A randomized control trial for evaluation of transfusion related immuno-modulation in patients with meningioma

BACKGROUND

Blood transfusion necessity in neurosurgery varies based on surgical type, blood loss, and patient anemia. Leukocytes in red blood cells (RBCs) component release pro-inflammatory cytokines during storage, contributing to transfusion-related immunomodulation (TRIM). Our aim was to examine the impact of the leukocyte content in transfused PRBCs on patients undergoing neurosurgery for meningioma tumours.

STUDY DESIGN AND METHODS

This prospective randomized controlled trial conducted from 2018 to 2020 by dividing patients randomly into non-leukoreduced (NLR) (n = 65) and leuko-reduced (LR) (n = 65) groups based on PRBCs received during surgery and hospital stay. Hospital and ICU stays, mechanical ventilation duration, and postoperative bacterial infections were observed. Hematological parameters and cytokine levels (IL-10, INF-gamma, and FAS-L) were assessed at pre-transfusion, 24 h, and 7 days post-transfusion. Data analysis included Mann-Whitney U test, Friedman test, Fisher's chi-square test, with statistical significance at p < 0.05.

RESULTS

In our study, ICU and hospital stay duration showed no significant difference (p = 0.06) between groups. However, NLR group had longer mean mechanical ventilation (18 ± 40.1 h) than the LR group (12.8 ± 8.6 h). Both groups showed statistically significant increase in Fas-L level on days 1 and 7 (p < 0.05). The IL-10 levels rose 43% in the NLR group, while and decreased by 7% the LR group on day 1. On day 7, IL-10 increased by 75% in NLR and decreased by 40% in LR, with no significance (p > 0.05).

CONCLUSION

In conclusion, leukoreduction appeared to offer some immune response protection in term of reducing mechanical ventilation timings and cytokine level changes.

Local Ulceration following Peripheral Neurolysis with Absolute Alcohol in Patients with Drug-Refractory Trigeminal Neuralgia: A Series of Four Cases

A significant number of patients with trigeminal neuralgia (TGN) are refractory to first-line drugs and require interruption of the pain pathway by various percutaneous procedures. One such percutaneous technique involves an injection of absolute alcohol (AA) into the peripheral branches of the trigeminal nerve. This procedure is useful in elderly and medically compromised drug-refractory cases of TGN who are not interested in undergoing open neurosurgery. Peripheral neurolysis with AA is easy, quick, and safe. It may be carried out in the outpatient department; however, its use is not free from complications. Here, we report four such patients who were complicated with local necrosis and ulceration following administration of AA. The most probable attributable etiologies are sympathetic nerve involvement, intravascular injection of alcohol, vascular spasm of the terminal arteries, distal micro-emboli effect, and faulty technique, including repeated injections.

Anesthesia for same day neurosurgery with updates on awake craniotomy and awake spine surgery

PURPOSE OF REVIEW

This article delves into recent advances in same-day neurosurgery (SDNS), specifically concerning indications, perioperative protocol, safety, and outcomes. Additionally, it explores the recent updates on awake craniotomy and awake spine surgery.

RECENT FINDINGS

There is an evolving body of literature on studies about SDNS that reaffirm its safety and feasibility. awake craniotomy is associated with lesser neurological deficits and better survival benefits in patients with lesions in eloquent areas. Monitored anesthesia care, compared with the asleep-awake-asleep technique, is associated with lower failure rates, shorter procedure time, and shorter length of stay. However, the incidence of intraoperative seizures is lower with the asleep-awake-asleep technique. Propofol-based and dexmedetomidine-based anesthesia are similar with regard to procedure duration, intraoperative adverse events, and patient satisfaction; however, surgeon satisfaction is higher with dexmedetomidine-based anesthesia. In spine surgery, regional anesthesia when compared with general anesthesia, is associated with less intraoperative blood loss and a lower incidence of postoperative nausea and vomiting after 24 h. In addition, implementing an enhanced multimodal analgesia protocol improved disability scores and reduced the likelihood of postoperative complications.

SUMMARY

SDNS offers promising prospects for patients and healthcare providers alike, with the potential to provide well tolerated, efficient, and cost-effective neurosurgical care in carefully selected cases.

Differences in Perioperative Management of Patients Undergoing Complex Spine Surgery: A Global Perspective

BACKGROUND

The aim of this survey was to understand institutional spine surgery practices and their concordance with published best practices/recommendations.

METHODS

Using a global internet-based survey examining perioperative spine surgery practice, reported institutional spine pathway elements (n=139) were compared with the level of evidence published in guideline recommendations. The concordance of clinical practice with guidelines was categorized as poor (≤20%), fair (21%-40%), moderate (41%-60%), good (61%-80%), or very good (81%-100%).

RESULTS

Seventy-two of 409 (17.6%) institutional contacts started the survey, of which 31 (7.6%) completed the survey. Six (19.4%) of the completed surveys were from respondents in low/middle-income countries, and 25 (80.6%) were from respondents in high-income countries. Forty-one incomplete surveys were not included in the final analysis, as most were less than 40% complete. Five of 139 (3.6%) reported elements had very good concordance for the entire cohort; hospitals with spine surgery pathways reported 18 elements with very good concordance, whereas institutions without spine surgery pathways reported only 1 element with very good concordance. Reported spine pathways included between 7 and 47 separate pathway elements. There were 87 unique elements in the reviewed pathways. Only 3 of 87 (3.4%) elements with high-quality evidence demonstrated very good practice concordance.

CONCLUSIONS

This global survey-based study identified practice variation and low adoption rates of high-quality evidence in the care of patients undergoing complex spine surgery.

A Century With Craniopagus Twin Separation Surgeries: Nihilism to Optimism

Craniopagus conjoined twins are extremely rare, reported 1 in 2.5 million live births. To date, 62 separation attempts in 69 well-documented cases of craniopagus twins have been made. Of these, 34 were performed in a single-stage approach, and 28 were attempted in a multistage approach. One or both twins died of massive intraoperative blood loss and cardiac arrest in 14 cases. We report our surgical experience with conjoined craniopagus twins (JB) with type III total vertical joining and shared circumferential/circular sinus with left-sided dominance. A brief review of the literature is also provided. In our twins, the meticulous preoperative study and planning by the multidisciplinary team consisting of 125-member, first-staged surgical separation consisted of creation of venous conduit to bypass part of shared circumferential sinus and partial hemispheric disconnection. Six weeks later, twin J manifested acute cardiac overload because of one-way fistula development from blocked venous bypass graft necessitating emergency final separation surgery. Unique perioperative issues were abnormal anatomy, hemodynamic sequelae from one-way fistula development after venous bypass graft thrombosis, cardiac arrest after massive venous air embolism requiring prolonged cardiopulmonary resuscitation, and return of spontaneous circulation at 15 minutes immediately after separation. This is the first Indian craniopagus separation surgery in a complex total vertical craniopagus twin reported by a single-center multidisciplinary team. Both twins could be sent home, but one remained severely handicapped. Adequate perioperative planning and multidisciplinary team approach are vital in craniopagus twin separation surgeries.

A Rare Case of Postoperative Extradural Hematoma in the Posterior Fossa Complicated by Both Stunned Myocardium and Neurogenic Pulmonary Edema

Acute neurological insult can trigger a cascade of events in other organ systems such as the heart and lung. Neurogenic stunned myocardium (NSM) and Neurogenic pulmonary edema (NPE) are mostly reported after stroke, subarachnoid hemorrhage, or seizures whenever sympathetic storm and autonomic dysregulation occurs. We report here for the first time, a case of postoperative infratentorial extradural hematoma in a patient triggering NSM and NPE at the same time. The challenges involved in the management of such a patient are described in this case report. The patient was successfully managed and discharged home with no new neurological deficits.

Effect of Stellate Ganglion Block on Intraoperative Propofol and Fentanyl Consumption in Patients with Complex Regional Pain Syndrome Undergoing Surgical Repair of Brachial Plexus Injury: A Randomized, Double-blind, Placebo-controlled Trial

Introduction

Stellate ganglion block (SGB) is commonly performed to treat chronic painful conditions, such as complex regional pain syndrome (CRPS) and postherpetic neuralgia. However, whether it is effective in reducing anesthesia and analgesia requirement during surgery (acute pain) is not known.

Materials and Methods

Sixty American Society of Anesthesiologists (ASA) physical status I and II patients with CRPS type II undergoing surgery for repair of brachial plexus injury were randomized (1:1) to receive SGB with either 10 mL of 0.5% bupivacaine (Group B) or a matching placebo (Group S) before induction of anesthesia.

Results

There was a significant reduction in the requirement of total intraoperative propofol (1659.7 ± 787.5 vs. 2500.7 ± 740.9 mg, P = 0.0003) and fentanyl (190.0 ± 82.5 vs. 327.3 ± 139.3, P = 0.0001) in Group B compared with Group S. Similarly, in Group B, the time to first analgesic was much longer (328 ± 219 vs. 64 ± 116 min, P = 0.000) and postoperative fentanyl requirement for 24 h was lesser compared to Group S (0.6 ± 1.1 vs. 2.1 ± 1.3 μg/kg, P = 0.000).

Conclusion

SGB is effective in reducing the requirement of intraoperative propofol and fentanyl as well as decreasing opioid requirement in the postoperative period in patients with CRPS type II undergoing surgery.

Conditioning Effect of Inhalational Anesthetics on Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH) has been identified as an independent predictor of poor outcome in numerous studies.

OBJECTIVE

To investigate the potential protective role of inhalational anesthetics against angiographic vasospasm, DCI, and neurologic outcome in SAH patients.

METHODS

After Institutional Review Board approval, data were collected retrospectively for SAH patients who received general anesthesia for aneurysm repair between January 1st, 2010 and May 31st, 2018. Primary outcomes were angiographic vasospasm, DCI, and neurologic outcome as measured by modified Rankin scale at hospital discharge. Univariate and logistic regression analysis were performed to identify independent predictors of these outcomes.

RESULTS

The cohort included 390 SAH patients with an average age of 56 ± 15 (mean ± SD). Multivariate logistic regression analysis identified inhalational anesthetic only technique, Hunt-Hess grade, age, anterior circulation aneurysm and average intraoperative mean blood pressure as independent predictors of angiographic vasospasm. Inhalational anesthetic only technique and modified Fishers grade were identified as independent predictors of DCI. No impact on neurological outcome at time of discharge was noted.

CONCLUSION

Our data provide additional evidence that inhalational anesthetic conditioning in SAH patients affords protection against angiographic vasospasm and new evidence that it exerts a protective effect against DCI. When coupled with similar results from preclinical studies, our data suggest further investigation into the impact of inhalational anesthetic conditioning on SAH patients, including elucidating the most effective dosing regimen, defining the therapeutic window, determining whether a similar protective effect against early brain injury, and on long-term neurological outcome exists.

Predictive value of intraoperative D-wave and m-MEP neurophysiological monitoring in patients with preoperative motor deficits in immediate and late postoperative period

Background:

Presence of preoperative motor deficits in patients poses a distinct challenge in monitoring the integrity of corticospinal tracts during spinal surgeries. The inconsistency of the motor-evoked potentials is such patients, limits its clinical utility. D-wave is a robust but less utilized technique for corticospinal tract monitoring. The comparative clinical value of these two techniques has not been evaluated in the patients with preoperative deficits.

Objectives:

The objective of the study was to compare the predictive utility of myogenic Motor Evoked Potentials (m-MEP) and D-wave in terms of recordability and their sensitivity and specificity in predicting transient and permanent new motor deficits.

Materials and Methods:

Thirty-one patients with preoperative motor deficit scheduled to undergo spinal surgery were included in the study. Intraoperative m-MEP and D-wave changes were identified and correlated with postoperative neurology in the immediate postoperative period and at the time of discharge.

Results:

The mean preoperative motor power of the patient pool in left and right lower limb was 2.97 ± 1.56 and 3.32 ± 1.49, respectively. The recordability of m-MEPs and D-wave was observed to be 79.4% and 100%, respectively. The m-MEP predicted the motor deterioration in immediate postoperative period with 100% sensitivity and 80% specificity, while D-wave had 14% sensitivity and 100% specificity. At the time of discharge, m-MEPs' specificity reduced to 61%, while D-wave demonstrated 100% specificity.

Conclusions:

D-wave has a better recordability than m-MEPs in neurologically compromised patients. D-wave predicts development of long-term deficits with 100% specificity, while m-MEPs have a high sensitivity for transient neurological deficit. A combination of D-wave and m-MEP is recommended for monitoring the integrity of the corticospinal tract in patients with preoperative motor deficits.

Emergency neurological procedures during COVID-19 pandemic: Practical issues

The novel coronavirus disease 2019 (COVID-19) has emerged as a global pandemic. A significant number of these patients would present to hospitals with neurological manifestations and neurosurgical emergencies requiring urgent treatment. The anesthesiologists should be prepared to manage these cases in an efficient and timely manner in the operating room, intensive care units, and interventional neuroradiology suites. The clinical course of the disease is in an evolving stage. As we acquire more knowledge about COVID-19, new recommendations and guidelines are being formulated and regularly updated. This article discusses the anesthetic management of urgent neurosurgical and neurointerventional procedures. In addition, a brief overview of intrahospital transport of neurologically injured patients has been addressed.

Effect of dexmedetomidine on dynamic cerebral autoregulation and carbon dioxide reactivity during sevoflurane anesthesia in healthy patients

BACKGROUND

There are conflicting opinions on the effect of dexmedetomidine on cerebral autoregulation. This study assessed its effect on dynamic cerebral autoregulation (dCA) using a transcranial Doppler (TCD).

METHODS

Thirty American Society of Anesthesiologists physical status I and II patients between 18 and 60 years, who underwent lumbar spine surgery, received infusions of dexmedetomidine (Group D) or normal saline (Group C), followed by anesthesia with propofol and fentanyl, and maintenance with oxygen, nitrous oxide and sevoflurane. After five minutes of normocapnic ventilation and stable bispectral index value (BIS) of 40-50, the right middle cerebral artery flow velocity (MCAFV) was recorded with TCD. The transient hyperemic response (THR) test was performed by compressing the right common carotid artery for 5-7 seconds. The lungs were hyperventilated to test carbon dioxide (CO2) reactivity. Hemodynamic parameters, arterial CO2 tension, pulse oximetry (SpO2), MCAFV and BIS were measured before and after hyperventilation. Dexmedetomidine infusion was discontinued ten minutes before skin-closure. Time to recovery and extubation, modified Aldrete score, and emergence agitation were recorded.

RESULTS

Demographic parameters, durations of surgery and anesthesia, THR ratio (Group D: 1.26 ± 0.11 vs. Group C: 1.23 ± 0.04; P = 0.357), relative CO2 reactivity (Group D: 1.19 ± 0.34 %/mmHg vs. Group C: 1.23 ± 0.25 %/mmHg; P = 0.547), blood pressure, SpO2, BIS, MCAFV, time to recovery, time to extubation and modified Aldrete scores were comparable.

CONCLUSIONS

Dexmedetomidine administration does not impair dCA and CO2 reactivity in patients undergoing spine surgery under sevoflurane anesthesia.

Effect of Intraoperative Blood Loss on Perioperative Complications and Neurological Outcome in Adult Patients Undergoing Elective Brain Tumor Surgery

Background Major blood loss during neurosurgery can lead to several complications, including life-threatening hemodynamic instabilities. Studies addressing these complications in patients undergoing intracranial tumor surgery are limited. Materials and Methods During the study period, 456 patients who underwent elective craniotomy for brain tumor excision were categorized into four groups on the basis of estimated intraoperative blood volume loss: Group A (<20%), Group B (20-50%), Group C (>50-100%), and Group D (more than estimated blood volume). The occurrence of various perioperative complications was correlated with these groups to identify if there was any association with the amount of intraoperative blood loss. Results The average blood volume loss was 11% ± 5.3% in Group A, 29.8% ± 7.9% in Group B, 68.3% ± 13.5% in Group C, and 129.1% ± 23.9% in Group D. Variables identified as risk factors for intraoperative bleeding were female gender ( p < 0.001), hypertension ( p = 0.008), tumor size >5 cm ( p < 0.001), high-grade glioma ( p = 0.004), meningioma ( p < 0.001), mass effect ( p = 0.002), midline shift ( p = 0.014), highly vascular tumors documented on preoperative imaging ( p < 0.001), extended craniotomy approach ( p = 0.002), intraoperative colloids use >1,000 mL ( p < 0.001), intraoperative brain bulge ( p = 0.03), intraoperative appearance as highly vascular tumor ( p < 0.001), and duration of surgery >300 minutes ( p < 0.001). Conclusions Knowledge of these predictors may help anesthesiologists anticipate major blood loss during brain tumor surgery and be prepared to mitigate these complications to improve patient outcome.

Effect of Pregabalin on Postcraniotomy Pain in Patients Undergoing Supratentorial Tumor Surgery: A Randomized, Double-Blind, Placebo-Controlled Trial

Background and Objectives Suboptimal management of postcraniotomy pain causes sympathetic and hemodynamic perturbations, leading to deleterious effects on the neurological system and overall patient outcome. Opioids are the mainstay of postoperative pain management but have various problems when given in high doses, or for prolonged durations in neurosurgical patients. The ideal method of pain control following craniotomy generally relies on a combination of various drugs. Oral pregabalin may be an attractive alternative in these patients.

Materials and Methods Sixty, American Society of Anesthesiologists class I and II patients posted for elective supratentorial craniotomy, aged 18 and 60 years, were randomly assigned into three groups of 20 each to receive oral placebo (Group A), pregabalin 75 mg (Group B), or pregabalin 150 mg (Group C) before the induction of anesthesia. At the end of the surgery, patient-controlled analgesia was started with intravenous fentanyl. Visual analog scale (VAS) score was recorded every 2 hours for 24 hours, along with total postoperative fentanyl requirement.

Results There were no differences in sex, duration of surgery or anesthesia and total intraoperative fentanyl administered among the three groups. The median postoperative VAS score (Group A—18.0, Group B—20, and Group C—22.0; p = 0.63) was similar in all the groups. However, postoperative fentanyl requirement over 24 hours was least in the group that received 150 mg pregabalin (Group A—190 μg, Group B—240 μg, and Group C—100 μg; p = 0.03).

Conclusions Even though pain scores were not significantly different, patients receiving 150 mg oral pregabalin required the least amount of postoperative opioids.

Anesthetic considerations for extracranial injuries in patients with associated brain trauma

Patients with severe traumatic brain injury often presents with extracranial injuries, which may contribute to fatal outcome. Anesthetic management of such polytrauma patients is extremely challenging that includes prioritizing the organ system to be dealt first, reducing on-going injury, and preventing secondary injuries. Neuroprotective and neurorescue measures should be instituted simultaneously during extracranial surgeries. Selection of anesthetic drugs that minimally interferes with cerebral dynamics, maintenance of hemodynamics and cerebral perfusion pressure, optimal utilization of multimodal monitoring techniques, and aggressive rehabilitation approach are the key factors for improving overall patient outcome.

Asystole during Percutaneous Ethanol Injection of Symptomatic Vertebral Haemangioma

Computed tomography guided percutaneous ethanol injection is frequently employed for treatment of symptomatic vertebral haemangiomas. The procedure is performed under monitored anaesthesia care in the prone position. It has several advantages over open surgery and other therapeutic modalities and is generally considered safe. There is no previous report of any significant haemodynamic disturbance attributable to alcohol ablation of vertebral haemangiomas. We report a case in which a patient of ASA physical status I developed asystole following injection of 100% alcohol into a vertebral haemangioma, and became apnoeic and unresponsive. He recovered following intravenous administration of atropine. All staff involved in this procedure should be aware of, and prepared for, this rare but potentially life-threatening complication.

Variations in Cerebral Haemodynamics during Irrigation Phase in Neuroendoscopic Procedures

Not many centres measure intracranial pressure during an endoscopic procedure. However, if the irrigation fluid during endoscopy is not simultaneously drained, then some rise in intracranial pressure can be anticipated. This study was carried out to measure and monitor changes in intracranial pressure during the irrigation phase in a neuroendoscopic procedure using a Codman catheter placed in the parenchyma. Intracranial pressure was monitored in 13 patients undergoing surgical neuroendoscopic procedures under a standardised anaesthetic technique. Heart rate, mean arterial pressure, intracranial pressure and cerebral perfusion pressure were recorded at baseline and during the irrigation phase of the procedure. The heart rate during irrigation was comparable to baseline values, but the mean arterial pressure at the time of irrigation increased an average of 7 mmHg (P =0.02). At the same time there was an average 34 mmHg increase in intracranial pressure (P <0.001), producing an average 26 mmHg decrease in the cerebral perfusion pressure (P <0.001) during irrigation. There was an average of four episodes of raised intracranial pressure (> 25 mmHg) during the irrigation phase per patient. We suggest that the intracranial pressure be routinely monitored during neuroendoscopic procedures. Only then can the potential adverse effect of irrigation on intracranial pressure and cerebral perfusion pressure be assessed.

Long Term Outcome in Survivors of Decompressive Craniectomy following Severe Traumatic Brain Injury

Background:

Decompressive craniectomy (DC) is done for the management of intracranial hypertension due to severe traumatic brain injury (sTBI). Despite DC, a number of patients die and others suffer from severe neurological disability. We conducted this observational study to assess functional outcome as measured by Glasgow outcome scale-extended (GOSE) in survivors of DC. The correlation between various factors at admission and hospital with functional outcome was also obtained.

Materials and Methods:

Patients (15–65 years) posted for cranioplasty following DC due to sTBI were prospectively enrolled. Demographic profile, clinical data, and GOSE were noted at the time of admission for cranioplasty from the patient or nearest relative or both. Retrospective data noted from hospital records included admission Marshalls grading, Glasgow coma score (GCS), motor response, mean arterial pressure (MAP), and timing of DC at the time of initial admission following sTBI.

Results:

A total of 85 patients (71 males and 14 females) were enrolled over a period of 2 years. The mean age of the patients was 33.42 ± 12.70 years. The median GCS at the time of admission due to head injury, at the time of discharge, and at the time of cranioplasty was 8 (interquartile range [IQR] 3–15), 10 (IQR 4–15), and 15 (IQR 7–15), respectively. Thirty-one patients (36%) had good functional outcome (GOSE 5–8) and 54 patients (64%) had poor functional outcome (GOSE 1–4). On univariate analysis tracheostomy (P = 0.00), duration of hospital stay (P = 0.002), MAP at admission (P = 0.01), and GCS at discharge (P = 0.01) correlated with outcome [Table 1]. On multivariate analysis MAP at admission (odds ratio [OR] [95% confidence interval {CI}]; 0.07 [0.01–0.40] and tracheostomy (OR [95% CI]; 15 [1.45–162.9]) were found to be the independent predictors of functional outcome.

Conclusion:

Significant disability is seen among the survivors of DC. Tracheostomy and MAP at admission were found to be independently associated with the patient outcome.

Incidence and predictors of postoperative pulmonary complications in patients undergoing craniotomy and excision of posterior fossa tumor

Background and Aims:

Infratentorial neurosurgical procedures are considered high risk for the development of postoperative pulmonary complications (POPCs), prolonging hospital stay of patients with substantial morbidity and mortality.

Material and Methods:

Patients between the ages of 18 and 65 years, who underwent elective surgery for posterior fossa tumors over a period of two years, were reviewed. Data including American Society of Anesthesiologists physical status; comorbidities like hypertension, diabetes mellitus and hypothyroidism, history of smoking, obstructive sleep apnea, respiratory symptoms, lower cranial nerve (LCN) palsy; intraoperative complications such as hemodynamic alterations suggestive of brain stem or cranial nerve handling, tight brain as informed by the operating neurosurgeon, blood loss, and transfusion; and postoperative duration of mechanical ventilation, tracheostomy, POPCs, length of ICU and hospital stay, general condition of the patient at discharge, and cause of in-hospital mortality were collected. POPC was defined as the presence of atelectasis, tracheobronchitis, pneumonia, bronchospasm, respiratory failure, reintubation, or weaning failure.

Results:

Case files of 288 patients fulfilling the study criteria were analyzed; POPCs were observed in 35 patients (12.1%). On multivariate analysis, postoperative blood transfusion, LCN palsy, prolonged ICU stay, and tracheostomy were found to be independent predictors of POPC.

Conclusions:

The incidence of POPC was 12.1% following infratentorial tumor surgery. The predictors for the occurrence of POPCs were postoperative blood transfusion, LCN palsy, prolonged ICU stay, and tracheostomy.

Effect of magnesium and lignocaine on post-craniotomy pain: A comparative, randomized, double blind, placebo-controlled study

Background:

Lignocaine and Magnesium have an analgesic action and reduce perioperative opioid requirements. We carried out this study to evaluate the effect of magnesium and lignocaine on postoperative pain as assessed using the visual analog scale (VAS) and fentanyl consumption. We also measured S-100 B levels and noted the side effect of drugs if any.

Materials and Methods:

In this prospective preliminary study, 45 patients undergoing supratentorial craniotomy for tumor surgery were randomized to receive either lignocaine (group I-1.5 mg/kg bolus followed by 2 mg/kg/h infusion), saline (Group II) or magnesium (group III: bolus of 50 mg/kg followed by 25 mg/kg/hr) intraoperatively. The amount of fentanyl required, VAS over first 24 hours and any side effects were noted. S100 B levels were also measured to assess brain protective effect of these drugs, if any. Appropriate statistical tests were applied for analysis of data and a P value < 0.05 was considered statistically significant.

Results:

None of the patient experienced any adverse hemodynamic effect intraoperatively secondary to the study drugs. The amount of intraoperative fentanyl consumption was comparable among the three groups. The mean VAS score was significantly less in group I and III [Group I (15.3 ± 6.0), Group II (24.8 ± 6.7), Group III (17.9 ± 7.6); (P < 0.01)]. The fentanyl consumed in first 24 hours was significantly less in those patients who received lignocaine and magnesium [Group I (204.4 ± 136.4), Group II (383 ± 168.2), Group III (194 ± 148.9); (P = 0.01)]. S100 value did not differ in the lignocaine and the saline group during the perioperative period. However, a significant decline was noted in the levels of S100 B in the magnesium group.

Conclusion:

Intraoperative infusion of lignocaine and magnesium results in lower VAS score and decreases the postoperative opioid requirement in patients undergoing craniotomy for excision of supratentorial tumors.

Ketamine: A Neuroanesthesiologist's Friend or Foe?

Ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, introduced into clinical practice six decades ago, has often been the worst fear of a neuroanesthesiologist due to its concerns of causing a rise in intracranial pressure and increasing cerebral blood volume. However, the recent literature clarifies that it may have a beneficial role, even in neurosurgical patients, because of its propensity to cause neuroprotection through antiglutamatergic action on the NMDA receptors in the ischemic brain. Apart from having an anticonvulsive role in refractory status epilepticus, its inherent property of increasing blood flow to the ischemic areas offers protection to the penumbral zone, thus preventing secondary brain injuries. Also, it has been widely used as an analgesic at subanesthetic doses post spine surgeries. Recently, enough scientific evidence has been published in favor of ketamine establishing the fact that it does not cause a rise in intracranial pressure when the patient is mechanically ventilated and normocarbia is maintained. It has also been used during evoked potential monitoring as it amplifies signals even under general anesthesia and proves to be quite effective during neuromonitoring. However, its adverse effects of increasing muscle tone, excessive salivation, emergence delirium, agitation, and “out of body” experiences with long-term psychomimetic effects and potential to cause addiction have precluded its widespread use.

This review on ketamine summarizes the benefits of using it in neurosurgical anesthesia with the aim of removing the fears we had in the past, which did not seem to be evidence based.

Efficacy and safety of dexmedetomidine infusion for patients undergoing awake craniotomy: An observational study

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.

Alleviating Stress Response to Tracheal Extubation in Neurosurgical Patients: A Comparative Study of Two Infusion Doses of Dexmedetomidine

BACKGROUND

Tracheal extubation is almost always associated with increase in sympathoadrenal activity may result in hypertension, tachycardia, and arrhythmias. Attempts have been made to oppose the pressor response by the use of various drugs. Dexmedetomidine decreases norepinephrine which reduces the blood pressure and the heart rate (HR). We hypothesize that the infusion of dexmedetomidine may produce more stable hemodynamics during extubation as compared to boluses.

MATERIALS AND METHODS

Ninety adult patients aged 18-65 years, the American Society of Anesthesiologists Grade I-II undergoing intracranial surgeries for various neurologic problem at All India Institute of Medical Sciences were enrolled in this randomized controlled trial. Primary.

OBJECTIVES

(1) To observe the hemodynamic changes (HR and mean arterial pressure [MAP]) and airway responses during tracheal extubation following two infusion doses of dexmedetomidine.

SECONDARY OBJECTIVES

(1) Time to emergence and time to tracheal extubation, (2) Early postoperative complications such as laryngospasm and bronchospasm, and (3) adverse effects of the study drug. Patients were assigned into three groups - (1) Group D0.2 - 0.2 μg/kg/h diluted to 50 ml, (2) Group D0.4 - 0.4 μg/kg/h diluted to 50 ml and Group P (Placebo) - 0.9% NS 50 ml. The hemodynamics including the HR and MAP were recorded just before the loading dose of the study drug and then were recorded every 5 min till the infusion was stopped at tracheal extubation and every 1 min till 10 min postextubation. In addition, the airway, respiratory and cardiovascular complications along with postoperative nausea and vomiting, shivering, cough grading, Aldrete score, Ramsay sedation scale, and intraoperative awareness were recorded.

STATISTICAL ANALYSIS

Continuous variables such as HR and MAP were analyzed using analysis of variance and categorical variables were analyzed using the Chi-square test.

RESULTS

Patient demographics were comparable between the three groups. There was a significant reduction in HR and MAP just before extubation and up to 10 min post extubation in the D0.2 and D0.4 groups as compared to placebo (P < 0.001) but the difference among the dexmedetomidine groups were not significant. Patients belonging to D0.2 group emerged faster than D0.4 group, however, the results were comparable with placebo group. 73.3% patients of the placebo group had tachycardia and hypertension at emergence as compared to only 3.3% patients in the D0.4 group (P < 0.001). Eighty percentage patients of D0.2 and 100% patients of D0.4 group had a significant reduction in cough as compared to placebo (P < 0.001). No patient in either groups had intraoperative awareness, any respiratory complications, or allergic reactions to the study drug. Modified Aldrete scoring and Ramsay sedation scale were comparable in all the three groups.

CONCLUSION

Dexmedetomidine suppresses cough and hemodynamic responses (HR and MAP) to tracheal extubation significantly without delaying emergence.

Active Surveillance of Health Care Associated Infections in Neurosurgical Patients

INTRODUCTION

Health Care Associated Infections (HCAI) are frequent complications in neurosurgery. There is limited data available on the incidence and burden of HCAI in neurosurgical patients of Southeast Asian region.

AIM

To identify various HCAIs, associated aetiological agents and their antimicrobial susceptibility pattern among the patients admitted in the neurosurgery unit.

MATERIALS AND METHODS

An observational prospective study was carried out for three months duration on all neurosurgical patients admitted to a tertiary-care center. The site-specific nosocomial infection rates and device utilization ratios were calculated. Data on demographic profiles, invasive procedures, HCAI, isolated microorganisms and antimicrobial susceptibilities were recorded. Statistical analysis of all the variables was done. The association between categorical variables was assessed by Chi-square/Fisher-exact test. Continuous variables such as infected and non-infected were compared by Wilcoxon rank-sum test. A p-value of less than 0.05 was considered significant.

RESULTS

A total of 330 patients with 4054 patient-days were analysed for HCAI. Twenty-two HCAIs were identified in 21 patients. The overall rate of HCAI was 6.67% and 5.42 per 1000 patient-days. Urinary Tract Infection (UTI) was most common (71.4%) followed by Laboratory Confirmed Blood-Stream Infection (LCBI) (28.5%) and pneumonia (4.7%). No central line-associated blood stream infection was identified. Klebsiella pneumoniae and Escherichia coli were the most common organisms causing UTI and LCBI. All the isolates (100%) were found to be multidrug resistant.

CONCLUSION

This study generates a baseline data for records of device-associated infection in neurocritical care patients, which will further help monitoring its trend of infection and antimicrobial resistance pattern. Moreover, it will help in the formulation of the antibiotic policy and the preventive measures which may reduce morbidity and mortality.

Comparison of 20% mannitol and 3% hypertonic saline on intracranial pressure and systemic hemodynamics

Mannitol and hypertonic saline (HS) are most commonly used hyperosmotic agents for intraoperative brain relaxation. We compared the changes in ICP and systemic hemodynamics after infusion of equiosmolar solutions of both agents in patients undergoing craniotomy for supratentorial tumors. Forty enrolled adults underwent a standard anesthetic induction. Apart from routine monitoring parameters, subdural ICP with Codmann catheter and cardiac indices by Vigileo monitor, were recorded. The patients were randomized to receive equiosmolar solutions of either 20% mannitol (5ml/kg) or 3% HS (5.35ml/kg) for brain relaxation. The time of placement of ICP catheter was marked as T₀ and baseline ICP and systemic hemodynamic variables were noted; it was followed by recording of the same parameters every 5min till 45min (Study Period). After the completion of study period, brain relaxation score as assessed by the neurosurgeon was recorded. Arterial blood gas (ABG) was analysed every 30min starting from T₀ upto one and half hours (T₉₀), and values of various parameters were recorded. Data was analysed using appropriate statistical methods. Both mannitol and HS significantly reduced the ICP; the values were comparable in between the two groups at most of the times. The brain relaxation score was comparable in both the groups. Urine output was significantly higher with mannitol. The perioperative complications, overall hospital stay, and Glasgow outcome score at discharge were comparable in between the two groups. To conclude, both mannitol and hypertonic saline in equiosmolar concentrations produced comparable effects on ICP reduction, brain relaxation, and systemic hemodynamics.

Effect of tranexamic acid on intraoperative blood loss and transfusion requirements in patients undergoing excision of intracranial meningioma

Surgical excision of meningioma is often complicated by significant blood loss requiring blood transfusion with its attendant risks. Although tranexamic acid is used to reduce perioperative blood loss, its blood conservation effect is uncertain in neurosurgery. Sixty adults undergoing elective craniotomy for meningioma excision were randomized to receive either tranexamic acid or placebo, initiated prior to skin incision. Patients in the tranexamic acid group received intravenous bolus of 20mg/kg over 20min followed by an infusion of 1mg/kg/h till the conclusion of surgery. Intraoperative blood loss, transfusion requirements and estimation of surgical hemostasis using a 5-grade scale were noted. Postoperatively, the extent of tumor excision on CT scan and complications were observed. Demographics, tumor characteristics, amount of fluid infusion, and duration of surgery and anesthesia were comparable between the two groups. The amount of blood loss was significantly less in tranexamic acid group compared to placebo (830mlvs 1124ml; p=0.03). The transfusion requirement was less in tranexamic acid group (p>0.05). The patients in tranexamic acid group fared better on a 5-grade surgical hemostasis scale with more patients showing good hemostasis (p=0.007). There were no significant differences between the groups with regards to extent of tumor removal, perioperative complications, hospital stay or neurologic outcome. To conclude, administration of tranexamic acid significantly reduced blood loss in patients undergoing excision of meningioma. Fewer patients in the tranexamic acid group received blood transfusions. Surgical field hemostasis was better achieved in patients who received tranexamic acid.

Perioperative problems in patients with brainstem tumors and their influence on patient outcome

Background and Aims:

Patients with brainstem tumors have many associated systemic abnormalities and are prone to develop perioperative complications. We studied the problems associated with brainstem tumors and their influence on the postoperative neurological outcome.

Material and Methods:

Retrospective review of records of patients who underwent surgery for brainstem tumors over a period of 8 years was done. Preoperative variables, perioperative complications and neurological outcome as assessed by Glasgow Outcome Scale at the time of hospital discharge were noted. Association between perioperative factors and the unfavorable neurological outcome was evaluated.

Results:

Data of 70 patients were retrieved, 7 patients were excluded from the study because of incomplete data and data analysis was carried out for 63 patients. We found that lower cranial nerve palsies (32%) and hydrocephalus (43%) were common preoperatively. Various intraoperative problems encountered were hemodynamic instability (56%), major blood loss requiring blood transfusion (40%) and venous air embolism (11%), and postoperative problems were meningitis (51%), hypokalemia (38%), chest infection (21%), seizure (11%), deterioration of Glasgow Coma Scale (GCS, 11%), hyponatremia (8%), hydrocephalus (6%), respiratory distress (3%) and operatives site hematoma (3%). Fifty-six (89%) patients had favorable outcome at hospital discharge whereas, 7 (11%) had an unfavorable outcome. There was no association between pre- and intra-operative factors and the neurological outcome. Deterioration of GCS, chest infection, and the need for reintubation and tracheostomy were associated with unfavorable neurological outcome.

Conclusion:

Patients of brainstem tumors are at increased risk of perioperative complications. Some of the postoperative complications were associated with unfavorable neurological outcome.

A comparative study of early and late extubation following transoral odontoidectomy and posterior fixation

Background and Aims:

Elective ventilation is the usual practice after transoral odontoidectomy (TOO) and posterior fixation. This practice of elective ventilation is not based on any evidence. The primary objective of our study was to find out the difference in oxygenation and ventilation in patients extubated early compared to those extubated late after TOO and posterior fixation. The secondary objectives were to compare the length of Intensive Care Unit (ICU)/hospital stay and pulmonary complications between the two groups.

Material and Methods:

After TOO and posterior fixation, patients were either extubated in the operating room (Group E) or extubated next day (Group D). The oxygenation (PaO₂:FiO₂ ratio) and ventilation (PaCO₂) of the two groups before surgery, at 30 min and at 6/12/24 and 48 h after extubation were compared. Complications, durations of ICU and hospital stay were noted.

Results:

The base-line PaO₂:FiO₂ and PaCO₂ was comparable between the groups. No significant change in the PaO₂:FiO₂ was noted in the postoperative period in either group as compared to the preoperative values. Except for at 12 h after surgery, there was no significant difference between the two groups at various time intervals. No significant change in the PaCO₂ level was seen during the study period in either group. PaCO₂ measured at 30 min after surgery was more in Group E (37.5 ± 3.2 mmHg in Group E vs. 34.6 ± 2.9 mmHg in Group D), otherwise there was no significant difference between the two groups at various time intervals. One patient in Group E (7.1%) and two patients in Group D (13%) developed postoperative respiratory complication, but the difference was not statistically significant. The mean ICU stay (Group D = 42 ± 25 h vs. Group E = 25.1 ± 16.9 h) and mean hospital stay (Group D = 9.9 ± 4 days vs. Group E = 7.6 ± 2.2 days) were longer in Group D patients.

Conclusion:

Ventilation and oxygenation in the postoperative period in patients undergoing TOO and posterior fixation are not different between the two groups. However, the duration of ICU and hospital stay was prolonged in group D.

Increased airway pressure due to superior mediastinal hematoma during endovascular coiling by transcarotid approach

An elderly woman with subarachanoid hemorrhage presented to our interventional neuroradiology suite for coil embolization of multiple intracranial aneurysms. The patient had difficult vascular access for the passage of microcatheter; hence, the embolization procedure was carried out with direct puncture of the left common carotid artery. During the procedure, the patient developed thromboembolism which was treated by administration of an antiplatelet agent, abciximab. At the end of procedure, she developed airway compromise due to extension of a local neck hematoma into the superior mediastinum. The management issues in such a scenario have been discussed.

Comparison between sevoflurane and desflurane on emergence and recovery characteristics of children undergoing surgery for spinal dysraphism

Background and Aims:

Rapid recovery is desirable after neurosurgery as it enables early post-operative neurological evaluation and prompt management of complications. Studies have been rare comparing the recovery characteristics in paediatric neurosurgical patients. Hence, this study was carried out to compare the effect of sevoflurane and desflurane anaesthesia on emergence and extubation in children undergoing spinal surgery.

Methods:

Sixty children, aged 1–12 years, undergoing elective surgery for lumbo-sacral spinal dysraphism were enrolled. Anaesthesia was induced with sevoflurane using a face mask. The children were then randomised to receive either sevoflurane or desflurane with oxygen and nitrous oxide, fentanyl (1 μg/kg/h) and rocuronium. The anaesthetic depth was guided by bispectral index (BIS^®) monitoring with a target BIS^® between 45 and 55. Perioperative data with regard to demographic profile, haemodynamics, emergence and extubation times, modified Aldrete score (MAS), pain (objective pain score), agitation (Cole's agitation score), time to first analgesic and complications, thereof, were recorded. Statistical analysis was done using STATA 11.2 (StataCorp., College Station, TX, USA) and data are presented as median (range) or mean ± standard deviation.

Results:

The demographic profile, haemodynamics, MAS, pain and agitation scores and time to first analgesic were comparable in between the two groups (P > 0.05). The emergence time was shorter in desflurane group (2.75 [0.85–12] min) as compared to sevoflurane (8 [2.5–14] min) (P < 0.0001). The extubation time was also shorter in desflurane group (3 [0.8–10] min) as compared to the sevoflurane group (5.5 [1.2–14] min) (P = 0.0003).

Conclusion:

Desflurane provided earlier tracheal extubation and emergence as compared to sevoflurane in children undergoing surgery for lumbo-sacral spinal dysraphism.

Anaesthesia for awake craniotomy: A retrospective study of 54 cases

Background and Aims:

The anaesthetic challenge of awake craniotomy is to maintain adequate sedation, analgesia, respiratory and haemodynamic stability in an awake patient who should be able to co-operate during intraoperative neurological assessment. The current literature, sharing the experience on awake craniotomy, in Indian context, is minimal. Hence, we carried out a retrospective study with the aim to review and analyse the anaesthetic management and perioperative complications in patients undergoing awake craniotomy, at our centre.

Methods:

Medical records of 54 patients who underwent awake craniotomy for intracranial lesions over a period of 10 years were reviewed, retrospectively. Data regarding anaesthetic management, intraoperative complications and post-operative course were recorded.

Results:

Propofol (81.5%) and dexmedetomidine (18.5%) were the main agents used for providing conscious sedation to facilitate awake craniotomy. Hypertension (16.7%) was the most commonly encountered complication during intraoperative period, followed by seizures (9.3%), desaturation (7.4%), tight brain (7.4%), and shivering (5.6%). The procedure had to be converted to general anaesthesia in one of patients owing to refractory brain bulge. The incidence of respiratory and haemodynamic complications were comparable in the both groups (P > 0.05). There was less incidence of intraoperative seizures in patients who received propofol (P = 0.03). In post-operative period, 20% of patients developed new motor deficit. Mean intensive care unit stay was 2.8 ± 1.9 day (1–14 days) and mean hospital stay was 7.0 ± 5.0 day (3–30 days).

Conclusions:

‘Conscious sedation’ was the technique of choice for awake craniotomy, at our institute. Fentanyl, propofol, and dexmedetomidine were the main agents used for this purpose. Patients receiving propofol had less incidence of intraoperative seizure. Appropriate selection of patients, understanding the procedure of surgery, and judicious use of sedatives or anaesthetic agents are key to the success for awake craniotomy as a procedure.

Advances in neuro-monitoring

Neuromonitoring aims to detect harmful physiologic events, early enough to guide the treatment instituted. Evidences encourage us to implement multimodal monitoring, as no single monitor is capable of providing a complete picture of dynamic cerebral state. This review highlights the role of intracranial pressure monitoring, cerebral oxygenation (jugular venous oximetry, brain tissue oxygenation, near infrared oximetry, cerebral microdialysis) and cerebral blood flow monitoring (direct and indirect methods) in the management of neurologically injured patients. In this context, the recent developments of these monitors along with the relevant clinical implications have been discussed. Nevertheless, the diverse range of data obtained from these monitors needs to be integrated and simplified for the clinician. Hence, the future research should focus on identification of a most useful monitor for integration into multimodal system.

Blood groups systems

International Society of Blood Transfusion has recently recognized 33 blood group systems. Apart from ABO and Rhesus system, many other types of antigens have been noticed on the red cell membranes. Blood grouping and cross-matching is one of the few important tests that the anaesthesiologist orders during perioperative period. Hence, a proper understanding of the blood group system, their clinical significance, typing and cross-matching tests, and current perspective are of paramount importance to prevent transfusion-related complications. Nonetheless, the knowledge on blood group system is necessary to approach blood group-linked diseases which are still at the stage of research. This review addresses all these aspects of the blood groups system.

Effect of intraoperative brain protection with propofol on postoperative cognition in patients undergoing temporary clipping during intracranial aneurysm surgery

BACKGROUND

Cognitive dysfunction after subarachnoid hemorrhage (SAH) has been attributable to presence of subarachnoid blood, hydrocephalus (HCP), cerebral edema, vasospasm, and temporary clipping of intracranial aneurysm. Provision of neuroprotection during temporary clipping may improve postoperative cognition in such patients.

MATERIALS AND METHODS

Good-grade aneurysmal SAH patients undergoing temporary clipping during surgery were allocated either to group C (control) or group P (propofol). Patients in group P received propofol in titrated doses to attain a burst suppression ratio of 75 ± 5% on bispectral index (BIS) monitor. The cognitive function as assessed by Hindi-language modification of mini-mental state examination (HMSE) score was evaluated preoperatively, 24 h after surgery, and at discharge from hospital. A score of ≤23 was indicative of cognitive dysfunction. Perioperative complications, duration of intensive care unit (ICU) and hospital stay, and outcome at discharge were noted.

RESULTS

A total of 66 patients (32 and 34 in group C and P respectively) were included in the study. 97% of the patients had anterior circulation aneurysms. At 24 h after surgery, eight and 12 patients in group C and P respectively; and at discharge, five patients in each group had cognitive dysfunction. In both groups, the trend showed a decline in cognition at 24 h followed by improvement at discharge. Glasgow outcome score in both the groups was comparable (P > 0.05). Intraoperative brain bulge, postoperative vasospasm, and cerebral infarction were found to be independent risk factors for cognitive dysfunction.

CONCLUSIONS

Pharmacologic neuroprotection with propofol at the time of temporary clipping during surgery for aneurysmal SAH did not offer any advantage as far as preservation of cognition is concerned.

See-saw pattern in ventilator graphic: Is there any story behind?

The importance of ventilator graphics cannot be over emphasized that provide the useful information about airway, ventilation, compliance and lung mechanics. Some bizarre forms of graphics are usually overlooked in view of artifacts, but sometimes these tracings may in fact predict some relevant information.

Percutaneous retrieval of malpositioned, kinked and unraveled guide wire under fluoroscopic guidance during central venous cannulation

The placement of central venous catheter using Seldinger's technique, remains a commonly performed procedure with its own risks and benefits. Various complications have been reported with the use of guide wire as well as catheter. We report a unique problem during subclavian vein cannulation due to guidewire malposition which led to its kinking and difficult retrieval requiring removal in fluoroscopy suit. The probable mechanism of guide wire entrapment and possible bedside management of similar problems is described.

Causes of tracheal re-intubation after craniotomy: A prospective study

Background:

Re-intubation of neurosurgical patients after a successful tracheal extubation in the operating room is not uncommon. However, no prospective study has ever addressed this concern. This study was aimed at analyzing various risk factors of re-intubation and its effect on patient outcome.

Methods:

Patients aged between 18-60 yrs and of ASA physical status I and II undergoing elective craniotomies over a period of two yrs were included. A standard anesthetic technique using propofol, fentanyl, rocuronium, and isoflurane/sevoflurane was followed, in all these patients. ‘Re-intubation’ was defined as the necessity of tracheal intubation within 72 hrs of a planned extubation. Data were collected and analyzed employing standard statistical methods.

Results:

One thousand eight hundred and fifty patients underwent elective craniotomy, of which 920 were included in this study. A total of 45 (4.9%) patients required re-intubation. Mean anesthesia duration and time of re-intubation were 6.3±1.8 and 24.6±21.9 hrs, respectively. The causes of re-intubation were neurological deterioration (55.6%), respiratory distress (22.2%), unmanageable respiratory secretion (13.3%), and seizures (8.9%). The most common post-operative radiological (CT scan) finding was residual tumor and edema (68.9%). Seventy-three percent of the re-intubated patients had satisfactory post-operative cough-reflex. The ICU and hospital stay, and Glasgow outcome scale at discharge were not significantly affected by different causes of re-intubation.

Conclusion:

Neurological deterioration is the most common cause of re-intubation following elective craniotomies owing to residual tumor and surrounding edema. A satisfactory cough reflex may not prevent subsequent re-intubation in post-craniotomy patients.

Clinical evaluation of C-MAC videolaryngoscope with or without use of stylet for endotracheal intubation in patients with cervical spine immobilization

PURPOSE

This study was carried out to evaluate the relative efficacy of the C-MAC videolaryngoscope as compared to the conventional Macintosh laryngoscope using both styletted and non-styletted endotracheal tube (ETT) in patients undergoing elective cervical spine surgery with head and neck stabilized by manual in-line stabilization.

METHODS

We randomized 120 consenting adults into four groups (30 each) to undergo tracheal intubation using either the Macintosh laryngoscope or C-MAC videolaryngoscope with styletted and non-styletted ETT.

RESULTS

There was no significant difference between the C-MAC videolaryngoscope and Macintosh laryngoscope in Intubation Difficulty Scale (IDS) score using either styletted [median (IQR) 2 (1, 3) vs. 3 (2, 4); p = 0.58] or non-styletted ETT [median (IQR) 4 (2, 6) vs. 3 (2, 8); p = 1.00]. Similarly, when using a similar ETT-stylet assembly, the duration of successful intubation attempt, first attempt success rate, complications, use of airway optimization maneuvers, and adjuncts to facilitate intubation were comparable. The Cormack-Lehane view of the glottis was better with the C-MAC videolaryngoscope (p < 0.001). The use of stylet significantly reduced the IDS score [median (IQR) 2 (1, 3) vs. 4 (2, 6); p = 0.02], intubation time [median (IQR) 27 s (23, 31) vs. 52 s (28, 76); p < 0.001], and use of gum elastic bougie (3.3% vs. 43.3%, p < 0.001) with the C-MAC videolaryngoscope whereas no such effect was observed with the Macintosh laryngoscope.

CONCLUSIONS

Use of the C-MAC videolaryngoscope and Macintosh laryngoscope resulted in similar levels of intubation difficulty during cervical immobilization when used with a similar ETT-stylet assembly. The inclusion of the stylet significantly reduced the intubation difficulty experienced with the C-MAC videolaryngoscope.

Anaesthesia for neurosurgical procedures in paediatric patients

Recent advances in neurosurgery, neuromonitoring and neurointensive care have dramatically improved the outcome in patients affected by surgical lesions of central nervous system (CNS). Although most of these techniques were applied first in the adult population, paediatric patients present a set of inherent challenges because of their developing and maturing neurological and physiological status, apart from the CNS disease process. To provide optimal neuroanaesthesia care, the anaesthesiologist must have the knowledge of basic neurophysiology of developing brain and effects of various drugs on cerebral haemodynamics apart from the specialised training on paediatric neuroanaesthesia. This article highlights on the perioperative management of paediatric neurosurgical patients.