenous Slit2 was increased after SBI. Robo1 was expressed by peripheral immune cells. Endogenous Slit2 knockdown worsened brain edema after SBI. Recombinant Slit2 administration reduced brain edema, neurological deficits, and pro-inflammatory cytokines after SBI. Recombinant Slit2 reduced peripheral immune cell markers cluster of differentiation 45 (CD45) and myeloperoxidase (MPO), as well as Cdc42 activity in the perisurgical brain tissue which was reversed by recombinant Robo1 co-administration and srGAP1 siRNA. CONCLUSIONS Recombinant Slit2 improved outcomes by reducing neuroinflammation after SBI, possibly by decreasing peripheral immune cell infiltration to the perisurgical site through Robo1-srGAP1 mediated inhibition of Cdc42 activity. These results suggest that Slit2 may be beneficial to reduce SBI-induced neuroinflammation.
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Affiliation(s)
- Prativa Sherchan
- Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA 92354, U.S.A
| | - Lei Huang
- Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA 92354, U.S.A.; Department of Anesthesiology, Loma Linda University, CA 92354, U.S.A
| | - Yuechun Wang
- Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA 92354, U.S.A
| | - Onat Akyol
- Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA 92354, U.S.A
| | - Jiping Tang
- Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA 92354, U.S.A
| | - John H Zhang
- Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA 92354, U.S.A.; Department of Anesthesiology, Loma Linda University, CA 92354, U.S.A.; Department of Neurosurgery, Loma Linda University, CA 92354, U.S.A..
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Yan LM, Chen H, Yu RG, Wang ZH, Zhou GH, Wang YJ, Zhang X, Xu M, Chen L, Zhou JX. Emergence agitation during recovery from intracranial surgery under general anaesthesia: a protocol and statistical analysis plan for a prospective multicentre cohort study. BMJ Open 2015; 5:e007542. [PMID: 25900467 PMCID: PMC4410113 DOI: 10.1136/bmjopen-2014-007542] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Emergence agitation after intracranial surgery is an important clinical issue during anaesthesia recovery. The aim of this multicentre cohort study is to investigate the incidence of emergence agitation, identify the risk factors and determine clinical outcomes in adult patients after intracranial surgery under general anaesthesia. Additionally, we will deliberately clarify the relationship between postoperative pneumocephalus and agitation. METHODS AND ANALYSIS The present study is a prospective multicentre cohort study. Five intensive care units (ICUs) in China will participate in the study. Consecutive adult patients admitted to the ICUs after intracranial surgery will be enrolled. Sedation-Agitation Scale (SAS) or Richmond Agitation-Sedation Scale (RASS) will be used to evaluate the patients 12 h after the enrolment. Agitation is defined as an SAS score of 5-7, or an RASS score of +2 to +4. According to the maximal SAS and RASS score, patients will be divided into two cohorts: the agitation group and the non-agitation group. Factors potentially related to emergence agitation will be collected at study entry, during anaesthesia and operation, during postoperative care. Univariate analyses between the agitation and the non-agitation groups will be performed. The stepwise backward logistic regression will be carried out to identify the independent predictors of agitation. Patients will be followed up for 72 h after the operation. Accidental self-extubation of the endotracheal tube and removal of other catheters will be documented. The use of sedatives and analgesics will be collected. ETHICS AND DISSEMINATION Ethics approval has been obtained from each of five participating hospitals. Study findings will be disseminated through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER NCT02318199.
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Affiliation(s)
- Li-Mei Yan
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Critical Care Medicine, Inner Mongolia People's Hospital, Hohhot, Inner Mongolia, China
| | - Han Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Rong-Guo Yu
- Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Zhu-Heng Wang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Critical Care Medicine, Daxing Teaching Hospital, Capital Medical University, Beijing, China
| | - Guan-Hua Zhou
- Department of Critical Care Medicine, Daxing Teaching Hospital, Capital Medical University, Beijing, China
| | - Yong-Jin Wang
- Department of Critical Care Medicine, Bethune International Peace Hospital, Hebei Medical University, Shijiazhuang, Hebei, China
| | - Xia Zhang
- Department of Critical Care Medicine, Bethune International Peace Hospital, Hebei Medical University, Shijiazhuang, Hebei, China
| | - Ming Xu
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lu Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Gracia I, Perelló L, Valero R, Hervías A, Perdomo J, Pujol R, González J, Hurtado P, de Riva N, Tercero FJ, Carrero E, Ferrer E, Fàbregas N. Eficacia diagnóstica y manejo posoperatorio de los pacientes sometidos a biopsia cerebral en un hospital universitario. Neurocirugia (Astur) 2015; 26:23-31. [DOI: 10.1016/j.neucir.2014.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 04/16/2014] [Accepted: 06/10/2014] [Indexed: 01/22/2023]
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Chen L, Xu M, Li GY, Cai WX, Zhou JX. Incidence, Risk Factors and Consequences of Emergence Agitation in Adult Patients after Elective Craniotomy for Brain Tumor: A Prospective Cohort Study. PLoS One 2014; 9:e114239. [PMID: 25493435 PMCID: PMC4262354 DOI: 10.1371/journal.pone.0114239] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2014] [Accepted: 11/04/2014] [Indexed: 12/11/2022] Open
Abstract
Emergence agitation is a frequent complication that can have serious consequences during recovery from general anesthesia. However, agitation has been poorly investigated in patients after craniotomy. In this prospective cohort study, adult patients were enrolled after elective craniotomy for brain tumor. The sedation-agitation scale was evaluated during the first 12 hours after surgery. Agitation developed in 35 of 123 patients (29%). Of the agitated patients, 28 (80%) were graded as very and dangerously agitated. By multivariate stepwise logistic regression analysis, independent predictors for agitation included male sex, history of long-term use of anti-depressant drugs or benzodiazepines, frontal approach of the operation, method and duration of anesthesia and presence of endotracheal intubation. Total intravenous anesthesia and balanced anesthesia with short duration were protective factors. Emergence agitation was associated with self-extubation (8.6% vs 0%, P = 0.005). Sedatives were administered more in agitated patients than non-agitated patients (85.7% vs 6.8%, P<0.001). In conclusion, emergence agitation was a frequent complication in patients after elective craniotomy for brain tumors. The clarification of risk factors could help to identify the high-risk patients, and then to facilitate the prevention and treatment of agitation. For patients undergoing craniotomy, greater attention should be paid to those receiving a frontal approach for craniotomy and those anesthetized under balanced anesthesia with long duration. More researches are warranted to elucidate whether total intravenous anesthesia could reduce the incidence of agitation after craniotomy. Trial Registration ClinicalTrials.gov NCT00590499.
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Affiliation(s)
- Lu Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Beijing, 100050, China
| | - Ming Xu
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Beijing, 100050, China
| | - Gui-Yun Li
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Beijing, 100050, China
| | - Wei-Xin Cai
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Beijing, 100050, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Beijing, 100050, China
- * E-mail:
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Cai YH, Zeng HY, Shi ZH, Shen J, Lei YN, Chen BY, Zhou JX. Factors influencing delayed extubation after infratentorial craniotomy for tumour resection: a prospective cohort study of 800 patients in a Chinese neurosurgical centre. J Int Med Res 2013; 41:208-17. [PMID: 23569147 DOI: 10.1177/0300060513475964] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES To investigate prospectively the rate of, and factors influencing, delayed extubation following infratentorial craniotomy in a Chinese neurosurgical centre. METHODS Patients undergoing infratentorial craniotomy for tumour resection were prospectively enrolled and stratified according to whether extubation was attempted in the operating theatre (early extubation) or not (delayed extubation). Pre- and intraoperative variables were collected and analysed. Multiple logistic regression analysis was performed, to identify factors related to delayed extubation. RESULTS The study included 800 patients, 398 (49.8%) of whom underwent delayed extubation. The overall rate of extubation failure was 3.6%. Independent factors related to delayed extubation were: preoperative lower cranial nerve dysfunction; hydrocephalus; tumour location; duration of surgery ≥ 6 h; estimated blood loss ≥ 1000 ml. Compared with patients in the early extubation group, those in the delayed extubation group had a higher rate of pneumonia, longer intensive care unit and postoperative hospital stays, and higher hospitalization costs. CONCLUSIONS Brain stem and lower cranial nerve function were the main factors affecting extubation decision-making. Further research is required, to establish criteria for delayed extubation following infratentorial craniotomy.
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Affiliation(s)
- Ye-Hua Cai
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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CLINICAL NEUROSCIENCES. Br J Anaesth 2012. [DOI: 10.1093/bja/aer476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Kawaguchi M, Kawaraguchi Y, Yamamoto Y, Hayashi H, Abe R, Inoue S, Nakase H, Furuya H. Effects of landiolol on systemic and cerebral hemodynamics and recovery from anesthesia in patients undergoing craniotomy. J Anesth 2010; 24:503-10. [PMID: 20339879 DOI: 10.1007/s00540-010-0931-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2010] [Accepted: 03/02/2010] [Indexed: 01/13/2023]
Abstract
PURPOSE Maintenance of systemic and cerebral hemodynamics and quick recovery from anesthesia are required for craniotomy. We conducted a prospective randomized study to investigate the effects of continuous infusion of landiolol on hemodynamic responses to various stimuli, changes in systemic and cerebral hemodynamics during anesthesia, and recovery from anesthesia in patients undergoing craniotomy. METHODS Thirty patients undergoing elective craniotomy were randomly divided into two groups: a landiolol group and a control (saline) group. Landiolol was administered as an infusion rate of 0.125 mg/kg/min for 1 min, followed by an infusion at 0.01-0.04 mg/kg/min until 6 h after the end of anesthesia. Maximal values of heart rate (HR) and systolic blood pressure (SBP) in response to tracheal intubation, pin fixation, the beginning of operation, and extubation were compared between groups. Tissue oxygen index (TOI), mean arterial pressure (MAP), cardiac index (CI), and stroke volume index (SVI) before, during, and at the end of operation were compared between groups. Total doses of fentanyl, interval for the recovery from anesthesia, and incidence of postoperative nausea and vomiting (PONV) were also compared. RESULTS Maximal values of HR at intubation and pin fixation and of HR and SBP at extubation were significantly less in the landiolol group compared with those in the control group. TOI, MAP, CI, and SVI were similar between groups during anesthesia. Total doses of fentanyl were significantly less in the landiolol group than in the control group. Interval for recovery from anesthesia and incidence of PONV were similar between groups. CONCLUSION This study indicates that continuous infusion of landiolol suppressed hyperdynamic responses to stimuli during anesthesia while maintaining arterial blood pressure and cerebral oxygen balance during craniotomy. Although landiolol infusion did not affect recovery from anesthesia and incidence of PONV, it reduced intraoperative requirement of fentanyl.
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Affiliation(s)
- Masahiko Kawaguchi
- Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 623-8522, Japan.
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Kerscher C, Zimmermann M, Graf BM, Hansen E. [Scalp blocks. A useful technique for neurosurgery, dermatology, plastic surgery and pain therapy]. Anaesthesist 2009; 58:949-58; quiz 959-60. [PMID: 19779756 DOI: 10.1007/s00101-009-1604-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Safe and effective cranial analgesia can be achieved by blocking the sensitive nerves of that region. These include the supraorbital nerve, the supratrochlear nerve, the zygomaticotemporal nerve, the auriculotemporal nerve and the greater and lesser occipital nerves which are accessible at typical and most proximal points. Preferably long acting local anesthetics such as ropivacaine 0.75% or levobupivacaine 0.5% are used supplemented with 5 microg/ml epinephrine to reduce systemic resorption and to elongate the duration. Scalp blocks are useful for intraoperative neurologic testing of the patient during awake craniotomy or for supplementation of general anesthesia for other forms of craniotomy. Other applications are minimally invasive and stereotactic neurosurgery including deep brain stimulation, photodynamic therapy of actinic ceratosis, cranial plastic surgery and pain therapy.
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Affiliation(s)
- C Kerscher
- Klinik für Anästhesiologie, Universitätsklinikum Regensburg, 93042, Regensburg, Deutschland
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Early postoperative cognitive recovery and gas exchange patterns after balanced anesthesia with sevoflurane or desflurane in overweight and obese patients undergoing craniotomy: a prospective randomized trial. J Neurosurg Anesthesiol 2009; 21:207-13. [PMID: 19542997 DOI: 10.1097/ana.0b013e3181a19c52] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Overweight and obese patients are at especially high risk for delayed awakening after general surgery. Whether this risk also applies to cerebral neurosurgical procedures remains unclear. This study evaluated early postoperative cognitive recovery and gas exchange patterns, after balanced anesthesia with sevoflurane or desflurane, in overweight and obese patients undergoing craniotomy for supratentorial expanding lesions. Fifty-six patients were consecutively enrolled, and randomly assigned to 1 of 2 study groups to receive balanced anesthesia with sevoflurane or desflurane. Cognitive function was evaluated with the Short Orientation Memory Concentration Test and the Rancho Los Amigos Scale and gas exchange patterns (pH, PaO2, and PaCO2) were recorded in all patients at 5 time-points: preoperatively and postoperatively, after patients reached an Aldrete score >or=9, at 15, 30, 45, and 60 minutes. Preoperative cognitive status was similar in the 2 treatment groups. Early postoperative cognitive recovery was more delayed and Short Orientation Memory Concentration Test scores at 15 and 30 minutes postanesthesia were lower in patients receiving sevoflurane-based anesthesia than in those receiving desflurane-based anesthesia (21.5+/-3.5 vs. 14.9+/-3.5) (P<0.005) and (26.9+/-0.7 vs. 21.5+/-1.4) (P<0.005), and the postoperative Rancho Los Amigos Scalegrade 8 showed a similar trend (25/28 patients 89% vs. 8/28 patients 28% (P<0.005) and 28/28 patients (100% vs. 13/28 patients 46%) (P<0.005). Similarly, gas-exchange analysis showed higher PaCO2 at 15 and 30 minutes and lower pH up to 45 minutes postextubation in patients receiving sevoflurane-based anesthesia. In overweight and obese patients undergoing craniotomy desflurane-based anesthesia allows earlier postoperative cognitive recovery and reversal to normocapnia and normal pH.
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Esmolol blunts postoperative hemodynamic changes after propofol-remifentanil total intravenous fast-track neuroanesthesia for intracranial surgery. J Clin Anesth 2009; 20:426-30. [PMID: 18929282 DOI: 10.1016/j.jclinane.2008.04.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2007] [Revised: 04/03/2008] [Accepted: 04/14/2008] [Indexed: 11/20/2022]
Abstract
STUDY OBJECTIVE To investigate whether esmolol is effective in attenuating postoperative hemodynamic changes related to sympathetic overdrive. DESIGN Clinical study. SETTING Operating room of a university hospital. PATIENTS 60 ASA physical status I, II, and III patients, age 18 to 65 years, scheduled for elective craniotomy for supratentorial neurosurgery. INTERVENTIONS Patients were given total intravenous anesthesia (TIVA) during emergence from anesthesia and up to 60 minutes after extubation. Those patients who had hypertension (defined as an increase in systolic blood pressure >20% from baseline values) and tachycardia (defined as an increase >20% in heart rate from baseline) received a loading dose of 500 microg/kg esmolol in one minute, followed by an infusion titrated stepwise (50, 100, 200, and 300 microg/kg per min) every two minutes. MEASUREMENTS The mean dose and duration of esmolol therapy were measured. MAIN RESULTS Of 60 patients, 49 (82%) who received propofol-remifentanil TIVA developed significant tachycardia and hypertension soon after extubation. Treatment with esmolol (500 microg/kg in bolus maintained at a mean rate of 200 +/- 50 microg/kg per min) effectively controlled hypertension and tachycardia in 45 of 49 patients (92%; P < 0.05) within a mean 4.30 +/- 2.20 minutes. After extubation, mean esmolol infusion time was 29 +/- 8 minutes. CONCLUSION In patients undergoing elective neurosurgery with propofol-remifentanil TIVA, a relatively small esmolol dose and short infusion time effectively blunts early postoperative arterial hypertension and tachycardia.
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Bhagat H, Dash HH, Bithal PK, Chouhan RS, Pandia MP. Planning for early emergence in neurosurgical patients: a randomized prospective trial of low-dose anesthetics. Anesth Analg 2008; 107:1348-55. [PMID: 18806051 DOI: 10.1213/ane.0b013e31817f9476] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND For early detection of a cerebral complication, rapid awakening from anesthesia is essential after craniotomy. Systemic hypertension is a major drawback associated with fast tracking, which may predispose to formation of intracranial hematoma. Although various drugs have been widely evaluated, there are limited data with regards to use of anesthetics to blunt emergence hypertension. We hypothesized that use of low-dose anesthetics during craniotomy closure facilitates early emergence with a decrease in hemodynamic consequences. METHODS Three emergent techniques were evaluated in 150 normotensive adult patients operated for supratentorial tumors under standard isoflurane anesthesia. At the time of dural closure, the patients were randomized to receive low-dose propofol (3 mg.kg(-1).h(-1)), fentanyl (1.5 microg.kg(-1).h(-1)) or isoflurane (end-tidal concentration of 0.2%) until the beginning of skin closure. Nitrous oxide was discontinued after head dressing. RESULTS Median time to emergence was 6 min with propofol, 4 min with fentanyl, and 5 min with isoflurane (P=0.008). More patients had hypertension in the pre-extubation compared with extubation or postextubation phase (P=0.009). Comparing the three groups, fewer patients required esmolol with fentanyl use overall, and in the pre-extubation phase (P=0.01). Significant midline shift in the preoperative cerebral imaging scans was found to be an independent risk factor for emergence hypertension. CONCLUSIONS Pain during surgical closure may be an important cause of sympathetic stimulation leading to emergence hypertension. The use of low-doses of fentanyl during craniotomy closure is more advantageous than propofol or isoflurane for early emergence in neurosurgical patients and is the most effective technique for preventing early postoperative hypertension.
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Affiliation(s)
- Hemant Bhagat
- Department of Neuroanesthesiology, Chief of Neurosciences Centre, Room no 709-A, CN Centre, AII, New Delhi 110029, India.
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Abstract
Neuroanaesthesia continues to develop and expand. It is a speciality where the knowledge and expertise of the anaesthetist can directly influence patient outcome. Evolution of neurosurgical practice is accompanied by new challenges for the anaesthetist. Increasingly, we must think not only as an anaesthetist but also as a neurosurgeon and neurologist. With the focus on functional and minimally invasive procedures, there is an increased emphasis on the provision of optimal operative conditions, preservation of neurocognitive function, minimizing interference with electrophysiological monitoring, and a rapid, high-quality recovery. Small craniotomies, intraoperative imaging, stereotactic interventions, and endoscopic procedures increase surgical precision and minimize trauma to normal tissues. The result should be quicker recovery, minimal perioperative morbidity, and reduced hospital stay. One of the peculiarities of neuroanaesthesia has always been that as much importance is attached to wakening the patient as sending them to sleep. With the increasing popularity of awake craniotomies, there is even more emphasis on this skill. However, despite high-quality anaesthetic research and advances in drugs and monitoring modalities, many controversies remain regarding best clinical practice. This review will discuss some of the current controversies in elective neurosurgical practice, future perspectives, and the place of awake craniotomies in the armamentarium of the neuroanaesthetist.
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Affiliation(s)
- J Dinsmore
- Department of Anaesthesia, St George's Hospital, London SW17 0RE, UK.
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Raisis AL, Leece EA, Platt SR, Adams VJ, Corletto F, Brearley J. Evaluation of an anaesthetic technique used in dogs undergoing craniectomy for tumour resection. Vet Anaesth Analg 2007; 34:171-80. [PMID: 17444930 DOI: 10.1111/j.1467-2995.2006.00318.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To evaluate a total intravenous anaesthetic technique in dogs undergoing craniectomy. STUDY DESIGN Prospective clinical study. ANIMALS Ten dogs admitted for elective surgical resection of rostro-tentorial tumours. METHODS All dogs were premedicated with methadone, 0.2 mg kg(-1) intramuscularly 30 minutes prior to induction of anaesthesia. Anaesthesia was induced with propofol administered intravenously (IV) to effect, following administration of lidocaine 1 mg kg(-1) IV and maintained with a continuous infusion of propofol at < or =0.4 mg kg(-1) minute(-1) during instrumentation and preparation and during movement of the animals to recovery. During surgery, anaesthesia was maintained using a continuous infusion of propofol at <or =0.4 mg kg(-1) minute(-1) and alfentanil < or =1 microg kg(-1) minute(-1). Lidocaine was administered at 1 mg kg(-1) IV immediately prior to extubation. Arterial blood pressure and heart rate (HR) were recorded prior to induction and every 5 minutes throughout preparation and surgery. Central venous pressure was recorded every 5 minutes throughout surgery. RESULTS Administration of propofol and lidocaine prevented significant increases in mean arterial blood pressure (MAP) and HR during endotracheal intubation and extubation. Adequate MAP was maintained throughout anaesthesia. Recovery was smooth and excitement free. There was no association between duration of anaesthesia, total drugs administered, or severity of neurological disease and recovery times. Postoperatively there was no deterioration in neurological function in the immediate postoperative period with complete resolution of pre-existing neurological deficits within 7 days of surgery. CONCLUSION This technique provided minimal response to intubation and extubation, adequate arterial blood pressure and a smooth predictable recovery. All animals were neurologically improved by the time of discharge, suggesting that this technique had not caused significant neuronal damage. CLINICAL RELEVANCE Total intravenous anaesthesia with propofol and alfentanil appears to be a satisfactory anaesthetic technique for use in dogs undergoing surgery for debulking/removal of rostro-tentorial tumours.
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Affiliation(s)
- Anthea L Raisis
- Department of Veterinary and Biomedical Sciences, Murdoch University, Perth, WA, Australia.
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Bilotta F, Caramia R, Paoloni FP, Favaro R, Araimo F, Pinto G, Rosa G. Early postoperative cognitive recovery after remifentanil–propofol or sufentanil–propofol anaesthesia for supratentorial craniotomy: a randomized trial. Eur J Anaesthesiol 2007; 24:122-7. [PMID: 16938153 DOI: 10.1017/s0265021506001244] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2006] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE This study was designed to evaluate early postoperative cognitive recovery after total intravenous anaesthesia with remifentanil-propofol or sufentanil-propofol in patients undergoing craniotomy for supratentorial expanding lesions. METHODS Sixty patients were consecutively enrolled, and randomly assigned to one of two study groups: remifentanil-propofol or sufentanil-propofol anaesthesia. To evaluate cognitive function the Short Orientation Memory Concentration Test (SOMCT) and Rancho Los Amigos Scale (RLAS) were administered to all patients in a double-blind procedure before surgery at 15, 45 min and 3 h after extubation. RESULTS Mean extubation time was similar in the two groups (13 +/- 5 min vs. 19 +/- 6 min). A significantly larger number of patients in the remifentanil-propofol group than in the sufentanil-propofol group required antihypertensive medication postoperatively to maintain mean arterial pressure within 20% of baseline (18/30 vs. 4/29; P = 0.0004). Intergroup analysis showed no differences in baseline SOMCT scores (28 +/- 1 vs. 28 +/- 1) whereas mean SOMCT scores at 15, 45 min and 3 h after extubation were significantly higher in the remifentanil-propofol group (30 patients) than in the sufentanil-propofol group (29 patients) (22 +/- 3 vs. 16 +/- 3; P < 0.0001 and 27 +/- 1 vs. 22 +/- 3; P < 0.0001; 28 +/- 1 vs. 26 +/- 2; P = 0.0126). CONCLUSIONS In conclusion, propofol-remifentanil and propofol-sufentanil are both suitable for fast-track neuroanaesthesia and provide similar intraoperative haemodynamics, awakening and extubation times. Despite a higher risk of treatable postoperative hypertension propofol-remifentanil allows earlier cognitive recovery.
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Affiliation(s)
- F Bilotta
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Rome La Sapienza, Viale Somalia 81, 00199 Rome, Italy.
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Bruder N, Ravussin P. Modifications hémodynamiques cérébrales et systémiques au moment du réveil en neurochirurgie. ACTA ACUST UNITED AC 2004; 23:410-6. [PMID: 15120789 DOI: 10.1016/j.annfar.2004.01.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Major complications after intracranial surgery occur in 13-27% of patients. Among multiple causes, haemodynamic and metabolic changes of anaesthesia recovery may be responsible for intracranial complications. Recovery from neurosurgical anaesthesia is followed by an increase in body oxygen consumption and catecholamines concentrations. However, in normothermic patients, theses changes are usually mild and not prevented by a 2-h recovery delay. Systemic hypertension is common after neurosurgery and a link between perioperative hypertension and intracranial haemorrhage has been established. The cerebral consequences of recovery associate cerebral hyperaemia and increased ICP in patients with a tight brain at the end of surgery. Cerebral hyperaemia may promote or exacerbate cerebral haemorrhage or oedema. This has been demonstrated in patients operated for subdural haematoma removal or undergoing carotid surgery. Prevention of hypothermia and pain are key factors to prevent metabolic changes. Beta-blockers seem to be suitable agents to obtain haemodynamic control in neurosurgical patients.
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Affiliation(s)
- N Bruder
- Département d'anesthésie-réanimation, CHU de la Timone, 13385 Marseille, France.
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