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Badenes R, Nato CG, Peña JD, Bilotta F. Inhaled anesthesia in neurosurgery: Still a role? Best Pract Res Clin Anaesthesiol 2020; 35:231-240. [PMID: 34030807 DOI: 10.1016/j.bpa.2020.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/28/2020] [Accepted: 10/13/2020] [Indexed: 11/17/2022]
Abstract
In patients undergoing craniotomy, general anesthesia should be addressed to warrant good hypnosis, immobility, and analgesia, to ensure systemic and cerebral physiological status and provide the best possible surgical field. Regarding craniotomies, it is unclear if there are substantial differences in providing general anesthesia using total intravenous anesthesia (TIVA) or balanced anesthesia (BA) accomplished using the third generation halogenates. New evidence highlighted that the last generation of halogenated agents has possible advantages compared with intravenous drugs: rapid induction, minimal absorption and metabolization, reproducible pharmacokinetic, faster recovery, cardioprotective effect, and opioid spare analgesia. This review aims to report evidence related to the use of the latest halogenated agents in patients undergoing craniotomy and to present available clinical evidence on their effects: cerebral and systemic hemodynamic, neurophysiological monitoring, and timing and quality of recovery after anesthesia.
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Affiliation(s)
- Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitario Valencia, University of Valencia, Valencia, Spain
| | - Consolato Gianluca Nato
- Department of Anesthesiology, Critical Care and Pain Medicine, 'Sapienza' University of Rome, Rome, Italy
| | - Juan David Peña
- Department of Anesthesiology, North-Western Medical University Named After Mechnikov, St Petersburg, Russian Federation
| | - Federico Bilotta
- Department of Anesthesiology, Critical Care and Pain Medicine, 'Sapienza' University of Rome, Rome, Italy.
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Abstract
Aneurysmal subarachnoid hemorrhage is an acute neurologic emergency. Prompt definitive treatment of the aneurysm by craniotomy and clipping or endovascular intervention with coils and/or stents is needed to prevent rebleeding. Extracranial manifestations of aneurysmal subarachnoid hemorrhage include cardiac dysfunction, neurogenic pulmonary edema, fluid and electrolyte imbalances, and hyperglycemia. Data on the impact of anesthesia on long-term neurologic outcomes of aneurysmal subarachnoid hemorrhage do not exist. Perioperative management should therefore focus on optimizing systemic physiology, facilitating timely definitive treatment, and selecting an anesthetic technique based on patient characteristics, severity of aneurysmal subarachnoid hemorrhage, and the planned intervention and monitoring. Anesthesiologists should be familiar with evoked potential monitoring, electroencephalographic burst suppression, temporary clipping, management of external ventricular drains, adenosine-induced cardiac standstill, and rapid ventricular pacing to effectively care for these patients.
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Plasma nitrite as an indicator of cerebral ischemia during extracranial/intracranial bypass surgery in moyamoya patients. J Stroke Cerebrovasc Dis 2020; 29:104830. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.104830] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 02/17/2020] [Accepted: 03/22/2020] [Indexed: 01/19/2023] Open
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Comparison of the effect of sevoflurane or propofol anesthesia on the regional cerebral oxygen saturation in patients undergoing carotid endarterectomy: a prospective, randomized controlled study. BMC Anesthesiol 2019; 19:157. [PMID: 31421685 PMCID: PMC6698343 DOI: 10.1186/s12871-019-0820-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 08/01/2019] [Indexed: 11/26/2022] Open
Abstract
Background The monitoring of regional cerebral oxygen saturation (SrO2) using near-infrared spectroscopy is useful method to detect cerebral ischemia during. Sevoflurane and propofol decrease cerebral metabolic rate (CMRO2) in a similar manner, but the effects on the cerebral blood flow (CBF) are different. We hypothesized that the effects of sevoflurane and propofol on SrO2 were different in patients with deficits of CBF. This study compared the effect of sevoflurane and propofol on SrO2 of patients undergoing cerebral endarterectomy (CEA). Method Patients undergoing CEA were randomly assigned to the sevoflurane or propofol group (n = 74). The experiment was preceded in 2 stages based on carotid artery clamping. The first stage was from induction of anaesthesia to immediately before clamping of the carotid artery, and the second stage was until the end of the operation after clamping of the carotid artery. Oxygen saturation (SrO2, SpO2), haemodynamic variables (blood pressure, heart rate), respiratory parameters (end-tidal carbon dioxide tension, inspired oxygen tension), concentration of anesthetics, and anesthesia depth (bispectral index score) were recorded. Results During stage 1 period (before carotid artery clamping), the mean value of the relative changes in SrO2 was higher (P = 0.033) and the maximal decrease in SrO2 was lower in the sevoflurane group compared with the propofol group (P = 0.019) in the contralateral (normal) site. However, there is no difference in ipsilateral site (affected site). SrO2 decreased after carotid artery clamping and increased after declamping, but the difference was not significant between two groups. Changes in mean arterial blood pressure was lower in sevoflurane group than propofol group after the carotid artery declamping (P = 0.048). Conclusion Propofol-remifentanil anesthesia was comparable with sevoflurane-remifentanil anesthesia in an aspect of preserving the SrO2 in patients undergoing carotid endarterectomy. Trial registration Clinical Trials.gov identifier: NCT02609087, retrospectively registered on November 18, 2015.
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Intraoperative Secondary Insults During Orthopedic Surgery in Traumatic Brain Injury. J Neurosurg Anesthesiol 2018; 29:228-235. [PMID: 26954768 DOI: 10.1097/ana.0000000000000292] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Secondary insults worsen outcomes after traumatic brain injury (TBI). However, data on intraoperative secondary insults are sparse. The primary aim of this study was to examine the prevalence of intraoperative secondary insults during orthopedic surgery after moderate-severe TBI. We also examined the impact of intraoperative secondary insults on postoperative head computed tomographic scan, intracranial pressure (ICP), and escalation of care within 24 hours of surgery. MATERIALS AND METHODS We reviewed medical records of TBI patients 18 years and above with Glasgow Coma Scale score <13 who underwent single orthopedic surgery within 2 weeks of TBI. Secondary insults examined were: systemic hypotension (systolic blood pressure<90 mm Hg), intracranial hypertension (ICP>20 mm Hg), cerebral hypotension (cerebral perfusion pressure<50 mm Hg), hypercarbia (end-tidal CO2>40 mm Hg), hypocarbia (end-tidal CO2<30 mm Hg in absence of intracranial hypertension), hyperglycemia (glucose>200 mg/dL), hypoglycemia (glucose<60 mg/dL), and hyperthermia (temperature >38°C). RESULTS A total of 78 patients (41 [18 to 81] y, 68% male) met the inclusion criteria. The most common intraoperative secondary insults were systemic hypotension (60%), intracranial hypertension and cerebral hypotension (50% and 45%, respectively, in patients with ICP monitoring), hypercarbia (32%), and hypocarbia (29%). Intraoperative secondary insults were associated with worsening of head computed tomography, postoperative decrease of Glasgow Coma Scale score by ≥2, and escalation of care. After Bonferroni correction, association between cerebral hypotension and postoperative escalation of care remained significant (P<0.001). CONCLUSIONS Intraoperative secondary insults were common during orthopedic surgery in patients with TBI and were associated with postoperative escalation of care. Strategies to minimize intraoperative secondary insults are needed.
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Effects of hyperventilation on cerebral oxygen saturation estimated using near-infrared spectroscopy: A randomised comparison between propofol and sevoflurane anaesthesia. Eur J Anaesthesiol 2018; 33:929-935. [PMID: 27802250 DOI: 10.1097/eja.0000000000000507] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Near-infrared spectroscopy estimates cerebral regional tissue oxygen saturation (rSO2), which may decrease under hyperventilation. Propofol and sevoflurane act differently on cerebral blood vessels. Consequently, cerebral blood flow during hyperventilation with propofol and sevoflurane anaesthesia may differ. OBJECTIVES The first aim of this study was to compare the changes in rSO2 between propofol and sevoflurane anaesthesia during hyperventilation. The second aim was to assess changes in rSO2 with ventilation changes. DESIGN A randomised, open-label study. SETTING University of Yamanashi Hospital, Yamanashi, Japan from January 2014 to September 2014. PARTICIPANTS Fifty American Society of Anesthesiologists physical status 1 or 2 adult patients who were scheduled for elective abdominal surgery were assigned randomly to receive either propofol or sevoflurane anaesthesia. Exclusion criterion was a known history of cerebral disease such as cerebral infarction, cerebral haemorrhage, transient ischaemic attack and subarachnoid haemorrhage. INTERVENTIONS After induction of anaesthesia but before the start of surgery, rSO2, arterial carbon dioxide partial pressure (PaCO2) and arterial oxygen saturation were measured. Measurements were repeated at 5-min intervals during 15 min of hyperventilation with a PaCO2 around 30 mmHg (4 kPa), and again after ventilation was normalised. MAIN OUTCOME MEASURES The primary outcome was the difference of changes in rSO2 between propofol anaesthesia and sevoflurane anaesthesia during and after hyperventilation. The second outcome was change in rSO2 after the initiation of hyperventilation and after the normalisation of ventilation. RESULTS Changes of rSO2 during hyperventilation were -10 ± 7% (left) and -11 ± 8% (right) in the propofol group, and -10 ± 8% (left) and -9 ± 7% (right) in the sevoflurane group. After normalisation of PaCO2, rSO2 returned to baseline values. Arterial oxygen saturation remained stable throughout the measurement period. The rSO2 values were similar in the propofol and the sevoflurane groups at each time point. CONCLUSION The effects of hyperventilation on estimated rSO2 were similar with propofol and sevoflurane anaesthesia. Changes in rSO2 correlated well with ventilation changes. TRIAL REGISTRATION Japan Primary Registries Network (JPRN); UMIN-CTR ID; UMIN000010640.
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Meng L, Li SQ, Ji N, Luo F. Effects of Moderate Hyperventilation on Jugular Bulb Gases under Propofol or Isoflurane Anesthesia during Supratentorial Craniotomy. Chin Med J (Engl) 2015; 128:1321-5. [PMID: 25963351 PMCID: PMC4830310 DOI: 10.4103/0366-6999.156775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: The optimal ventilated status under total intravenous or inhalation anesthesia in neurosurgical patients with a supratentorial tumor has not been ascertained. The purpose of this study was to intraoperatively compare the effects of moderate hyperventilation on the jugular bulb oxygen saturation (SjO2), cerebral oxygen extraction ratio (O2ER), mean arterial blood pressure (MAP), and heart rate (HR) in patients with a supratentorial tumor under different anesthetic regimens. Methods: Twenty adult patients suffered from supratentorial tumors were randomly assigned to receive a propofol infusion followed by isoflurane anesthesia after a 30-min stabilization period or isoflurane followed by propofol. The patients were randomized to one of the following two treatment sequences: hyperventilation followed by normoventilation or normoventilation followed by hyperventilation during isoflurane or propofol anesthesia, respectively. The ventilation and end-tidal CO2 tension were maintained at a constant level for 20 min. Radial arterial and jugular bulb catheters were inserted for the blood gas sampling. At the end of each study period, we measured the change in the arterial and jugular bulb blood gases. Results: The mean value of the jugular bulb oxygen saturation (SjO2) significantly decreased, and the oxygen extraction ratio (O2ER) significantly increased under isoflurane or propofol anesthesia during hyperventilation compared with those during normoventilation (SjO2: t = −2.728, P = 0.011 or t = −3.504, P = 0.001; O2ER: t = 2.484, P = 0.020 or t = 2.892, P = 0.009). The SjO2 significantly decreased, and the O2ER significantly increased under propofol anesthesia compared with those values under isoflurane anesthesia during moderate hyperventilation (SjO2: t = −2.769, P = 0.012; O2ER: t = 2.719, P = 0.013). In the study, no significant changes in the SjO2 and the O2ER were observed under propofol compared with those values under isoflurane during normoventilation. Conclusions: Our results suggest that the optimal ventilated status under propofol or isoflurane anesthesia in neurosurgical patients varies. Hyperventilation under propofol anesthesia should be cautiously performed in neurosurgery to maintain an improved balance between the cerebral oxygen supply and demand.
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Affiliation(s)
| | | | | | - Fang Luo
- Department of Anesthesiology and Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China
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Does sevoflurane preserve regional cerebral oxygen saturation measured by near-infrared spectroscopy better than propofol? ACTA ACUST UNITED AC 2014; 33:e59-65. [DOI: 10.1016/j.annfar.2013.12.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 12/30/2013] [Indexed: 11/23/2022]
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The effect of desflurane versus propofol on regional cerebral oxygenation in the sitting position for shoulder arthroscopy. J Clin Monit Comput 2013; 28:371-6. [DOI: 10.1007/s10877-013-9543-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 12/03/2013] [Indexed: 10/25/2022]
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Sharma D, Siriussawakul A, Dooney N, Hecker JG, Vavilala MS. Clinical experience with intraoperative jugular venous oximetry during pediatric intracranial neurosurgery. Paediatr Anaesth 2013; 23:84-90. [PMID: 23004361 DOI: 10.1111/pan.12031] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/17/2012] [Indexed: 11/29/2022]
Abstract
AIM To report our institutional experience with intraoperative jugular venous oximetry during pediatric intracranial surgery to guide anesthetic care. BACKGROUND The utility of intraoperative jugular venous oximetry in adults undergoing intracranial surgery is well known. However, there is a little information on its' application in children during intracranial surgery. METHODS After IRB approval, we examined patient, equipment, placement, and sampling characteristics for jugular bulb catheters in children aged <18 years who were monitored with jugular oximetry during elective intracranial surgery between 2006 and 2010. We also determined the prevalence of intraoperative cerebral desaturation (SjvO(2) < 55%), its causes, and the interventions based on jugular oximetry values. RESULTS Data from 19 children (10 males and nine females), aged 12 ± 1 years (range 7-17) who underwent craniotomy for arteriovenous malformation (AVM) resection (68%), tumor removal (21%), or aneurysm clipping (11%), were reviewed. We analyzed 88 coincident SjvO(2), PaCO(2), and mean arterial pressure data points. Eleven (58%) patients experienced at least one episode of cerebral desaturation. There were 25 (28%) episodes of cerebral desaturation, six of which we attributed to relative hypotension, four to hypocarbia, and 15 to a combination of both. There were no intraoperative or immediate postoperative (first 24 h) complications because of jugular oximetry. CONCLUSION Findings from this series indicate that (i) intraoperative jugular venous oximetry in children is feasible in experienced hands, (ii) cerebral desaturation detected by jugular oximetry is common during pediatric intracranial procedures, and (iii) monitoring jugular venous saturation can impact anesthetic interventions to optimize cerebral physiology.
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Affiliation(s)
- Deepak Sharma
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, USA
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Prevalence and risk factors for intraoperative hypotension during craniotomy for traumatic brain injury. J Neurosurg Anesthesiol 2012; 24:178-84. [PMID: 22504924 DOI: 10.1097/ana.0b013e318254fb70] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hypotension after traumatic brain injury (TBI) is associated with poor outcomes. However, data on intraoperative hypotension (IH) are scarce and the effect of anesthetic agents on IH is unknown. We examined the prevalence and risk factors for IH, including the effect of anesthetic agents during emergent craniotomy for isolated TBI. METHODS This is a retrospective cohort study of patients 18 years and above, who underwent emergent craniotomy for TBI at Harborview Medical Center (level 1 trauma center) between October 2007 and January 2010. Demographic, clinical, and radiographic characteristics and hemodynamic and anesthetic data were abstracted from medical and electronic anesthesia records. Hypotension was defined as systolic blood pressure <90 mm Hg. Univariate analyses were performed to compare the clinical characteristics of patients with and without IH, and multiple logistic regression analysis was used to determine independent risk factors for IH. RESULTS Data abstracted from 113 eligible patients aged 48±19 years were analyzed. IH was common (n=73, 65%) but not affected by the choice of anesthetic agent. Independent risk factors for IH were multiple computed tomographic (CT) lesions [adjusted odds ratios (AOR) 19.1; 95% confidence interval (CI), 2.08-175.99; P=0.009], subdural hematoma (AOR 17.9; 95% CI, 2.97-108.10; P=0.002), maximum CT lesion thickness (AOR 1.1; 95% CI, 1.01-1.13; P=0.016), and anesthesia duration (AOR 1.1; 95% CI, 1.01-1.30; P=0.009). CONCLUSIONS IH was common in adult patients with isolated TBI undergoing emergent craniotomy. The presence of multiple CT lesions, subdural hematoma, maximum thickness of CT lesion, and longer duration of anesthesia increase the risk for IH.
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Sharma D, Ellenbogen RG, Vavilala MS. Use of transcranial Doppler ultrasonography and jugular oximetry to optimize hemodynamics during pediatric posterior fossa craniotomy. J Clin Neurosci 2010; 17:1583-4. [PMID: 20800495 DOI: 10.1016/j.jocn.2010.04.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2010] [Accepted: 04/03/2010] [Indexed: 10/19/2022]
Abstract
We describe a 13-year-old child who developed inadvertent intraoperative cerebral oxygen desaturation attributed to empiric hyperventilation during posterior fossa craniotomy, diagnosed by jugular venous oximetry. Although restoration of normocapnia at age-appropriate mean arterial blood pressure improved jugular venous saturation (SjvO), it remained below acceptable values. Transcranial-Doppler (TCD) ultrasonography-guided stepwise increase in mean arterial pressure led to a linear increase in the mean flow velocity of the middle cerebral artery and SjvO₂ to desirable values. Intraoperative SjvO₂ monitoring and TCD ultrasonography may be utilized together to individualize hemodynamic targets and ventilation parameters and maintain adequate cerebral oxygenation during paediatric craniotomies.
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Affiliation(s)
- Deepak Sharma
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, Washington 98104, USA
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Gelb AW, Craen RA, Rao GSU, Reddy KRM, Megyesi J, Mohanty B, Dash HH, Choi KC, Chan MTV. Does hyperventilation improve operating condition during supratentorial craniotomy? A multicenter randomized crossover trial. Anesth Analg 2008; 106:585-94, table of contents. [PMID: 18227320 DOI: 10.1213/01.ane.0000295804.41688.8a] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Hyperventilation has been an integral, but poorly validated part of neuroanesthetic practice. We conducted a two-period, crossover, randomized trial to evaluate surgeon-assessed brain bulk and measured intracranial pressure (ICP) in patients undergoing craniotomy for removal of supratentorial brain tumors during moderate hypocapnia or normocapnia. METHODS Two-hundred and seventy-five adult patients with supratentorial brain tumors were randomized to one of two treatment sequences: hyperventilation (arterial carbon dioxide tension, PaCO2 = 25 +/- 2 mm Hg) followed by normoventilation (PaCO2 = 37 +/- 2 mm Hg) or normoventilation followed by hyperventilation. Ventilation and end-tidal CO2 tension were kept constant for 20 min. Patients were also randomly assigned to receive a propofol infusion or isoflurane anesthesia. At the end of each study period, subdural ICP was measured and the neurosurgeon, blinded to the treatment group, was asked to rate the brain bulk using a four-point scale. RESULTS Using a generalized estimation equation model, we found that hyperventilation decreased the risk of increased brain bulk by 45%, P = 0.004, 95% confidence intervals 22% to 61%, and the number needed to treat was 8. The mean (+/-SD) ICP during hyperventilation, 12.3 +/- 8.1 mm Hg, was lower than that during normoventilation, 16.2 +/- 9.6 mm Hg, P < 0.001. Anesthetic regimen did not affect brain bulk assessment or ICP. CONCLUSIONS In patients with supratentorial brain tumors, intraoperative hyperventilation improves surgeon-assessed brain bulk which was associated with a decrease in ICP.
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Affiliation(s)
- Adrian W Gelb
- Department of Anesthesia and Perioperative Care, University of California San Francisco, 521 Parnassus Ave, C 450, San Francisco, CA 94143-0648, USA.
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Iwata M, Inoue S, Kawaguchi M, Takahama M, Tojo T, Taniguchi S, Furuya H. Jugular Bulb Venous Oxygen Saturation During One-Lung Ventilation Under Sevoflurane- or Propofol-Based Anesthesia for Lung Surgery. J Cardiothorac Vasc Anesth 2008; 22:71-6. [DOI: 10.1053/j.jvca.2007.03.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2006] [Indexed: 11/11/2022]
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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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Armitage-Chan EA, Wetmore LA, Chan DL. Anesthetic management of the head trauma patient. J Vet Emerg Crit Care (San Antonio) 2007. [DOI: 10.1111/j.1476-4431.2006.00194.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Hans P, Bonhomme V. Why we still use intravenous drugs as the basic regimen for neurosurgical anaesthesia. Curr Opin Anaesthesiol 2007; 19:498-503. [PMID: 16960481 DOI: 10.1097/01.aco.0000245274.69292.ad] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Evolution of neurosurgery mainly trends towards minimally invasive and functional procedures including endoscopies, small-size craniotomies, intraoperative imaging and stereotactic interventions. Consequently, new adjustments of anaesthesia should aim at providing brain relaxation, minimal interference with electrophysiological monitoring, rapid recovery, patients' cooperation during surgery and neuroprotection. RECENT FINDINGS In brain tumour patients undergoing craniotomy, propofol anaesthesia is associated with lower intracranial pressure and cerebral swelling than volatile anaesthesia. Hyperventilation used to improve brain relaxation may decrease jugular venous oxygen saturation below the critical threshold. It decreases the cerebral perfusion pressure in patients receiving sevoflurane, but not in those receiving propofol. The advantage of propofol over volatile agents has also been confirmed regarding interference with somatosensory, auditory and motor evoked potentials. Excellent and predictable recovery conditions as well as minimal postoperative side-effects make propofol particularly suitable in awake craniotomies. Finally, the potential neuroprotective effect of this drug could be mediated by its antioxidant properties which can play a role in apoptosis, ischaemia-reperfusion injury and inflammatory-induced neuronal damage. SUMMARY Although all the objectives of neurosurgical anaesthesia cannot be met by one single anaesthetic agent or technique, propofol-based intravenous anaesthesia appears as the first choice to challenge the evolution of neurosurgery in the third millennium.
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Affiliation(s)
- Pol Hans
- University Department of Anaesthesia and Intensive Care Medicine, CHR de la Citadelle, Liege University Hospital, Liege, Belgium.
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Engelhard K, Werner C. Inhalational or intravenous anesthetics for craniotomies? Pro inhalational. Curr Opin Anaesthesiol 2006; 19:504-8. [PMID: 16960482 DOI: 10.1097/01.aco.0000245275.76916.87] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW In neurosurgery, anesthesiologists and surgeons focus on the same target - the brain. The nature of anesthetics is to interact with brain physiology, leading to favorable and adverse effects. Research in neuroanesthesia over the last three decades has been dedicated to identifying the optimal anesthetic agent to maintain coupling between cerebral blood flow and metabolism, keep cerebrovascular autoregulation intact, and not increase cerebral blood volume and intracranial pressure. RECENT FINDINGS Sevoflurane is less vasoactive than halothane, enflurane, isoflurane, or desflurane. The context sensitive half-life is short and similar to that of desflurane, which translates into fast on and offset. Compared with propofol, sevoflurane decreases cerebral blood flow to a lesser extent, while cerebral metabolism is suppressed to the same degree. Sevoflurane does not increase intracranial pressure, while propofol decreases intracranial pressure. SUMMARY In neurosurgical patients with normal intracranial pressure, sevoflurane might be a good alternative to propofol. In patients with reduced intracranial elastance, caused by space occupying lesions, with elevated intracranial pressure or complex surgical approaches, propofol should remain first choice.
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Affiliation(s)
- Kristin Engelhard
- Klinik für Anästhesiologie, Johannes Gutenberg-Universität, Mainz, Germany.
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Rao GSU, Pillai SV. Cerebrovascular Reactivity to Carbon Dioxide in the Normal and Abnormal Cerebral Hemispheres Under Anesthesia in Patients With Frontotemporal Gliomas. J Neurosurg Anesthesiol 2006; 18:185-8. [PMID: 16799345 DOI: 10.1097/01.ana.0000211000.56151.df] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cerebral pathology may alter the cerebrovascular reactivity to carbon dioxide (CO2). In the present study, in patients with brain tumors, we examined the cerebral vascular reactivity to CO2 in the cerebral hemispheres with and without tumors under intravenous and inhalational anesthesia. Twenty-nine patients undergoing craniotomy for frontotemporal gliomas were randomized to receive intravenous anesthesia with propofol or inhalational anesthesia with isoflurane. Cerebral blood flow velocity in the middle cerebral artery (VMCA) and pulsatality index were measured under normocapnia and hypocapnia in the normal cerebral hemisphere and the hemisphere with tumor. Hypocapnia significantly decreased the VMCA in both the cerebral hemispheres under both the anesthetic techniques (P < 0.006). The percentage change in VMCA was similar between the hemispheres with and without tumor both under isoflurane (3.45 +/- 4.11% on the normal side and 2.91 +/- 2.40% on the tumor side; mean difference 0.54 +/- 1.31%; 95% CI -2.18 to +3.27) and propofol anesthesia (2.32 +/- 2.64% on the normal side and 1.69 +/- 4.04% on the tumor side; mean difference 0.63 +/- 1.2%; 95% CI -1.83 to +3.10). The changes in pulsatality index also were not significantly different between the hemispheres. In conclusion, cerebrovascular response to hypocapnia is similar between the normal and the abnormal cerebral hemispheres both under intravenous and inhalational anesthesia.
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Yoshitani K, Kawaguchi M, Iwata M, Sasaoka N, Inoue S, Kurumatani N, Furuya H. Comparison of changes in jugular venous bulb oxygen saturation and cerebral oxygen saturation during variations of haemoglobin concentration under propofol and sevoflurane anaesthesia. Br J Anaesth 2005; 94:341-6. [PMID: 15591331 DOI: 10.1093/bja/aei046] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND A severe reduction in haemoglobin concentration can lead to a decrease in jugular venous bulb oxygen saturation (Sj(O(2))). However, recent evidences suggests that cerebral oxygen saturation (Sc(O(2))) measured by near infrared spectroscopy decreased during even mild haemodilution. We therefore tested the hypothesis that the changes in Sc(O(2)) may not be parallel to those in Sj(O(2)) during haemodilution. In addition, as cerebral oxygen balance during the operation can vary depending on the anaesthetics used, the changes in Sj(O(2)) and Sc(O(2)) during haemodilution were compared between patients under propofol and isoflurane/nitrous oxide anaesthesia. METHODS Forty-two patients with pre-donated autologous blood were randomly assigned to receive propofol (Group P) or sevoflurane/nitrous oxide (Group S) anaesthesia. A fibreoptic catheter was placed in the jugular bulb to measure Sj(O(2)). A cerebral oximeter, INVOS 4100S was used to monitor Sc(O(2)). Arterial and jugular bulb blood samples were drawn simultaneously at: (i) 10 min after the start of operation, (ii) after 400 ml of blood loss, (iii) after 800 ml of blood loss, (iv) just before the transfusion of pre-donated autologous blood, and (v) after 400 ml transfusion. RESULTS Mean (sd) control values of Sj(O(2)) in Group P were significantly lower than those in Group S (55 (8)% vs 71 (10)%, respectively; P<0.05), whereas there was no significant difference in control values of Sc(O(2)) between the two groups. During the operation, haemoglobin (Hb) concentrations significantly deceased in the both groups compared with control values (from 9.8 to 7.6 g dl(-1) in Group P and from 9.9 to 8.0 g dl(-1) in Group S). During a reduction in Hb concentration, Sj(O(2)) values remained unchanged in both groups, whereas Sc(O(2)) values significantly decreased in both groups (from 57 to 51% in Group P and from 59 to 52% in Group S). CONCLUSION The results indicated that, although the changes in Sj(O(2)) and Sc(O(2)) during a reduction in haemoglobin concentration were similar under propofol and sevoflurane/nitrous oxide anaesthesia, the changes in Sc(O(2)) were not parallel to those in Sj(O(2)). The discrepancy of the results in Sj(O(2)) and Sc(O(2)) may make the interpretation of their values difficult during haemodilution.
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Affiliation(s)
- K Yoshitani
- Department of Anaesthesiology, Nara Medical University, Kashihara, Nara 634-8521, Japan.
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