Journal of neurosurgical anesthesiology最新文献

Perioperative neurocognitive disorder (pNCD) and stroke are frequent and serious complications following noncardiac surgery, leading to increased mortality and healthcare expenditure. While intraoperative hypotension has long been considered a potentially modifiable risk factor through its impact on cerebral perfusion, a direct role in causing pNCD is now challenged. Large randomized controlled trials, including the recent CogPOISE trial, have demonstrated that strategies targeting higher perioperative mean arterial pressure do not reduce the incidence of delirium, long-term cognitive decline, or major vascular events in the surgical population. These findings suggest that the "one size fits all" approach to blood pressure management is insufficient. The pathophysiology of perioperative brain injury is multifactorial, and the role of cerebral hypoperfusion remains uncertain. Future research must shift from population-based blood pressure thresholds towards investigating the impact of personalized, multimodal, neurophysiology-guided care for vulnerable patients, including cerebral autoregulation and metabolic markers to protect against pNCD and stroke.

Antiplatelet and anticoagulant medications are widely prescribed to the general population for therapeutic and prophylactic purposes in a wide range of diseases, mainly of cardiovascular interest, spanning from acute events such as acute coronary syndromes (ACS), strokes, and thromboembolic disorders to chronic conditions like atrial fibrillation (AF) and peripheral vascular diseases. The management of such therapies is expected to escalate over time due to the aging population, which has a growing need for these medications, and the rising demand for surgical procedures. The management of anticoagulants and antiplatelets still represents a tough challenge for clinicians in elective neurosurgical procedures, where the balance between preventing thromboembolic events and an increased bleeding risk plays a crucial role in all phases of the perioperative setting. Managing antiplatelet and anticoagulant drugs in elective neurosurgery is complex and requires a tailored and multidisciplinary approach. Careful assessment of patient factors, surgery type, and potential risks and benefits is essential. POC testing can be valuable in optimizing therapy management and bleeding risk assessment. This narrative review for clinicians aims to provide an updated overview of the management of these drugs in the perioperative setting of elective neurosurgical procedures. We explored coagulation abnormalities commonly found in neurosurgical patients, the pharmacological profile of each class of drugs, the appropriate management according to the type of procedure (brain or spinal), and the available diagnostic tests, focusing on the application of point-of-care (POC) coagulation testing.

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.