Abstract
We aimed to compare systemic and cerebral hemodynamics and coughing during emergence after pituitary surgery after endotracheal tube (ETT) extubation or after replacing ETT with a laryngeal mask airway (LMA). Patients were randomized to awaken with an ETT in place or after replacing it with an LMA. We recorded mean arterial pressure (MAP), heart rate, middle cerebral artery (MCA) flow velocity, regional cerebral oxygen saturation (SrO2), cardiac index, plasma norepinephrine, need for vasoactive drugs, coughing during emergence, and postoperative cerebrospinal fluid (CSF) leakage. The primary endpoint was postoperative MAP; secondary endpoints were SrO2 and coughing incidence. Forty-five patients were included. MAP was lower during emergence than at baseline in both groups. There were no significant between-group differences in blood pressure, nor in the number of patients that required antihypertensive drugs during emergence (ETT: 8 patients (34.8%) vs. LMA: 3 patients (14.3%); p = 0.116). MCA flow velocity was higher in the ETT group (e.g., mean (95% CI) at 15 min, 103.2 (96.3–110.1) vs. 89.6 (82.6–96.5) cm·s−1; p = 0.003). SrO2, cardiac index, and norepinephrine levels were similar. Coughing was more frequent in the ETT group (81% vs. 15%; p < 0.001). CSF leakage occurred in three patients (13%) in the ETT group. Placing an LMA before removing an ETT during emergence after pituitary surgery favors a safer cerebral hemodynamic profile and reduces coughing. This strategy may lower the risk for CSF leakage.
Highlights
This article is an open access articleThe transnasal transsphenoidal endoscopic approach to the sella turca for pituitary surgery and the expanded endonasal approach to the skull base have both improved over the last decade [1,2]
One patient from the endotracheal tube (ETT) group was lost to follow-up because extubation was delayed due to life-threatening intraoperative bleeding (Figure 1)
Arterial blood pressure during emergence from anesthesia was stable in both groups but lower than baseline values, regardless of whether the ETT was replaced with an laryngeal mask airway (LMA) or not before discontinuation of general anesthesia
Summary
This article is an open access articleThe transnasal transsphenoidal endoscopic approach to the sella turca for pituitary surgery and the expanded endonasal approach to the skull base have both improved over the last decade [1,2]. Laryngeal mask airway (LMA) removal has been reported to have a better safety profile than tracheal extubation, with lower incidence of coughing, retching, and laryngospasm [6]. In this context, replacing an endotracheal tube (ETT) with an LMA at the end of a procedure has been recommended to allow for smooth emergence in at-risk extubations [7], in patients with highly irritable airway or in surgical procedures, such as after neurosurgery, where cardiovascular stimuli during extubation are to be avoided. Our previous results showed that neurosurgical patients undergoing brain surgery emerged from anesthesia with a more favorable hemodynamic profile, a lower incidence of coughing, and less cerebral hyperemia when an LMA replaced the ETT at the end of surgery but before emergence after undergoing a supratentorial craniotomy [8]
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