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Athiraman U, Norris AJ, Jayaraman K, Lele AV, Kentner R, Singh PM, Higo OM, Zipfel GJ, Dhar R. Intraoperative Blood Pressure and Carbon Dioxide Values during Aneurysmal Repair and the Outcomes after Aneurysmal Subarachnoid Hemorrhage. J Clin Med 2023; 12:5488. [PMID: 37685555 PMCID: PMC10488211 DOI: 10.3390/jcm12175488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
Cerebral autoregulation impairment is a critical aspect of subarachnoid hemorrhage (SAH)-induced secondary brain injury and is also shown to be an independent predictor of delayed cerebral ischemia (DCI) and poor neurologic outcomes. Interestingly, intraoperative hemodynamic and ventilatory parameters were shown to influence patient outcomes after SAH. The aim of the current study was to evaluate the association of intraoperative hypotension and hypocapnia with the occurrence of angiographic vasospasm, DCI, and neurologic outcomes at discharge. Intraoperative data were collected for 390 patients with aneurysmal SAH who underwent general anesthesia for aneurysm clipping or coiling between January 2010 and May 2018. We measured the mean intraoperative blood pressure and end-tidal carbon dioxide (ETCO2), as well as the area under the curve (AUC) for the burden of hypotension: SBP below 100 or MBP below 65 and hypocapnia (ETCO2 < 30), during the intraoperative period. The outcome measures were angiographic vasospasm, DCI, and the neurologic outcomes at discharge as measured by the modified Rankin scale score (an mRS of 0-2 is a good outcome, and 3-6 is a poor outcome). Univariate and logistic regression analyses were performed to evaluate whether blood pressure (BP) and ETCO2 variables were independently associated with outcome measures. Out of 390 patients, 132 (34%) developed moderate-to-severe vasospasm, 114 (29%) developed DCI, and 46% (169) had good neurologic outcomes at discharge. None of the measured intraoperative BP and ETCO2 variables were associated with angiographic vasospasm, DCI, or poor neurologic outcomes. Our study did not identify an independent association between the degree of intraoperative hypotension or hypocapnia in relation to angiographic vasospasm, DCI, or the neurologic outcomes at discharge in SAH patients.
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Affiliation(s)
| | - Aaron J. Norris
- Department of Anesthesiology, Washington University, St. Louis, MO 63110, USA
| | - Keshav Jayaraman
- Department of Anesthesiology, Washington University, St. Louis, MO 63110, USA
| | - Abhijit V. Lele
- Department of Anesthesiology, University of Washington, Seattle, WA 98122, USA
| | - Rainer Kentner
- Department of Anesthesiology, Washington University, St. Louis, MO 63110, USA
| | | | - Omokhaye M. Higo
- Department of Anesthesiology, Washington University, St. Louis, MO 63110, USA
| | - Gregory J. Zipfel
- Departments of Neurological Surgery and Neurology, Washington University, St. Louis, MO 63110, USA
| | - Rajat Dhar
- Department of Neurology, Washington University, St. Louis, MO 63110, USA
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2
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Budiansky AS, Hjartarson EP, Polis T, Krolczyk G, Sinclair J. Emerging anesthesia techniques for managing intraoperative rupture of cerebral aneurysms. Int Anesthesiol Clin 2023; 61:64-72. [PMID: 37218511 DOI: 10.1097/aia.0000000000000400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Affiliation(s)
- Adele S Budiansky
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Emma P Hjartarson
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Tomasz Polis
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Gregory Krolczyk
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - John Sinclair
- Division of Neurosurgery, The Ottawa Hospital, Ottawa, Ontario, Canada
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3
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Wang J, Li R, Li S, Ma T, Zhang X, Ren Y, Chen X, Peng Y. Intraoperative arterial pressure and delayed cerebral ischemia in patients with aneurysmal subarachnoid hemorrhage after surgical clipping: A retrospective cohort study. Front Neurosci 2023; 17:1064987. [PMID: 36875639 PMCID: PMC9982002 DOI: 10.3389/fnins.2023.1064987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 01/30/2023] [Indexed: 02/19/2023] Open
Abstract
Background Delayed cerebral ischemia (DCI) is the major predictor of poor outcomes in patients with aSAH. Previous studies have attempted to assess the relationship between controlling blood pressure and DCI. However, the management of intraoperative blood pressure in reducing the occurrence of DCI still remains inconclusive. Methods All patients with aSAH who received general anesthesia for surgical clipping between January 2015 and December 2020 were prospectively reviewed. Patients were divided in the DCI group or the non-DCI group depending on whether DCI occurred or not. Intraoperative arterial pressure was measured every minute and recorded in an electronic anesthesia recording system along with intraoperative medication and other vital signs. The initial neurological function score, aneurysm characteristics, surgical and anesthetic information, and outcomes were compared between the DCI and the non-DCI groups. Results Among 534 patients who were enrolled, a total of 164 (30.71%) patients experienced DCI. The baseline characteristics of patients were similar between the groups. The World Federation of Neurosurgical Societies (WFNS) Scale > 3, age ≥ 70 years, and the modified Fisher Scale > 2 were significantly higher in patients with DCI than those without. Though it was the second derivative of the regression analysis, 105 mmHg was adopted as the threshold for intraoperative hypotension and was not associated with DCI. Conclusions The threshold of 105 mmHg was adopted as intraoperative hypotension even though it was the second derivative of the regression analysis and could not be proved to be associated with delayed cerebral ischemia adjusted by the baseline severity of aSAH and age.
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Affiliation(s)
- Jie Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Runting Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Shu Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tingting Ma
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingyue Zhang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yue Ren
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Gathier CS, Zijlstra IJAJ, Rinkel GJE, Groenhof TKJ, Verbaan D, Coert BA, Müller MCA, van den Bergh WM, Slooter AJC, Eijkemans MJC. Blood pressure and the risk of rebleeding and delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. J Crit Care 2022; 72:154124. [PMID: 36208555 DOI: 10.1016/j.jcrc.2022.154124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 07/04/2022] [Accepted: 07/29/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION AND OBJECTIVE Blood pressure is presumably related to rebleeding and delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (aSAH) and could serve as a target to improve outcome. We assessed the associations between blood pressure and rebleeding or DCI in aSAH-patients. MATERIALS AND METHODS In this observational study in 1167 aSAH-patients admitted to the intensive care unit (ICU), adjusted hazard ratio's (aHR) were calculated for the time-dependent association of blood pressure and rebleeding or DCI. The aHRs were presented graphically, relative to a reference mean arterial pressure (MAP) of 100 mmHg and systolic blood pressure (sBP) of 150 mmHg. RESULTS A MAP below 100 mmHg in the 6, 3 and 1 h before each moment in time was associated with a decreased risk of rebleeding (e.g. within 6 h preceding rebleeding: MAP = 80 mmHg: aHR 0.30 (95% confidence interval (CI) 0.11-0.80)). A MAP below 60 mmHg in the 24 h before each moment in time was associated with an increased risk of DCI (e.g. MAP = 50 mmHg: aHR 2.59 (95% CI 1.12-5.96)). CONCLUSIONS Our results suggest that a MAP below 100 mmHg is associated with decreased risk of rebleeding, and a MAP below 60 mmHg with increased risk of DCI.
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Affiliation(s)
- Celine S Gathier
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Neurology and Neurosurgery and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - IJsbrand A J Zijlstra
- Department of Radiology, Amsterdam University Medical Center, location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - T Katrien J Groenhof
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Dagmar Verbaan
- Neurosurgical Center Amsterdam, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Bert A Coert
- Neurosurgical Center Amsterdam, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Marcella C A Müller
- Department of Intensive Care, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
| | - Marinus J C Eijkemans
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
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Su R, Zhou J, Zhu N, Chen X, Zhou JX, Li HL. Efficacy and safety of remifentanil dose titration to correct the spontaneous hyperventilation in aneurysmal subarachnoid haemorrhage: protocol and statistical analysis for a prospective physiological study. BMJ Open 2022; 12:e064064. [PMID: 36351728 PMCID: PMC9664281 DOI: 10.1136/bmjopen-2022-064064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Spontaneous hyperventilation (SHV) is common in aneurysmal subarachnoid haemorrhage (aSAH). The reduction in arterial partial pressure of carbon dioxide (PaCO2) may change the brain physiology, such as haemodynamics, oxygenation, metabolism and may lead to secondary brain injury. However, how to correct SHV safely and effectively in patients with aSAH has not been well investigated. The aim of this study is to investigate the efficacy and safety of remifentanil dose titration to correct hyperventilation in aSAH, as well as the effect of changes in PaCO2 on cerebral blood flow (CBF). METHODS AND ANALYSIS This study is a prospective, single-centre, physiological study in patients with aSAH. The patients who were mechanically ventilated and who meet with SHV (tachypnoea combined with PaCO2 <35 mm Hg and pH >7.45) will be enrolled. The remifentanil will be titrated to correct the SHV. The predetermined initial dose of remifentanil is 0.02 μg/kg/min and will be maintained for 30 min, and PaCO2 and CBF will be measured. After that, the dose of remifentanil will be sequentially increased to 0.04, 0.06, and 0.08 μg/kg/min, and the measurements for PaCO2 and CBF will be repeated 30 min after each dose adjustment and will be compared with their baseline values. ETHICS AND DISSEMINATION This study has been approved by the Institutional Review Board of Beijing Tiantan Hospital, Capital Medical University (KY 2021-006-02) and has been registered at ClinicalTrials.gov. The results of this study will be disseminated through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER NCT04940273.
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Affiliation(s)
- Rui Su
- Capital Medical University, Department of Critical Care Medicine, Beijing Tiantan Hospital, Beijing, Beijing, China
| | - Jianfang Zhou
- Capital Medical University, Department of Critical Care Medicine, Beijing Tiantan Hospital, Beijing, Beijing, China
| | - Ning Zhu
- Capital Medical University, Department of Critical Care Medicine, Beijing Tiantan Hospital, Beijing, Beijing, China
| | - Xiaolin Chen
- Capital Medical University, Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, Beijing, China
| | - Jian-Xin Zhou
- Capital Medical University, Department of Critical Care Medicine, Beijing Tiantan Hospital, Beijing, Beijing, China
- Capital Medical University, Department of Critical Care Medicine, Beijing Shijitan Hospital, Beijing, Beijing, China
| | - Hong-Liang Li
- Capital Medical University, Department of Critical Care Medicine, Beijing Tiantan Hospital, Beijing, Beijing, China
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Akkermans A, van Waes JA, Kheterpal S, Pasma W, Saager L, Thompson A, van Klei WA. Outlying End-Tidal Carbon Dioxide During General Anesthesia Is Associated With Postoperative Pulmonary Complications: A Multicenter Retrospective Observational Study From US Hospitals Between 2010 and 2017. Anesth Analg 2022; 135:341-353. [PMID: 35839498 DOI: 10.1213/ane.0000000000006062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Postoperative pulmonary complications (PPCs) occur in up to 33% of patients who undergo noncardiothoracic surgery. Emerging evidence suggests that permissive hypercapnia may reduce the risk of lung injury. We hypothesized that higher intraoperative end-tidal carbon dioxide (Etco2) concentrations would be associated with a decreased risk of PPCs. METHODS This retrospective, observational, multicenter study included patients undergoing general anesthesia for noncardiothoracic procedures (January 2010-December 2017). The primary outcome was PPC within 30 postoperative days. Secondary outcomes were PPC within 1 week, postoperative length of stay, and inhospital 30-day mortality. The association between these outcomes, median Etco2, and 4 time-weighted average area-under-the-curve (TWA-AUC) thresholds (<28, <35, <45, and >45 mm Hg) was explored using a multivariable mixed-effect model and by plotting associated risks. RESULTS Among 143,769 cases across 11 hospitals, 10,276 (7.1%) experienced a PPC. When compared to a baseline median Etco2 of 35 to 40 mm Hg, a median Etco2 >40 mm Hg was associated with an increase in PPCs within 30 days (median Etco2, 40-45 mm Hg; adjusted OR, 1.16 [99% confidence interval {CI}, 1.00-1.33]; P value = .008 and median Etco2, >45 mm Hg; OR, 1.64 [99% CI, 1.33-2.02]; P value < .001). The occurrence of any Etco2 value <28 mm Hg (ie, a positive TWA-AUC < 28 mm Hg) was associated with PPCs (OR, 1.40 [95% CI, 1.33-1.49]; P value < .001), mortality, and length of stay. Any Etco2 value >45 mm Hg (ie, a positive TWA-AUC >45 mm Hg) was also associated with PPCs (OR, 1.24 [95% CI, 1.17-1.31]; P < .001). The Etco2 range with the lowest incidence of PPCs was 35 to 38 mm Hg. CONCLUSIONS Both a very low (<28 mm Hg) and a high Etco2 (>45 mm Hg) were associated with PPCs within 30 days. The lowest PPC incidence was found in patients with an Etco2 of 35 to 38 mm Hg. Prospective studies are needed to clarify the relationship between postoperative PPCs and intraoperative Etco2.
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Affiliation(s)
- Annemarie Akkermans
- From the Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Judith A van Waes
- From the Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Wietze Pasma
- From the Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Leif Saager
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan.,Department of Anesthesiology, University Medical Center Goettingen, Goettingen, Germany
| | - Aleda Thompson
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Wilton A van Klei
- From the Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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7
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Dong L, Takeda C, Yamazaki H, Kamitani T, Kimachi M, Hamada M, Fukuhara S, Mizota T, Yamamoto Y. Intraoperative end-tidal carbon dioxide and postoperative mortality in major abdominal surgery: a historical cohort study. Can J Anaesth 2021; 68:1601-1610. [PMID: 34357567 DOI: 10.1007/s12630-021-02086-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 06/23/2021] [Accepted: 06/23/2021] [Indexed: 11/26/2022] Open
Abstract
PURPOSE There is a paucity of data on the effect of intraoperative end-tidal carbon dioxide (EtCO2) levels on postoperative mortality. The purpose of this study was to investigate the relationship between intraoperative EtCO2 and 90-day mortality in patients undergoing major abdominal surgery under general anesthesia. METHODS We conducted a historical cohort study of patients undergoing major abdominal surgery under general anesthesia at Kyoto University Hospital. We measured the intraoperative EtCO2, and patients with a mean EtCO2 value < 35 mm Hg were classified as low EtCO2. The time effect was determined based on minutes below an EtCO2 of 35 mm Hg, and cumulative effects were evaluated by measuring the area under the threshold of 35 mm Hg for each patient. RESULTS Of 4,710 patients, 1,374 (29%) had low EtCO2 and 55 (1.2%) died within 90 days of surgery. Multivariable Cox regression analysis-adjusted for age, American Society of Anesthesiologists Physical Status classification, sex, laparoscopic surgery, emergency surgery, blood loss, mean arterial pressure, duration of surgery, type of surgery, and chronic obstructive pulmonary disease-revealed an association between low EtCO2 and 90-day mortality (adjusted hazard ratio, 2.2; 95% confidence interval [CI], 1.2 to 3.8; P = 0.006). In addition, severity of low EtCO2 was associated with an increased 90-day mortality (area under the threshold; adjusted hazard ratio; 2.9, 95% CI, 1.2 to 7.4; P =0.02); for long-term exposure to an EtCO2 < 35 mm Hg (≥ 226 min), the adjusted hazard ratio for increased 90-day mortality was 2.3 (95% CI, 0.9 to 6.0; P = 0.08). CONCLUSION A mean intraoperative EtCO2 < 35 mm Hg was associated with increased postoperative 90-day mortality.
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Affiliation(s)
- Li Dong
- Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
- Department of Anesthesia, Kyoto University Hospital, 54 Shogoin-Kawahara-cho, Kyoto, 606-8507, Japan
| | - Chikashi Takeda
- Department of Anesthesia, Kyoto University Hospital, 54 Shogoin-Kawahara-cho, Kyoto, 606-8507, Japan
| | - Hajime Yamazaki
- Section of Clinical Epidemiology, Department of Community Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tsukasa Kamitani
- Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Miho Kimachi
- Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Miho Hamada
- Department of Anesthesia, Kyoto University Hospital, 54 Shogoin-Kawahara-cho, Kyoto, 606-8507, Japan
| | - Shunichi Fukuhara
- Section of Clinical Epidemiology, Department of Community Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Toshiyuki Mizota
- Department of Anesthesia, Kyoto University Hospital, 54 Shogoin-Kawahara-cho, Kyoto, 606-8507, Japan.
| | - Yosuke Yamamoto
- Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
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Abstract
Anesthesia for intracranial vascular procedures is complex because it requires a balance of several competing interests and potentially can result in significant morbidity and mortality. Frequently, periods of ischemia, where perfusion must be maintained, are combined with situations that are high risk for hemorrhage. This review discusses the basic surgical approach to several common pathologies (intracranial aneurysms, arteriovenous malformations, and moyamoya disease) along with the goals for anesthetic management and specific high-yield recommendations.
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Affiliation(s)
- William L Gross
- Department of Anesthesiology, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI 53132, USA.
| | - Raphael H Sacho
- Department of Neurosurgery, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI 53132, USA
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9
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Song T, Liu X, Han R, Huang L, Zhang J, Xu H. Effects of end-tidal carbon dioxide levels in patients undergoing direct revascularization for Moyamoya disease and risk factors associated with postoperative complications. Medicine (Baltimore) 2021; 100:e24527. [PMID: 33607783 PMCID: PMC7899818 DOI: 10.1097/md.0000000000024527] [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] [Received: 07/16/2020] [Accepted: 01/05/2021] [Indexed: 01/05/2023] Open
Abstract
A history of transient ischemic attack, severity of disease, urinary output, hematocrit, hypocapnia, and hypotension during direct revascularization (superficial temporal artery to middle cerebral artery [STA-MCA]) in patients with Moyamoya disease (MMD) may lead to a poor prognosis, however, to our knowledge evidence for end-tidal carbon dioxide (ETCO2) targets is lacking. Within the ranges of standardized treatment, the article was primarily designed to study the risk factors associated with the neurologic outcomes during STA-MCA for MMD especially including ETCO2 ranges and the duration in different groups. The primary goals of this study were to investigate the risk factors for neurologic deterioration and explore the association between ETCO2 ranges and neurologic outcome during general anesthesia for STA-MCA.This retrospective observational study included 56 consecutively adult Moyamoya patients who underwent STA-MCA under general anesthesia between January 2015 and August 2019. ETCO2 was summarized per patient every 5 minutes. Clinical outcome was assessed with clinical presentation, computed tomography findings, magnetic resonance imaging findings, cerebral angiography, and the modified Rankin Scale scores at discharge as main outcome measure. The outcomes were also compared for the duration of surgery, anesthesia, and the length of stay.A total of 56 patients were studied, all patients had comprehensive ETCO2 measurements. The incidence of postoperative complications was 44.6% (25/56). There was no association between age, sex, hypertension, diabetes, smoking history, drinking history, sevoflurane use, invasive arterial blood pressure monitoring, combined encephalomyosynangiosis and postoperative complications. Duration of surgery (P = .04), anesthesia (P = .036), hospital stay (P = .023) were significant correlates of postoperative complications. In the multiple logistic regression model, they were not the significant predictors. The ETCO2 ranges and the length of time in different groups within the current clinical setting was not associated with postoperative complications (P > .05).Within a standardized intraoperative treatment strategy, we found that postoperative complications had no significant correlation with sex, age, hypertension, diabetes, smoking history, drinking history, invasive arterial blood pressure monitoring, combined encephalomyosynangiosis, or sevoflurane use. Further, hypocapnia and hypercapnia during STA-MCA were not found to be associated with postoperative complications in patients with MMD.
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Affiliation(s)
- Tingting Song
- The First Hospital of Jilin University, Changchun, Jilin
| | - Xiancun Liu
- Linyi people's hospital, Linyi, Shandong, China
| | - Rui Han
- The First Hospital of Jilin University, Changchun, Jilin
| | - Lihua Huang
- The First Hospital of Jilin University, Changchun, Jilin
| | - Jingjing Zhang
- The First Hospital of Jilin University, Changchun, Jilin
| | - Haiyang Xu
- The First Hospital of Jilin University, Changchun, Jilin
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10
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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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11
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Choudhary N, Singh R, Bhalotra AR, Magoon R. Effect of intraoperative intravenous lignocaine infusion on the haemodynamic stability and postoperative recovery following intracranial aneurysm surgery: A case series. Indian J Anaesth 2020; 64:S205-S208. [PMID: 33162603 PMCID: PMC7641061 DOI: 10.4103/ija.ija_437_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/22/2020] [Accepted: 06/28/2020] [Indexed: 01/25/2023] Open
Affiliation(s)
- Nitin Choudhary
- Department of Anaesthesiology and Intensive Care, Maulana Azad Medical College, New Delhi, India
| | - Rahil Singh
- Department of Anaesthesiology and Intensive Care, Maulana Azad Medical College, New Delhi, India
| | - Anju R Bhalotra
- Department of Anaesthesiology and Intensive Care, Maulana Azad Medical College, New Delhi, India
| | - Rohan Magoon
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India
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12
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Appropriate Blood Pressure in Cerebral Aneurysm Clipping for Prevention of Delayed Ischemic Neurologic Deficits. Anesthesiol Res Pract 2020; 2020:6539456. [PMID: 32308677 PMCID: PMC7152938 DOI: 10.1155/2020/6539456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 03/05/2020] [Indexed: 11/18/2022] Open
Abstract
Background Delayed ischemic neurologic deficit (DNID) is a problem after cerebral aneurysm clipping. Intraoperative hypotension seems to be indicated as a risk factor, but it remains a controversial issue with varying low-blood pressure levels accepted. Methods A retrospective, hospital-based, case-control study was performed with patients who received general anesthesia for cerebral aneurysm clipping. 42 medical record charts were randomly selected and matched 1 : 2 (1 case with DNID : 2 controls without DNID) based on the type of general anesthetic techniques and severity of subarachnoid hemorrhage. The optimal cutoff points of hemodynamic response were calculated by the area under the curve. Results Data suggested that the optimal cutoff points for lowest blood pressure for prevention of DNID should be systolic blood pressure (SBP) of 95 mmHg (sensitivity of 78.6%; specificity of 53.6%), diastolic blood pressure (DBP) of 50 mmHg (sensitivity of 71.4%; specificity of 67.9%), and mean arterial pressure (MAP) of 61.7 mmHg (sensitivity of 85.7%; specificity of 35.7%). Furthermore, the optimal cutoff point mean difference baseline blood pressure was recommended as Δ SBP of 36 mmHg (sensitivity of 85.7%; specificity of 60.7%), Δ DBP of 27 mmHg (sensitivity of 92.9%; specificity of 71.4%), and Δ MAP of 32 mmHg (sensitivity of 92.9%; specificity of 85.7%). No significant difference between DNID and non-DNID groups was found for end-tidal carbon dioxide (ETCO2) and has poor diagnostic value for predicting DNID. Conclusion To prevent DNID, we recommend that optimal blood pressure should not be lower than 95 for SBP, 50 for DBP, and 61.7 mmHg for MAP. Additionally, we suggest that Δ SBP, Δ DBP, and Δ MAP should be less than 36, 27, and 32 mmHg, respectively.
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13
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Abstract
Hyperventilation is commonly used in neurological patients to decrease elevated intracranial pressure (ICP) or relax a tense brain. However, the potentially deleterious effects of hyperventilation may limit its clinical application. The aim of this review is to summarize the physiological and outcome evidence related to hyperventilation in neurological patients.
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Abstract
This review is intended to provide a summary of the literature pertaining to the perioperative care of neurosurgical patients and patients with neurological diseases. General topics addressed in this review include general neurosurgical considerations, stroke, neurological monitoring, and perioperative disorders of cognitive function.
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Reiff T, Barthel O, Schönenberger S, Mundiyanapurath S. High-normal P aCO 2 values might be associated with worse outcome in patients with subarachnoid hemorrhage - a retrospective cohort study. BMC Neurol 2020; 20:31. [PMID: 31959120 PMCID: PMC6972024 DOI: 10.1186/s12883-020-1603-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 01/06/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND While both hypercapnia and hypocapnia are harmful in patients with subarachnoid hemorrhage (SAH), it is unknown whether high-normal PaCO2 values are better than low-normal values. We hypothesized that high-normal PaCO2 values have more detrimental than beneficial effects on outcome. METHODS Consecutive patients with aneurysmal subarachnoid hemorrhage (aSAH) requiring mechanical ventilation treated in a tertiary care university hospital were retrospectively analyzed regarding the influence of PaCO2 on favorable outcome, defined as modified Rankin scale score < 3 at discharge. Primary endpoint was the difference in the proportion of PaCO2 values above 40 mmHg in relation to all measured PaCO2 values between patients with favorable and unfavorable outcome. RESULTS 150 patients were included. Median age was 57 years (p25:50, p75:64), median Hunt-Hess score was 4 (p25:3, p75:5). PaCO2 values were mainly within normal range (median 39.0, p25:37.5, p75:41.4). Patients with favorable outcome had a lower proportion of high-normal PaCO2 values above 40 mmHg compared to patients with unfavorable outcome (0.21 (p25:0.13, p75:0.50) vs. 0.4 (p25:0.29, p75:0.59)) resulting in a lower chance for favorable outcome (OR 0.04, 95% CI 0.00-0.55, p = 0.017). In multivariable analysis adjusted for Hunt-Hess score, pneumonia and length of stay, elevated PaCO2 remained an independent predictor of outcome (OR 0.05, 95% CI 0.00-0.81, p = 0.035). CONCLUSIONS A higher proportion of PaCO2 values above 40 mmHg was an independent predictor of outcome in patients with aSAH in our study. The results need to be confirmed in a prospective trial.
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Affiliation(s)
- Tilman Reiff
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany
| | - Oliver Barthel
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany
| | - Silvia Schönenberger
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany
| | - Sibu Mundiyanapurath
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany.
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