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Jolly S, Paliwal S, Gadepalli A, Chaudhary S, Bhagat H, Avitsian R. Designing Enhanced Recovery After Surgery Protocols in Neurosurgery: A Contemporary Narrative Review. J Neurosurg Anesthesiol 2024; 36:201-210. [PMID: 38011868 DOI: 10.1097/ana.0000000000000946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 10/16/2023] [Indexed: 11/29/2023]
Abstract
Enhanced Recovery After Surgery (ERAS) protocols have revolutionized the approach to perioperative care in various surgical specialties. They reduce complications, improve patient outcomes, and shorten hospital lengths of stay. Implementation of ERAS protocols for neurosurgical procedures has been relatively underexplored and underutilized due to the unique challenges and complexities of neurosurgery. This narrative review explores the barriers to, and pioneering strategies of, standardized procedure-specific ERAS protocols, and the importance of multidisciplinary collaboration in neurosurgery and neuroanesthsia, patient-centered approaches, and continuous quality improvement initiatives, to achieve better patient outcomes. It also discusses initiatives to guide future clinical practice, research, and guideline creation, to foster the development of tailored ERAS protocols in neurosurgery.
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Affiliation(s)
- Sagar Jolly
- Department of General Anesthesiology, Cleveland Clinic, OH
| | | | - Aditya Gadepalli
- Department of Anaesthetics and Intensive Care, Royal Free London NHS Foundation Trust, London, UK
| | - Sheena Chaudhary
- Department of Neuroanesthesia and Critical Care, Fortis Memorial Research Institute, Gurugram, HR, India
| | - Hemant Bhagat
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rafi Avitsian
- Department of General Anesthesiology, Cleveland Clinic, OH
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Kim SH, Choi SH, Moon J, Kim HD, Choi YS. Enhanced Recovery After Surgery for Craniotomies: A Systematic Review and Meta-analysis. J Neurosurg Anesthesiol 2024:00008506-990000000-00107. [PMID: 38651841 DOI: 10.1097/ana.0000000000000967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 03/15/2024] [Indexed: 04/25/2024]
Abstract
The efficacy of the enhanced recovery after surgery (ERAS) protocols in neurosurgery has not yet been established. We performed a systematic review and meta-analysis of randomized controlled trials to compare the effects of ERAS protocols and conventional perioperative care on postoperative outcomes in patients undergoing craniotomy. The primary outcome was postoperative length of hospital stay. Secondary outcomes included postoperative pain visual analog pain scores, incidence of postoperative nausea and vomiting (PONV), postoperative complications, all-cause reoperation, readmission after discharge, and mortality. A literature search up to August 10, 2023, was conducted using PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus databases. Five studies, including 871 patients, were identified for inclusion in this review. Compared with conventional perioperative care, ERAS protocols reduced the length of postoperative hospital stay (difference of medians, -1.52 days; 95% CI: -2.55 to -0.49); there was high heterogeneity across studies (I2, 74%). ERAS protocols were also associated with a lower risk of PONV (relative risk, 0.79; 95% CI: 0.69-0.90; I2, 99%) and postoperative pain with a visual analog scale score ≥4 at postoperative day 1 (relative risk, 0.37; 95% CI: 0.28-0.49; I2, 14%). Other outcomes, including postoperative complications, did not differ between ERAS and conventional care groups. ERAS protocols may be superior to conventional perioperative care in craniotomy patients in terms of lower length of hospital stay, lower incidence of PONV, and improved postoperative pain scores. Further randomized trials are required to identify the impact of ERAS protocols on the quality of recovery after craniotomy.
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Affiliation(s)
- Seung Hyun Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine
| | - Seung Ho Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine
| | - Jisu Moon
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Korea
| | - Hae Dong Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine
| | - Yong Seon Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine
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Kapoor I, Singh DJ, Prabhakar H, Mahajan C, Chaturvedi A, Pandey S. Role of Preoperative Anesthesia Counseling in the Neurosurgical Patients: A Randomized Controlled Open-Label Study. World Neurosurg 2024; 182:1-5. [PMID: 37923011 DOI: 10.1016/j.wneu.2023.10.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/27/2023] [Accepted: 10/28/2023] [Indexed: 11/07/2023]
Affiliation(s)
- Indu Kapoor
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India.
| | - Davinder Jit Singh
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Hemanshu Prabhakar
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Charu Mahajan
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Arvind Chaturvedi
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Shivam Pandey
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
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Guo C, Gao T. The advantages of general anesthesia subthalamic deep brain stimulation for Parkinson's disease in the enhanced recovery after surgery: A randomized clinical trial. Health Sci Rep 2023; 6:e1766. [PMID: 38089594 PMCID: PMC10711149 DOI: 10.1002/hsr2.1766] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/07/2023] [Accepted: 11/28/2023] [Indexed: 10/16/2024] Open
Abstract
Background and Aims With advancements in imaging and microelectrode recording techniques, general anesthesia (GA) has emerged as an alternative option for Parkinson's disease (PD) patients undergoing subthalamic nucleus deep brain stimulation (STN-DBS). In this study, we compared the advantages and disadvantages of using GA and local anesthesia for STN-DBS in enhanced recovery after surgery (ERAS). Methods Surgical outcomes of STN-DBS were evaluated using the unified PD rating scales (UPDRS). CT and magnetic resonance imaging scans are used to evaluate intracranial conditions. State-trait anxiety inventory and hospital anxiety and depression scale are used to evaluate patients' perioperative psychology. Results Anesthesia method does not significantly impact the accuracy of microelectrode placement or the improvement of postoperative symptoms. However, the local anesthesia group had a higher incidence of intracranial air, as well as higher rates of postoperative complications such as headache, dizziness, vomiting, and delirium. GA effectively alleviated preoperative anxiety and resulted in lower levels of perioperative anxiety and psychological stress compared to local anesthesia. Additionally, the GA group had shorter surgery duration, earlier ambulation, and a shorter average hospital stay. Conclusion DBS under GA is safe and effective. Due to shorter surgical duration, reduced occurrence of perioperative complications, effective reduction of preoperative anxiety, and faster postoperative recovery, DBS under GA is better aligned with the concept of ERAS.
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Affiliation(s)
- Cunbao Guo
- Department of AnesthesiologyShandong Provincial Hospital Affiliated to Shandong First Medical University (Shandong Academy of Medical Sciences)JinanShandongChina
| | - Taihong Gao
- Department of NeurosurgeryShandong Provincial Hospital Affiliated to Shandong First Medical University (Shandong Academy of Medical Sciences)JinanShandongChina
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Luo M, Zhao X, Deng M, Hu Y, Yang X, Mei Z, Meng L, Wang Y. Scalp Nerve Block, Local Anesthetic Infiltration, and Postoperative Pain After Craniotomy: A Systematic Review and Network Meta-analysis of Randomized Trials. J Neurosurg Anesthesiol 2023; 35:361-374. [PMID: 36040025 DOI: 10.1097/ana.0000000000000868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 07/27/2022] [Indexed: 11/25/2022]
Abstract
The most efficacious methods for controlling postoperative pain in craniotomy remain unknown. A systematic review and network meta-analysis were performed to compare the efficacies of different strategies of scalp nerve block (SNB), scalp infiltration (SI), and control in patients undergoing craniotomy. MEDLINE, Embase, and CENTRAL databases were searched for randomized controlled trials. The primary outcome was postoperative 24-hour pain score, and the secondary outcome was opioid consumption within the first 24 hour after surgery. The effect was estimated using the between-group mean difference and ranked using the surface under the cumulative ranking curve (SUCRA) score. Twenty-four randomized trials were identified for inclusion. SNB using ropivacaine reduced postoperative 24-hour pain score when compared with control (mean difference [95% credible interval], -2.04 [-3.13, -0.94]; low quality), and when compared with SI using ropivacaine (-1.77 [-3.04, -0.51]; low quality) or bupivacaine (-1.96 [-3.65, -0.22]; low quality). SNB using ropivacaine was likely the most efficacious method for pain control (SUCRA, 91%), and also reduced opioid consumption within the first postoperative 24 hours as compared with control (mean difference [95% credible interval], -11.91 [-22.42, -1.4]; low quality). SNB using bupivacaine, lidocaine, and epinephrine combined, and SNB using ropivacaine, were likely the most efficacious methods for opioid consumption reduction (SUCRA, 88% and 80%, respectively). In summary, different methods of SNB / SI seem to have different efficacies after craniotomy. SNB using ropivacaine may be superior to other methods for postcraniotomy pain control; however, the overall quality of evidence was low.
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Affiliation(s)
- Mengqiang Luo
- Department of Anesthesiology, Huashan Hospital, Fudan University
| | - Xu Zhao
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou
| | - Meng Deng
- Department of Anesthesiology, Huashan Hospital, Fudan University
| | - Yue Hu
- Department of Anesthesiology, Huashan Hospital, Fudan University
| | - Xiaoyu Yang
- Department of Anesthesiology, Huashan Hospital, Fudan University
| | - Zubing Mei
- Anorectal Disease Institute of Shuguang Hospital, Shanghai
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Lingzhong Meng
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yingwei Wang
- Department of Anesthesiology, Huashan Hospital, Fudan University
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Kaewborisutsakul A, Kitsiripant C, Kaewsridam S, Kaewborisutsakul WK, Churuangsuk C. The influence of enhanced recovery after surgery protocol adherence in patients undergoing elective neuro-oncological craniotomies. World Neurosurg X 2023; 19:100196. [PMID: 37181587 PMCID: PMC10173293 DOI: 10.1016/j.wnsx.2023.100196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 04/05/2023] [Accepted: 04/11/2023] [Indexed: 05/16/2023] Open
Abstract
Objectives Enhanced recovery after surgery (ERAS) protocols have reduced the length of hospital stay (LOS) and healthcare costs without increasing adverse outcomes. We describe the impact of adherence to an ERAS protocol for elective craniotomy among neuro-oncology patients at a single institution. Methods This retrospective study enrolled adult patients who underwent elective craniotomy and the ERAS protocol at our institute between January 2020 and April 2021. The patients were divided into high- and low-adherence groups depending on their adherence to ≥9 or <9 of the 16 items, respectively. Inferential statistics were used to compare group outcomes, and multivariable logistic regression analysis was used to examine factors related to delayed discharge (LOS>7 days). Results Among the 100 patients assessed, median adherence was 8 items (range, 4-16), and 55 and 45 patients were classified into the high- and low-adherence groups, respectively. Age, sex, comorbidities, brain pathology, and operative profiles were comparable at baseline. The high-adherence group showed significantly better outcomes, including shorter median LOS (8 days vs. 11 days; p = 0.002) and lower median hospital costs (131,657.5 baht vs. 152,974 baht; p = 0.005). The groups showed no differences in 30-day postoperative complications or Karnofsky performance status. In the multivariable analysis, high adherence to the ERAS protocol (>50%) was the only significant factor preventing delayed discharge (OR = 0.28; 95% CI = 0.10 to 0.78; p = 0.04). Conclusions High adherence to ERAS protocols showed a strong association with short hospital stays and cost reductions. Our ERAS protocol was feasible and safe for patients undergoing elective craniotomy for brain tumors.
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Affiliation(s)
- Anukoon Kaewborisutsakul
- Neurological Surgery Unit, Division of Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Chanatthee Kitsiripant
- Division of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
- Corresponding author. Division of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand.
| | - Sukanya Kaewsridam
- Division of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | | | - Chaitong Churuangsuk
- Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
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Luo M, Zhao X, Tu M, Yang X, Deng M, Wang Y. The effectiveness of scalp nerve block on hemodynamic response in craniotomy: a systematic review and meta-analysis of randomized trials. Minerva Anestesiol 2023; 89:85-95. [PMID: 36448987 DOI: 10.23736/s0375-9393.22.16775-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
INTRODUCTION Strategies that blunt noxious stimuli and stabilize hemodynamics may reduce perioperative cardiovascular complications and enhance recovery after craniotomy. EVIDENCE ACQUISITION Our systematic literature review and meta-analysis investigated whether scalp nerve block (SNB) reduces the acute hemodynamic response compared with non-SNB (scalp infiltration or control) in adult patients undergoing elective craniotomy. We searched MEDLINE, EMBASE, CENTRAL, and two Chinese databases for randomized trials. Primary outcomes included mean arterial pressure and heart rate during skull pin insertion and surgical incision in craniotomy. Secondary outcomes included incidence of hypertension and dosage of intraoperative analgesic opioids used. Random-effects models were used for meta-analyses. EVIDENCE SYNTHESIS SNB significantly reduced the mean arterial pressure (mean difference: -14.00 mmHg; 95% confidence interval [CI]: -19.71 to -8.28) and heart rate (mean difference: -11.55 beat/min; 95% CI: -19.31 to -3.80), when compared with non-SNB during skull pin insertion. A similar trend was observed during skin incisions (SNB vs. non-SNB, mean difference in mean arterial pressure: -9.46 mmHg; 95% CI: -14.53 to -4.38; mean difference in heart rate: -9.34 beat/min; 95% CI: -15.40 to -3.28). Subgroup analysis showed that, compared with scalp infiltration, SNB reduced mean arterial pressure and heart during pin insertion but not during skin incisions. SNB also reduced the incidence of intraoperative hypertension, but no difference was observed in intraoperative opioid consumption when compared with non-SNB. CONCLUSIONS SNB alleviated the craniotomy-associated hemodynamic response. SNB may be superior to scalp infiltration in maintaining hemodynamic stability during pin insertion. However, high-quality trials are still needed to provide more conclusive evidence.
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Affiliation(s)
- Mengqiang Luo
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xu Zhao
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Mengyun Tu
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaoyu Yang
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Meng Deng
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yingwei Wang
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China -
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Wang L, Cai H, Wang Y, Liu J, Chen T, Liu J, Huang J, Guo Q, Zou W. Enhanced recovery after elective craniotomy: A randomized controlled trial. J Clin Anesth 2021; 76:110575. [PMID: 34739947 DOI: 10.1016/j.jclinane.2021.110575] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/25/2021] [Accepted: 10/26/2021] [Indexed: 12/11/2022]
Abstract
STUDY OBJECTIVES Enhanced recovery after surgery (ERAS) protocols have been proven to improve outcomes but have not been widely used in neurosurgery. The purpose of this study was to design a multidisciplinary enhanced recovery after elective craniotomy protocol and to evaluate its clinical efficacy and safety after implementation. DESIGN A prospective randomized controlled trial. SETTING The setting is at an operating room, a post-anesthesia care unit, and a hospital ward. PATIENTS This randomized controlled trial (RCT) prospectively analyzed 151 patients who underwent elective craniotomy between January 2019 and June 2020. INTERVENTIONS The neurosurgical ERAS group was cared for with evidence-based systematic optimization approaches, while the control group received routine care. MEASUREMENTS The primary outcomes were the postoperative length of stay (LOS) and hospitalization costs. The secondary outcomes included 30-day readmission rates, postoperative complications, postoperative pain scores, length of intensive care unit (ICU) stay, duration of the drainage tube, time to oral intake, time to ambulation, and postoperative functional recovery status. MAIN RESULTS After ERAS protocol implementation, the median postoperative LOS (4 days to 3 days, difference [95% confidence interval, CI], 2 [1 to 2], P < 0.0001) and hospitalization costs (6266 USD to 5880 USD, difference [95% CI], 427.0 [234.8 to 633.6], P < 0.0001) decreased. Compared to routine perioperative care, the ERAS protocol reduced the incidence of postoperative nausea and vomiting (PONV) (28.0% to 9.2%, adjusted odds ratio [OR] 0.3, 95% CI 0.1-0.7, P = 0.003), shortened urinary catheter removal time by 24 h (64.0% to 83.0%, adjusted OR 2.9, 95% CI 1.3-6.5, P = 0.031), improved ambulation on postoperative day 1 (POD 1) (30.7% to 75.0%, adjusted OR 7.5, 95% CI 3.6-15.8, P < 0.0001), shortened the time to oral intake (15 h to 13 h, difference [95% CI], 3 [1 to 4], P < 0.001), and improved perioperative pain management. CONCLUSIONS Implementation of an enhanced recovery after elective craniotomy protocol had significant benefits over conventional perioperative management. It was associated with a significant reduction in postoperative length of stay, medical cost, and postoperative complications.
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Affiliation(s)
- Lei Wang
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Hongwei Cai
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yanjin Wang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jian Liu
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Tiange Chen
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jing Liu
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, KY, United States of America
| | - Qulian Guo
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Wangyuan Zou
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China.
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Enhanced Recovery After Neurosurgery. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00478-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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