Journal of neurosurgical anesthesiology最新文献

Background: Patients undergoing resection of spinal cord tumours require intraoperative neuromonitoring. Transcranial electrical stimulation is used to record myogenic responses during surgery. This study aimed to compare the effect of 2 anaesthetic regimens, propofol/fentanyl versus desflurane/dexmedetomidine, on the ability to record MEPs with an amplitude of 50 µV or greater. Our secondary outcome compared intraoperative haemodynamics, recovery profile, and postoperative analgesia between the groups.

Methods: We conducted a prospective, double-blinded, open-label, single-centre, randomized controlled trial of 50 adult patients undergoing spinal cord tumour resection with TcmMEP monitoring. Patients were randomized to 2 groups: Group P (n=25) received intravenous anaesthesia with propofol and fentanyl; group D (n=25) received desflurane and dexmedetomidine.

Results: We recorded TcmMEP's in 80% of group P and 76% group D (95% CI: -23% to 31%, P=1.00). The time in minutes for spontaneous breathing (21.04±11.31 vs. 8.00±3.42 [8.29-,17.79, P=0.01]), extubation (31.56±17.56 vs. 10.84±3.99 [13.48-27.96; P=0.01]), emergence (33.68±18.11 vs. 10.92±4.01 [15.30-30.22, P=0.001]), discharge readiness (45.00±25.24 vs. 15.56±6.08 [19.00-39.88; P=0.001]) and requirement of first analgesia (136.6±108.04 vs. 230.8±81.33) (-148.58 to -39.82; P=0.01) was lower in group D compared with group P. Postoperative analgesia assessed using the Visual Analogue Score was lower in group D compared with group P at 12 and 24 hours. (1.68±1.18 vs. 0.64±1.31 [0.33-1.74 P=0.001]) :1.4±0.95 vs. 0.36± 0.70 (0.56-1.51; P=0.001).

Conclusions: We found similar rates of successful TcMEP monitoring using desflurane-dexmedetomidine and propofol-fentanyl. Patients who received desflurane-dexmedetomidine had reduced emergence time, discharge readiness, and lower pain scores in the postoperative period.

Background: Postoperative nausea and vomiting (PONV) are common complications, leading to prolonged hospital stays and reduced patient satisfaction. Acoustic neuroma (AN) resections are associated with a higher risk of PONV than other craniotomies. We aimed to detect if preoperative aprepitant is associated with less PONV following AN surgery.

Methods: Perioperative data were collected from the electronic medical record for patients undergoing AN resection between December 19, 2017 and April 26, 2022. Variables were compared between a cohort that received aprepitant and a matched cohort. Univariable and multivariable regression analyses were performed. Our primary outcome was PONV on the day of surgery.

Results: A total of 579 patients were included, of which 49% (n=283) developed PONV. A cohort of 108 patients who received aprepitant was matched in a 1:2 manner. Aprepitant was not associated with reduced PONV (P=0.239, odds ratio=0.756 [95% CI: 0.475-1.204]). On the basis of our univariable logistic regression model, tumor size, a translabyrinthine approach, total dose of propofol, total volume of crystalloids, highest nitrous oxide concentration, and anesthetic duration were associated with decreased odds of PONV. In multivariable regression modeling, none of these characteristics were associated with decreased odds of PONV.

Conclusion: Our results confirm that PONV is a common complication following AN resection. Preoperative aprepitant administration was not associated with reduced PONV. Intraoperative variables such as the surgical approach and duration of anesthesia might play a role in mitigating the risk of PONV. Future studies should identify other perioperative interventions to allow for the development of protocols addressing PONV.

Background: The association between intraoperative hypotension and delirium in patients with brain tumors remains unclear. We thus evaluated the association between intraoperative hypotension and postoperative delirium in patients recovering from neurological surgery.

Methods: This was a secondary analysis of 3 prospective studies. Patients aged greater than 18 years who were scheduled for elective craniotomy for resection of glioma or frontotemporal lobe tumor were enrolled. Intraoperative hypotension was quantified through 3 metrics: mean arterial pressure area under the curve, time-weighted mean arterial pressure, and cumulative duration of hypotension. Our primary outcome was the association between hypotension and postoperative delirium.

Results: The study comprised 738 patients (median age 56 y; 50% male) undergoing craniotomy for brain tumor resection. Postoperative delirium occurred in 29.0% (95% CI: 25.7%-32.3%) of patients. No statistically significant associations between intraoperative hypotension (absolute mean arterial pressure 60 to 75 mm Hg, relative reductions 10% to 40% from baseline) and postoperative delirium. However, the presence of preoperative tumor midline shift was an independent risk factor for postoperative delirium (adjusted odds ratio: 1.56, 95% CI: 1.09-2.22, P=0.014), and interacted with time-weighted average mean arterial pressure at relative reductions 10% based on the subgroup analysis.

Conclusions: In adult patients undergoing elective craniotomy for tumor resection, no significant association is found between intraoperative hypotension and postoperative delirium.

Background: Venous air embolism (VAE) is a potentially catastrophic complication during neurosurgical procedures, particularly in the sitting position. As practices vary widely, we conducted a survey to describe the global practice patterns for intraoperative detection and management of VAE.

Methods: Following institutional review board (IRB) approval, we conducted a cross-sectional study using a 48-question online survey that was distributed via a snowball sampling approach, initially to the Society of Neuroscience in Anesthesiology and Critical Care (SNACC) community and subsequently to international collaborators. Descriptive statistics summarized responses, and proportional comparisons between high-income and low- and middle-income country respondents were assessed using a χ2 or the Fisher exact tests, as appropriate.

Results: Of 307 responses, 297 were analyzed, representing 40 countries. Survey response rate was 25% among SNACC members. End-tidal carbon dioxide (EtCO2) monitoring was the most frequently reported VAE monitoring modality, particularly for sitting craniotomies. Common barriers to implementing advanced monitoring included limited equipment availability and a lack of a transesophageal echocardiography (TEE) specialist. Decision-making for cases at VAE risk relied on team consensus (62%), review articles and primary literature (48%), and institutional protocols (42%). Among respondents, 89% expressed interest in consensus guidelines for VAE management.

Conclusions: There is substantial global variability in both the preparation for and management of VAE during neurosurgical procedures. EtCO2 is the preferred monitoring approach in routine practice, as resource limitations prevent the broader adoption of more sensitive techniques, such as TEE. The high interest in consensus guidelines underscores an opportunity for professional societies to standardize approaches and improve patient safety.

Background: Although general anesthesia is commonly utilized for endovascular thrombectomy for acute ischemic stroke, whether anesthetic agents affect clinical outcome is unknown. Retrospective studies comparing propofol and volatile agents have shown mixed results. A randomized controlled trial is needed to determine whether anesthetic agent affects clinical outcomes. This pilot study aimed to evaluate the feasibility of conducting a definitive randomized controlled trial comparing propofol and sevoflurane-based anesthesia in patients undergoing endovascular thrombectomy.

Methods: Patients booked to undergo endovascular thrombectomy were randomized to receive either propofol or sevoflurane-based general anesthesia. Feasibility outcomes assessed were recruitment rate, protocol adherence, and data completeness. Secondary outcomes included functional recovery (90-d modified Rankin Scale 0 to 2), mortality, early neurological improvement, blood pressure control intraoperatively and postoperatively, and adverse events. We also assessed for independent risk factors for functional recovery and death.

Results: Of 201 eligible patients, 93 (46.3%) were enrolled and 73 (36.3%) included in the final analysis. The consent and randomization model was challenging. Adherence to drug protocols was 94.5%. Data completion rate was 99%. There were no differences in secondary outcomes between groups. Mortality was associated with higher admission National Institutes of Health Stroke Scale. Higher 90-day modified Rankin scores were associated with higher systolic blood pressures pre-reperfusion (r=0.32, P<0.01) and post-reperfusion (r=27, P=0.03).

Conclusions: A definitive randomized controlled trial of propofol and sevoflurane-based anesthesia is feasible. Future studies would benefit from adapting the trial model to better integrate research into the clinical workflow.

Trial registration: Australian New Zealand Clinical Trials Registry (ACTRN12621000074897), January 29, 2021.

Background: Opioid-free anesthesia (OFA) offers potential benefits of smoother recovery and reduced complications, compared with conventional opioid-based approach. We aimed to evaluate the use of OFA as an alternative approach to conventional opioid-based anesthetic regimen in patients undergoing supratentorial brain tumor surgery.

Methods: Adult patients (>18 y) with supratentorial tumors undergoing elective craniotomy under general anesthesia (Aug 2022 to Dec 2023) were randomized into Dexmedetomidine (group D) or Fentanyl (group F) group. Primary outcome included emergence and extubation times and secondary outcomes were hemodynamic responses, pain scores, rescue analgesic use, and complications.

Results: A total of 44 patients were randomized (22 per group). Of these, 33 patients completed the study. Demographic variables were comparable, except for age and body mass index. Emergence (8.2±3.3 min vs. 6.8±2.6 min [ P =0.18]; Mean Difference [MD], 95% CI: 1.42, -0.69 to 3.55) and extubation times (12.7±4.2 min vs. 11.2±3.9 min [ P =0.27]; MD, 95% CI: 1.58, -1.31 to 4.46) were comparable between the groups, respectively. Group D demonstrated better hemodynamic stability during Mayfield pin application and tracheal extubation. Postoperative pain scores were similar, except at 12 hours, where group D reported lower Numerical Rating Scale. Postoperative Richmond Agitation-Sedation Scale at different time points was comparable between the groups.

Conclusion: Our preliminary data suggest that OFA may provide better hemodynamic stability and improved pain control at 12 hours compared with opioid-based anesthesia, while maintaining similar emergence and extubation times.