Journal of neurosurgical anesthesiology最新文献

Background: Venous air embolism (VAE) occurs when air enters the venous circulation. During nonsitting craniotomies with elevated VAE risk due to proximity to a venous sinus, our institutional practice is to employ precordial Doppler ultrasound (PDU) and transesophageal echocardiography (TEE) for monitoring, as well as central venous catheterization (CVC) for aspiration. We utilized an electronic medical record (EMR) database to assess the frequency of VAE occurrence, its clinical detection, and the use of VAE-specific monitoring modalities.

Methods: EMR review identified all patients who underwent nonsitting craniotomies for an intracranial tumor. To identify episodes of VAE occurrence, the EMR was screened for intraoperative VAE events as determined by clinical diagnosis (cVAE) as well as an EtCO 2 drop >20% over a 2-minute interval, concerning for suspected VAE (sVAE). To identify patients who had VAE-specific monitoring, the EMR was scanned for placement of a CVC, TEE, or PDU.

Results: Three thousand nine hundred forty-five patients underwent a craniotomy for resection of tumor, and 3531 met study inclusion criteria. There were 14 episodes of intraoperative VAE diagnosed by a clinician (cVAE) and 86 episodes of suspected VAE (sVAE) based on review of anesthesia records for significant changes in EtCO 2 . There were 261 cases that used VAE-specific monitoring, with minimal overlap with sVAE cases.

Conclusions: We identified 100 episodes of VAE, diagnosed either clinically (cVAE) or by abrupt EtCO 2 decrease (sVAE). Our data suggest that VAE in nonsitting craniotomy often occurs in instances where VAE-specific monitoring modalities are not used, and that our ability to preoperatively identify neurosurgical cases where VAE may occur is limited.

This systematic review aimed to identify and describe best practice for the intraoperative anesthetic management of patients undergoing emergent/urgent decompressive craniotomy or craniectomy for any indication. The PubMed, Scopus, EMBASE, and Cochrane databases were searched for articles related to urgent/emergent craniotomy/craniectomy for intracranial hypertension or brain herniation. Only articles focusing on intraoperative anesthetic management were included; those investigating surgical or intensive care unit management were excluded. Nine studies meeting the inclusion criteria were identified after screening 1885 abstracts and full text review of 276 articles. Six of the 9 included studies were prospective and 3 were retrospective, and included sample sizes ranging between 48 and 373 patients. All were single center studies. Three studies examined anesthetic technique (volatile vs. intravenous), 1 examined osmotic diuresis, 1 examined extubation in the operating room, 1 examined quality metrics, and 3 examined intracranial pressure and changes in vital sign. There was insufficient evidence to perform a meta-analysis. Overall, there was limited evidence regarding the anesthetic management of patients having urgent/emergent craniotomy or craniectomy for intracranial hypertension or herniation due to any cause.

Background: Anterior cervical discectomy and fusion (ACDF) is a common procedure in the United States. Unanticipated postoperative reintubation after ACDF is a rare but serious complication associated with increased morbidity, mortality, and health care costs. This study identifies risk factors for reintubation after ACDF using a large, contemporary cohort.

Methods: This retrospective cohort study examined demographic, clinical, and operative variables associated with unanticipated reintubation within 2 days of ACDF surgery using 2017 to 2022 data from the American College of Surgeons National Surgical Quality Improvement Program. Univariate analyses explored the relationship between variables and reintubation. Variables with P<0.15 were included in a multivariable model using logistic regression.

Results: Unanticipated reintubation occurred in 101 (0.2%) of 41,398 patients. Associated factors identified by univariate analysis included age, sex, race, operative time, corpectomy, number of vertebrae fused, posterior approach, ASA-PS, functional status, and select comorbidities. Using a multivariable model, independent risk factors for reintubation included older age (OR: 1.03, 95% CI: 1.01-1.06), male sex (OR: 1.59, 95% CI: 1.05-2.40), Black race (OR: 2.72, 95% CI: 1.73-4.30), longer operative time (OR per hour 1.20, 95% CI: 1.05-1.36), corpectomy (OR: 2.58, 95% CI: 1.67-3.98), procedures involving 3 or more levels (OR: 1.56, 95% CI: 1.00-2.44), and dependent functional status (OR: 2.99, 95% CI: 1.54-5.79).

Conclusions: This study identified several surgical and nonmodifiable patient risk factors for reintubation after ACDF, which may aid in risk stratification to guide preoperative counseling, surgical planning, and patient disposition. Further research is needed to explore mitigation strategies and the association between race and reintubation.

Introduction: Takotsubo syndrome (TTS) is a transient left ventricular dysfunction triggered by stress, often associated with intracranial disorders. This review examines intracranial triggers of TTS, summarizing evidence and implications.

Methods: We searched PubMed and Web of Science following PRISMA guidelines. Eligible studies included case reports of TTS precipitated by intracranial events. Outcomes analyzed included TTS-associated complications, cardiomyopathy status at last follow-up, and recurrence rates. Subgroup analyses were performed based on trigger type and for the reverse TTS (rTTS).

Results: A total of 167 studies were included, comprising 156 patients with conventional TTS and 28 with rTTS. The mean age in the conventional cohort was 57.73 years, with 85.9% being female. Hypertension (16.5%) was the most common comorbidity. ST-segment elevation (45.1%) and T-wave inversion (38.2%) were predominant electrocardiographic findings, while left ventricular systolic dysfunction (65.2%) was the main echocardiographic abnormality. Complications occurred in 95 patients, most commonly arrhythmias (39.4%), pulmonary edema (15.1%), and new valve disorders (11.2%). At last follow-up, 134 cases resolved, 15 patients died, and recurrence was 10.9%. Triggers were: seizures (n=43), subarachnoid hemorrhage (SAH) (n=36), ischemic stroke (n=18), multiple sclerosis (n=6), traumatic brain injury (n=6), tumor removal (n=6), and others (n=30).

Conclusion: Intracranial events are significant TTS triggers. While outcomes are favorable, mortality was more common in patients with SAH compared with other triggers. Standardized studies are needed to optimize treatment. Given that all included studies were case reports, findings should be interpreted cautiously, recognizing the exploratory nature of the data and the limitations in the level of evidence.

Background: Scalp nerve block (SNB) enhances neurosurgical recovery, but local anesthetics alone provide short-term analgesia. This study aimed to ascertain if a betamethasone and ropivacaine combination (betamethasone plus ropivacaine) prolongs analgesia relative to ropivacaine alone.

Method: This prospective, single-center, randomized controlled clinical trial was conducted from August 16, 2022, to December 19, 2024. Eligible patients for elective craniotomy were randomly allocated in a 1:1 ratio to the betamethasone group (n=45), which received SNB with 0.5% ropivacaine combined with betamethasone, or the control group (n=45), which received SNB with 0.5% ropivacaine alone. The primary outcome was the Numerical Rating Scale (NRS) pain score at 48 hours postoperatively. The secondary outcomes were NRS pain score within 48 hours postoperatively and plasma concentrations of interleukin-6, interleukin-10, and interferon-γ.

Results: The baseline data of the groups showed no significant differences. The betamethasone group had significantly lower NRS scores at 48 hours postoperatively (1 [0 to 2] vs 2 [2 to 3], P<0.001). Betamethasone plus 0.5% ropivacaine improved the NRS scores within 24 hours postoperatively. The betamethasone group had significantly lower interleukin-6 (3.3 [2.5 to 5.6] vs 11.6 [4.5 to 21.5] pg/ml, P=0.001) and interferon-gamma (3.4 [2.4 to 8.3] vs 5.3 [3.6 to 9.1] pg/ml, P=0.042) concentrations than the control group. Their interleukin-10 concentrations were not different (P=0.582).

Conclusion: Betamethasone plus 0.5% ropivacaine SNB significantly decreased postoperative pain intensity within and at 48 hours postoperatively, likely due to prolonged analgesia and reduced inflammatory responses.

Clinical trial registration: No. ChiCTR2200062670.