Effects of Anesthetic Management on Early Postoperative Recovery, Hemodynamics and Pain After Supratentorial Craniotomy

Efficacy of propofol-based anesthesia against risk of brain swelling during craniotomy: A meta-analysis of randomized controlled studies

STUDY OBJECTIVE

This meta-analysis aimed to compare the risk of brain swelling during craniotomy between propofol-based and volatile-based anesthesia.

DESIGN

Meta-analysis of randomized controlled trials (RCTs).

SETTING

Operating room.

INTERVENTION

Propofol-based anesthesia.

PATIENTS

Adult patients undergoing craniotomy.

MEASUREMENTS

Databases, including EMBASE, MEDLINE, Google Scholar, and Cochrane Library, were searched from inception to April 2023. The primary outcome was the risk of brain swelling, while the secondary outcomes included the impact of anesthetic regimens on surgical and recovery outcomes, as well as the risk of hemodynamic instability.

MAIN RESULTS

Our meta-analysis of 17 RCTs showed a significantly lower risk of brain swelling (risk ratio [RR]: 0.85, p = 0.03, I2 = 21%, n = 1976) in patients receiving propofol than in those using volatile agents, without significant differences in surgical time or blood loss between the two groups. Moreover, propofol was associated with a lower intracranial pressure (ICP) (mean difference: -4.06 mmHg, p < 0.00001, I2 = 44%, n = 409) as well as a lower risk of tachycardia (RR = 0.54, p = 0.005, I2 = 0%, n = 822) and postoperative nausea/vomiting (PONV) (RR = 0.59, p = 0.002, I2 = 19%, n = 1382). There were no significant differences in other recovery outcomes (e.g., extubation time), risk of bradycardia, hypertension, or hypotension between the two groups. Subgroup analysis indicated that propofol was not associated with a reduced risk of brain swelling when compared to individual volatile agents. Stratified by craniotomy indications, propofol reduced brain swelling in elective craniotomy, but not in emergency craniotomy (e.g., traumatic brain injury), when compared to volatile anesthetics.

CONCLUSIONS

By reviewing the available evidence, our results demonstrate the beneficial effects of propofol on the risk of brain swelling, ICP, PONV, and intraoperative tachycardia. In emergency craniotomy for traumatic brain injury and subarachnoid hemorrhage, brain swelling showed no significant difference between propofol and volatile agents. Further large-scale studies are warranted for verification.

Effect of anesthesia on the outcome of high-grade glioma patients undergoing supratentorial resection: study protocol for a pragmatic randomized controlled trial

Background

High-grade glioma (HGG) is the most malignant brain tumor with poor outcomes. Whether anesthetic methods have an impact on the outcome of these patients is still unknown. Retrospective study has found no difference between intravenous and inhalation anesthesia on the overall survival (OS) of the HGG patients, however, intravenous anesthesia with propofol might be beneficial in a subgroup of patients with a Karnofsky Performance Status (KPS) Scale less than 80. Further prospective studies are needed to evaluate the results.

Methods

This is a single-centered, randomized controlled, parallel-group trial. Three hundred forty-four patients with primary HGG for tumor resection will be randomly assigned to receive either intravenous anesthesia with propofol or inhalation anesthesia with sevoflurane. The primary outcome is the OS of the patients within 18 months. Secondary outcomes include progression-free survival (PFS), the numerical rating scale (NRS) of pain intensity and sleep quality, the postoperative encephaloedema volume, complications, and the length of hospital stay of the patients.

Discussion

This is a randomized controlled trial to compare the effect of intravenous and inhalation anesthesia maintenance on the outcome of supratentorial HGG patients. The results will contribute to optimizing the anesthesia methods in these patients.

Trial registration

ClinicalTrials.gov NCT02756312. Registered on 29 April 2016 and last updated on 9 Sep 2020

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06716-9.

Scalp block for postoperative pain after craniotomy: A meta-analysis of randomized control trials

Background

Postoperative pain after craniotomy is an important clinical concern because it might lead to brain hyperemia and elevated intracranial pressure. Considering the side effects of opioid, several studies have been conducted to investigate the effect of local anesthetics, especially the scalp block, on postoperative pain. However, the strength of evidence supporting this practice for postoperative pain after craniotomy was unclear and the best occasion of scalp block was also not identified. Therefore, we conducted a meta-analysis to evaluate the efficacy, safety, and the best occasion of scalp block for postoperative pain after craniotomy.

Methods

PubMed, Embase, and the Cochrane Library databases from database inception to October 10, 2021 were searched for all randomized controlled trials evaluating the effect of scalp block on postoperative pain after craniotomy. Data were assessed by StataMP 16 software.

Results

A total of 12 studies were included. A random-effect model was used to analyze all data. Patients under scalp block earned fewer scores than the non-scalp block group in visual analogue scale at the very early period (MD = −1.97, 95% CI = −3.07 to −0.88), early period (MD = −1.84, 95% CI = −2.95 to −0.73) and intermediate period (MD = −1.16, 95% CI = −1.84 to −0.49). Scalp block could also significantly prolong the time of the first request of rescue analgesia and reduce the use of additional analgesics without a significant difference in the incidence of complications. Subgroup analysis showed there was no significant difference in analgesia effect between pre-incision scalp block and post-incision scalp block in all periods.

Conclusion

Scalp block could lead to lower pain intensity scores, more time of the first request of rescue analgesia, and fewer analgesic drugs applied in the first 12 h after craniotomy. There was no significant difference between pre-incision and post-incision scalp block in the occurrence and severity of postoperative pain.

The effect of scalp block or local wound infiltration versus systemic analgesia on post-craniotomy pain relief

BACKGROUND

This is a prospective, double-blind observational study in which different types of analgesia and its effect on postoperative pain reduction in patients undergoing craniotomy for brain tumor removal were compared.

METHODS

The study included 141 adult craniotomy patients that were randomly separated into three equal groups. A group with scalp nerve blockade (B) and wound infiltration (I) received 0.25% bupivacaine combined with 1% lidocaine and 1:200,000 epinephrine. One gram of paracetamol and 2 mg/kg ketoprofen were administered intravenously (IV) after skin closure in a group with systemic analgesia (S). Pain intensity was evaluated after 1, 3, 6, and 24 h postoperatively using a visual analogue scale (VAS). The amount of rescue analgesia (ketorolac, paracetamol, and pethidine) and the duration for its first requirement were recorded.

RESULTS

One hundred and forty-one patients were included in the study. The main pain scores were significantly lower in the groups with regional anesthesia compared to group S in the first hours post-surgery (p < 0.05). Significantly lower pain scores were observed in the group with a scalp nerve blockade compared to the group with systemic analgesia or wound infiltration after 24 h (p < 0.05). Regional anesthesia ensured a stable analgesic effect for all 24 h. Patients in groups B and I required significantly fewer rescue analgesics compared to patients in group S. The duration for the requirement of the first rescue analgesia was significantly longer in groups B and I compared to group S (p = 0.000).

CONCLUSIONS

The results of our study show that most patients experience pain in the early postsurgical hours. Regional analgesia could help reduce the incidence and severity of pain after a craniotomy and the amount of rescue analgesia used in this group of patients.

Operative duration and early outcomes in patients having a supratentorial craniotomy for brain tumor: A propensity matched analysis

It is unclear how variations in operative duration affect outcomes after craniotomy for supratentorial brain tumor. We characterized three populations of patients with typical, shorter, and longer durations of craniotomy for supratentorial brain tumor using prospectively collected clinical data from 16,335 patients in the 2012-2018 ACS National Surgical Quality Improvement Program (NSQIP) database. We compared baseline characteristics including demographics, comorbidities, tumor type, and operative features. We used propensity score matching to attain covariate balance and logistic regression to assess odds of unfavorable outcomes. Patients with the shortest operation durations tended to be older, with fewer males, higher ASA class, more metastatic brain tumors, more medical comorbidities, and less use of intraoperative microscope or ultrasound. Patients with the longest operative durations tended to be younger, with more males, fewer non-white minorities, more obesity, lower ASA classes, more intrinsic brain tumors, fewer medical comorbidities, fewer emergency operations, and increased use of intraoperative microscope. For patients with the shortest operations, after matching, we observed significantly decreased odds of prolonged length-of-stay (LOS), major complication, any complication, reoperation, and discharge to a facility; however, there was a significantly increased risk of 30-day mortality. For patients with the longest operations, after matching, we observed significantly increased odds of prolonged LOS; minor, major, and any complication; discharge to facility; and 30-day reoperation. After matching to balance baseline characteristics, operative duration has implications for outcomes following craniotomy for supratentorial brain tumor.

Frequency of early postoperative adverse events (AEs) in adult patients undergoing elective neurosurgical intervention at tertiary care center in Pakistan

Objective:

The postoperative period is critical in neurosurgical patients, where the incidence of postoperative AEs is significantly high. Most of events occurs during recovery phase and has got relation to anaesthetic management. The objective of study was to determine frequency of early AEs in elective neurosurgical patients.

Methods:

This cross sectional study was conducted at our tertiary care center. The duration of study was one year, from August 2017-July 2018. The data was collected using predesigned proforma. The assessment was done on arrival in recovery room (T1) and then at forty five minutes (T2), twenty-fourth hour (T3) and forty-eighth hour (T4) postoperatively.

Results:

Total ninety-five patients were included. Overall, five hundred and forty AEs were recorded at T1, T2, T3 and T4. Anaesthesia related events like pain, postoperative sore throat, hoarseness, shivering and hypothermia were the commonest (73%). There was a gradual decline in incidence of these events over period of 48 hours. There was no effect of age, sex, BMI and blood loss on incidence of AEs.

Conclusions:

Postoperative pain, PONV and shivering were frequently reported AEs. We did not identify the impact of age, sex, BMI, comorbid or type of surgery in terms of having these events.

Inhaled anesthesia in neurosurgery: Still a role?

In patients undergoing craniotomy, general anesthesia should be addressed to warrant good hypnosis, immobility, and analgesia, to ensure systemic and cerebral physiological status and provide the best possible surgical field. Regarding craniotomies, it is unclear if there are substantial differences in providing general anesthesia using total intravenous anesthesia (TIVA) or balanced anesthesia (BA) accomplished using the third generation halogenates. New evidence highlighted that the last generation of halogenated agents has possible advantages compared with intravenous drugs: rapid induction, minimal absorption and metabolization, reproducible pharmacokinetic, faster recovery, cardioprotective effect, and opioid spare analgesia. This review aims to report evidence related to the use of the latest halogenated agents in patients undergoing craniotomy and to present available clinical evidence on their effects: cerebral and systemic hemodynamic, neurophysiological monitoring, and timing and quality of recovery after anesthesia.

Comparative effects of fentanyl versus sufentanil on cerebral oxygen saturation and postoperative cognitive function in elderly patients undergoing open surgery

This study was aimed to systematically evaluate the effects of fentanyl and sufentanil on intraoperative cerebral oxygen saturation changes and postoperative cognitive function in elderly patients undergoing open surgery. Ninety-six elderly patients who had undergone open surgery under general anesthesia were randomly divided into fentanyl group (F group, anesthesia by fentanyl, 4 g/kg) and sufentanil group (S group, anesthesia by sufentanil, 0.4 µg/kg). There were no significant differences between the F group and S group in the general characteristics of patients. Compared to the F group, the S group had a better effect on suppressing the stress response, maintaining a stable hemodynamic status and achieving better anesthesia effects. The anesthesia recovery time of the S group was significantly shorter than that of the F group. There was no significant difference between the two groups in the intraoperative and postoperative agitation. Patient's waking time and extubation time were significantly shorter in the S group than the F group. The VAS scores in the S group were significantly lower than those in the F group at each time point. The Ramsay scores in the S group were significantly higher than those in the F group at each time point. The cerebral oxygen saturation (SctO₂) levels in both groups were significantly increased following anesthesia induction and intubation compared to that of the awake state (P < 0.05), and SctO₂ was significantly decreased during the surgery in both groups. The changes in SctO₂ levels were not significantly different between the two groups (P > 0.05). The SctO₂ level was significantly higher during surgery than that after intubation. Compared with the F group, the relative value of SctO₂ decline in the S group was smaller. Compared to the day before surgery, the Montreal Cognitive Assessment (MoCA) scores of both groups were significantly reduced after surgery. At 1 day post-surgery, the MoCA scores of the S group were significantly higher and the incidence of postoperative cognitive dysfunction (POCD) was significantly lower compared to the F group. POCD occurred in three patients (6.2%) in the S group, and the ratio was significantly lower than that in the F group (11.9%) (P < 0.05). It showed a consistent trend with the SctO₂ status during the surgery. The relative value of SctO₂ decline in the S group was significantly smaller than that in the F group. The reduction of cognitive function in the S group was significantly lower than that in the F group. These results indicate that the changes in SctO₂ are a good prediction of the incidence of POCD.

REGIONAL ANESTHESIA FOR NEUROSURGERY

During neurosurgery procedures it is vital to assure optimal cerebral perfusion and oxygenation. Despite physiological autoregulation of brain perfusion, maintaining hemodynamic stability and good oxygenation during anesthesia is vital for success. General anesthesia with mechanical ventilation and current drugs provide excellent hemodynamic condition and it is the first choice for most neurosurgery procedures. However, sometimes it is very hard to avoid brief increase or decrease in blood pressure especially during period of intense pain, or without pain stimulation. This could be detrimental for patients presented with high intracranial pressure and brain edema. Modifying anesthesia depth or treatment with vasoactive drugs usually is needed to overcome such circumstances. On the other hand it is important to wake the patients quickly after anesthesia for neurological exam. That is why regional anesthesia of scalp and spine could show beneficial effects by decreasing pain stimuli and hemodynamic variability with sparing effect of anesthetics drugs. Also regional techniques provide excellent postoperative pain relief, especially after spinal surgery

Routine Postoperative Computed Tomography Is Not Helpful After Elective Craniotomy

BACKGROUND

Next-day postoperative computed tomography (CT) has been routinely used to obtain radiographic "clearance" for transferring patients after elective craniotomy out of the intensive care unit. The value of this traditional policy, however, has repeatedly been questioned. However, the limited patient numbers might have underestimated the very rare, but catastrophic, events. Therefore, we analyzed the value of routine postoperative CT in a larger cohort of elective tumor, epilepsy, and vascular cases.

METHODS

All the patients who had undergone elective craniotomy were included in our study. The routine postoperative CT scans were analyzed by a neuroradiologist who was unaware of the clinical data. The medical records were retrospectively reviewed for events of arterial hypertension and clinical deterioration.

RESULTS

The data from 660 patients with tumors (n = 393; 59.5%), aneurysms (n = 107; 16.2%), and skull base lesions were evaluated. In nearly one half of the patients (n = 264; 45.8%), CT depicted the presence of blood that was not associated with symptoms. Of the 660 patients, 21 (3.6%) showed a mass effect radiographically, 11 of whom underwent revision surgery. Arterial hypertension was documented in only 8 patients (1.3%) and was related to the revision surgery (P = 0.018). The overall revision rate was 2.7% (n = 18). All patients who had undergone revision for postoperative hematoma had presented with a new neurological deficit immediately before CT.

CONCLUSION

Routine postoperative CT did not reveal 1 patient with a serious hematoma that would not have been identified by clinical examination. Patients could be transferred safely from the intensive care unit, if the weaning process and clinical observation findings were uneventful, without deterioration of neurological symptoms or consciousness.

Options for perioperative pain management in neurosurgery

Moderate-to-severe pain following neurosurgery is common but often does not get attention and is therefore underdiagnosed and undertreated. Compounding this problem is the traditional belief that neurosurgical pain is inconsequential and even dangerous to treat. Concerns about problematic effects associated with opioid analgesics such as nausea, vomiting, oversedation, and increased intracranial pressure secondary to elevated carbon dioxide tension from respiratory depression have often led to suboptimal postoperative analgesic strategies in caring for neurosurgical patients. Neurosurgical patients may have difficulty or be incapable of communicating their need for analgesics due to neurologic deficits, which poses an additional challenge. Postoperative pain control should be a priority, because pain adversely affects recovery and patient outcomes. Inconsistent practices and the quality of current analgesic strategies for neurosurgical patients still leave room for improvement. Given the complexity of postoperative pain management for these patients, multimodal strategies are often required to optimize pain control and at the same time limit undesired side effects.