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Di L, Tiefenbach J, McCarthy DJ, Sedighim S, Dagal A, Blandino CF, Luther EM, Lu VM, Ivan ME, Komotar RJ, Eichberg DG, Shah AH. The Utility of Transcranial Electrical Stimulation Motor Evoked Potential Monitoring in Predicting Postoperative Supplementary Motor Area Syndrome and Motor Function Recovery. World Neurosurg 2024; 183:e892-e899. [PMID: 38237803 DOI: 10.1016/j.wneu.2024.01.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 01/09/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND Postoperative hemiparesis following frontal lobe lesion resection is alarming, and predicting motor function recovery is challenging. Supplementary motor area (SMA) syndrome following resection of frontal lobe lesions is often indistinguishable from postoperative motor deficit due to surgical injury of motor tracts. We aimed to describe the use of intraoperative transcranial electrical stimulation (TES) with motor evoked potential monitoring data as a diagnostic tool to distinguish between SMA syndrome and permanent motor deficit (PMD). METHODS A retrospective analysis of 235 patients undergoing craniotomy and resection with TES-MEP monitoring for a frontal lobe lesion was performed. Patients who developed immediate postoperative motor deficit were included. Motor deficit and TES-MEP findings were categorized by muscle group as left upper extremity, left lower extremity, right upper extremity, or right lower extremity. Statistical analysis was performed to determine the predictive value of stable TES-MEP for SMA syndrome versus PMD. RESULTS This study included 20 patients comprising 29 cases of immediate postoperative motor deficit by muscle group. Of these, 27 cases resolved and were diagnosed as SMA syndrome, and 2 cases progressed to PMD. TES-MEP stability was significantly associated with diagnosis of SMA syndrome (P = 0.015). TES-MEP showed excellent diagnostic utility with a sensitivity and positive predictive value of 100% and 92.6%, respectively. Negative predictive value was 100%. CONCLUSIONS Temporary SMA syndrome is difficult to distinguish from PMD immediately postoperatively. TES-MEP may be a useful intraoperative adjunct that may aid in distinguishing SMA syndrome from PMD secondary to surgical injury.
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Affiliation(s)
- Long Di
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jakov Tiefenbach
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
| | - David J McCarthy
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Shaina Sedighim
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Arman Dagal
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA; Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Carlos F Blandino
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Evan M Luther
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Victor M Lu
- 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, University of Miami, Miami, Florida, USA
| | - Ricardo J Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA; Sylvester Comprehensive Cancer, University of Miami, Miami, Florida, USA
| | - Daniel G Eichberg
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ashish H Shah
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
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Ng IC, Barnes C, Biswas S, Wright D, Dagal A. When is it safe to resume anticoagulation in traumatic brain injury? Curr Opin Anaesthesiol 2022; 35:166-171. [PMID: 35131968 DOI: 10.1097/aco.0000000000001117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW When to resume or initiate anticoagulation therapy following traumatic brain injury (TBI) is controversial. This summary describes the latest evidence to guide best practice. RECENT FINDINGS Following trauma, prophylactic, and therapeutic anticoagulation (TAC) have been widely encouraged to prevent major comorbidities such as pulmonary embolism and deep venous thrombosis. Increased rebleeding risk and potentially catastrophic outcome from initiation of anticoagulation treatment in TBI are mainly influenced by institutional guidelines or physician preference in the absence of level I or II recommendations. In recent years, there has been an increasing number of TBI in the elderly population on anticoagulation for other medical conditions; this complicates the decision and timing to restart anticoagulation after the injury. SUMMARY Strategies and timing to start prophylactic and TAC differ significantly between institutions and physicians. Each TBI patient should be evaluated on a case-by-case basis on when to start anticoagulation. More investigation is required to guide best practice.
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Affiliation(s)
- Ireana C Ng
- Harborview Medical Center, UW Medicine, Seattle, Washington
| | | | - Subarna Biswas
- Keck School of Medicine of USC, Health Sciences Campus, Los Angeles, California, USA
| | - David Wright
- Harborview Medical Center, UW Medicine, Seattle, Washington
| | - Arman Dagal
- Harborview Medical Center, UW Medicine, Seattle, Washington
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Bhalla PI, Solomon S, Zhang R, Witt CE, Dagal A, Joffe AM. Comparison of serratus anterior plane block with epidural and paravertebral block in critically ill trauma patients with multiple rib fractures. Trauma Surg Acute Care Open 2021; 6:e000621. [PMID: 33490606 PMCID: PMC7798406 DOI: 10.1136/tsaco-2020-000621] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/10/2020] [Indexed: 12/02/2022] Open
Abstract
Background Pain from rib fractures is associated with significant pulmonary morbidity. Epidural and paravertebral blocks (EPVBs) have been recommended as part of a multimodal approach to rib fracture pain, but their utility is often challenging in the trauma intensive care unit (ICU). The serratus anterior plane block (SAPB) has potential as an alternative approach for chest wall analgesia. Methods This retrospective study compared critically injured adults sustaining multiple rib fractures who had SAPB (n=14) to EPVB (n=25). Patients were matched by age, body mass index, American Society of Anesthesiology Physical Status, whether the patient required intubation, number of rib fractures and injury severity score. Outcome measures included hospital length of stay, ICU length of stay, preblock and post block rapid shallow breathing index (RSBI) in intubated patients, pain scores and morphine equivalent doses administered 24-hour preblock and post-block in non-intubated patients, and mortality. Results There were no demographic differences between the two groups after matching. Nearly all of the patients who received either SAPB or EPVB demonstrated a reduction in RSBI or pain scores. The preblock RSBI was higher in the serratus anterior plane block group, but there was no difference between any of the other outcome measures. Discussion This retrospective study of our institutional data suggests no difference in efficacy between the serratus anterior plane block and neuraxial block for traumatic rib fracture pain in critically ill patients, but the sample size was too small to show statistical equivalence. Serratus anterior plane block is technically easier to perform with fewer theoretical contraindications compared with traditional neuraxial block. Further study with prospective comparative trials is warranted. Level of evidence Retrospective matched cohort; Level IV.
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Affiliation(s)
- Paul I Bhalla
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, Seattle, Washington, USA
| | - Stuart Solomon
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, Seattle, Washington, USA
| | - Ray Zhang
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, Seattle, Washington, USA
| | - Cordelie E Witt
- Department of Surgery, University of Washington, Seattle, Washington, USA.,Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington, USA
| | - Arman Dagal
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, Seattle, Washington, USA
| | - Aaron M Joffe
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, Seattle, Washington, USA
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Katipoglu B, Dagal A, Korkut S, Kocak AO. Acute Management of Spinal Cord Injury at the Out-of-Hospital and Emergency Department Settings. EAJEM 2017. [DOI: 10.5152/eajem.2017.98698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Dagal A, Lesnik I, Bentov N, Dong J, Qiu Q, Hayes K, Gordon D. (458) Using a perioperative enhanced recovery care pathway for major spine surgery (PERMS) to improve pain management & patient-reported outcomes. The Journal of Pain 2016. [DOI: 10.1016/j.jpain.2016.01.435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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McCunn M, Dutton RP, Dagal A, Varon AJ, Kaslow O, Kucik CJ, Hagberg CA, McIsaac JH, Pittet JF, Dunbar PJ, Grissom T, Vavilala MS. Trauma, Critical Care, and Emergency Care Anesthesiology. Anesth Analg 2015; 121:1668-73. [PMID: 26579665 DOI: 10.1213/ane.0000000000000782] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
To minimize risk of spinal cord injury, airway management providers must understand the anatomic and functional relationship between the airway, cervical column, and spinal cord. Patients with known or suspected cervical spine injury may require emergent intubation for airway protection and ventilatory support or elective intubation for surgery with or without rigid neck stabilization (i.e., halo). To provide safe and efficient care in these patients, practitioners must identify high-risk patients, be comfortable with available methods of airway adjuncts, and know how airway maneuvers, neck stabilization, and positioning affect the cervical spine. This review discusses the risks and benefits of various airway management strategies as well as specific concerns that affect patients with known or suspected cervical spine injury.
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Affiliation(s)
- Naola Austin
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Vijay Krishnamoorthy
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Arman Dagal
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
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Dooney NM, Dagal A. Etomidate for induction of the septic patient. Br J Anaesth 2011; 106:416; author reply 416. [PMID: 21317228 DOI: 10.1093/bja/aer013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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