Neurosurgical Anesthesiology

JNA Is Looking Forward to 2020 and Beyond No abstract available

The Promise and Perils of Big Data in the Clinical Neurosciences No abstract available

Power and Challenges of Big Data: Why Clinical Researchers Should Not Be Ignored No abstract available

Revisiting Ischemia After Brain Injury: Oxygen May Not Be the Only Problem No abstract available

Anesthesia and Cognitive Outcome in Elderly Patients: A Narrative Viewpoint Better ways to manage preoperative, intraoperative and postoperative care of surgical patients is the bailiwick of anesthesiologists. Although we care for patients of all ages, protecting the cognitive capacity of elderly patients more frequently requires procedures and practices that go beyond routine care for nonelderly adults. This narrative review will consider current understanding of the reasons that elderly patients need enhanced care, and recommendations for that care based on established and recent empirical research. In that latter regard, unless and until we are able to classify anesthetic neurotoxicity as a rare complication, the first-do-no-harm approach should: (1) add anesthesia to surgical intervention on the physiological cost side of the cost/benefit ratio when making decisions about whether and when to proceed with surgery; (2) minimize anesthetic depth and periods of electroencephalographic suppression; (3) limit the duration of continuous anesthesia whenever possible; (4) consider the possibility that regional anesthesia with deep sedation may be as neurotoxic as general anesthesia; and (5) when feasible, use regional anesthesia with light or no sedation.

Effects of Vasopressors on Cerebral Circulation and Oxygenation: A Narrative Review of Pharmacodynamics in Health and Traumatic Brain Injury The clinical use of vasoactive drugs aims to improve hemodynamic variables and thereby maintain or restore adequate perfusion and oxygenation in accordance with metabolic demands. A main focus in the management of patients with brain pathology during surgery and neurointensive care is restoring and/or maintaining adequate cerebral perfusion pressure in order to ensure cerebral blood flow in accordance with metabolic demands. One commonly used clinical strategy is the administration of vasoactive drugs aiming to increase mean arterial blood pressure and thereby cerebral perfusion pressure. Here, we first describe the anatomic and physiological basis for the cerebrovascular effects of vasopressor agents. Next, we review the pharmacodynamics of commonly used vasopressors under normal circumstances and in the presence of head injury. We further discuss the role of blood-brain barrier disruption and microvascular dysfunction with regard to the effects of the reviewed vasopressor agents.

Regional Versus General Anesthesia: Effect of Anesthetic Techniques on Clinical Outcome in Lumbar Spine Surgery: A Prospective Randomized Controlled Trial Background: There are only a few prospective clinical trials investigating the effects of different anesthetic techniques on clinical outcomes after lumbar spine surgery. The purpose of this study was to evaluate clinical outcomes in patients receiving general (GA) and regional anesthesia (RA) for lumbar spine surgery. Methods: This was a single-center, 2-arm, trial in which 100 patients undergoing lumbar spine surgery were randomized to receive either RA or GA (50 per group). The primary endpoint was morphine consumption during the first postoperative 48 hours. In addition, anesthesia time, transition time (defined as time from end of surgery to admission to the postoperative anesthesia care unit), visual analogue scale (VAS) for pain, and patient satisfaction at hospital discharge were recorded. Results: There was no difference in the primary endpoint (cumulative morphine consumption at 48 h) between the 2 anesthesia types. Anesthesia and transition times were significantly shorter in the RA compared with the GA group—anesthesia time 125.4±23.6 minutes for GA versus 99.4±13.5 minutes for RA, transition time 22.5 minutes for GA versus 10.0 minutes for RA (both P<0.001). The VAS for pain on arrival to the postoperative anesthetic care unit was lower for patients who received RA compared with GA (crude and adjusted, both <0.001). 84% of patients in the RA group were completely satisfied compared with 74% in the GA group (P<0.001). There was a significant difference in the sex analysis for VAS for pain over time; females reported higher VAS for pain from the preoperative assessment to 6 weeks after the operation (P<0.001). Conclusions: There was no difference in postoperative morphine consumption in patients receiving GA and RA for lumbar spine surgery. RA was associated with shorter anesthesia and transition times, lower VAS for pain at arrival at the postoperative anesthesia care unit, and higher patient satisfaction at hospital discharge.

Immediate Use of Continuous Positive Airway Pressure in Patients with Obstructive Sleep Apnea Following Transsphenoidal Pituitary Surgery: A Case Series Background: Patients who undergo transsphenoidal pituitary resection have an elevated risk of obstructive sleep apnea (OSA) yet their outcomes and the safety of continuous positive airway pressure (CPAP) remains unclear. Our study objective was to determine the incidence of complications related to the use of early positive airway pressure following pituitary resection. Methods: We retrospectively identified all patients who underwent endoscopic transsphenoidal pituitary tumor resection between January 1, 2005 and March 24, 2016 at our institution, including those with diagnosed or suspected OSA. We compared characteristics and postoperative complications of OSA patients who did and did not receive CPAP postoperatively. Results: In total, 427 patients underwent transsphenoidal pituitary resection. Of these, 64 (15%) had OSA. Acromegaly was more common in patients with OSA (42% vs. 10%; P<0.001) but not Cushing Disease (19% vs. 16%; P=0.54). Hypoxia was more common in patients with OSA as compared to those without (14% vs. 5%; P<0.001) and one patient with OSA was reintubated compared with none in the control group (P=0.017). Eight patients had CPAP applied in the immediate postoperative period and the incidence of postoperative cerebrospinal fluid (CSF) leak, infection, and pneumocephalus was similar between OSA patients with and without CPAP. Discussion: Our case series of patients with OSA who received CPAP immediately following transsphenoidal pituitary resection resulted in similar rates of surgical complications. Our results support further investigation to establish the safety of CPAP in this population.

Choice of ANesthesia for EndoVAScular Treatment of Acute Ischemic Stroke (CANVAS): Results of the CANVAS Pilot Randomized Controlled Trial Background: The effect of choice of anesthesia on clinical outcome for endovascular treatment (EVT) in patients with acute ischemic stroke (AIS) remains unclear. Methods: We conducted a pilot trial of 43 patients with acute anterior circulation ischemic stroke having EVT. Patients were randomly allocated to receive general anesthesia or conscious sedation. We documented the rate of recruitment and rate of conversion from conscious sedation to general anesthesia. In addition, we recorded the change in National Institute of Health stroke scale (NIHSS) on day 7, the rate of successful reperfusion and measured neurological function by certified researchers using modified Rankin Score (mRS 0 to 2) at 90 days. Results: The recruitment rate was 31.4% and majority of patients were excluded because of delay in hospital presentation and posterior circulation stroke. The rate of conversion from conscious sedation to general anesthesia was 18.2%. This was primarily related to excessive sedation and uncontrolled movement. Change in NIHSS score, rate of successful reperfusion and functional recovery were similar between groups. Conclusions: It was feasible to randomize AIS patients receiving either general anesthesia or conscious sedation for EVT.

Hyperlactatemia After Intracranial Tumor Surgery Does Not Affect 6-Month Survival: A Retrospective Case Series Background: Patients undergoing neurosurgery frequently exhibit hyperlactatemia. The aim of this study was to identify factors associated with hyperlactatemia and assess how hyperlactatemia impacts survival and hospital length of stay after intracranial tumor surgery. Materials and Methods: This retrospective cohort study included 496 adult patients that underwent surgery between January 1, 2014 and December 31, 2015. We evaluated patient characteristics, surgery characteristics, pH, lactate, and blood glucose from blood samples collected on admission to the high-dependency unit and the morning after surgery, and 6-month outcome data. Results: Hyperlactatemia (>2.0 mmol/L) occurred in >50% of patients, but only 7.7% had acidosis. Postoperative hyperlactatemia was not correlated with 6-month survival (P=0.987), but was correlated with (median [interquartile range]) longer hospital stays (6 [4 to 8.5] d vs. 5 [4 to 8] d; P=0.006), longer surgery duration (4:53 [4:01 to 6:18] h:min vs. 4:28 [3:33 to 5:53] h:min; P=0.001), higher dexamethasone dose (16 [16 to 35] mg vs. 16 [16 to 20] mg; P<0.001), and higher blood glucose concentration (8.4 [7.5 to 9.6] mmol/L vs. 8.0 [7.1 to 8.9] mmol/L; P<0.001). Patients that received total intravenous anesthesia developed hyperlactatemia less frequently than those that received balanced anesthesia with inhalational agents (48.4% vs. 61.5%, P=0.008). Hyperlactatemia was not associated with increased postoperative neurological deficits or the need for rehabilitation therapy. Conclusions: Hyperlactatemia was common after intracranial tumor surgery. It did not influence 6-month outcomes but was associated with longer hospital length of stay. Several potential causative factors for hyperlactatemia were identified.