1
|
Lele AV, Shiferaw AA, Theard MA, Vavilala MS, Tavares C, Han R, Assefa D, Dagne Alemu M, Mahajan C, Tandon MS, Karmarkar NV, Singhal V, Lamsal R, Athiraman U. A Global Review of the Perioperative Care of Patients With Aneurysmal Subarachnoid Hemorrhage Undergoing Microsurgical Repair of Ruptured Intracerebral Aneurysm. J Neurosurg Anesthesiol 2024; 36:164-171. [PMID: 37294597 PMCID: PMC10584987 DOI: 10.1097/ana.0000000000000913] [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: 10/19/2022] [Accepted: 02/20/2023] [Indexed: 06/10/2023]
Abstract
INTRODUCTION To describe the perioperative care of patients with aneurysmal subarachnoid hemorrhage (aSAH) who undergo microsurgical repair of a ruptured intracerebral aneurysm. METHODS An English language survey examined 138 areas of the perioperative care of patients with aSAH. Reported practices were categorized as those reported by <20%, 21% to 40%, 41% to 60%, 61% to 80%, and 81% to 100% of participating hospitals. Data were stratified by Worldbank country income level (high-income or low/middle-income). Variation between country-income groups and between countries was presented as an intracluster correlation coefficient (ICC) and 95% confidence interval (CI). RESULTS Forty-eight hospitals representing 14 countries participated in the survey (response rate 64%); 33 (69%) hospitals admitted ≥60 aSAH patients per year. Clinical practices reported by 81 to 100% of the hospitals included placement of an arterial catheter, preinduction blood type/cross match, use of neuromuscular blockade during induction of general anesthesia, delivering 6 to 8 mL/kg tidal volume, and checking hemoglobin and electrolyte panels. Reported use of intraoperative neurophysiological monitoring was 25% (41% in high-income and 10% in low/middle-income countries), with variation between Worldbank country-income group (ICC 0.15, 95% CI 0.02-2.76) and between countries (ICC 0.44, 95% CI 0.00-0.68). The use of induced hypothermia for neuroprotection was low (2%). Before aneurysm securement, variable in blood pressure targets was reported; systolic blood pressure 90 to 120 mm Hg (30%), 90 to 140 mm Hg (21%), and 90 to 160 mmHg (5%). Induced hypertension during temporary clipping was reported by 37% of hospitals (37% each in high and low/middle-income countries). CONCLUSIONS This global survey identifies differences in reported practices during the perioperative management of patients with aSAH.
Collapse
Affiliation(s)
- Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | | | - Marie Angele Theard
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | | | - Ruquan Han
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | | | - Mihret Dagne Alemu
- Department of Anesthesiology, University of Addis Ababa, Addis Ababa, Ethiopia
| | - Charu Mahajan
- All-India Institute of Medical Sciences, New Delhi, India
| | - Monica S Tandon
- G.B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | | | | | - Ritesh Lamsal
- Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal
| | | |
Collapse
|
2
|
Leppert J, Küchler J, Wagner A, Hinselmann N, Ditz C. Prospective Observational Study of Volatile Sedation with Sevoflurane After Aneurysmal Subarachnoid Hemorrhage Using the Sedaconda Anesthetic Conserving Device. Neurocrit Care 2024:10.1007/s12028-024-01959-7. [PMID: 38485879 DOI: 10.1007/s12028-024-01959-7] [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: 11/06/2023] [Accepted: 02/09/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Volatile sedation is still used with caution in patients with acute brain injury because of safety concerns. We analyzed the effects of sevoflurane sedation on systemic and cerebral parameters measured by multimodal neuromonitoring in patients after aneurysmal subarachnoid hemorrhage (aSAH) with normal baseline intracranial pressure (ICP). METHODS In this prospective observational study, we analyzed a 12-h period before and after the switch from intravenous to volatile sedation with sevoflurane using the Sedaconda Anesthetic Conserving Device with a target Richmond Agitation Sedation Scale score of - 5 to - 4. ICP, cerebral perfusion pressure (CPP), brain tissue oxygenation (PBrO2), metabolic values of cerebral microdialysis, systemic cardiopulmonary parameters, and the administered drugs before and after the sedation switch were analyzed. RESULTS We included 19 patients with a median age of 61 years (range 46-78 years), 74% of whom presented with World Federation of Neurosurgical Societies grade 4 or 5 aSAH. We observed no significant changes in the mean ICP (9.3 ± 4.2 vs. 9.7 ± 4.2 mm Hg), PBrO2 (31.0 ± 13.2 vs. 32.2 ± 12.4 mm Hg), cerebral lactate (5.0 ± 2.2 vs. 5.0 ± 1.9 mmol/L), pyruvate (136.6 ± 55.9 vs. 134.1 ± 53.6 µmol/L), and lactate/pyruvate ratio (37.4 ± 8.7 vs. 39.8 ± 9.2) after the sedation switch to sevoflurane. We found a significant decrease in mean arterial pressure (MAP) (88.6 ± 7.6 vs. 86.3 ± 5.8 mm Hg) and CPP (78.8 ± 8.5 vs. 76.6 ± 6.6 mm Hg) after the initiation of sevoflurane, but the decrease was still within the physiological range requiring no additional hemodynamic support. CONCLUSIONS Sevoflurane appears to be a feasible alternative to intravenous sedation in patients with aSAH without intracranial hypertension, as our study did not show negative effects on ICP, cerebral oxygenation, or brain metabolism. Nevertheless, the risk of a decrease of MAP leading to a consecutive CPP decrease should be considered.
Collapse
Affiliation(s)
- Jan Leppert
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Jan Küchler
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Andreas Wagner
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Niclas Hinselmann
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Claudia Ditz
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| |
Collapse
|
3
|
Liu CC, Chen IW, Liu PH, Wu JY, Liu TH, Huang PY, Yu CH, Fu PH, Hung KC. Efficacy of propofol-based anesthesia against risk of brain swelling during craniotomy: A meta-analysis of randomized controlled studies. J Clin Anesth 2024; 92:111306. [PMID: 37883902 DOI: 10.1016/j.jclinane.2023.111306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/10/2023] [Accepted: 10/20/2023] [Indexed: 10/28/2023]
Abstract
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.
Collapse
Affiliation(s)
- Chien-Cheng Liu
- Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan; Department of Nursing, College of Medicine, I-Shou University, Kaohsiung City, Taiwan; School of Medicine, I-Shou University, Kaohsiung City, Taiwan
| | - I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan City, Taiwan
| | - Ping-Hsin Liu
- Department of Anesthesiology, E-Da Dachang Hospital, I-Shou University, Kaohsiung City, Taiwan
| | - Jheng-Yan Wu
- Department of Nutrition, Chi Mei Medical Center, Tainan City, Taiwan
| | - Ting-Hui Liu
- Department of Psychiatry, Chi Mei Medical Center, Tainan City, Taiwan
| | - Po-Yu Huang
- Department of Internal Medicine, Chi Mei Medical Center, Tainan City, Taiwan
| | - Chia-Hung Yu
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Pei-Han Fu
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan; School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan.
| |
Collapse
|
4
|
Sree A, Hrishi AP, Praveen R, Sethuraman M. Periprocedural management of patients presenting for neurointerventional procedures using flow diverters for complex intracranial aneurysms: An anesthetist's perspective - A narrative review. Brain Circ 2024; 10:21-27. [PMID: 38655436 PMCID: PMC11034442 DOI: 10.4103/bc.bc_77_23] [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: 09/04/2023] [Revised: 10/31/2023] [Accepted: 11/10/2023] [Indexed: 04/26/2024] Open
Abstract
Complex intracranial aneurysms pose significant challenges in the realm of neurointervention, necessitating meticulous planning and execution. This article highlights the crucial roles played by anesthetists in these procedures, including patient assessment, anesthesia planning, and continuous monitoring and maintaining hemodynamic stability, which are pivotal in optimizing patient safety. Understanding these complex procedures and their complications will aid the anesthetist in delivering optimal care and in foreseeing and managing the potential associated complications. The anesthetist's responsibility extends beyond the procedure itself to postprocedure care, ensuring a smooth transition to the recovery phase. Successful periprocedural anesthetic management in flow diverter interventions for complex intracranial aneurysms hinges on carefully orchestrating these elements. Moreover, effective communication and collaboration with the interventional neuroradiologist and the procedural team are emphasized, as they contribute significantly to procedural success. This article underscores the essential requirement for a multidisciplinary team approach when managing patients undergoing neurointerventions. In this collaborative framework, the expertise of the anesthetist harmoniously complements the skills and knowledge of other team members, contributing to the overall success and safety of these procedures. By providing a high level of care throughout the periprocedural period, anesthetists play a pivotal role in enhancing patient outcomes and minimizing the risks associated with these intricate procedures. In conclusion, the periprocedural anesthetic management of neurointervention using flow diverters for complex intracranial aneurysms is a multifaceted process that requires expertise, communication, and collaboration.
Collapse
Affiliation(s)
- Anjane Sree
- Department of Neuroanesthesia and Critical Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Ajay Prasad Hrishi
- Department of Neuroanesthesia and Critical Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Ranganatha Praveen
- Department of Neuroanesthesia and Critical Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Manikandan Sethuraman
- Department of Neuroanesthesia and Critical Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| |
Collapse
|
5
|
Ankolekar RR, Kaur K, Jangra K, Aggarwal A, Panda NB, Bhagat H, Barik AK. Propofol versus Desflurane in Moyamoya Disease Patients-A Pilot Study. Asian J Neurosurg 2023; 18:826-830. [PMID: 38161613 PMCID: PMC10756770 DOI: 10.1055/s-0043-1775588] [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] [Indexed: 01/03/2024] Open
Abstract
Objectives The choice of inhalational or intravenous anesthetic agents is debatable in neurosurgical patients. Desflurane, a cerebral vasodilator, may be advantageous in ischemic cerebral pathologies. Hence, we planned to compare desflurane and propofol in patients with moyamoya disease (MMD) with the objective of comparing neurological outcomes. Materials and Methods This prospective pilot trial was initiated after institutional ethics committee approval. Patients with MMD undergoing revascularization surgery were randomized into two groups receiving either desflurane or propofol intraoperatively. Neurological outcomes were assessed using a modified Rankin score (mRS) at discharge and an extended Glasgow outcome score (GOS-E) at 1 month. Intraoperative parameters, including hemodynamic parameters, end-tidal carbon dioxide, entropy, intraoperative brain relaxation scores (BRS), and rescue measures for brain relaxation, were compared. Statistical Analysis The normality of quantitative data was checked using Kolmogorov-Smirnov tests of normality. Normally distributed data were compared using unpaired t -tests, skewed data using Mann-Whitney U tests, and categorical variables using chi-squared tests. Results A total of 17 patients were randomized, 10 in the desflurane and 7 in the propofol group. mRS (1.3 ± 0.6 and 1.14 ± 0.4, p = 0.450) and GOS-E (6.7 ± 0.6 and 6.85 ± 0.5, p = 0.45) were comparable between desflurane and propofol groups, respectively. BRS was significantly higher in the desflurane group (3.6 ± 0.5) compared to the propofol group (2.1 ± 0.3, p = 0.001), with a significant number of patients requiring rescue measures in the desflurane group (70%, p < 0.001). Other outcome parameters were comparable ( p > 0.05). Conclusion We conclude that postoperative neurological outcomes were comparable with using either an anesthetic agent, desflurane, or propofol in MMD patients undergoing revascularization surgery. Maintenance of anesthesia with propofol had significantly superior surgical field conditions.
Collapse
Affiliation(s)
- Ronak R. Ankolekar
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
- Senior Registrar Department of Critical Care Medicine, Narayana Health, Bangalore, Karnataka, India
| | - Kirandeep Kaur
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kiran Jangra
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Aggarwal
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nidhi B. Panda
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Hemant Bhagat
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amiya K. Barik
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
6
|
Jiang Z, Wu Y, Liang F, Jian M, Liu H, Mei H, Han R. Brain relaxation using desflurane anesthesia and total intravenous anesthesia in patients undergoing craniotomy for supratentorial tumors: a randomized controlled study. BMC Anesthesiol 2023; 23:15. [PMID: 36624384 PMCID: PMC9830805 DOI: 10.1186/s12871-023-01970-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 01/03/2023] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Satisfactory brain relaxation is essential in neurosurgery. Desflurane anesthesia and propofol-based total intravenous anesthesia (TIVA) have different effects on cerebral hemodynamics, potentially contributing to discrepant brain relaxation. The purpose of this study was to compare the effects of desflurane and TIVA on brain relaxation in patients undergoing craniotomy for supratentorial tumors. METHODS In this randomized, controlled study, we enrolled patients aged 18-60 years, with ASA I-III, who were scheduled to undergo elective craniotomy for supratentorial tumors. Patients were randomly assigned in a 1:1 ratio to receive desflurane anesthesia or TIVA. The primary outcome was the proportion of satisfactory brain relaxation. Secondary outcomes included emergence and extubation times, recovery of cognitive function and postoperative complications. RESULTS Of 369 patients who were assessed for eligibility, 111 were randomized and 110 were included in the modified intention-to-treat analysis (55 in the desflurane group and 55 in the TIVA group). The proportion of satisfactory brain relaxation was similar between the two groups: 69% in the desflurane group and 73% in the TIVA group (RR: 0.950, 95% CI: 0.748-1.207; P = 0.675). Patients assigned to the desflurane group had shorter emergence (10 [8-13] min vs. 13 [10-20] min, P < 0.001) and extubation times (13 [10-18] min vs. 17 [13-23] min, P < 0.001), and better recovery of cognitive function at 15 min after extubation (16 [0-24] vs. 0 [0-20], P = 0.003), but experienced increased postoperative nausea and vomiting (PONV) (16 [29%] vs. 6 [11%] P = 0.017) and tachycardia (22 [40%] vs. 9 [16%], P = 0.006) during recovery. CONCLUSIONS Desflurane anesthesia and TIVA provide similar brain relaxation in patients without intracranial hypertension undergoing elective craniotomy. Desflurane accelerates the recovery from anesthesia but is associated with increased PONV and tachycardia during the recovery period. TRIAL REGISTRATION Clinicaltrial.gov (NCT04691128). Date of registration: December 31, 2020.
Collapse
Affiliation(s)
- Ze Jiang
- grid.411617.40000 0004 0642 1244Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 119, Southwest 4Th Ring Road, Fengtai District Beijing, People’s Republic of China
| | - Youxuan Wu
- grid.411617.40000 0004 0642 1244Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 119, Southwest 4Th Ring Road, Fengtai District Beijing, People’s Republic of China
| | - Fa Liang
- grid.411617.40000 0004 0642 1244Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 119, Southwest 4Th Ring Road, Fengtai District Beijing, People’s Republic of China
| | - Minyu Jian
- grid.411617.40000 0004 0642 1244Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 119, Southwest 4Th Ring Road, Fengtai District Beijing, People’s Republic of China
| | - Haiyang Liu
- grid.411617.40000 0004 0642 1244Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 119, Southwest 4Th Ring Road, Fengtai District Beijing, People’s Republic of China
| | - Hongxun Mei
- grid.411617.40000 0004 0642 1244Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 119, Southwest 4Th Ring Road, Fengtai District Beijing, People’s Republic of China
| | - Ruquan Han
- grid.411617.40000 0004 0642 1244Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 119, Southwest 4Th Ring Road, Fengtai District Beijing, People’s Republic of China
| |
Collapse
|