1
|
Favier V, Lavigne P, Ayad T, Herman P, Vérillaud B, Manet R, Jouanneau E, Crampette L, Fieux M, Carsuzaa F. Peri-operative management of endoscopic endonasal cerebrospinal fluid leak repair: an international survey. Eur Arch Otorhinolaryngol 2024:10.1007/s00405-024-08770-2. [PMID: 38914813 DOI: 10.1007/s00405-024-08770-2] [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: 04/09/2024] [Accepted: 05/29/2024] [Indexed: 06/26/2024]
Abstract
PURPOSE Peri-operative management of nasal cerebrospinal fluid (CSF) leaks is not consensual due to limited evidence. The main aim of this study was to identify key factors in peri-operative management of endoscopic endonasal CSF leak repair among international experts. METHODS A 60-item survey questionnaire collected opinions of members of international learned societies of ENT surgeons and neurosurgeons on nasal packing, post-operative instructions, antibiotic prophylaxis, and CSF volume depletion. RESULTS The survey had 153 respondents (124 otorhinolaryngologists and 29 neurosurgeons). A resting position was recommended by 85% (130/151) of respondents for extended CSF leak of the anterior skull base, mainly in Fowler's position (72% (110/153)). Nasal packing was used by 85% (130/153) of respondents; 33.3% (51/153) used it to stabilize the reconstruction, and 22.2% (34/153) to prevent bleeding. It was usually removed after 48 h in 44.4% of cases (68/153). CSF depletion was considered by 47.1% (72/153) of respondents in case of CSF leak recurrence and by 34.6% (53/153) in cases of increased intracranial pressure. All respondents gave specific postoperative instructions to patients including driving, running, swimming, diving restrictions and flighting restrictions. In subgroup analysis, ENT surgeons more often recommended a resting position than neurosurgeons (71% vs. 37.9% ; p = 0.0008) and prescribed more antibiotics (82.3% vs. 21.4% ; p < 0.0001). CONCLUSION Although postoperative management after CSF closure remains challenging and not codified, this international survey revealed some points of consensus concerning resting position and restriction of post-operative activities. Prospective clinical studies must be undertaken to evaluate their efficiency.
Collapse
Affiliation(s)
- Valentin Favier
- Département d'ORL et chirurgie cervico-faciale, Centre Hospitalier Universitaire de Montpellier, Hopital Gui de Chauliac, 80 Avenue Augustin Fliche, Montpellier, 34000, France.
| | - Philippe Lavigne
- Division of Otolaryngology - Head & Neck Surgery, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Tareck Ayad
- Division of Otolaryngology - Head & Neck Surgery, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Philippe Herman
- ENT department - Skull Base Center, Lariboisière University Hospital, Paris, France
| | - Benjamin Vérillaud
- ENT department - Skull Base Center, Lariboisière University Hospital, Paris, France
| | - Romain Manet
- Service de neurochirurgie, chirurgie des adénomes hypophysaires et de la base du crane, Hôpital neurologique Pierre Wertheimer, Hospices civils de Lyon, Bron, France
| | - Emmanuel Jouanneau
- Service de neurochirurgie, chirurgie des adénomes hypophysaires et de la base du crane, Hôpital neurologique Pierre Wertheimer, Hospices civils de Lyon, Bron, France
| | - Louis Crampette
- Département d'ORL et chirurgie cervico-faciale, Centre Hospitalier Universitaire de Montpellier, Hopital Gui de Chauliac, 80 Avenue Augustin Fliche, Montpellier, 34000, France
| | - Maxime Fieux
- Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Service d'ORL, d'otoneurochirurgie et de chirurgie cervico-faciale, Pierre Bénite cedex, F-69310, France
- Université de Lyon, Université Lyon 1, Lyon, F-69003, France
| | - Florent Carsuzaa
- Service ORL, Chirurgie Cervico-Maxillo-Faciale et Audiophonologie, Centre Hospitalier Universitaire de Poitiers, Poitiers, 86000, France
- Laboratoire Inflammation Tissus Epithéliaux et Cytokines (LITEC), UR15560, Université de Poitiers, Poitiers, 86000, France
| |
Collapse
|
2
|
Kvolik S, Koruga N, Skiljic S. Analgesia in the Neurosurgical Intensive Care Unit. Front Neurol 2022; 12:819613. [PMID: 35185756 PMCID: PMC8848763 DOI: 10.3389/fneur.2021.819613] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 12/23/2021] [Indexed: 11/13/2022] Open
Abstract
Acute pain in neurosurgical patients is an important issue. Opioids are the most used for pain treatment in the neurosurgical ICU. Potential side effects of opioid use such as oversedation, respiratory depression, hypercapnia, worsening intracranial pressure, nausea, and vomiting may be problems and could interfere with neurologic assessment. Consequently, reducing opioids and use of non-opioid analgesics and adjuvants (N-methyl-D-aspartate antagonists, α2 -adrenergic agonists, anticonvulsants, corticosteroids), as well as non-pharmacological therapies were introduced as a part of a multimodal regimen. Local and regional anesthesia is effective in opioid reduction during the early postoperative period. Among non-opioid agents, acetaminophen and non-steroidal anti-inflammatory drugs are used frequently. Adverse events associated with opioid use in neurosurgical patients are discussed. Larger controlled studies are needed to find optimal pain management tailored to neurologically impaired neurosurgical patients.
Collapse
Affiliation(s)
- Slavica Kvolik
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
- Department of Anesthesiology and Critical Care, Osijek University Hospital, Osijek, Croatia
- *Correspondence: Slavica Kvolik
| | - Nenad Koruga
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
- Department of Neurosurgery, Osijek University Hospital, Osijek, Croatia
| | - Sonja Skiljic
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
- Department of Anesthesiology and Critical Care, Osijek University Hospital, Osijek, Croatia
- Sonja Skiljic
| |
Collapse
|
3
|
Kim TJ, Torres L, Paz A, Lee JS, Park SH, Choi HA, Ko SB. Neostigmine for Treating Acute Colonic Pseudo-Obstruction in Neurocritically Ill Patients. J Clin Neurol 2021; 17:563-569. [PMID: 34595865 PMCID: PMC8490912 DOI: 10.3988/jcn.2021.17.4.563] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/11/2021] [Accepted: 05/11/2021] [Indexed: 12/26/2022] Open
Abstract
Background and Purpose Acute colonic pseudo-obstruction (ACPO) is a common but understudied complication in neurocritically ill patients. The acetylcholinesterase inhibitor neostigmine can be used to treat ACPO in patients who do not respond to conventional treatment. This study investigated the effectiveness and adverse events when using neostigmine to manage ACPO in neurocritically ill patients. Methods This retrospective study investigated patients with ACPO who were treated using neostigmine in the neurological intensive-care units at two centers between March 2017 and August 2020. Neostigmine was administered intravenously or subcutaneously (at doses ranging from 0.25 mg to 2 mg) according to the protocols at the two centers. The outcomes were bowel movements and the changes in colon diameters on abdominal radiographs. Safety events such as bradycardia, vomiting, salivation, and sweating were evaluated. Results This study included 31 subjects with a mean age of 46.8 years (65.4% males). All patients had a bowel movement at a median of 120 minutes after administering neostigmine. The colon diameter decreased by a median of 17.5 mm (paired t-test: p<0.001) regardless of the dose and treatment protocols. Multilevel analysis confirmed that the mean colon diameter decreased from 66 mm pretreatment to 47.5 mm posttreatment (p<0.001), with an intraclass correlation coefficient of 13%. Three patients (9.7%) exhibited hypersalivation, sweating, bradycardia, and vomiting. Bradycardia (heart rate, 42 beats/minute) occurred in one patient (3.2%), and was successfully managed by injecting atropine. Conclusions Neostigmine injection is a safe and effective treatment option for ACPO in neurocritically ill patients who fail to respond to conservative management.
Collapse
Affiliation(s)
- Tae Jung Kim
- Department of Neurology, Seoul National University Hospital, Seoul, Korea.,Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Luis Torres
- Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Atzhiry Paz
- Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Ji Sung Lee
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Soo Hyun Park
- Department of Neurology, Inha University Hospital, Incheon, Korea
| | - Huimahn Alex Choi
- Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA.
| | - Sang Bae Ko
- Department of Neurology, Seoul National University Hospital, Seoul, Korea.,Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea.
| |
Collapse
|
4
|
Abstract
Bowel dysfunction, especially ileus, has been increasingly recognized in critically ill patients. Ileus is commonly associated to constipation, however abnormal motility can also concern the upper digestive tract, therefore impaired gastrointestinal transit (IGT) seems to be a more appropriate term. IGT, especially constipation, is common among patients under mechanical ventilation, occurring in up to 80% of the patients during the first week, and has been associated with worse outcome in intensive care unit (ICU). It is acknowledged that the most relevant definition for constipation in ICU is the absence of stool for the first six days after admission. Concerning the upper digestive intolerance (UDI), the diagnosis should rely only on vomiting and the systematic gastric residual volume (GRV) monitoring should be avoided. IGT results from a complex pathophysiology in which both the critical illness and its specific treatments may have a deleterious role. Both observational and experimental studies have shown the deleterious effect of sepsis, multiorgan failure, sedation (especially opioids) and mechanical ventilation on gut function. To date few studies have reported effect of treatment on IGT and the level of evidence is low. However, cholinesterase inhibitors seem safe and could probably be used in case of constipation but remains poorly prescribed. Prevention with bowel management protocol using osmotic laxatives appears to be safe but did not demonstrate its effectiveness. For patients treated with high posology of opioids during sedation, enteral opioid antagonists may be a promising strategy.
Collapse
Affiliation(s)
- Philippe Ariès
- Clermont-Tonnerre Military Teaching Hospital, Brest, France.,Val-de-Grâce French Military Health Service Academy, Paris, France.,Department of Anesthesia and Surgical Intensive Care, Brest Teaching Hospital, Brest, France
| | - Olivier Huet
- Department of Anesthesia and Surgical Intensive Care, Brest Teaching Hospital, Brest, France - .,UFR of Medicine, University of Western Brittany, Brest, France
| |
Collapse
|