Practice Of Neuroanaesthesia Research Articles

Recent advancements in the practice of neuroanaesthesia and neurocritical care: An update.

The practice of neuroanaesthesia has expanded significantly in recent years to keep up with various challenges posed in the perioperative care of patients for neurosurgical, interventional, neuroradiological, and diagnostic procedures. Technological advancements in neuroscience include the intraoperative use of computed tomography scans and angiograms for vascular neurosurgery, magnetic resonance imaging, neuronavigation, expansion of minimally invasive neurosurgery, neuroendoscopy, stereotaxy, radiosurgery, the performance of increasingly complex procedures, advancements in neurocritical care, etc. Recent advancements in neuroanaesthesia that can meet these challenges include the resurgence of ketamine, opioid-free anaesthesia, total intravenous anaesthesia, techniques to facilitate intraoperative neuromonitoring, awake neurosurgical and spine surgeries, etc. The current review provides an update on the recent advancements in neuroanaesthesia and neurocritical care.

Management of Cerebropontine Angle Tumors on Total Intravenous Anaesthesia Facilitating Neuromuscular Monitoring: A Retrospective Observational Study

Background: With the increasing trend of IONM in neurosurgery the role of total intravenous anaesthesia has gained upper hand in the practice of neuro anaesthesia. Propofol based TIVA techniques facilitates rapid recovery of consciousness and psychomotor function with lower incidence of post-operative nausea and vomiting. It also facilitates satisfactory IONM monitoring while maintaining the adequate depth of anaesthesia. Available literature focuses on the surgical aspects with IONM. Few studies are available, which compare TIVA with general anaesthesia that too without IONM. Earlier TIVA for IONM has been studied in patients undergoing kyphoscoliosis correction surgery. This study was conducted to evaluate the efficacy of TIVA in facilitating IONM in resection of intracranial masses and to study its effects on hemodynamics and post op recovery. Methods: In our retrospective study of 23 cases, patients undergoing intracranial tumor mass excision surgeries requiring IONM were given standardized general anaesthesia using intubating dose of short acting muscle relaxant and further maintenance of anaesthesia was done using infusion of propofol and dexmeditomidine with the minimal inhalational agents. IONM was recorded successfully. Results: 18 patients were haemodyanamically stable. 3 patients had intermittent episodes of bradycardia, and 2 patients had hypotension. Three patients elicited dampened response requiring reduction in anaesthetic dose. Six patients exhibited delayed recovery. Conclusion: TIVA with propofol and dexmeditomidine is a good anaesthetic modality to facilitate IONM in resection of intracranial masses.

Safe Neuroanesthesia Practice during COVID-19 Pandemic: How Different From Routine?

Currently, we are in the midst of a global pandemic caused by SARS-CoV-2 viral infection, termed Coronovirus disease or COVID-19. Despite the enormous working constraints imposed by this highly contagious virus and limited healthcare infrastructure, the neurosurgeons and neuroanaesthetists worldwide continue to provide their emergency services to neurocritically ill patients who need immediate intervention. Appropriate treatment modifications are mandatory to minimize nosocomial spread of SARS-CoV-2 while providing emergency care to the suspected or confirmed cases with COVID-19. In this review, we shall discuss the salient points about the various COVID-19 specific modifications involved in neuroanaesthesia practice, pertinent to the ongoing pandemic.

Desflurane in neurosurgery: Pros

Neurosurgery and neuroanaesthesia are making rapid progress, and with this progress, there is the search for excellence and ideal results. The practice of neuroanaesthesia is fairly standardised today, and any debate can only be on the fine-tuning aspects of the techniques. The aim of all research in anaesthesia is to provide the best possible and safest operating conditions and to have a complete recovery at the end of the surgery. The maintenance of anaesthesia for neurosurgery is with balanced general anaesthesia which combines intravenous and inhalational agents. A review of literature shows that desflurane has definite advantages, and hence, it is an integral part of modern neuroanaesthesia.

Desflurane in neurosurgery: Pros

AbstractNeurosurgery and neuroanaesthesia are making rapid progress, and with this progress, there is the search for excellence and ideal results. The practice of neuroanaesthesia is fairly standardised today, and any debate can only be on the fine-tuning aspects of the techniques. The aim of all research in anaesthesia is to provide the best possible and safest operating conditions and to have a complete recovery at the end of the surgery. The maintenance of anaesthesia for neurosurgery is with balanced general anaesthesia which combines intravenous and inhalational agents. A review of literature shows that desflurane has definite advantages, and hence, it is an integral part of modern neuroanaesthesia.

Effects of avoiding neuromuscular blocking agents during maintenance of anaesthesia on recovery characteristics in patients undergoing craniotomy for supratentorial lesions: A randomised controlled study.

Background and Aims:Neuromuscular blocking agents have been one of the cornerstones of anaesthesia. With the advent of newer surgical, anaesthetic and neurological monitoring techniques, their utility in neuroanaesthesia practice seems dispensable. The aim of this prospective, comparative, randomised study was to determine whether neuromuscular blocking agents are required in patients undergoing supratentorial surgery when balanced anaesthesia with desflurane, dexmedetomidine and scalp block is used.Methods:Sixty patients with the American Society of Anesthesiologists physical status I or II, aged between 18 and 60 years were included in the study. All patients received anaesthesia including desflurane, dexmedetomidine and scalp block. The patients were randomly allocated to receive no neuromuscular blocking agent (Group A) or atracurium infusion to keep train-of-four count 2 (Group B). The two groups were compared with respect to haemodynamic stability, brain relaxation scores and recovery characteristics. Haemodynamic parameters and time taken to achieve Aldrete score >9 and other secondary outcomes were analysed using Student's t-test. Non-parametric data were analysed using the Mann–Whitney test.Results:The mean arterial pressure was comparable between the groups. The intraoperative heart rate was comparable; however, in the post-operative period, it remained higher in Group B for 30 min after extubation (P = 0.02). The brain relaxation scores were comparable among the two groups (P = 0.27). Tracheal extubation time, time taken for orientation and time required to reach Aldrete score ≥9 were comparable among the two groups.Conclusion:The present study suggests that balanced anaesthesia using desflurane, dexmedetomidine and scalp block can preclude the use of neuromuscular blocking agents in patients undergoing supratentorial surgery under intense haemodynamic monitoring.

Dexmedetomidine: Its fascination, fad, and facts in neuroanaesthesia practice!

Dexmedetomidine: Its fascination, fad, and facts in neuroanaesthesia practice!

Blood transfusion practices in neuroanaesthesia.

Neuroanaesthesia practice is associated with risk of significant blood loss resulting in anaemia in the intraoperative and postoperative period. The transfusion triggers in a neurologically injured brain are not clearly defined. Both a low haematocrit and a high haematocrit have not shown any improvement in the outcome. Transfusion of red blood cells may improve the cerebral oxygenation on neurophysiological monitors. However, these benefits have not been translated into clinical practice. Transfusion in subarachnoid haemorrhage leads to increased incidence of vasospasm and a poor outcome. Restrictive transfusion strategy is seen to have a lower incidence of pneumonia, urinary tract infection, bacteremia and septic shock in severe head injury. Current evidence suggests that a haemoglobin (Hb) level of <7 g/dl may be deleterious to the neurosurgical population. Target Hb of 8-9 g/dl may be desirable intraoperatively. Different transfusion triggers may hold true for different neurosurgical pathologies.

Anaesthetic considerations in measuring Aldrete score and long-term outcomes in craniotomy patients

Editor, It is with great interest that we read the article ‘A multicentre, randomised, open-label, controlled trial evaluating equivalence of inhalational and intravenous anaesthesia during elective craniotomy’ by Citerio et al.1 The authors are to be congratulated on completing a randomised study of such magnitude. Our neuroanaesthesia practice at the University of Texas M.D. Anderson Cancer Center averages 888 craniotomies annually, the majority of which are for tumour resection. As such, this article was of particular interest to our group. However, in our discussion, we identified several issues that might strengthen the study or perhaps contribute to future studies. First, all patients received midazolam 5 mg intravenously preoperatively. In our practice, standard premedication is midazolam 1 to 2 mg, and in some instances, premedication is not administered to craniotomy patients because of its potential to contribute to delayed emergence from anaesthesia or contribute to postoperative sedation. Because the primary endpoint of this study was the time to achieve an Aldrete postanaesthesia score (of which one component is consciousness) of 9 after tracheal extubation, what was the rationale for the use of midazolam, and particularly at the relatively high dose of 5 mg? Second, we would also like to inquire about the rationale for both urine and serum biomarkers. In the authors’ opinion, how clinically relevant are urinary markers? Specifically, how is one certain that the urine captured at a specific time point, such as during dural opening, accurately reflects biological stress markers at that time, given that markers have to get filtered through the kidneys and urine may pool in the bladder as a function of patient position? Also, diurnal fluctuations of cortisol and catecholamines are known to occur.2,3 Was this accounted for in the study? Finally, the authors do not comment on the administration of corticosteroids. In our practice, dexamethasone is routinely administered to help control perioperative cerebral oedema.4 If corticosteroids were administered, as is done commonly, could this not have impacted biomarker levels? Third, our final thought was why a fourth arm in the study was not included? We would anticipate that an arm consisting of patients randomised to propofol and fentanyl would allow a more complete comparison between the interplay of inhalational and intravenous anaesthetics and narcotics. We suspect that for the primary outcome, equivalence would be found. However, more importantly, we would expect to further delineate differences in the secondary endpoints such as postoperative opioid requirements and nausea/vomiting. Again, we applaud the authors for conducting a study of this size and importance. As the accompanying Commentary suggested,5 we as anaesthesiologists need to look beyond the operating room and examine further how our patient care in the perioperative period can contribute to outcomes. Acknowledgements Assistance with the letter: none declared. Financial support and sponsorship: none declared. Conflicts of interest: none declared.

Comparison of Different Induction Doses of Rocuronium and Vecuronium in Neuroanaesthesia Practice.

To evaluate the efficiency of use of rocuronium and vecuronium in different dose regimens in neuroanaesthesia practice in terms of intubation time and first additional dose requirement. Sixty-eight neurosurgery patients with intracranial mass that were operated on were included in our study. Patients were randomly divided into 4 groups according to the induction dose of neuromuscular blocker (NMB) as: Group 1: Vecuronium 0.1 mg kg(-1), Group 2: Priming, 20% of total vecuronium (0.1 mg kg(-1)) needed for induction injected 5 minutes before induction and then the rest used for induction, Group 3: Rocuronium group: 0.6 mg kg(-1), Group 4: Rocuronium with rapid-sequence induction dose (RSID) (1.2 mg kg(-1)). TOF (Train of four) test was used to decide on intubation and an additional NMB dose during surgery. Intubation quality, time from induction to intubation, time until the first additional NMB dose and subsequent NMB dose intervals were recorded. The RSID of rocuronium provided a significantly shorter time period for intubation against the other groups. Also, the time period from induction to first additional NMB requirement was significantly longer in the RSID group than the others. There were no statistically significant differences between the groups' in terms of time period for monitorisation, positioning and start of surgery. With the use of RSID of rocuronium, it was seen that excellent intubation quality is provided at around 1 minute and, with its longer duration of action until a first additional dose, it covers the time period for monitorisation, positioning and start of surgery. Because of these effects, we think that RSID of rocuronium may be a better choice of dose regimen for neuroanaesthesia practice.

Survey of neuroanaesthesia practice patterns in Colombia

Survey of neuroanaesthesia practice patterns in Colombia

Survey of neuroanaesthesia practice patterns in Colombia

1Department of Anesthesia, University of Western Ontario, Canada, 2Fundación Médica Santa Fe Bogotá, Colombia, 3Fundación Valle de Lili Cali, Colombia

New updates on neuroanaesthesia

As in previous editions, Anesthesia and Neurosurgery brings together experts in all specialties related to the state-of-the-art practice of neuroanaesthesia: neuroanatomy, physiology, neurosurgery, neuroradiology, and, of course, neuroanaesthesia. Although the format and length of the fourth edition is essentially the same as previous editions, much about it is new. Two new chapters—on transcranial doppler and neurological disease and anaesthesia—have replaced less pertinent ones. Four chapters are written by entirely new authors, and six chapters have one or more new authors.

Ethical issues surrounding the practice of neuroanaesthesia

Medical ethics is now recognised to be an important specialty within the medical curriculum. In recent times the number and complexity of ethical issues have increased in proportion to the greater breadth of medical interventions now possible. The neuroanaesthetist especially must be aware not only of the ethical problems he will inevitably encounter but he must be prepared to fully involve himself in the debate and so needs to acquaint himself with a knowledge of the principles underlying the ethical arguments. In this chapter it will be seen that beneficence may not be as simple as it sounds. Various commonly encountered clinical situations are explored and some ethical guidance offered.

Agents anesthésiques : anesthésie exclusivement intraveineuse ou anesthésie par inhalation en neurochirurgie

In this review article the pro's and contra's of the use of either inhalational or intravenous anaesthetics for neurosurgical procedures are discussed. The objective is to stimulate thoughts concerning controversial subjects, rather than to resolve issues. It is much less complicated to approach the practice of neuroanaesthesia with a few straight forward « rulesbased on laboratory measurements (such as intravenous drugs are good because they reduce CBF and ICP, whereas inhalational agents are bad because they increase CBF and ICP). It should also be noted that wehereas statements about potential detrimental or beneficial effects of different anaesthetic agents are relatively common, there is a dearth of well-designed prospective studies of sufficient power to substantiate the outcome advantages or disadvantages. The choice of an anaesthetic should include more than just a consideration of the potential intracranial effects of a drug : it should also include experience with a drug and, more important a consideration of the patient as a whole.

Book Review: Principles and Practice of Neuroanaesthesia

Book Review: Principles and Practice of Neuroanaesthesia

Principles of anaesthesia for craniotomy

Principle: a) a comprehensive and fundamental law, doctrine or assumption; b) a rule or code of conduct. Craniotomy or opening the skull is one of the oldest surgical procedures known to man. However, the outcome of these surgical endeavours usually proved unsuccessful and it took the advent of both anaesthesia (1840) and endotracheal intubation (1920) to put the fledgling discipline of neurosurgery onto a sounder footing. It is the purpose of this chapter to discuss the principles underlying the practice of neuroanaesthesia as it relates to the operation of craniotomy. The ultimate goal, however, is to provide a framework for an anaesthetist faced with caring for a patient with a neurosurgical lesion; with this framework he will be able to formulate an anaesthetic plan that will optimize cerebral haemodynamics and metabolism and also provide excellent operating conditions for the neurosurgeon. In order to carry out this goal, certain principles need to be adhered to and these are described in Table 1.

Book Review: A Basis and Practice of Neuroanaesthesia

Book Review: A Basis and Practice of Neuroanaesthesia

A Basis and Practice of Neuroanaesthesia, Second Edition

A Basis and Practice of Neuroanaesthesia, Second Edition

Book reviews

Cardiopulmonary Cerebral Resuscitation. A Manual for Physicians and Paramedical Instructors, Prepared for the World Federation of Societies of Anaesthesiologists By Peter Safar. A Basis and Practice of Neuroanaesthesia. Monographs in Anaesthesiology Volume 2 Edited by Emeric Gordon. Physiology of Spinal Anesthesia By Nicholas M. Greene. Spinal Cord Sensation, Sensory Processing in Dorsal Horn. The Proceedings of a Satellite Symposium of the International Congress of Physiological Sciences held at Keszthely, Hungary, July 9–12, 1980 Edited by A.G. Brown and M. Rethelyi.