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Bindra A. Perioperative pearls on epilepsy surgery. Int Anesthesiol Clin 2023; 61:19-28. [PMID: 37249170 DOI: 10.1097/aia.0000000000000401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Ashish Bindra
- Department of Neuroanaesthesiology and Critical Care, JPNA Trauma Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, Delhi, India
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Shakir M, Khowaja AH, Altaf A, Tameezuddin A, Bukhari SS, Enam SA. Risk factors and predictors of intraoperative seizures during awake craniotomy: A systematic review and meta-analysis. Surg Neurol Int 2023; 14:195. [PMID: 37404511 PMCID: PMC10316139 DOI: 10.25259/sni_135_2023] [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: 02/08/2023] [Accepted: 05/04/2023] [Indexed: 07/06/2023] Open
Abstract
Background Awake craniotomy (AC) aims to minimize postoperative neurological complications while allowing maximum safe resection. Intraoperative seizures (IOSs) have been a reported complication during AC; however, literature delving into the predictors of IOS remains limited. Therefore, we planned a systematic review and meta-analysis of existing literature to explore predictors of IOS during AC. Methods From the inception until June 1, 2022, systematic searches of PubMed, Scopus, the Cochrane Library, CINAHL, and Cochrane's Central Register of Controlled Trials were conducted to look for published studies reporting IOS predictors during AC. Results We found 83 different studies in total; included were six studies with a total of 1815 patients, and 8.4% of them experienced IOSs. The mean age of included patients was 45.3 years, and 38% of the sample was female. Glioma was the most common diagnosis among the patients. A pooled random effect odds ratio (OR) of frontal lobe lesions was 2.42 (95% confidence intervals [CI]: 1.10-5.33, P = 0.03). Those with a pre-existing history of seizures had an OR of 1.80 (95% CI: 1.13-2.87, P = 0.01), and patients on antiepileptic drugs (AEDs) had a pooled OR of 2.47 (95% CI: 1.59-3.85, P < 0.001). Conclusion Patients with lesions of the frontal lobe, a prior history of seizures, and patients on AEDs are at higher risk of IOSs. These factors should be taken into consideration during the patient's preparation for an AC to avoid an intractable seizure and consequently a failed AC.
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Affiliation(s)
- Muhammad Shakir
- Department of Surgery, Section of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Aly Hamza Khowaja
- Medical student, Aga Khan University Medical College, Aga Khan University, Karachi, Pakistan
| | - Ahmed Altaf
- Department of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan
| | | | - Syed Sarmad Bukhari
- Department of Neurosurgery, Northwest School of Medicine, Peshawar, Pakistan
| | - Syed Ather Enam
- Department of Surgery, Section of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan
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Neurosurgical Anesthesia: Optimizing Outcomes with Agent Selection. Biomedicines 2023; 11:biomedicines11020372. [PMID: 36830909 PMCID: PMC9953550 DOI: 10.3390/biomedicines11020372] [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: 01/13/2023] [Accepted: 01/22/2023] [Indexed: 01/31/2023] Open
Abstract
Anesthesia in neurosurgery embodies a vital element in the development of neurosurgical intervention. This undisputed interest has offered surgeons and anesthesiologists an array of anesthetic selections to utilize, though with this allowance comes the equally essential requirement of implementing a maximally appropriate agent. To date, there remains a lack of consensus and official guidance on optimizing anesthetic choice based on operating priorities including hemodynamic parameters (e.g., CPP, ICP, MAP) in addition to the route of procedure and pathology. In this review, the authors detail the development of neuroanesthesia, summarize the advantages and drawbacks of various anesthetic classes and agents, while lastly cohesively organizing the current literature of randomized trials on neuroanesthesia across various procedures.
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Monitored anesthesia care and asleep-awake-asleep techniques combined with multiple monitoring for resection of gliomas in eloquent brain areas: a retrospective analysis of 225 patients. Chin Neurosurg J 2022; 8:45. [PMID: 36582003 PMCID: PMC9801549 DOI: 10.1186/s41016-022-00311-2] [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: 08/27/2022] [Accepted: 11/22/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Awake craniotomy (AC) has become gold standard in surgical resection of gliomas located in eloquent areas. The conscious sedation techniques in AC include both monitored anesthesia care (MAC) and asleep-awake-asleep (AAA). The choice of optimal anesthetic method depends on the preferences of the surgical team (mainly anesthesiologist and neurosurgeon). The aim of this study was to compare the difference in physiological and blood gas data, dosage of different drugs, the probability of switching to endotracheal intubation, and extent of tumor resection and dysfunction after operation between AAA and MAC anesthetic management for resection of gliomas in eloquent brain areas. METHODS Two-hundred and twenty-five patients with super-tentorial tumor located in eloquent areas underwent AC from 2009 to 2021 in Xijing Hospital. Forty-one patients underwent AAA technique, and the rest one-hundred eighty-four patients underwent MAC technique. Anesthetic management, dosage of different drugs, intraoperative complications, postoperative outcomes, adverse events, extent of resection and motor, and sensory and language dysfunction after operation were compared between MAC and AAA. RESULT There was no significant difference in gender, KPS score, MMSE score, glioma grade, type, and growth site between the patients in the two groups, except the older age of patients in MAC group than that in AAA group. During the whole process of operation, there were greater pulse pressure difference (P = 0.046), shorter operation time (P = 0.039), less dosage of remifentanil (P = 0.000), more dosage of dexmedetomidine (P = 0.013), more use of antiemetics (81%, P = 0.0067), lower use of vasoactive agent (45.1%, P = 0.010), and lower probability of conversion to general anesthesia (GA, P = 0.027) in MAC group than that in AAA group. Blood gas analysis showed that PetCO2 (P = 0.000), Glu concentration (P = 0.000), and PaCO2 (P = 0.000) were higher, but SPO2 (P = 0.002) and PaO2 (P = 0.000) were lower in MAC group than that in AAA group. In the postoperative recovery stage, compared with that of AAA group, the probability of dysfunction in MAC group at 1, 3, 5, and 7 days after operation was lower, which were 27.8% vs 53.6% (P = 0.003), 31% vs 68.3% (P = 0.000), 28.8% vs 63.4% (P = 0.000), and 25.6% vs 58.5% (P = 0.000), respectively. CONCLUSION Compared with AAA, it seems that MAC has more advantages in the management for resection of gliomas in eloquent brain areas, and MAC combined with multiple monitoring such as cerebral cortical mapping, neuronavigation, and ultrasonic detection is worthy of popularization for the resection of gliomas in eloquent brain areas.
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Tomasino B, Guarracino I, Pauletto G, Pez S, Ius T, Furlan D, Nilo A, Isola M, De Martino M, Mauro S, Verriello L, Lettieri C, Gigli GL, Valente M, Deana C, Skrap M. Performing real time neuropsychological testing during awake craniotomy: are dexmedetomidine or propofol the same? A preliminary report. J Neurooncol 2022; 160:707-716. [DOI: 10.1007/s11060-022-04191-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/03/2022] [Indexed: 11/16/2022]
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Thakkar K, Mariappan R, Prabhu K, Yadav B, Singh G. Comparison of Monitored Anesthesia Care with Propofol Versus Dexmedetomidine for Awake Craniotomy: A Retrospective study. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2022. [DOI: 10.1055/s-0042-1748195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
Abstract
Abstract
Background Anesthetic agents used for awake craniotomy should be safe, short-acting, titratable, and provide an adequate level of sedation and analgesia, along with facilitating adequate neurological assessment during the functional testing. Our study aims to review the efficacy and safety profile, along with the potential for neurophysiological monitoring, of two commonly used anesthetic regimens, i.e., propofol and dexmedetomidine.
Methods After the Ethics Committee approval, a retrospective analysis of 51 patients who underwent awake craniotomy for brain tumor excision over a period of 7 years was done. Those who received monitored anesthesia care (MAC) were divided into two groups, namely, Group P for that received propofol, and Group D that received dexmedetomidine and their hemodynamic profile, perioperative complications, neuromonitoring techniques, and postoperative course was noted from the records.
Results A total of 31 patients were administered MAC with propofol and 20 with dexmedetomidine. The baseline demographic data, duration of surgery, intensive care unit (ICU), and hospital stay were comparable between the two. The hemodynamic profile as assessed by the heart rate and blood pressure was also comparable. The incidence of intraoperative seizures was found to be less in Group P, though. Episodes of transient desaturation were observed more in Group P (9.7%) than in Group D (5%), but none of the patients required conversion to general anesthesia. Direct cortical stimulation was satisfactorily elicited in 80% in Group P and 85% in Group D.
Conclusions MAC with propofol and dexmedetomidine are acceptable techniques with comparable hemodynamic profile, intraoperative and postoperative complications, and potential for neurophysiological monitoring.
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Affiliation(s)
- Keta Thakkar
- Department of Neuroanaesthesia, Christian Medical college, Vellore, Tamil Nadu, India
| | - Ramamani Mariappan
- Department of Neuroanaesthesia, Christian Medical college, Vellore, Tamil Nadu, India
| | - Krishna Prabhu
- Department of Neurosurgery, Christian Medical college, Vellore, Tamil Nadu, India
| | - Bijesh Yadav
- Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India
| | - Georgene Singh
- Department of Neuroanaesthesia, Christian Medical college, Vellore, Tamil Nadu, India
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Kumar G K, Chigurupalli C, Balasubramaniam A, Rajesh BJ, Manohar N. Role of Asleep Surgery for Supplementary Motor Area Tumors. INDIAN JOURNAL OF NEUROSURGERY 2022. [DOI: 10.1055/s-0042-1743266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Abstract
Background The supplementary motor area (SMA) is involved in planning of voluntary motor activities. Tumors in SMA usually present with seizures and, rarely, motor deficits. Postoperatively, these patients may develop SMA syndrome. Patients with SMA tumors usually undergo awake craniotomy along with neuromonitoring for maximal safe resection, and some of these patients tend to have residual tumor.
Objective To completely excise the SMA region tumors under general anesthesia without causing any permanent neurological deficits.
Methods We operated upon four patients with SMA region tumor under general anesthesia (GA) with direct electrocortical stimulation (DES). Motor-evoked potential was used to monitor corticospinal tracts through corkscrew or strip electrodes. Intraoperative MRI was done to assess the tumor excision.
Results All four patients had complete resection of tumor and, postoperatively, all four developed SMA syndrome. All of them recovered completely over a period of time.
Conclusion SMA tumors can be excised completely under GA with DES, thereby increasing progression-free survival.
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Affiliation(s)
- Krishna Kumar G
- Department of Neurosurgery, Yashoda hospitals, Secunderabad, Telangana, India
| | | | | | - BJ Rajesh
- Department of Neurosurgery, Yashoda hospitals, Secunderabad, Telangana, India
| | - Nitin Manohar
- Department of Neuroanesthesia, Yashoda hospitals, Secunderabad, Telangana, India
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Gray K, Avitsian R, Kakumanu S, Venkatraghavan L, Chowdhury T. The Effects of Anesthetics on Glioma Progression: A Narrative Review. J Neurosurg Anesthesiol 2022; 34:168-175. [PMID: 32658099 DOI: 10.1097/ana.0000000000000718] [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: 12/20/2019] [Accepted: 06/15/2020] [Indexed: 11/26/2022]
Abstract
There are many established factors that influence glioma progression, including patient age, grade of tumor, genetic mutations, extent of surgical resection, and chemoradiotherapy. Although the exposure time to anesthetics during glioma resection surgery is relatively brief, the hemodynamic changes involved and medications used, as well as the stress response throughout the perioperative period, may also influence postoperative outcomes in glioma patients. There are numerous studies that have demonstrated that choice of anesthesia influences non-brain cancer outcomes; of particular interest are those describing that the use of total intravenous anesthesia may yield superior outcomes compared with volatile agents in in vitro and human studies. Much remains to be discovered on the topic of anesthesia's effect on glioma progression.
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Affiliation(s)
| | - Rafi Avitsian
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Saranya Kakumanu
- Department of Radiation Oncology, Cancer Care Manitoba, Winnipeg, MB
| | - Lashmi Venkatraghavan
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, Toronto, ON, Canada
| | - Tumul Chowdhury
- Department of Anesthesiology, Perioperative, and Pain Medicine, Health Sciences Center, University of Manitoba
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Krambek MC, Vitorino-Araújo JL, Lovato RM, Veiga JCE. Awake craniotomy in brain tumors - Technique systematization and the state of the art. Rev Col Bras Cir 2021; 48:e20202722. [PMID: 33978121 PMCID: PMC10683424 DOI: 10.1590/0100-6991e-20202722] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 02/03/2021] [Indexed: 02/07/2023] Open
Abstract
The anesthesia for awake craniotomy (AC) is a consecrated anesthetic technique that has been perfected over the years. Initially used to map epileptic foci, it later became the standard technique for the removal of glial neoplasms in eloquent brain areas. We present an AC anesthesia technique consisting of three primordial times, called awake-asleep-awake, and their respective particularities, as well as delve into the anesthetic medications used. Its use in patients with low and high-grade gliomas was favorable for the resection of tumors within the functional boundaries of patients, with shorter hospital stay and lower direct costs. The present study aims to systematize the technique based on the experience of the largest philanthropic hospital in Latin America and discusses the most relevant aspects that have consolidated this technique as the most appropriate in the surgery of gliomas in eloquent areas.
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Affiliation(s)
- Márcio Cardoso Krambek
- - Irmandade da Santa Casa de Misericórdia de São Paulo, Anestesiologia - ISCMSP, SP, Brasil
- - Hospital Sírio Libanês - São Paulo, SP, Brasil
- - Hospital HCOR - São Paulo, SP, Brasil
| | - João Luiz Vitorino-Araújo
- - Irmandade da Santa Casa de Misericórdia de São Paulo, Neurocirurgia - ISCMSP, SP, Brasil
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), São Paulo, SP, Brasil
- - Hospital Sírio Libanês - São Paulo, SP, Brasil
- - Hospital HCOR - São Paulo, SP, Brasil
| | - Renan Maximilian Lovato
- - Irmandade da Santa Casa de Misericórdia de São Paulo, Neurocirurgia - ISCMSP, SP, Brasil
- - Hospital Sírio Libanês - São Paulo, SP, Brasil
- - Hospital HCOR - São Paulo, SP, Brasil
| | - José Carlos Esteves Veiga
- - Irmandade da Santa Casa de Misericórdia de São Paulo, Neurocirurgia - ISCMSP, SP, Brasil
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), São Paulo, SP, Brasil
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Vaithialingam B, Sriganesh K. Clinical utility of trans-nasal humidified rapid insufflation ventilatory exchange (THRIVE) during awake craniotomy. Indian J Anaesth 2021; 65:262-263. [PMID: 33776123 PMCID: PMC7989483 DOI: 10.4103/ija.ija_1188_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/12/2020] [Accepted: 12/07/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Balaji Vaithialingam
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Kamath Sriganesh
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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Permutation entropy in intraoperative ECoG of brain tumour patients in awake tumour surgery- a robust parameter to separate consciousness from unconsciousness. Sci Rep 2019; 9:16482. [PMID: 31712616 PMCID: PMC6848144 DOI: 10.1038/s41598-019-52949-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 10/25/2019] [Indexed: 01/10/2023] Open
Abstract
Awake craniotomies represent an essential opportunity in the case of lesions in eloquent areas. Thus, optimal surveillance of the patient during different stages of sedation, as well as the detection of seizure activity during brain surgery, remains difficult, as skin electrodes for electroencephalographic (EEG) analysis are not applicable in most cases. We assessed the applicability of ECoG to monitor different stages of sedation, as well as the influence of different patient characteristics, such as tumour volume, size, entity, and age or gender on permutation entropy (PeEn). We conducted retrospective analysis of the ECoG data of 16 patients, who underwent awake craniotomies because of left-sided brain tumours at our centre between 2014 and 2016. PeEn could be easily calculated and compared using frontal and parietal cortical electrodes. A comparison of PeEn scores showed significantly higher values in awake patients than in patients under anaesthesia (p ≤ 0.004) and significantly higher ones in the state of transition than under general anaesthesia (p = 0.023). PeEn scores in frontal and parietal leads did not differ significantly, making them both applicable for continuous surveillance during brain surgery. None of the following clinical characteristics showed significant correlation with PeEn scores: tumour volume, WHO grade, first or recurrent tumour, gender, and sex. Being 50 years or older led to significantly lower values in parietal leads but not in frontal leads. ECoG and a consecutive analysis of PeEn are feasible and suitable for the continuous surveillance of patients during awake craniotomies. Hence, the analysis is not influenced by patients' clinical characteristics.
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Anesthesia for Awake Craniotomy: What Is New? CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0285-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Özlü O. Anaesthesiologist's Approach to Awake Craniotomy. Turk J Anaesthesiol Reanim 2018; 46:250-256. [PMID: 30140530 DOI: 10.5152/tjar.2018.56255] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 03/13/2018] [Indexed: 12/29/2022] Open
Abstract
Awake craniotomy, which was initially used for the surgical treatment of epilepsy, is performed for the resection of tumours in the vicinity of some eloquent areas of the cerebral cortex which is essential for language and motor functions. It is also performed for stereotactic brain biopsy, ventriculostomy, and supratentorial tumour resections. In some institutions, avoiding risks of general anaesthesia, shortened hospitalization and reduced use of hospital resources may be the other indications for awake craniotomy. Anaesthesiologists aim to provide safe and effective surgical status, maintaining a comfortable and pain-free condition for the patient during surgical procedure and prolonged stationary position and maintaining patient cooperation during intradural interventions. Providing anaesthesia for awake craniotomy require scalp blockage, specific sedation protocols and airway management. Long-acting local anaesthetic agents like bupivacaine or levobupivacaine are preferred. More commonly, propofol, dexmedetomidine and remifentanyl are used as sedative agents. A successful anaesthesia for awake craniotomy depends on the personal experience and detailed planning of the anaesthetic procedure. The aim of this review was to present an anaesthetic technique for awake craniotomy under the light of the literature.
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Affiliation(s)
- Onur Özlü
- Department of Anaesthesiology and Reanimation, TOBB University of Economics and Technology, Ankara, Turkey
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Gernsback JE, Kolcun JPG, Starke RM, Ivan ME, Komotar RJ. Who Needs Sleep? An Analysis of Patient Tolerance in Awake Craniotomy. World Neurosurg 2018; 118:e842-e848. [PMID: 30026153 DOI: 10.1016/j.wneu.2018.07.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 07/06/2018] [Accepted: 07/07/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Awake craniotomy (AC) is generally a safe and effective procedure; however, a small but not insignificant portion of cases are aborted due to patient intolerance of the awake portion of surgery. There is not yet a firm understanding of what characteristics indicate patient tolerance or failure of AC. METHODS We retrospectively reviewed a single-surgeon database of patients treated by AC over a 5-year period. Charts were reviewed for demographic, clinical, and operative characteristics, including anesthetic administration during the awake portion of surgery. Statistical analysis was performed to determine which factors predicted patient tolerance or failure. RESULTS Our study cohort comprised 120 patients with an average age of 56.0 ± 15.2 years. A majority of patients were male (55.8%). The most common surgical indication was tumor (95.8%), with gliobastoma as the most common diagnosis (43.3%). Male sex predicted surgical tolerance on univariate analysis (P = 0.015). Remifentanil administration was associated with surgical failure on univariate analysis (P = 0.068), and also predicted failure on multivariate analysis (P = 0.030). Preoperative seizure, ketamine administration, and right-sided surgery each predicted patient tolerance, but did not achieve statistical significance. Similarly, respiratory comorbidity was associated with surgical failure, but did not achieve significance. CONCLUSIONS AC remains an effective treatment option; the majority of patients tolerate the procedure without issue. Male patients have lower rates of surgical failure, whereas remifentanil administration may increase failure rate.
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Affiliation(s)
- Joanna E Gernsback
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - John Paul G Kolcun
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Michael E Ivan
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA; Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ricardo J Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA; Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
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Mahajan C, Rath GP, Singh GP, Mishra N, Sokhal S, Bithal PK. Efficacy and safety of dexmedetomidine infusion for patients undergoing awake craniotomy: An observational study. Saudi J Anaesth 2018; 12:235-239. [PMID: 29628833 PMCID: PMC5875211 DOI: 10.4103/sja.sja_608_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: The goal of awake craniotomy is to maintain adequate sedation, analgesia, respiratory, and hemodynamic stability and also to provide a cooperative patient for neurologic testing. An observational study carried out to evaluate the efficacy of dexmedetomidine sedation for awake craniotomy. Materials and Methods: Adult patients with age >18 year who underwent awake craniotomy for intracranial tumor surgery were enrolled. Those who were uncooperative and had difficult airway were excluded from the study. In the operating room, the patients received a bolus dose of dexmedetomidine 1 μg/kg followed by an infusion of 0.2–0.7 μg/kg/h (bispectral index target 60–80). Once the patients were sedated, scalp block was given with bupivacaine 0.25%. The data on hemodynamics at various stages of the procedure, intraoperative complications, total amount of fentanyl used, intravenous fluids required, blood loss and transfusion, duration of surgery, Intensive Care Unit (ICU), and hospital stay were collected. The patients were assessed for Glasgow outcome scale (GOS) score and patient satisfaction score (PSS). Results: A total of 27 patients underwent awake craniotomy during a period of 2 years. Most common intraoperative complication was seizures; observed in five patients (18.5%). None of these patients experienced any episode of desaturation. Two patients had tight brain for which propofol boluses were administered. The average fentanyl consumption was 161.5 ± 85.0 μg. The duration of surgery, ICU, and hospital stays were 231.5 ± 90.5 min, 14.5 ± 3.5 h, and 4.7 ± 1.5 days, respectively. The overall PSS was 8 and GOS was good in all the patients. Conclusion: The use of dexmedetomidine infusion with regional scalp block in patients undergoing awake craniotomy is safe and efficacious. The absence of major complications and higher PSS makes it close to an ideal agent for craniotomy in awake state.
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Affiliation(s)
- Charu Mahajan
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Girija Prasad Rath
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Gyaninder Pal Singh
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Nitasha Mishra
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Suman Sokhal
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Parmod Kumar Bithal
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Awake Craniotomy Anesthesia: A Comparison of the Monitored Anesthesia Care and Asleep-Awake-Asleep Techniques. World Neurosurg 2017; 104:679-686. [PMID: 28532922 DOI: 10.1016/j.wneu.2017.05.053] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 05/09/2017] [Accepted: 05/11/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Commonly used sedation techniques for an awake craniotomy include monitored anesthesia care (MAC), using an unprotected airway, and the asleep-awake-asleep (AAA) technique, using a partially or totally protected airway. We present a comparative analysis of the MAC and AAA techniques, evaluating anesthetic management, perioperative outcomes, and complications in a consecutive series of patients undergoing the removal of an eloquent brain lesion. METHODS Eighty-one patients underwent awake craniotomy for an intracranial lesion over a 9-year period performed by a single-surgeon and a team of anesthesiologists. Fifty patients were treated using the MAC technique, and 31 were treated using the AAA technique. A retrospective analysis evaluated anesthetic management, intraoperative complications, postoperative outcomes, pain management, and complications. RESULTS The MAC and AAA groups had similar preoperative patient and tumor characteristics. Mean operative time was shorter in the MAC group (283.5 minutes vs. 313.3 minutes; P = 0.038). Hypertension was the most common intraoperative complication seen (8% in the MAC group vs. 9.7% in the AAA group; P = 0.794). Intraoperative seizure occurred at a rate of 4% in the MAC group and 3.2% in the AAA group (P = 0.858). Awake cases were converted to general anesthesia in no patients in the MAC group and in 1 patient (3.2%) in the AAA group (P = 0.201). No cases were aborted in either group. The mean hospital length of stay was 3.98 days in the MAC group and 3.84 days in the AAA group (P = 0.833). CONCLUSIONS Both the MAC and AAA sedation techniques provide an efficacious and safe method for managing awake craniotomy cases and produce similar perioperative outcomes, with the MAC technique associated with shorter operative time.
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Stevanovic A, Rossaint R, Veldeman M, Bilotta F, Coburn M. Anaesthesia Management for Awake Craniotomy: Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0156448. [PMID: 27228013 PMCID: PMC4882028 DOI: 10.1371/journal.pone.0156448] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Accepted: 05/13/2016] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Awake craniotomy (AC) renders an expanded role in functional neurosurgery. Yet, evidence for optimal anaesthesia management remains limited. We aimed to summarise the latest clinical evidence of AC anaesthesia management and explore the relationship of AC failures on the used anaesthesia techniques. METHODS Two authors performed independently a systematic search of English articles in PubMed and EMBASE database 1/2007-12/2015. Search included randomised controlled trials (RCTs), observational trials, and case reports (n>4 cases), which reported anaesthetic approach for AC and at least one of our pre-specified outcomes: intraoperative seizures, hypoxia, arterial hypertension, nausea and vomiting, neurological dysfunction, conversion into general anaesthesia and failure of AC. Random effects meta-analysis was used to estimate event rates for four outcomes. Relationship with anaesthesia technique was explored using logistic meta-regression, calculating the odds ratios (OR) and 95% confidence intervals [95%CI]. RESULTS We have included forty-seven studies. Eighteen reported asleep-awake-asleep technique (SAS), twenty-seven monitored anaesthesia care (MAC), one reported both and one used the awake-awake-awake technique (AAA). Proportions of AC failures, intraoperative seizures, new neurological dysfunction and conversion into general anaesthesia (GA) were 2% [95%CI:1-3], 8% [95%CI:6-11], 17% [95%CI:12-23] and 2% [95%CI:2-3], respectively. Meta-regression of SAS and MAC technique did not reveal any relevant differences between outcomes explained by the technique, except for conversion into GA. Estimated OR comparing SAS to MAC for AC failures was 0.98 [95%CI:0.36-2.69], 1.01 [95%CI:0.52-1.88] for seizures, 1.66 [95%CI:1.35-3.70] for new neurological dysfunction and 2.17 [95%CI:1.22-3.85] for conversion into GA. The latter result has to be interpreted cautiously. It is based on one retrospective high-risk of bias study and significance was abolished in a sensitivity analysis of only prospectively conducted studies. CONCLUSION SAS and MAC techniques were feasible and safe, whereas data for AAA technique are limited. Large RCTs are required to prove superiority of one anaesthetic regime for AC.
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Affiliation(s)
- Ana Stevanovic
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Michael Veldeman
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
- Department of Neurosurgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Federico Bilotta
- Department of Anaesthesiology, Critical Care and Pain Medicine, University of Rome “La Sapienza”, Rome, Italy
| | - Mark Coburn
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
- * E-mail:
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