Anesthesia For Craniotomy Research Articles

Efficacy and Safety of Sufentanil-Propofol Versus Remifentanil-Propofol as Anesthesia in Patients Undergoing Craniotomy: A Meta-Analysis

In this study, we aimed to evaluate the efficacy and safety of sufentanil-propofol (SF) versus remifentanil-propofol (RF) as maintenance therapy for anesthesia in patients undergoing craniotomy. Randomized controlled studies on SF and RF as anesthesia for craniotomy were searched in electronic databases such as PubMed, Web of Science, Cochrane Library, Embase, CNKI, and Wanfang Data. All studies were published up to December 31, 2017. The primary outcomes were wake-up time, extubation time, and pain score. The secondary outcomes were heart rate, mean arterial pressure (MAP), and adverse reactions. In this meta-analysis, 14 studies involving 927 patients were investigated. Compared with the SF group, RF could significantly reduce the wake-up time and extubation time after craniotomy (P= 0.02, standardized mean difference [SMD], 1.19; 95% confidence interval [CI], 0.21-2.18; P= 0.0001; SMD, 1.87; 95% CI, 0.90-2.83, respectively). Meanwhile, SF had better efficacy to alleviate postoperative pain than RF (P= 0.001; SMD, 2.10; 95% CI,-3.37 to-0.82). However, there were no obvious differences in improving heart rate and MAP between the 2 groups (P= 0.46; SMD, 0.17; 95% CI,-0.28 to 0.62; P=0.43; SMD, 0.16; 95% CI,-0.54 to 0.23, respectively). Moreover, there were no significant differences in the incidents of nausea and vomiting, shivering, fidgeting, and respiratory depression between the SF and RF groups. RF as anesthesia for craniotomy had better effects in reducing the time of postoperative wake-up and extubation and significantly alleviating pain. Moreover, there were no significant differences in the incidence of adverse reactions between the 2 groups. The findings will prove beneficial for the rational use of clinical anesthetic drugs in the future.

Regional anesthesia in craniotomy and its effect on the post-operative analgesia

Regional anesthesia in craniotomy and its effect on the post-operative analgesia

Does scalp block with general anesthesia in craniotomy affect the intraoperative course and outcome in geriatric patients?

Background The noxious stimuli during supratentorial brain tumor resection in geriatric patients result in a vigorous hemodynamic response and stress response, which represents a challenge during anesthesia. Patients and methods A total of 80 patients were enrolled in the study. There were 43 male and 37 female patients undergoing elective supratentorial craniotomy. Patients were randomly assigned into two equal groups: group B patients had scalp block using bupivacaine (0.5%) and epinephrine (1 : 400 000) and group F patients received fentanyl 2 μg/kg (during maintenance of general anesthesia (GA)). Heart rate (HR), mean arterial pressure (MAP), plasma cortisol level, and intracranial pressure (ICP) were recorded at baseline (before induction of anesthesia), 1 min after intubation, 1 min after skin incision, 1 min after dural incision, 1 min after dural closure, 1 min after skin closure, and 1 min after extubation. ICP measurement ceased at dural incision. Time to recovery from anesthesia was also recorded. Results MAP, HR, and plasma cortisol level showed significant differences between groups, wherein group F had higher MAP, HR, and plasma cortisol level than group B. Group B had rapid recovery period. Conclusion Scalp block with 0.5% bupivacaine with adrenaline 1 : 400 000 can be used as an alternative to general anesthesia with fentanyl in preventing the increase in arterial blood pressure (ABP), HR, ICP, cerebral perfusion pressure (CPP), and cortisol level, and also it allows early extubation and assessment of conscious level.

Update on anesthesia for craniotomy

In this review, we present an update on the relationship between anesthesia and intraoperative hemodynamic complications, early postanesthesia recovery, postoperative pain and postoperative nausea and vomiting after craniotomy. We also review latest advances in education and research in neuroanesthesia for brain surgery. Insights from clinical reports published from January 2012 to April 2013 on anesthesia for craniotomy will be summarized. Recent findings address the need for a tight intraoperative hemodynamic monitoring - that should include aggressive prevention of arterial hypotension and cardiac arrhythmias - and a careful management of fluids and electrolytes balance. Data on the relationship between anesthesia (selection of anesthetics used intraoperatively) and early recovery demonstrate a limited benefit when ultra-short acting drugs (as remifentanil vs fentanyl) are used. Evidence on postoperative pain and postoperative nausea and vomiting contribute to define how to better prevent and treat these complications. Latest guidelines on training and research in neuroanesthesia define unique end points in this subspecialty. Neuroanesthesia for craniotomy should be aimed to ensure intraoperative loss of consciousness (unless awake craniotomy is the selected anesthesiological approach), pain control and an uneventful postoperative recovery, but should also be addressed to manipulate physiological variables including cerebral blood flow and to obtain optimal surgical exposure.

Anesthesia for Craniotomy

Anesthesia for Craniotomy

Anesthesia for Craniotomy

Anesthesia for Craniotomy

Direct Assessments of the Antioxidant Effects of Propofol Medium Chain Triglyceride/Long Chain Triglyceride on the Brain of Stroke-prone Spontaneously Hypertensive Rats Using Electron Spin Resonance Spectroscopy

Antioxidant anesthetics such as propofol (2,6-diisopropylphenol) directly inhibit lipid peroxidation via the generation of reactive oxygen species. Currently, there are no other studies regarding the direct effects of propofol medium chain triglyceride/long chain triglyceride (MCT/LCT) on reactive oxygen species generation or in experimental models of reactive oxygen species-induced oxidative stress in the brain. The authors investigated the effects of propofol MCT/LCT on reactive oxygen species (hydroxyl radical or superoxide) by electron spin resonance spin trapping with 5,5-dimethyl-1-pyrroline-N-oxide. The effects of propofol MCT/LCT on oxidative stress in the brain of Wistar-Kyoto rats or stroke-prone spontaneously hypertensive rats were investigated by using an in vivo L-band electron spin resonance system to monitor the decay rate of 3-methoxycarbonyl-2,2,5,5-tetramethyl-pyrrolidine-1-oxyl as a nitroxyl spin probe. These studies provided direct evidence that propofol MCT/LCT inhibited hydroxyl radical generation, but not superoxide generation. Regarding the hydroxyl radical from the Fenton system, it is likely to be due to the scavenging effects of vehicle. Anesthesia with propofol MCT/LCT reduced the degree of the high oxidative stress in the brain of stroke-prone spontaneously hypertensive rats. The current data show that propofol, mixed with clinical reagents (propofol MCT/LCT), resulted in the down-regulation of high oxidative stress due to scavenging hydroxyl radical, as demonstrated by in vitro or in vivo electron spin resonance analysis. These results led to reduced levels of hydroxyl radical, formed by brain injury such as stroke, and may therefore provide advantages for neuroprotection during anesthesia for craniotomy, e.g., in cases of brain disease.

Anesthesia for craniotomy in a patient with previous paralytic polio

Poliomyelitis remains endemic in many developing nations. Patients may develop residual muscle weakness in one or more limbs after an attack of poliomyelitis in childhood. We report an adult patient who presented for right temporal cortical grid placement. He had childhood poliomyelitis and, while showing no evidence of postpolio syndrome, demonstrated excessive sensitivity to nondepolarizing muscle relaxants and developed prolonged muscle weakness during the postoperative period.

Anaesthesia for craniotomy in a child with cardiac disease

Background: Children with congenital heart disease (CHD) may present for non-cardiac surgery. Their anaesthetic management depends on their pre-morbid pathology. Aim: To report the anaesthetic management of a patient with congenital heart disease for a non-cardiac surgery. Case report: Craniotomy for evacuation of an intracerebral abscess was performed on a 4-year-old female child with severe congenital ventricular septal defect (VSD). Induction was with halothane, nitrous oxide and oxygen using a Mapleson F breathing circuit. Endotracheal intubation was performed after a second dose of suxamethonium was administered. Muscle relaxant was maintained using atracurium. Spontaneous ventilation was resumed at the end of operation, after a repeat reversal of muscle paralysis. Lesson: The pathophysiology of CHD alters cardiovascular dynamics and therefore the uptake and distribution of anaesthetic agents Keywords : Congenital heart disease, Anaesthesia, Pulmonary vascular pressure Port Harcourt Medical Journal Vol. 1 (2) 2007: pp. 126-129

Anesthesia for Craniotomy with Intraoperative Awakening: How to Avoid Respiratory Depression and Hypertension?

To the Editor: We read with interest the article by Keifer et al. (1). However, we have some concerns about their anesthetic technique for craniotomy with intraoperative awakening. The authors managed the airway with a nasal cannula, facemask, or nasal trumpets. Patients breathed spontaneously. They observed respiratory depression in 69 of 96 patients (defined as an episode of apnea lasting at least 30 s) and hypercarbia (Paco2 >50 mm Hg) in almost one third of the patients. The authors used mannitol and furosemide in all patients and did not report cases of “tight brain.” We believe that a laryngeal mask airway might have offered advantages by providing a more secure airway and allowing controlled ventilation, as described by Sarang and Dinsmore (2). This technique might avoid the ventilatory depression and hypercarbia observed by Keifer et al., as well as the need to administer mannitol and furosemide. Diuretics may cause dehydration, hypotension, and electrolyte disturbance, and routine administration of diuretics might be avoided if CO2 were not allowed to increase. The use of laryngeal mask and controlled ventilation would require larger doses of propofol and remifentanil, possibly delaying emergence for brain mapping. The use of target-controlled infusion devices (or pharmacokinetic simulations) has been shown to decrease time for awakening during craniotomies and provide hemodynamic stability (3,4). This technique may be a useful alternative for craniotomies requiring intraoperative awakening. The authors also reported the occurrence of hypertensive episodes during Mayfield holder placement and suggested the use of short-acting vasodilators to avoid those episodes. Such episodes might be avoided by administering a bolus of remifentanil. Vasodilators may cause cerebral vasodilatation and increase intracranial pressure, whereas remifentanil would have a limited effect on intracranial pressure. Hypertensive episodes related with intraoperative emergence can be avoided by continuing a small-dose infusion of remifentanil and propofol (3,4). Francisco A. Lobo, MD Pedro Amorim, MD Department of Anesthesiology Hospital Geral de Santo António Porto, Portugal [email protected]

Anesthesia for Craniotomy with Intraoperative Awakening: How to Avoid Respiratory Depression and Hypertension?

Anesthesia for Craniotomy with Intraoperative Awakening: How to Avoid Respiratory Depression and Hypertension?

Anesthesia for craniotomy

Anesthesia for craniotomy

Surgery of Intrinsic Cerebral Neoplasms in Eloquent Areas under Local Anesthesia

28 patients with a mean age of 43.6 years were operated on for a cerebral neoplasm situated in close proximity to an eloquent area (24 speech area, 4 motor cortex) from 1996 to 1999. Preoperatively, all patients had undergone a detailed neuropsychological examination. In 10 patients aphasic disturbances could be detected. All patients underwent preoperative PET studies (methionine and (15)O-labeled water with activation during speech or finger tapping). These were performed and co-registered with MRI data to demonstrate the topographical relationship between motor or language function and the tumor borders. Anesthesia was induced with i.v. administration of propofol (150-250 mg/h). Craniotomy was performed under local infiltration anesthesia. After opening of the dura, sedation was stopped and operation was continued with the patient being alert and co-operative. With close clinical observation during electrical cortex stimulation, a speech arrest could be triggered or avoided. The motor cortex was identified by recording the phase reversal of the contralateral SEP of the median nerve and by direct cortical stimulation. As soon as aphasic or motor disturbances appeared, the tumor removal was continued with the goal of avoiding these specific regions. In 27 patients, preexisting neuropsychological and neurological deficits did not worsen. Only one patient was left postoperatively with a major permanent aphasic deficit that was present preoperatively to a minor degree. The use of local anesthesia in craniotomy for surgery of intrinsic cerebral neoplasms in eloquent areas allows for a continuous and repetitive monitoring of speech and motor function during the removal of even those tumors that were previously considered inoperable.

An open, randomized comparison of alfentanil, remifentanil, and alfentanil followed by remifentanil in anaesthesia for craniotomy

We studied 52 adults undergoing elective craniotomy, allocated randomly to one of three opioid treatments: alfentanil 50 micrograms kg-1 followed by 0.833 microgram kg-1 min-1 until dural closure (group Alf.); alfentanil 50 micrograms kg-1 followed by 0.833 microgram kg-1 min-1 for 2 h, then remifentanil 0.25 microgram kg-1 min-1 (group Alf.-Remi.); or remifentanil 1 microgram kg-1 followed by 0.5 microgram kg-1 min-1 reducing to 0.25 microgram kg-1 min-1 after craniotomy (group Remi.). Anaesthesia was maintained with infusion of propofol and 66% nitrous oxide in oxygen. Infusions of propofol and remifentanil were stopped at head bandaging. Group Remi. had the least intraoperative haemodynamic responses and group Alf. the most (P < 0.05). Times to tracheal extubation and obey commands were similar in all groups. In all patients in group Alf.-Remi. and group Remi., the trachea was extubated 27 min from the end of anaesthesia; three patients in group Alf. were slower to recover. Use of analgesia in the recovery room and time to transfer to the neurosurgical unit were similar in the three groups.

An open, randomized comparison of alfentanil, remifentanil and alfentanil followed by remifentanil in anaesthesia for craniotomy

We studied 52 adults undergoing elective craniotomy, allocated randomly to one of three opioid treatments: alfentanil 50 micrograms kg-1 followed by 0.833 microgram kg-1 min-1 until dural closure (group Alf.); alfentanil 50 micrograms kg-1 followed by 0.833 microgram kg-1 min-1 for 2 h, then remifentanil 0.25 microgram kg-1 min-1 (group Alf.-Remi.); or remifentanil 1 microgram kg-1 followed by 0.5 microgram kg-1 min-1 reducing to 0.25 microgram kg-1 min-1 after craniotomy (group Remi.). Anaesthesia was maintained with infusion of propofol and 66% nitrous oxide in oxygen. Infusions of propofol and remifentanil were stopped at head bandaging. Group Remi. had the least intraoperative haemodynamic responses and group Alf. the most (P < 0.05). Times to tracheal extubation and obey commands were similar in all groups. In all patients in group Alf.-Remi. and group Remi., the trachea was extubated 27 min from the end of anaesthesia; three patients in group Alf. were slower to recover. Use of analgesia in the recovery room and time to transfer to the neurosurgical unit were similar in the three groups.

A comparison of the 2% and 1% formulations of propofol during anaesthesia for craniotomy

This study investigated the pharmacodynamic and pharmacokinetic equivalence of 1% and 2% propofol emulsions when used for total intravenous anaesthesia for intracranial surgery. The same infusion rate (6.7 mg.kg-1 x h-1) of the two preparations was administered. Induction doses, recovery times, and haemodynamic profiles were identical. Similar propofol concentration profiles were produced and total body clearance of propofol was identical. Both preparations were associated with a similar incidence of injection pain but neither resulted in venous thrombosis or thrombophlebitis at 24 h. Plasma triglyceride concentrations were significantly higher with the 1% solution, but there were no differences in cholesterol concentrations. The 1% and 2% emulsions appeared to be pharmacologically equivalent with similar minor effects on arterial blood pressure and heart rate. Two percent propofol may be preferable to the 1% solution for maintenance of anaesthesia in patients in whom a large lipid load might be considered undesirable.

Anesthesia for Craniotomy

Anesthesia for Craniotomy

Anesthesia for craniotomy: Total intravenous anesthesia with propofol and alfentanil compared to anesthesia with thiopental sodium, isoflurane, fentanyl, and nitrous oxide

Anesthesia for craniotomy: Total intravenous anesthesia with propofol and alfentanil compared to anesthesia with thiopental sodium, isoflurane, fentanyl, and nitrous oxide

Anesthesia for craniotomy: Total intravenous anesthesia with propofol and alfentanil compared to anesthesia with thiopental sodium, isoflurane, fentanyl, and nitrous oxide

Study Objective: To compare a total intravenous (IV) anesthetic technique based on propofol and alfentanil with a commonly used anesthetic technique for craniotomy. Design: Open-label, randomized, clinical study. Setting: Neurosurgical clinic at a university hospital. Patients: Forty patients, aged 18 to 55 years, scheduled. for brain tumor surgery. Interventions: In 20 patients, anesthesia was induced with fentanyl and thiopental sodium and maintained with fentanyl, dehydrobenzperidol, isoflurane, nitrous oxide (N 2O), and a thiopental sodium infusion. Twenty patients were anesthetized with a propofol loading infusion followed by a maintenance infusion at a fixed rate. In addition, alfentanil was administered as a. loading bolus, followed by a variable-rate infusion, with additional doses as necessary to maintain hemodynamic stability. Measurements and Main Results: A decrease in blood pressure (BP) after induction with thiopental sodium was followed by a significant increase in BP and heart rate (HR) during intubation. BP and HR did not change during the propofol loading infusion. However, the administration of alfentanil was followed by a similar decrease in BP with a return to baseline values during the intubation period. Return of normal orientation (7 ± 5 minutes vs 27 ± 23 minutes) and concentration (12 ± 12 minutes vs 35 ± 37 minutes) was shorter and more predictable for the propofol-alfentanil—treated patients than for the thiopental sodium patients. Maintenance propofol concentration (nine patients) was between 3 ±0.69 μg/ml and 3.36 ± 1.17 μg/ml, while the concentration at awakening was 1.09 μg/ml. Alfentanil concentration at extubation (nine patients) was 79 ± 34 ng/ml. Conclusion: A total IV anesthetic technique with propofol and alfentanil is a valuable alternative to a more commonly used technique based on thiopental sodium, N 2O fentanyl, and isoflurane.

Anticonvulsant Therapy Increases Fentanyl Requirements During Anesthesia for Craniotomy

Department of Anesthesiology, Division of Neuroanesthesia, Washington Universtiy School of Medicine, St. Louis, Missouri