Isabel Gracia

Craniotomy in sitting position: anesthesiology management.

Purpose of review Sitting position to surgically approach posterior fossa disorder continues to be the first choice for some neurosurgical teams. We underwent a literature research for recent published studies involving neurosurgical patients operated on in this position. Preoperative evaluation, anesthetic technique, intraoperative monitoring, detection and treatment of venous or arterial air embolism episodes, and all the reported complications were recorded. Recent findings A modified semisitting (lounging) position aiming to create a positive pressure in the transverse and sigmoid sinuses, with lower head and higher legs positioned above the top of the head, decreases the incidence and severity of venous air embolism. Hyperventilation, compromising cerebral blood flow, has to be avoided during a sitting position. Precordial Doppler or transesophageal echocardiography monitoring improves the detection of small venous air embolism enabling its early treatment and diminishing its consequences. Patients with known patent foramen ovale can be operated on in a sitting position, under strict protocol, with few reported clinical venous air embolism and no paradoxical air embolism. Summary Sitting position for neurosurgical procedures may be a well tolerated approach for the patient if neurosurgeons and neuroanesthesiologists undergo a strict team protocol, including all necessary monitoring and meticulously followed.

Eficacia diagnóstica y manejo posoperatorio de los pacientes sometidos a biopsia cerebral en un hospital universitario

OBJECTIVE To assess the diagnostic yield and the incidence of perioperative complications in patients undergoing an open or closed cerebral biopsy and to determine the length of intensive care monitoring, for early diagnosis and fast management of perioperative complications. MATERIAL AND METHOD This was a retrospective analysis of all the patients that underwent brain biopsy between January 2006 and July 2012. We recorded demographic data, comorbidities, modality of biopsy, intraoperative clinical data, histological results, computed tomography scanning findings and occurrence, and type of perioperative complications and moment of appearance. RESULTS Seventy-six brain biopsies in 75 consecutive patients (51 closed and 25 open) were analysed. Diagnostic yield was 98% for closed biopsies and 96% for open biopsies. Mortality related to the procedures was 3.9 and 4%, respectively. The incidence of major complications was 3.9% for closed biopsies and 8% for open biopsies; half of these appeared within the first 24 postoperative hours, during patient stay in the Intensive Care Unit. Age was the only risk factor for complications (P=.04) in our study. No differences in morbimortality were found between the studied groups. CONCLUSIONS Diagnostic yield was very high in our series. Because the importance of early diagnosis of complications for preventing long-term sequelae, we recommend overnight hospital stay for observation after open or closed brain biopsy.

ProSeal Laryngeal Mask Airway Attenuates Systemic and Cerebral Hemodynamic Response During Awakening of Neurosurgical Patients: A Randomized Clinical Trial.

Background: Extubation and emergence from anesthesia may lead to systemic and cerebral hemodynamic changes that endanger neurosurgical patients. We aimed to compare systemic and cerebral hemodynamic variables and cough incidence in neurosurgery patients emerging from general anesthesia with the standard procedure (endotracheal tube [ETT] extubation) or after replacement of the ETT with a laryngeal mask airway (LMA). Materials and Methods: Forty-two patients undergoing supratentorial craniotomy under general anesthesia were included in a randomized open-label parallel trial. Patients were randomized (sealed envelopes labeled with software-generated randomized numbers) to awaken with the ETT in place or after its replacement with a ProSeal LMA. We recorded mean arterial pressure as the primary endpoint and heart rate, middle cerebral artery flow velocity, regional cerebral oxygen saturation, norepinephrine plasma concentrations, and coughing. Results: No differences were found between groups at baseline. All hemodynamic variables increased significantly from baseline in both groups during emergence. The ETT group had significantly higher mean arterial pressure (11.9 mm Hg; 95% confidence interval [CI], 2.1-21.8 mm Hg) (P=0.017), heart rate (7.2 beats/min; 95% CI, 0.7-13.7 beats/min) (P=0.03), and rate-pressure product (1045.4; 95% CI, 440.8-1650) (P=0.001). Antihypertensive medication was administered to more ETT-group patients than LMA-group patients (9 [42.9%] vs. 3 [14.3%] patients, respectively; P=0.04). The percent increase in regional cerebral oxygen saturation was greater in the ETT group by 26.1% (95% CI, 9.1%-43.2%) (P=0.002), but no between-group differences were found in MCA flow velocity. Norepinephrine plasma concentrations rose in both groups between baseline and the end of emergence: LMA: from 87.5±7.1 to 125.6±17.3 pg/mL; and ETT: from 118.1±14.1 to 158.1±24.7 pg/mL (P=0.007). The differences between groups were not significant. The incidence of cough was higher in the ETT group (87.5%) than in the LMA group (9.5%) (P<0.001). Conclusions: Replacing the ETT with the LMA before neurosurgical patients emerge from anesthesia results in a more favorable hemodynamic profile, less cerebral hyperemia, and a lower incidence of cough.

Bone embolism during neurosurgery in sitting position.

To JNA Readers: Venous air embolism (VAE) is a common complication of surgical procedures performed in the sitting position. Similarly, bone marrow embolism is reported during orthopedic procedures. We report a patient who developed VAE, followed by a documented episode of bone embolism during a craniectomy performed in the sitting position. A 49-year-old lady with a medical history of cerebellar hematoma due to arteriovenous malformation in the posterior inferior cerebellar artery, which could not be occluded completely with angiographic approach, was scheduled for craniectomy and excision of the posterior fossa arteriovenous malformation in the sitting position. The patient was monitored using ECG, invasive blood pressure, pulse oximetry (Datex-S5 monitor; Datex Ohmeda Inc., Helsinki, Finland), central venous catheter (Certodyn; B. Braun, Melsungen, Germany), precordial Doppler (BidopES-100VII; Hadeco, Kawasaky, Japan), transcranial Doppler (MultiDop E, Compumedics DWL Germany GMBH, Singen, Germany), and near-infrared spectroscopy (INVOS Oximeter 5100C, Somanetics; Troy, MI). During the surgery, 3 episodes of VAE were diagnosed (quick decrease in EtCO2 and hypercapnia in the blood gas sample), with no hemodynamic compromise, easily solved with the aspiration of the air through the central venous catheter, and the cease of the surgical manipulation. At the end of the surgery and during the hemostatic control of the dura mater, the patient presents an episode of atrial bigeminy accompanied by a decrease in EtCO2 level and hypercapnia. A new air embolism was diagnosed. Lidocain 90mg was administered intravenously. Aspiration through the central venous catheter allowed us to recover, with difficulty, a dense pink material floating in the blood. The patient recovered from the sinusal rhythm and could be extubated at the end of the surgery, with no hemodynamic, respiratory, or neurological defect neither during immediate postoperative care nor during all her stay in the hospital, being discharged home after a week. Material aspired through the central line was sent for pathology examination, which confirms the exclusive presence of bone fragments (Fig. 1). As far as we know, this is the first time that a bone embolism in a neurosurgical procedure in the sitting position is described with an uneventful postoperative recuperation as well.1–3

A50 Rationalization of the postoperative care in transsphenoidal pituitary surgery: application of a risk scale protocol

Background and Goal of study: A safe postoperative care with accurate resources is not well defined in the neuroendoscopic transsphenoidal pituitary surgery. The objective of our prospective study was to assess post-operative management according to a two levels risk classification. Materials and methods: Analysis of anaesthesia records (drugs, ECG, PA invasive, PVC, TOF, T, BIS and bilateral rSO2.) and perioperative complications in all scheduled patients operated on between 2006 and 2011 divided in two groups. A “high risk group” (HRG) of patients above 60 years old, severe comorbidity, clinically active acromegaly, Cushings disease, large tumour with risk of hypothalamic affectation or intraoperative or early postoperative complications. All sent postoperatively to an ICU for 24 h. “Low risk group” (LRG) were controlled in a post-anaesthesia recovery unit for 6 h and then sent to neurosurgical ward. Results: A total of 126 patients were included (56.3% women, 43.7% men), mean age 51.5 ± 16.4 years. Diagnoses: acromegaly 27.8%, Cushings Sd 11.92.7% and others (prolactinoma, non secreting macro and microadenoma) 46%. 65.9% belonged to HRG and 34.1% met LRG criteria. Intraoperative complications appeared in 32.5% of the HRG (n = 27),and 14%(n = 6) in LRG all them minors. A 26%(n = 33) had intraoperative complications in both groups, including two major complications (internal carotid injury). Postoperative complications in both groups 13%(n = 17), 11%(n = 14) severe (bleeding, reoperation, stroke, acute myocardial infarction, pneumonia). In the high risk group 19%(n = 16), low risk group 2%(n = 1). Mortality in HRG: 2.4%(n = 2) secondary to the two internal carotid injuries, none in the LRG. Conclusions/ Discussion: The risk assessment scale proposed was useful to identify high-risk patients submitted to neuroenscopic transsphenoidal pituitary surgery. References:Ausiello JC, Bruce JN, Freda PU. Postoperative assessment of the patient after transsphenoidal pituitary surgery. Pituitary. 2008;11(4):391-401.Dehdashti AR, Gentili F.Current state of the art in the diagnosis and surgical treatment of Cushing disease: early experience with a purely endoscopic endonasal technique. Neurosurg Focus. 2007;23(3):E9.Buchfelder M, Schlaffer S.Pituitary surgery for Cushings disease. Neuroendocrinology. 2010;92 Suppl 1:102–6. Epub 2010 Sep 10.

Airway Management in Neurosurgical Procedures (Along with Ventilation Management)

Airway management for neurosurgery procedures poses unique challenges to anaesthetists. Difficult airways are often associated with common neurosurgical pathology. Careful preoperative assessment of the airway and neurologic status of the patient, as well as discussion of the planned surgical position and details are essential to plan the best-suited strategy to establish and maintain airway patency and optimal oxygenation throughout the procedure.

Experience with “Fast track” postoperative care after deep brain stimulation surgery

BACKGROUND A 24-h-stay in the post-anesthesia care unit (PACU) is a common postoperative procedure after deep brain stimulation surgery (DBS). OBJECTIVE We evaluated the impact of a fast-track (FT) postoperative care protocol. METHODS An analysis was performed on all patients who underwent DBS in 2 periods: 2006, overnight monitored care (OMC group), and 2007-2013, FT care (FT group). RESULTS The study included 19 patients in OMC and 95 patients in FT. Intraoperative complications occurred in 26.3% patients in OMC vs. 35.8% in FT. Post-operatively, one patient in OMC developed hemiparesis, and agitation in 2 patients. In FT, two patients with intraoperative hemiparesis were transferred to the ICU. While on the ward, 3 patients from the FT developed hemiparesis, two of them 48h after the procedure. Thirty eight percent of FT had an MRI scan, while the remaining 62% and all patients of OMC had a CT-scan performed on their transfer to the ward. One patient in OMC had a subthalamic hematoma. Two patients in FT had a pallidal hematoma, and 3 a bleeding along the electrode. CONCLUSIONS A FT discharge protocol is a safe postoperative care after DBS. There are a small percentage of complications after DBS, which mainly occur within the first 6h.

Respuesta del autor al artículo «Sobre las complicaciones de las biopsias cerebrales», de J. Ibáñez et al.

1. Gracia I, Perello L, Valero R, Hervias A, Perdomo J, Pujol R, et al. Diagnostic yield and postoperative management of patients submitted to brain biopsy in a university hospital [Article in Spanish]. Neurocirugia (Astur). 2015;26:23–31. 2. Brell M, Ibáñez J, Caral L, Ferrer E. Factors influencing surgical complications of intra-axial brain tumours. Acta Neurochir (Wien). 2000;142:739–50. 3. Sawaya R, Hammoud M, Schoppa D, Hess KR, Wu SZ, Shi WM, et al. Neurosurgical outcomes in a modern series of 400 craniotomies for treatment of parenchymal tumors. 4. Black PM. What is a complication in neurological surgery? A practical approach. En: Apuzzo ML, editor. Brain Surgery: Complication Avoidance and Management. New York: Churchill Livignstone; 1993. XXVXXVII.

Comentario al trabajo «Sobre las complicaciones de las biopsias cerebrales», de J. Ibáñez et al.

1. Gracia I, Perello L, Valero R, Hervias A, Perdomo J, Pujol R, et al. Diagnostic yield and postoperative management of patients submitted to brain biopsy in a university hospital [Article in Spanish]. Neurocirugia (Astur). 2015;26:23–31. 2. Brell M, Ibáñez J, Caral L, Ferrer E. Factors influencing surgical complications of intra-axial brain tumours. Acta Neurochir (Wien). 2000;142:739–50. 3. Sawaya R, Hammoud M, Schoppa D, Hess KR, Wu SZ, Shi WM, et al. Neurosurgical outcomes in a modern series of 400 craniotomies for treatment of parenchymal tumors. 4. Black PM. What is a complication in neurological surgery? A practical approach. En: Apuzzo ML, editor. Brain Surgery: Complication Avoidance and Management. New York: Churchill Livignstone; 1993. XXVXXVII.