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Kornilov E, Baker Erdman H, Kahana E, Fireman S, Zarchi O, Israelashvili M, Reiner J, Glik A, Weiss P, Paz R, Bergman H, Tamir I. Interleaved Propofol-Ketamine Maintains DBS Physiology and Hemodynamic Stability: A Double-Blind Randomized Controlled Trial. Mov Disord 2024; 39:694-705. [PMID: 38396358 DOI: 10.1002/mds.29746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/18/2023] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND The gold standard anesthesia for deep brain stimulation (DBS) surgery is the "awake" approach, using local anesthesia alone. Although it offers high-quality microelectrode recordings and therapeutic-window assessment, it potentially causes patients extreme stress and might result in suboptimal surgical outcomes. General anesthesia or deep sedation is an alternative, but may reduce physiological testing reliability and lead localization accuracy. OBJECTIVES The aim is to investigate a novel anesthesia regimen of ketamine-induced conscious sedation for the physiological testing phase of DBS surgery. METHODS Parkinson's patients undergoing subthalamic DBS surgery were randomly divided into experimental and control groups. During physiological testing, the groups received 0.25 mg/kg/h ketamine infusion and normal saline, respectively. Both groups had moderate propofol sedation before and after physiological testing. The primary outcome was recording quality. Secondary outcomes included hemodynamic stability, lead accuracy, motor and cognitive outcome, patient satisfaction, and adverse events. RESULTS Thirty patients, 15 from each group, were included. Intraoperatively, the electrophysiological signature and lead localization were similar under ketamine and saline. Tremor amplitude was slightly lower under ketamine. Postoperatively, patients in the ketamine group reported significantly higher satisfaction with anesthesia. The improvement in Unified Parkinson's disease rating scale part-III was similar between the groups. No negative effects of ketamine on hemodynamic stability or cognition were reported perioperatively. CONCLUSIONS Ketamine-induced conscious sedation provided high quality microelectrode recordings comparable with awake conditions. Additionally, it seems to allow superior patient satisfaction and hemodynamic stability, while maintaining similar post-operative outcomes. Therefore, it holds promise as a novel alternative anesthetic regimen for DBS. © 2024 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Evgeniya Kornilov
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
- Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel
| | - Halen Baker Erdman
- Department of Medical Neurobiology, Hebrew University, Jerusalem, Israel
| | - Eilat Kahana
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Shlomo Fireman
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Omer Zarchi
- Intraoperative Neurophysiology Unit, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | | | - Johnathan Reiner
- Department of Neurology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Amir Glik
- Department of Neurology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
- Cognitive Neurology Clinic, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Penina Weiss
- Occupational Therapy Department, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Rony Paz
- Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel
| | - Hagai Bergman
- Department of Medical Neurobiology, Hebrew University, Jerusalem, Israel
- Department of Neurosurgery, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
- The Edmond and Lily Safra Center for Brain Sciences, Hebrew University, Jerusalem, Israel
| | - Idit Tamir
- Department of Neurosurgery, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
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Zech N, Sinner B. [Anaesthesia and Perioperative Management for Patients with Parkinson's Disease]. Anasthesiol Intensivmed Notfallmed Schmerzther 2022; 57:578-586. [PMID: 36049741 DOI: 10.1055/a-1404-2154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Idiopathic Parkinson's syndrome is associated with the loss of dopaminergic cells. It is defined by the presence of akinesia together with one of the cardinal symptoms: rigor, tremor, or postural instability. As the perioperative management of these patients can be challenging and they have an increased perioperative risk, every anaesthesiologist should know some special features. If a patient with Parkinson's disease does not receive the required amount of dopa, akinetic crisis may occur. Moreover, the administration of dopamine-antagonistic drugs can trigger a malignant neuroleptic syndrome. These are life-threatening clinical pictures that require intensive medical treatment. Therefore, patients with Parkinson's disease should be enabled to keep the period without the intake of the specific medication as short as possible. General anaesthesia should be performed with short acting anaesthetics and a regional anaesthesia might be beneficial. Besides, all dopamine antagonists sometimes used for prophylaxis or therapy of delirium or PONV (haloperidol, metoclopramide) are contraindicated. Alternatives are short-acting benzodiazepines, atypical neuroleptics and domperidone.
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Amlong C, Rusy D, Sanders RD, Lake W, Raz A. Dexmedetomidine depresses neuronal activity in the subthalamic nucleus during deep brain stimulation electrode implantation surgery. BJA OPEN 2022; 3:100088. [PMID: 37588575 PMCID: PMC10430856 DOI: 10.1016/j.bjao.2022.100088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 08/03/2022] [Indexed: 08/18/2023]
Abstract
Background Micro-electrode recordings are often necessary during electrode implantation for deep brain stimulation of the subthalamic nucleus. Dexmedetomidine may be a useful sedative for these procedures, but there is limited information regarding its effect on neural activity in the subthalamic nucleus and on micro-electrode recording quality. Methods We recorded neural activity in five patients undergoing deep brain stimulation implantation to the subthalamic nucleus. Activity was recorded after subthalamic nucleus identification while patients received dexmedetomidine sedation (loading - 1 μg kg-1 over 10-15 min, maintenance - 0.7 μg kg-1 h-1). We compared the root-mean square (RMS) and beta band (13-30 Hz) oscillation power of multi-unit activity recorded by microelectrode before, during and after recovery from dexmedetomidine sedation. RMS was normalised to values recorded in the white matter. Results Multi-unit activity decreased during sedation in all five patients. Mean normalised RMS decreased from 2.8 (1.5) to 1.6 (1.1) during sedation (43% drop, p = 0.056). Beta band power dropped by 48.4%, but this was not significant (p = 0.15). Normalised RMS values failed to return to baseline levels during the time allocated for the study (30 min). Conclusions In this small sample, we demonstrate that dexmedetomidine decreases neuronal firing in the subthalamic nucleus as expressed in the RMS of the multi-unit activity. As multi-unit activity is a factor in determining the subthalamic nucleus borders during micro-electrode recordings, dexmedetomidine should be used with caution for sedation during these procedures. Clinical trial number NCT01721460.
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Affiliation(s)
- Corey Amlong
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - Deborah Rusy
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - Robert D. Sanders
- University of Sydney, Sydney, Australia
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Wendell Lake
- Department of Neurosurgery, University of Wisconsin, Madison, WI, USA
| | - Aeyal Raz
- Department of Anesthesiology, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion – Israel Institute of Technology, Haifa, Israel
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Meng W, Kang F, Dong M, Wang S, Han M, Huang X, Wang S, Li J, Yang C. Remifentanil requirement for i-gel insertion is reduced in male patients with Parkinson's disease undergoing deep brain stimulator implantation: an up-and-down sequential allocation trial. BMC Anesthesiol 2022; 22:197. [PMID: 35751029 PMCID: PMC9229424 DOI: 10.1186/s12871-022-01735-0] [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: 11/11/2021] [Accepted: 06/13/2022] [Indexed: 11/10/2022] Open
Abstract
Background Laryngeal mask airways have been widely used in clinical practice. The aim of this study was to investigate whether the remifentanil requirement for facilitation of i-gel insertion in Parkinson’s disease (PD) patients undergoing deep brain stimulation (DBS) surgery was different from that in non-PD (NPD) patients undergoing intracranial surgery. Study design An up-and-down sequential allocation trial. Methods Male patients aged between 40 and 64 years old were enrolled. The first patient in each group (PD and NPD) group received an effect-site concentration (Ce) of remifentanil (Minto pharmacokinetic model) of 4.0 ng.ml−1 during a target-controlled infusion (TCI) of 3.5 μg.ml−1 propofol (Marsh pharmacokinetic model). The next dose of remifentanil was determined by the response of the previous patient. The Ce of remifentanil required for i-gel insertion in 50% of patients (EC50) was estimated by the modified Dixon’s up-and-down method and by probit analysis. Results The PD group included 24 patients and the NPD group included 23. The EC50 of remifentanil for i-gel insertion during a TCI of 3.5 μg.ml−1 propofol estimated by the modified Dixon’s up-and-down method in PD patients (2.38 ± 0.65 ng.ml−1) was significantly lower than in NPD patients (3.21 ± 0.49 ng.ml−1) (P = 0.03). From the probit analysis, the EC50 and EC95 (effective Ce in 95% of patients) of remifentanil were 1.95 (95% CI 1.52–2.36) ng.ml−1 and 3.12 (95% CI 2.53–5.84) ng.ml−1 in PD patients and 2.85 (95% CI 2.26–3.41) ng.ml−1 and 4.57 (95% CI 3.72–8.54) ng.ml−1 in NPD patients, respectively. Conclusions The remifentanil requirement for successful i-gel insertion is reduced in male PD patients undergoing DBS implantation during propofol TCI induction. Clinicians should closely monitor the remifentanil requirement in patients with PD. Trial registration Registered at http://www.chictr.org.cn (ChiCTR1900021760).
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Affiliation(s)
- Wenjun Meng
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, China
| | - Fang Kang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, China
| | - Meirong Dong
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, China
| | - Song Wang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, China
| | - Mingming Han
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, China
| | - Xiang Huang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, China
| | - Sheng Wang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, China
| | - Juan Li
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, China.
| | - Chengwei Yang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, China.
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Raoul S, Brissot R, Lefaucheur JP, Nguyen JM, Rouaud T, Meas Y, Huchet A, Razafimahefa N, Damier P, Nizard J, Nguyen JP. Additional Benefit of Intraoperative Electroacupuncture in Improving Tolerance of Deep Brain Stimulation Surgical Procedure in Parkinsonian Patients. J Clin Med 2022; 11:jcm11102680. [PMID: 35628808 PMCID: PMC9145270 DOI: 10.3390/jcm11102680] [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: 02/14/2022] [Revised: 04/25/2022] [Accepted: 05/07/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Deep brain stimulation (DBS) is an effective technique to treat patients with advanced Parkinson’s disease. The surgical procedure of DBS implantation is generally performed under local anesthesia due to the need for intraoperative clinical testing. However, this procedure is long (5–7 h on average) and, therefore, the objective that the patient remains co-operative and tolerates the intervention well is a real challenge. Objective: To evaluate the additional benefit of electroacupuncture (EA) performed intraoperatively to improve the comfort of parkinsonian patients during surgical DBS implantation. Methods: This single-center randomized study compared two groups of patients. In the first group, DBS implantation was performed under local anesthesia alone, while the second group received EA in addition. The patients were evaluated preoperatively, during the different stages of the surgery, and 2 days after surgery, using the 9-item Edmonton Symptom Assessment System (ESAS), including a total sum score and physical and emotional subscores. Results: The data of nine patients were analyzed in each group. Although pain and tiredness increased in both groups after placement of the stereotactic frame, the ESAS item “lack of appetite”, as well as the ESAS total score and physical subscore increased after completion of the first burr hole until the end of the surgical procedure in the control group only. ESAS total score and physical subscore were significantly higher at the end of the intervention in the control group compared to the EA group. After the surgical intervention (D2), anxiety and ESAS emotional subscore were improved in both groups, but the feeling of wellbeing improved in the EA group only. Finally, one patient developed delirium during the intervention and none in the EA group. Discussion: This study shows that intraoperative electroacupuncture significantly improves the tolerance of DBS surgery in parkinsonian patients. This easy-to-perform procedure could be fruitfully added in clinical practice.
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Affiliation(s)
- Sylvie Raoul
- Service de Neurochirurgie, Hôpital Laennec, CHU, 44093 Nantes, France; (R.B.); (N.R.)
- Correspondence: ; Tel.: +33-240165080
| | - Régine Brissot
- Service de Neurochirurgie, Hôpital Laennec, CHU, 44093 Nantes, France; (R.B.); (N.R.)
| | - Jean-Pascal Lefaucheur
- EA4391, Excitabilité Nerveuse et Thérapeutique, Université Paris Est Créteil, 94000 Créteil, France; (J.-P.L.); (J.N.)
- Unité de Neurophysiologie Clinique, Hôpital Henri Mondor, AP-HP, 94000 Créteil, France
| | - Jean-Michel Nguyen
- Service de Biostatistiques et d’épidémiologie, Hôpital Saint Jacques, CHU, 44093 Nantes, France;
| | - Tiphaine Rouaud
- Service de Neurologie, Hôpital Laennec, CHU, 44093 Nantes, France; (T.R.); (P.D.)
| | - Yunsan Meas
- Service Douleur, Soins palliatifs et de Support et UIC22, Hôpital Laennec, CHU, 44093 Nantes, France; (Y.M.); (J.-P.N.)
| | | | | | - Philippe Damier
- Service de Neurologie, Hôpital Laennec, CHU, 44093 Nantes, France; (T.R.); (P.D.)
| | - Julien Nizard
- EA4391, Excitabilité Nerveuse et Thérapeutique, Université Paris Est Créteil, 94000 Créteil, France; (J.-P.L.); (J.N.)
- Service Douleur, Soins palliatifs et de Support et UIC22, Hôpital Laennec, CHU, 44093 Nantes, France; (Y.M.); (J.-P.N.)
| | - Jean-Paul Nguyen
- Service Douleur, Soins palliatifs et de Support et UIC22, Hôpital Laennec, CHU, 44093 Nantes, France; (Y.M.); (J.-P.N.)
- Centre D’évaluation et de Traitement de la Douleur, Clinique Brétéché, Groupe Elsan, 44000 Nantes, France
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Abstract
Patients with Parkinson's disease (PD) may undergo several elective and emergency surgeries. Motor fluctuations, the presence of a wide range of non-motor symptoms (NMS), and the use of several medications, often not limited to dopaminergic agents, make the perioperative management of PD challenging. However, the literature on perioperative management of PD is sparse. In this descriptive review article, we comprehensively discuss the issues in the pre-, intra-, and postoperative phases which may negatively affect the PD patients and discuss the approach to their prevention and management. The major preoperative challenges include accurate medication reconciliation and administration of the dopaminergic medications during the nil per os (NPO) state. While the former can be addressed with staff education and PD-specific admission protocols, knowledge of non-oral formulations of dopaminergic agents (apomorphine, inhalational levodopa, and rotigotine transdermal patch) is the key to the management of the Parkinsonian symptoms in NPO state. Deep brain stimulation (DBS) devices should be turned off to avert potential electromagnetic interference with surgical appliances. Choosing the appropriate anesthesia and avoiding and managing respiratory issues and dysautonomia are the major intraoperative challenges. Timely reinitiation of dopaminergic medications, adequate management of pain, nausea, and vomiting, and prevention of postoperative infections and delirium are the postoperative challenges. Overall, a multidisciplinary approach is pivotal to prevent and manage the perioperative complications in PD. Administration of anti-Parkinson medications during NPO state, prevention of anesthesia-related complications, and timely rehabilitation remain the key to healthy surgical outcomes.
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Benady A, Zadik S, Eimerl D, Heymann S, Bergman H, Israel Z, Raz A. Sedative drugs modulate the neuronal activity in the subthalamic nucleus of parkinsonian patients. Sci Rep 2020; 10:14536. [PMID: 32884017 PMCID: PMC7471283 DOI: 10.1038/s41598-020-71358-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 08/10/2020] [Indexed: 11/09/2022] Open
Abstract
Microelectrode recording (MER) is often used to identify electrode location which is critical for the success of deep brain stimulation (DBS) treatment of Parkinson’s disease. The usage of anesthesia and its’ impact on MER quality and electrode placement is controversial. We recorded neuronal activity at a single depth inside the Subthalamic Nucleus (STN) before, during, and after remifentanil infusion. The root mean square (RMS) of the 250–6000 Hz band-passed signal was used to evaluate the regional spiking activity, the power spectrum to evaluate the oscillatory activity and the coherence to evaluate synchrony between two microelectrodes. We compare those to new frequency domain (spectral) analysis of previously obtained data during propofol sedation. Results showed Remifentanil decreased the normalized RMS by 9% (P < 0.001), a smaller decrease compared to propofol. Regarding the beta range oscillatory activity, remifentanil depressed oscillations (drop from 25 to 5% of oscillatory electrodes), while propofol did not (increase from 33.3 to 41.7% of oscillatory electrodes). In the cases of simultaneously recorded oscillatory electrodes, propofol did not change the synchronization while remifentanil depressed it. In conclusion, remifentanil interferes with the identification of the dorsolateral oscillatory region, whereas propofol interferes with RMS identification of the STN borders. Thus, both have undesired effect during the MER procedure. Trial registration: NCT00355927 and NCT00588926.
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Affiliation(s)
- Amit Benady
- St George's University of London Medical School, Sheba Medical Center, Ramat Gan, Israel.,Center of Advanced Technologies in Rehabilitation, Sheba Medical Center, Ramat Gan, Israel
| | - Sean Zadik
- St George's University of London Medical School, Sheba Medical Center, Ramat Gan, Israel
| | - Dan Eimerl
- Department of Anesthesia, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Sami Heymann
- Department of Neurosurgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Hagai Bergman
- Department of Medical Neurobiology, Hebrew University - Hadassah Medical Scholl, Jerusalem, Israel
| | - Zvi Israel
- Department of Neurosurgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Aeyal Raz
- Department of Anesthesiology, Rambam Health Care Center affiliated with the Ruth and Bruce Rappaport Faculty of Medicine, Rambam Health Care Campus, Technion - Israel Institute of Technology, 8 HaAliya HaShniya St., 3109601, Haifa, Israel.
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Park YS, Kim J, Kim SH, Moon YJ, Kwon HM, Park HS, Kim WJ, Ha S. Comparison of recovery profiles in patients with Parkinson's disease for 2 types of neuromuscular blockade reversal agent following deep brain stimulator implantation. Medicine (Baltimore) 2019; 98:e18406. [PMID: 31876713 PMCID: PMC6946526 DOI: 10.1097/md.0000000000018406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
As an anesthetic reversal agent, there are concerns with cholinesterase inhibitors regarding worsening of Parkinson's disease (PD)-related symptoms. Sugammadex, a relatively new reversal agent, does not inhibit acetylcholinesterase and does not require co-administration of an antimuscarinic agent. The present study compared the recovery profiles of 2 agents initially administered for reversal of neuromuscular blockade in patients with advanced PD who underwent deep brain stimulator implantation.A total of 121 patients with PD who underwent deep brain stimulator implantation were retrospectively analyzed. Patients were divided into 1 of 2 groups according to the type of neuromuscular blockade reversal agent (pyridostigmine vs sugammadex) initially administered. Recovery profiles reflecting time to extubation, reversal failure at first attempt, and hemodynamic stability, including incidence of hypertension or tachycardia during the emergence period, were compared.Time to extubation in the sugammadex group was significantly shorter (P < .001). In the sugammadex group, reversal failure at first attempt did not occur in any patient, while it occurred in seven (9.7%) patients in the pyridostigmine group (P = .064), necessitating an additional dose of pyridostigmine (n = 3) or sugammadex (n = 4). The incidence of hemodynamic instability during anesthetic emergence was significantly lower in the sugammadex group than in the pyridostigmine group (P = .019).Sugammadex yielded a recovery profile superior to that of pyridostigmine during the anesthesia emergence period in advanced PD patients. Sugammadex is also likely to be associated with fewer adverse effects than traditional reversal agents, which in turn would also improve overall postoperative management in this patient population.
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Affiliation(s)
- Yong-Seok Park
- Department of Anesthesia and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul
| | - Jaewon Kim
- Department of Biomedical Science and Engineering, Gwangju Institute of Science and Technology, Gwangju, Republic of Korea
| | - Sung-Hoon Kim
- Department of Anesthesia and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul
| | - Young-Jin Moon
- Department of Anesthesia and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul
| | - Hye-Mee Kwon
- Department of Anesthesia and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul
| | - Hee-Sun Park
- Department of Anesthesia and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul
| | - Wook-Jong Kim
- Department of Anesthesia and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul
| | - Seungil Ha
- Department of Anesthesia and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul
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The Effects of Intraoperative Sedation on Surgical Outcomes of Deep Brain Stimulation Surgery. Can J Neurol Sci 2017; 45:168-175. [PMID: 29237514 DOI: 10.1017/cjn.2017.269] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Intraoperative sedation is often used to facilitate deep brain stimulation (DBS) surgery; however, these sedative agents also suppress microelectrode recordings (MER). To date, there have been no studies that have examined the effects of differing sedatives on surgical outcomes and the success of DBS surgery. METHODS We performed a retrospective study to evaluate the effect of differing sedative agents on postoperative surgical outcomes at 6 months in parkinsonian adult patients who underwent DBS surgery, from January 2004 through December 2014, at one academic center. Surgical outcomes of DBS were evaluated using a simplified Unified Parkinson Diseases Rating Score-III and levodopa dose equivalent reduction at baseline and 6 months postoperatively. RESULTS We analyzed data from 121 of 124 consecutive parkinsonian patients. Propofol, dexmedetomidine, remifentanil, and midazolam were used individually or in combination. All sedatives were routinely discontinued 20 to 30 minutes before MER, in accordance with our institutional protocol. We found no statistically significant association between the use of individual agent or combination of sedative agents and surgical outcomes at 6 months, the success of DBS, duration of MER, duration of stage 1 procedure, and perioperative complications. CONCLUSIONS Our study showed that the choice of sedative agent was not associated with poor surgical outcomes after DBS surgery using MER and macrostimulation techniques in parkinsonian patients.
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Roberts DP, Lewis SJG. Considerations for general anaesthesia in Parkinson's disease. J Clin Neurosci 2017; 48:34-41. [PMID: 29133106 DOI: 10.1016/j.jocn.2017.10.062] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 10/23/2017] [Indexed: 12/19/2022]
Abstract
Parkinson's disease is a common neurodegenerative disorder in the elderly which when present has a significant influence on surgical management. These patients necessitate additional perioperative and anaesthetic considerations across disease specific domains as well as in relation to the respiratory and cardiovascular systems. This brief review focuses on the factors which contribute to perioperative morbidity, including the use of medications that may exacerbate symptoms or adversely interact with treatments for Parkinson's disease. Recommended dosing practices to reduce complications during hospitalisation are covered. In addition, recent concerns regarding anaesthetic exposure in early childhood as a risk factor for the development of Parkinson's disease are discussed in light of data from animal models of anaesthetic neurotoxicity and epidemiological studies.
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Affiliation(s)
| | - Simon J G Lewis
- Parkinson's Disease Research Clinic, Brain and Mind Centre, University of Sydney, NSW, Australia.
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Remifentanil Requirement for Inhibiting Responses to Tracheal Intubation and Skin Incision Is Reduced in Patients With Parkinson's Disease Undergoing Deep Brain Stimulator Implantation. J Neurosurg Anesthesiol 2017; 28:303-8. [PMID: 26368663 DOI: 10.1097/ana.0000000000000229] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Parkinson's disease (PD) is a common neurodegenerative disease affecting the quality of life in the elderly. We speculated that PD patients might have abnormal pharmacodynamics due to the degenerative neural system, and the present study was performed to investigate the pharmacodynamics of remifentanil in PD patients. MATERIALS AND METHODS Two arms of patients were recruited, including 31 PD patients undergoing pulse generator placement after deep brain stimulator implantation and 31 pair-controlled patients undergoing intracranial surgery without PD (NPD). Patients were anesthetized with target-controlled infusion of propofol and remifentanil. The effective concentration of remifentanil to inhibit responses to intubation and skin incision in 50% and 95% patients (EC50 and EC95) was determined by the up and down method. RESULTS Demographic data, bispectral index, and hemodynamic values were similar between the PD and the NPD groups. The average remifentanil concentration used in the PD group for tracheal intubation is significantly lower than in the NPD group (P<0.001). The EC50 for inhibiting the response to tracheal intubation were 1.86 ng/mL (95% confidential interval [CI], 1.77-1.96 ng/mL) in the PD group and 3.20 ng/mL (95% CI, 3.13-3.27 ng/mL) in the NPD group. The average remifentanil concentration used in the PD group for skin incision is significantly lower than in the NPD group (P<0.001). EC50 for inhibiting the response to skin incision were 2.17 ng/mL (95% CI, 2.09-2.25 ng/mL) in the PD group and 3.09 ng/mL (95% CI, 3.02-3.17 ng/mL) in the NPD group. CONCLUSIONS The remifentanil concentrations required for inhibiting responses to tracheal intubation and skin incision are reduced markedly in PD patients undergoing pulse generator placement (NCT01992692).
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Sreedhar N, Choudhury M, Pradeep K, Devagourou V. Bentall procedure in a patient with parkinson disease. Ann Card Anaesth 2017; 20:383-384. [PMID: 28701615 PMCID: PMC5535591 DOI: 10.4103/aca.aca_82_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
| | | | - K Pradeep
- Cardiothoracic Sciences Centre, AIIMS, New Delhi, India
| | - V Devagourou
- Cardiothoracic Sciences Centre, AIIMS, New Delhi, India
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Propofol requirement for induction of unconsciousness is reduced in patients with Parkinson's disease: a case control study. BIOMED RESEARCH INTERNATIONAL 2015; 2015:953729. [PMID: 26495319 PMCID: PMC4606158 DOI: 10.1155/2015/953729] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 09/07/2015] [Indexed: 12/15/2022]
Abstract
Parkinson's disease (PD) is the second most prevalent neurodegenerative disease, but whether the neurodegenerative process influences the pharmacodynamics of propofol remains unclear. We aimed to evaluate the effect of PD on pharmacodynamics of propofol. A total of 31 PD patients undergoing surgical treatment (PD group) and 31 pair-controlled non-PD patients undergoing intracranial surgery (NPD group) were recruited to investigate the propofol requirement for unconsciousness induction. Unconsciousness was induced in all patients with target-controlled infusion of propofol. The propofol concentration at which unconsciousness was induced was compared between the two groups. EC50 and EC95 were calculated as well. Demographic data, bispectral index, and hemodynamic values were comparable between PD and NPD groups. The mean target concentration of propofol when unconsciousness was achieved was 2.32 ± 0.38 μg/mL in PD group, which was significantly lower than that in NPD group (2.90 ± 0.35 μg/mL). The EC50 was 2.05 μg/mL (95% CI: 1.85–2.19 μg/mL) in PD group, much lower than the 2.72 μg/mL (95% CI: 2.53–2.88 μg/mL) in NPD group. In conclusion, the effective propofol concentration needed for induction of unconsciousness in 50% of patients is reduced in PD patients. (This trial is registered with NCT01998204.)
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Krishna V, Elias G, Sammartino F, Basha D, King NKK, Fasano A, Munhoz R, Kalia SK, Hodaie M, Venkatraghavan L, Lozano AM, Hutchison WD. The effect of dexmedetomidine on the firing properties of STN neurons in Parkinson's disease. Eur J Neurosci 2015; 42:2070-7. [DOI: 10.1111/ejn.13004] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 06/10/2015] [Accepted: 06/18/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Vibhor Krishna
- Division of Neurosurgery; Toronto Western Hospital; University of Toronto; 399 Bathurst Street Toronto ON M5T2S8 Canada
| | - Gavin Elias
- Division of Neurosurgery; Toronto Western Hospital; University of Toronto; 399 Bathurst Street Toronto ON M5T2S8 Canada
| | - Francesco Sammartino
- Division of Neurosurgery; Toronto Western Hospital; University of Toronto; 399 Bathurst Street Toronto ON M5T2S8 Canada
| | - Diellor Basha
- Department of Physiology; Toronto Western Hospital; University of Toronto; Toronto ON Canada
| | - Nicolas K. K. King
- Division of Neurosurgery; Toronto Western Hospital; University of Toronto; 399 Bathurst Street Toronto ON M5T2S8 Canada
| | - Alfonso Fasano
- Morton and Gloria Shulman Movement Disorders Centre and the Edmond J. Safra Program in Parkinson's Disease; Toronto Western Hospital; Toronto ON Canada
| | - Renato Munhoz
- Morton and Gloria Shulman Movement Disorders Centre and the Edmond J. Safra Program in Parkinson's Disease; Toronto Western Hospital; Toronto ON Canada
| | - Suneil K. Kalia
- Division of Neurosurgery; Toronto Western Hospital; University of Toronto; 399 Bathurst Street Toronto ON M5T2S8 Canada
| | - Mojgan Hodaie
- Division of Neurosurgery; Toronto Western Hospital; University of Toronto; 399 Bathurst Street Toronto ON M5T2S8 Canada
| | - Lashmi Venkatraghavan
- Department of Anesthesiology; Toronto Western Hospital; University of Toronto; Toronto ON Canada
| | - Andres M. Lozano
- Division of Neurosurgery; Toronto Western Hospital; University of Toronto; 399 Bathurst Street Toronto ON M5T2S8 Canada
| | - William D. Hutchison
- Department of Physiology; Toronto Western Hospital; University of Toronto; Toronto ON Canada
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15
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Lange M, Zech N, Seemann M, Janzen A, Halbing D, Zeman F, Doenitz C, Rothenfusser E, Hansen E, Brawanski A, Schlaier J. Anesthesiologic regimen and intraoperative delirium in deep brain stimulation surgery for Parkinson's disease. J Neurol Sci 2015; 355:168-73. [PMID: 26073485 DOI: 10.1016/j.jns.2015.06.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 05/23/2015] [Accepted: 06/07/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND In many centers the standard anesthesiological care for deep brain stimulation (DBS) surgery in Parkinson's disease patients is an asleep-awake-asleep procedure. However, sedative drugs and anesthetics can compromise ventilation and hemodynamic stability during the operation and some patients develop a delirious mental state after the initial asleep phase. Further, these drugs interfere with the patient's alertness and cooperativeness, the quality of microelectrode recordings, and the recognition of undesired stimulation effects. In this study, we correlated the incidence of intraoperative delirium with the amount of anesthetics used intraoperatively. METHODS The anesthesiologic approach is based on continuous presence and care, avoidance of negative suggestions, use of positive suggestions, and utilization of the patient's own resources. Clinical data from the operations were analyzed retrospectively, the occurrence of intraoperative delirium was extracted from patients' charts. The last 16 patients undergoing the standard conscious sedation procedure (group I) were compared to the first 22 (group II) psychologically-guided patients. RESULTS The median amount of propofol decreased from 146 mg (group I) to 0mg (group II), remifentanyl from 0.70 mg to 0.00 mg, respectively (P<0.001 for propofol and remifentanyl). Using the new procedure, 12 of 22 patients (55%) in group II required no anesthetics. Intraoperative delirium was significantly less frequent in group II (P=0.03). CONCLUSIONS The occurrence of intraoperative delirium correlates with the amount of intraoperative sedative and anesthetic drugs. Sedation and powerful analgesia are not prerequisites for patients' comfort during awake-DBS-surgery.
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Affiliation(s)
- M Lange
- Department of Neurosurgery, University of Regensburg, Medical Center, Germany; Centre for Deep Brain Stimulation, University of Regensburg, Medical Center, Germany
| | - N Zech
- Centre for Deep Brain Stimulation, University of Regensburg, Medical Center, Germany; Department of Anesthesiology, University of Regensburg, Medical Center, Germany
| | - M Seemann
- Centre for Deep Brain Stimulation, University of Regensburg, Medical Center, Germany; Department of Anesthesiology, University of Regensburg, Medical Center, Germany
| | - A Janzen
- Centre for Deep Brain Stimulation, University of Regensburg, Medical Center, Germany; Department of Neurology, University of Regensburg, Medical Center, Germany
| | - D Halbing
- Department of Neurosurgery, University of Regensburg, Medical Center, Germany
| | - F Zeman
- Center for Clinical Studies, University of Regensburg, Medical Center, Germany
| | - C Doenitz
- Department of Neurosurgery, University of Regensburg, Medical Center, Germany
| | - E Rothenfusser
- Centre for Deep Brain Stimulation, University of Regensburg, Medical Center, Germany; Department of Neurology, University of Regensburg, Medical Center, Germany
| | - E Hansen
- Centre for Deep Brain Stimulation, University of Regensburg, Medical Center, Germany; Department of Anesthesiology, University of Regensburg, Medical Center, Germany
| | - A Brawanski
- Department of Neurosurgery, University of Regensburg, Medical Center, Germany
| | - J Schlaier
- Department of Neurosurgery, University of Regensburg, Medical Center, Germany; Centre for Deep Brain Stimulation, University of Regensburg, Medical Center, Germany.
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Gombert C, Nadjar Y, Grabli D. Maladie de Parkinson et réanimation : des problèmes spécifiques ? MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-013-0722-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bilotta F, Titi L, Lanni F, Stazi E, Rosa G. Training anesthesiology residents in providing anesthesia for awake craniotomy: learning curves and estimate of needed case load. J Clin Anesth 2013; 25:359-366. [PMID: 23965201 DOI: 10.1016/j.jclinane.2013.01.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 01/22/2013] [Accepted: 01/29/2013] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE To measure the learning curves of residents in anesthesiology in providing anesthesia for awake craniotomy, and to estimate the case load needed to achieve a "good-excellent" level of competence. DESIGN Prospective study. SETTING Operating room of a university hospital. SUBJECTS 7 volunteer residents in anesthesiology. MEASUREMENTS Residents underwent a dedicated training program of clinical characteristics of anesthesia for awake craniotomy. The program was divided into three tasks: local anesthesia, sedation-analgesia, and intraoperative hemodynamic management. The learning curve for each resident for each task was recorded over 10 procedures. Quantitative assessment of the individual's ability was based on the resident's self-assessment score and the attending anesthesiologist's judgment, and rated by modified 12 mm Likert scale, reported ability score visual analog scale (VAS). This ability VAS score ranged from 1 to 12 (ie, very poor, mild, moderate, sufficient, good, excellent). The number of requests for advice also was recorded (ie, resident requests for practical help and theoretical notions to accomplish the procedures). MAIN RESULTS Each task had a specific learning rate; the number of procedures necessary to achieve "good-excellent" ability with confidence, as determined by the recorded results, were 10 procedures for local anesthesia, 15 to 25 procedures for sedation-analgesia, and 20 to 30 procedures for intraoperative hemodynamic management. CONCLUSIONS Awake craniotomy is an approach used increasingly in neuroanesthesia. A dedicated training program based on learning specific tasks and building confidence with essential features provides "good-excellent" ability.
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Affiliation(s)
- Federico Bilotta
- Department of Anesthesiology, Critical Care and Pain Medicine, Section of Neuroanesthesia and Neurocritical Care, "Sapienza" University of Rome, Rome 00199, Italy.
| | - Luca Titi
- Department of Anesthesiology, Critical Care and Pain Medicine, Section of Neuroanesthesia and Neurocritical Care, "Sapienza" University of Rome, Rome 00199, Italy
| | - Fabiana Lanni
- Department of Anesthesiology, Critical Care and Pain Medicine, Section of Neuroanesthesia and Neurocritical Care, "Sapienza" University of Rome, Rome 00199, Italy
| | - Elisabetta Stazi
- Department of Anesthesiology, Critical Care and Pain Medicine, Section of Neuroanesthesia and Neurocritical Care, "Sapienza" University of Rome, Rome 00199, Italy
| | - Giovanni Rosa
- Department of Anesthesiology, Critical Care and Pain Medicine, Section of Neuroanesthesia and Neurocritical Care, "Sapienza" University of Rome, Rome 00199, Italy
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Solera Ruiz I, Uña Orejón R, Valero I, Laroche F. [Awake craniotomy. Considerations in special situations]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2013; 60:392-8. [PMID: 23433726 DOI: 10.1016/j.redar.2013.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Accepted: 01/09/2013] [Indexed: 11/19/2022]
Abstract
Awake craniotomy was the earliest surgical procedure known, and it has become fashionable again. In the past it was used for the surgical management of intractable epilepsy, but nowadays, its indications are increasing, and it is a widely recognized technique for the resection of mass lesions involving the eloquent cortex, and for deep brain stimulation. The procedure is safe, provides excellent results, and saves money and resources. The anesthesiologist should know the principles underlying neuroanesthesia, the technique of scalp blockade, and the sedation protocols, as well as feeling comfortable with advanced airway management. The main anesthetic aim is to keep patients cooperating when required (analgesia-based anesthesia). This review attempts to summarize the most recent evidence from the clinical literature, a long as the number of patients undergoing craniotomies in the awake state are increasing, specifically in the pediatric population.
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Affiliation(s)
- I Solera Ruiz
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital de Torrejón, Torrejón de Ardoz, Madrid, España.
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The impact of multichannel microelectrode recording (MER) in deep brain stimulation of the basal ganglia. ACTA NEUROCHIRURGICA. SUPPLEMENT 2013; 117:27-33. [PMID: 23652653 DOI: 10.1007/978-3-7091-1482-7_5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Deep brain stimulation (DBS) of the basal ganglia (Ncl. subthalamicus, Ncl. ventralis intermedius thalami, globus pallidus internus) has become an evidence-based and well-established treatment option in otherwise refractory movement disorders. The Ncl. subthalamicus (STN) is the target of choice in Parkinson's disease.However, a considerable discussion is currently ongoing with regard to the necessity for micro-electrode recording (MER) in DBS surgery.The present review provides an overview on deep brain stimulation and (MER) of the STN in patients with Parkinson's disease. Detailed description is given concerning the multichannel MER systems nowadays available for DBS of the basal ganglia, especially of the STN, as a useful tool for target refinement. Furthermore, an overview is given of the historical aspects, spatial mapping of the STN by MER, and its impact for accuracy and precision in current functional stereotactic neurosurgery.The pros concerning target refinement by MER means on the one hand, and cons including increased bleeding risk, increased operation time, local or general anesthesia, and single versus multichannel microelectrode recording are discussed in detail. Finally, the authors favor the use of MER with intraoperative testing combined with imaging to achieve a more precise electrode placement, aiming to ameliorate clinical outcome in therapy-resistant movement disorders.
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Zuleta J, Canseco AP. Ophthalmic Surgery. Perioper Med (Lond) 2012. [DOI: 10.1002/9781118375372.ch26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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21
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Abstracts presented at the 8th International Symposium on Memory and Awareness in Anesthesia (MAA8). Br J Anaesth 2012. [DOI: 10.1093/bja/aer442] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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22
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Scalp Block for Awake Craniotomy in a Patient With a Frontal Bone Mass: A Case Report. Anesth Pain Med 2012. [DOI: 10.5812/aapm.3608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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23
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Gerlach OHH, Winogrodzka A, Weber WEJ. Clinical problems in the hospitalized Parkinson's disease patient: systematic review. Mov Disord 2011; 26:197-208. [PMID: 21284037 PMCID: PMC3130138 DOI: 10.1002/mds.23449] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2009] [Revised: 07/16/2010] [Accepted: 08/27/2010] [Indexed: 11/07/2022] Open
Abstract
The problems Parkinson's disease (PD) patients encounter when admitted to a hospital, are known to be numerous and serious. These problems have been inventoried through a systematic review of literature on reasons for emergency and hospital admissions in PD patients, problems encountered during hospitalization, and possible solutions for the encountered problems using the Pubmed database. PD patients are hospitalized in frequencies ranging from 7 to 28% per year. PD/parkinsonism patients are approximately one and a half times more frequently and generally 2 to 14 days longer hospitalized than non-PD patients. Acute events occurring during hospitalization were mainly urinary infection, confusion, and pressure ulcers. Medication errors were also frequent adverse events. During and after surgery PD patients had an increased incidence of infections, confusion, falls, and decubitus, and 31% of patients was dissatisfied in the way their PD was managed. There are only two studies on medication continuation during surgery and one analyzing the effect of an early postoperative neurologic consultation, and numerous case reports, and opinionated views and reviews including other substitutes for dopaminergic medication intraoperatively. In conclusion, most studies were retrospective on small numbers of patients. The major clinical problems are injuries, infections, poor control of PD, and complications of PD treatment. There are many (un-researched) proposals for improvement. A substantial number of PD patients' admissions might be prevented. There should be guidelines concerning the hospitalized PD patients, with accent on early neurological consultation and team work between different specialities, and incorporating nonoral dopaminergic replacement therapy when necessary.
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Affiliation(s)
- Oliver H H Gerlach
- Section of Movement Disorders, Department of Neurology, Maastricht University Medical Centre, Maastricht, The Netherlands.
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Abstract
Awake craniotomy has become an increasingly frequent procedure. In this paper, the principles of its anaesthetic management are reviewed. The means allowing achievement of anaesthetic objectives are described, with emphasis on points that determine success of the procedure. A careful and adequate selection and preparation of patients are mandatory, and the intervening team must be a skilled team. Choosing an awake technique or general anaesthesia depends on several factors, including the risk of obstructive apnoea, seizures, nausea and vomiting, patient's ability to cooperate, and localization of lesions. The main challenge of intraoperative anaesthetic management relies on the ability of rapidly adjusting the level of sedation and analgesia according to the sequence of surgical events, while ensuring haemodynamic stability, adequate ventilation, and minimal interference with eventual electrophysiological recordings. Throughout the procedure, complications must be anticipated and managed according to predefined guidelines. More prospective randomized clinical trials are still needed to improve safety and efficacy of awake craniotomies, as well as to validate this technique in comparison with more conventional anaesthetic management.
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