For years, postoperative cognitive outcomes have steadily garnered attention, and in the past decade, they have remained at the forefront. This prominence is primarily due to empirical research ...emphasizing their potential to compromise patient autonomy, reduce quality of life, and extend hospital stays, and increase morbidity and mortality rates, especially impacting elderly patients. The underlying pathophysiological process might be attributed to surgical and anaesthesiological-induced stress, leading to subsequent neuroinflammation, neurotoxicity, burst suppression and the development of hypercoagulopathy. The beneficial impact of multi-faceted strategies designed to mitigate the surgical and perioperative stress response has been suggested. While certain potential risk factors are difficult to modify (e.g., invasiveness of surgery), others - including a more personalized depth of anaesthesia (EEG-guided), suitable analgesia, and haemodynamic stability - fall under the purview of anaesthesiologists. The ESAIC Safe Brain Initiative research group recommends implementing a bundle of non-invasive preventive measures as a standard for achieving more patient-centred care. Implementing multi-faceted preoperative, intraoperative, and postoperative preventive initiatives has demonstrated the potential to decrease the incidence and duration of postoperative delirium. This further validates the importance of a holistic, team-based approach in enhancing patients' clinical and functional outcomes. This review aims to present evidence-based recommendations for preventing, diagnosing, and treating postoperative neurocognitive disorders with the Safe Brain Initiative approach.
Sitting position (SP) or prone position (PP) are used for posterior fossa surgery. The SP induced reduction in cerebral blood flow and cerebral oxygen saturation (rSO2) has been shown in shoulder ...surgeries, but there is not enough data in intracranial tumor surgery. Studies showed that PP is safe in terms of cerebral oxygen saturation in patients undergoing spinal surgery. Our hypothesis is that the SP may improve cerebral oxygenation in the patients with intracranial pathologies due to reduction in intracranial pressure. Therefore, we compared the effects of the SP and PP on rSO2 in patients undergoing posterior fossa tumor surgery.
Data were collected patients undergoing posterior fossa surgery, 20 patients in SP compared to 21 patients in PP. The rSO2 was assessed using INVOS monitor. Heart rate (HR), mean arterial pressure (MAP), EtCO2, BIS, and bilateral rSO2 were recorded preoperatively, and at 5, 8, and 11.ßminutes after the intubation and every 3.ßminutes after patient positioning until the initial surgical incision.
Cerebral oxygenation slowly reduced in both the sitting and prone position patients following the positioning (p.ß<.ß0.002), without any difference between the groups. The HR and MAP were lower in the sitting SP after positioning compared to the PP.
Neurosurgery in the SP and PP is associated with slight reduction in cerebral oxygenation. We speculate that if we rise the lower limit of MAP, we might have showed the beneficial effect of the SP on rSO2.
Highlights • We compared the effectiveness of conscious sedation (CS) to “awake-asleep-awake” (AAA) techniques in awake craniotomy. • The AAA technique may provide better results with respect to ...agitation and seizure. • Otherwise, blood pressures were significantly higher in the AAA group than in the CS group. • As a result of hypertension, the amount of intraoperative bleeding was higher in the AAA group than in the CS group. • Therefore, hypertension needed a vigilant follow-up especially in the wake-up period.
Aneurysmal subarachnoid hemorrhage (aSAH) is an emergency that needs prompt diagnosis and treatment with endovascular coiling or surgical clipping of the aneurysm to prevent re-bleeding. In addition ...to neurologic manifestations, aSAH can cause respiratory and cardiovascular complications. The prevention of hypoxemia and hypercarbia, control of intracranial pressure, and restoration of cerebral perfusion pressure should be the primary aims of early management. Secondarily, the most important causes of persistent neurological deficits and physical dependence in aSAH are vasospasm and delayed ischemia following bleeding. During that period, a focus on the detection, prevention, and treatment of vasospasm should be the rule. Transcranial Doppler allows detection and follow-up of vasospasm, especially in severe cases. Nimodipine is the only drug that has proven efficacy for treating vasospasm. Balloon angioplasty is performed in cases of resistance to medical treatment. Along with angioplasty, intra-arterial vasodilators can be administered. New diagnostic and therapeutic advances will hopefully improve outcomes in the near future.
Volume controlled ventilation with low PEEP is used in neuro-anesthesia to provide constant PaCO2 levels and prevent raised intracranial pressure. Therefore, neurosurgery patients prone to ...atelectasis formation, however, we could not find any study that evaluates prevention of postoperative pulmonary complications in neurosurgery.
A prospective, randomized controlled study.
Intensive care unit in a university hospital in Istanbul.
Seventy-nine ASAI-II patients aged between 18 and 70years scheduled for elective supratentorial craniotomy were included in the study.
Patients randomized into 3 groups after surgery. The Group IS (n=20) was treated with incentive spirometry 5 times in 1min and 5min per hour, the Group CPAP (n=20) with continuous positive airway pressure 10 cmH2O pressure and 0.4 FiO2 via an oronasal mask 5min per hour, and the Group Control (n=20) 4L·min−1O2 via mask; all during the first 6h postoperatively. Respiratory functions tests and arterial blood gases analysis were performed before the induction of anesthesia (Baseline), 30min, 6h, 24h postoperatively.
The IS and CPAP applications have similar effects with respect to FVC values. The postoperative 30min FEV1 values were statistically significantly reduced compared to the Baseline in all groups (p<0.0001). FEV1 values were statistically significantly increased at the postoperative 24h compared to the postoperative 30min in the Groups IS and CPAP (p<0.0001). This increase, however, was not observed in the Group Control, and the postoperative 24h FEV1 values were statistically significantly lower in the Group Control compared to the Group IS (p=0.015).
Although this study is underpowered to detect differences in FEV1 values, the postoperative 24h FEV1 values were significantly higher in the IS group than the Control group and this difference was not observed between the CPAP and Control groups. It might be evaluate a favorable effect of IS in neurosurgery patients. But larger studies are needed to make a certain conclusion.
•Volume controlled MV with low PEEP and without recruitment maneuver in craniotomies often lends itself to atelectasis and V/Q mismatch.•The effects of IS and CPAP on pulmonary function tests as well as ABG’s were compared in patients after supratentorial craniotomy.•The IS and CPAP applications have similar effects with respect to FVC values.•The postoperative 24h FEV1 values were significantly higher in the IS group than the Control group•This difference was not observed between the CPAP and Control groups.
Objective: Morphine is commonly used in post-operative analgesia, but opioid-related respiratory depression causes a general reluctance for its use. The "Integrated Pulmonary Index" is a tool ...calculated from non-invasively obtained respiratory and hemodynamic parameters. The aim of this prospective, randomized, double blind, and placebo-controlled study is to determine a more safe and effective dose for morphine in patient-controlled analgesia following supratentorial craniotomy using the "Integrated Pulmonary Index".
Methods: This study included 60 patients (ASA I, II, and III). All patients used iv PCA for 24 h following supratentorial craniotomy. The PCA was set to administer a bolus dose of 1 mg morphine in Group 1 and 0.5 mg morphine in Group 2. The PCA contained placebo in Group 3 and patients received dexketoprofen 50 mg iv after awakening, repeated every 8 h. The IPI and NRS scores, total morphine consumption, and morphine related side-effects were recorded at 10 min, 1, 2, 6, 12, and 24 h post-operatively. The lowest IPI score, count of apnea, and desaturation events were recorded during the study period.
Results: The IPI scores were similar among the groups. Although a statistically significant difference was not observed among the groups the lowest IPI scores were observed in Group 1; apnea and desaturation counts were also higher in Group 1. Statistically significant differences were not observed among the groups in terms of pain scores, but were lower in Groups 1 and 2 compared to Group 3.
Conclusion: Patient controlled analgesia with 0.5 mg morphine may be safe and effective for pain management following supratentorial craniotomies. Integrated pulmonary index can be used for detecting opioid-induced respiratory depression.
Clinical Trials registration number: NCT02929147.
Highlights • The mannitol and furosemide-mannitol combination provides similar degree brain relaxation in supratentorial tumor surgery. • Furosemide with low or high doses of mannitol may cause ...electrolyte imbalance and high lactate levels. • Moreover high urine out-put and negative intra-operative fluid balance may occur. • 0.5 g kg−1 mannitol provides enough brain relaxation without causing systemic side effects.
General anesthesia with intravenous or inhalation anesthetics reduces respiratory functions. We investigated the effects of propofol, desflurane, and sevoflurane on postoperative respiratory function ...tests.
This single-center randomized controlled study was performed in a university hospital from October 2015 to February 2017. Ninety patients scheduled for endoscopic endonasal transsphenoidal pituitary surgery were randomly categorized into either of these three groups: propofol (n = 30, the Group TIVA), desflurane (n = 30, the Group D) or sevoflurane (n = 30, the Group S). We analyzed the patients before, after, and 24 h following surgery, to identify the following parameters: forced expiratory volume in 1 second (FEV1) %, forced vital capacity (FVC) %, FEV1/FVC, and arterial blood gases (ABG). Furthermore, we also recorded the intraoperative dynamic lung compliance and airway resistance values.
We did not find any significant differences in FEV1 values (primary outcome) among the groups (P = 0.336). There was a remarkable reduction in the FEV1 and FVC values in all groups postoperatively relative to the baseline (P < 0.001). The FVC, FEV1/FVC, ABG analysis, compliance, and airway resistance were similar among the groups. Intraoperative dynamic compliance values were lower at the 1st and 2nd hours than those immediately after intubation (P < 0.001).
We demonstrated that propofol, desflurane, and sevoflurane reduced FEV1 and FVC values postoperatively, without any significant differences among the drugs.
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