Journal of neurosurgical anesthesiology最新文献

Temporary blood flow reduction is essential in the management of complex neurovascular lesions in both open and endovascular settings. This focused review examines the four principal techniques commonly used to achieve flow reduction for neurovascular procedures. Deep hypothermic circulatory arrest (DHCA) has largely become obsolete in recent years due to significant perioperative morbidity and the emergence of less invasive flow reduction strategies. Intravenous adenosine remains a popular option since it is readily available in the perioperative setting, though the hemodynamic response may be unpredictable because of interindividual dose-response variability. Rapid ventricular pacing (RVP) provides controlled, predictable flow reduction but requires advanced procedural planning. Endovascular balloon-assisted occlusion provides localized control in anatomically challenging areas under a hybrid neurosurgical-endovascular approach. To date, no single technique has demonstrated superiority over another, and the optimal strategy should be individualized based on lesion characteristics, institutional expertise, and available resources. Future research should focus on potential neuroprotective strategies during flow reduction and further characterize the safety and efficacy profiles of various flow reduction techniques through prospective cohort studies.

Background: The objective of this study was to determine whether postoperative pager alerts to the Hospital Elder Life Program (HELP), a delirium prevention service, would accelerate program enrollment for older surgical patients. This study also tested feasibility of family care partner interventions for delirium prevention.

Methods: This single-center, pilot clinical trial factorially randomized 57 non-cardiac surgical patients ≥70 years of age to 4 arms: (1) standard care, (2) pager alerts to accelerate HELP enrollment, (3) family care partner-based delirium prevention interventions, or (4) a combined arm with both HELP and family interventions. The primary clinical outcome was delirium (assessed through the Confusion Assessment Method).

Results: In the pager alerting arms, 13/24 (54%) participants were enrolled by HELP on postoperative day 1 compared with 0/26 (0%, P <0.001) in the non-alerting arms. Median [interquartile range] time spent in delirium prevention protocols was significantly longer in pager alerting arms than in non-alerting arms (39 [5 to 75] min vs. 0 [0 to 0] min; P <0.001). Family care partners spent 18 [11 to 25)] hours at the bedside over the first 3 postoperative days. There was no significant difference in delirium occurrence in participants randomized to pager alert arms compared with non-alerting arms (odds ratio, 1.02, 95% CI, 0.97-1.07; P =0.390). Similarly, there was no significant difference in delirium occurrence in family intervention arms compared with nonintervention arms (odds ratio, 0.97; 95% CI 0.93-10.02; P =0.270).

Conclusions: Pager alerts significantly reduced time to HELP enrollment, albeit without reducing delirium incidence in this pilot study. Family care partners spent substantial time at the bedside during the study period.

Background: Smoking negatively impacts postoperative outcomes but acute abstinence from smoking during hospitalization can increase postoperative pain, lower pain thresholds, disrupt pain management, and trigger hyperalgesia due to abrupt nicotine withdrawal in tobacco users. Nicotine replacement therapy has been recommended to minimize these complications. We hypothesized that a high dose (21 mg/24 h) transdermal nicotine (TDN) patch would reduce postoperative pain and opioid requirements.

Methods: One hundred abstinent tobacco smokers undergoing single-level spinal fusion were randomized into placebo (n=50) and nicotine treatment (n=50) groups. Placebo and TDN patches were applied 24 hours before surgery until 48 hours after surgery. Primary outcomes were postoperative pain scores and opioid (morphine) consumption, and serum nicotine levels. The relationship between daily tobacco use and pain and opioid requirements, and between serum nicotine levels and morphine consumption, were assessed.

Results: Postoperative pain scores at rest and on movement were lower in the nicotine group than in the placebo group at 6 hours, 12 hours, and 24 hours after surgery ( P <0.05). Postoperative morphine consumption was lower in the nicotine group than in the placebo group (9.92 ± 4.0 vs. 15.9 ± 5.0 mg, respectively; P =0.0002). There was a positive correlation between the number of cigarettes smoked per day and postoperative pain scores at rest (r = 0.4553; P = 0.0001) and during movement and a negative correlation between serum nicotine concentration and postoperative morphine consumption (r =-0.3664; P = 0.0089).

Conclusions: TDN patches (21 mg/24 h) reduced postoperative pain and opioid requirements in abstinent tobacco smokes undergoing spinal fusion.

Background: Predictors of difficult fiberscopic intubation have not been fully elucidated. This study focused on identifying radiographic predictors of difficult fiberscopic intubation during general anesthesia in patients with a cervical collar.

Methods: This retrospective study included unconscious patients who underwent orotracheal intubation using a flexible fiberscope while wearing a cervical collar to simulate a difficult airway. Easy fiberscopic intubation was defined as successful fiberscopic intubation within 120 seconds on the first attempt without desaturation below 90%. The patients were divided into easy (n=133) and difficult (n=24) fiberscopic intubation groups. Demographic, mask ventilation-related, upper airway-related, and radiographic variables measured on sagittal images of preoperative cervical x-ray and magnetic resonance imaging were analyzed.

Results: The difficult fiberscopic intubation group had a smaller oral cavity area (2.1 [1.2-2.5] vs. 2.9 [2.1-3.7] cm 2 , P <0.001), higher tongue area divided by oral cavity area (9.3 [6.5-13.3] vs. 6.4 [4.6-8.3], P <0.001), smaller epiglottis angle (33±10° vs. 37±8°, P =0.02), and longer skin-glottis distance (1.3 [1.1-1.6] vs. 1.1 [1.0-1.3] cm, P =0.004). Tongue area/oral cavity area (odds ratio per 1 [95% CI]: 1.24 [1.09-1.40]) and skin-glottis distance (odds ratio per 1 cm [95% CI]: 13.0 [2.69-62.4]) were independently associated with the difficulty in fiberscopic intubation.

Conclusions: High tongue area/oral cavity area and long skin-glottis distance were predictive of difficult fiberscopic intubation during general anesthesia in patients with a cervical collar.

Background: An anesthesia information management system (AIMS) can be used to assess operating room utilization. The aim of this study was to assess neurosurgery OR utilization patterns using an AIMS.

Methods: This retrospective audit was performed at a tertiary neurosciences university hospital over a 1-year period. The time taken for various OR activities were identified from the timestamps recorded in the AIMS and used to assess whether the type of surgical procedure, patient's American Society of Anesthesiologists (ASA) physical status score, case schedule order, or surgeons' experience impacted operating room utilization.

Results: Data from 1800 patients were available for analysis. Utilization times for various operating room activities were different based on the type of surgery, ASA grade, case order, and surgeon seniority. The main differences were found in the durations of surgery and anesthesia, and the time from the arrival of a patient into the operating room and the start of surgery, which were significantly impacted by the type of surgery, case order, and surgeon seniority ( P <0.001), but not by ASA score.

Conclusions: AIMS can effectively track and identify operating room utilization patterns by analyzing the durations of various operating room activities. Prospective multicenter studies are required to validate these findings in different surgical populations and centers.

Background: Intraoperative neuromonitoring (IONM) is used to detect neurological complications during carotid endarterectomy (CEA), and current data show mixed results in clinical outcomes. This study aimed to examine health care utilization metrics and outcomes relating to the use of IONM in CEA using a large national database in the USA.

Methods: Data were abstracted from the 2016 to 2021 Nationwide Readmissions Database. The primary aim was to evaluate whether adverse neurological events, hospital costs, length of stay (LOS), and routine discharge differed by the presence of IONM. We additionally evaluated whether all-cause 30-day and 90-day readmissions, and in-hospital mortality differed by IONM. We adjusted outcomes to control for age, comorbidity burden, left-sided surgery, and elective admission.

Results: There were an estimated 283,045 hospitalizations for CEA, of which 13,469 (4.79%) had IONM. IONM was associated with 12% longer adjusted stays, 16% higher adjusted costs and 35% lower odds of routine discharge ( P <0.001). In addition, IONM was associated with increased odds of an adverse neurological event, which included ischemic and hemorrhagic cerebrovascular complications (IONM: 19.40% vs. 12.65%, aOR: 1.31, 95% CI: 1.18-1.45, P <0.001). Lower income quartiles and rural/nonteaching facilities were associated with lower odds of IONM use. There were no differences in mortality or all-cause readmissions.

Conclusions: Our findings showed worse outcomes associated with IONM use during CEA. IONM is typically utilized in high-surgical-risk patients, largely accounting for our findings. The higher costs, longer hospital stays, and lower odds of routine discharge associated with IONM use need to be balanced with potential benefits. We also found significant disparities based on facility type and income. Detailed procedural risk factors, which are lacking from this data, limit the results of this study.