Awake Laser Ablation for Patients With Tumors in Eloquent Brain Areas: Operative Technique and Case Series
Background Magnetic resonance imaging (MRI)-guided laser interstitial thermal therapy (LITT) is a minimally invasive treatment modality that has been gaining traction in neuro-oncology. Laser ablation is a particularly appealing treatment option when eloquent neurologic function at the tumor location precludes conventional surgical excision. Although typically performed under general anesthesia, LITT in awake patients may help monitor and preserve critical neurologic functions. Objective To describe intraoperative workflow and clinical outcomes in patients undergoing awake laser ablation of brain tumors. Methods We present a cohort of six patients with tumors located in eloquent brain areas that were treated with awake LITT and report three different workflow paradigms involving diagnostic or intraoperative MRI. In all cases, we used NeuroBlateÂ® (Monteris Medical, Plymouth, MN) fiberoptic laser probes for stereotactic laser ablation of tumors. The neurologic status of patients was intermittently assessed every few minutes during the ablation. Results The mean preoperative tumor volume that was targeted was 12.09 Â± 3.20 cm3, and the estimated ablation volume was 12.06 Â± 2.75 cm3. Performing the procedure in awake patients allowed us close monitoring of neurologic function intraoperatively. There were no surgical complications. The length of stay was one day for all patients except one. Three patients experienced acute or delayed worsening of pre-existing neurologic deficits that responded to corticosteroids. Conclusion We propose that awake LITT is a safe approach when tumors in eloquent brain areas are considered for laser ablation.
Midazolam at induction of general anesthesia does not reduce the incidence of postoperative nausea and vomiting after craniotomy [Meeting Abstract]
Backround: Intracranial surgery is high risk for postoperative nausea and vomiting. Despite routine prophylaxis with conventional antiemetics, about 50% of patients having this type of surgery will experience PONV. This is distressing and uncomfortable for patients, but it also runs the risk of precipitating intracranial bleeding. Recent retrospective reviews and randomized, placebo controlled trials have found that preoperative midazolam is associated with a decreased incidence of PONV. The mechanism for this effect is uncertain. If this intervention is effective it could become part of a multimodal approach for preventing PONV in patients having craniotomies. Currently intravenous midazolam 2 mg is used with other medications for induction of general anesthesia. Some craniotomy patients receive it and others do not, based on anesthesia provider preference and patient anxiety level. Comparing patients who received midazolam with those that did not could offer insight into the effectiveness of this treatment. Methods: Our group conducted a retrospective chart review of patients receiving craniotomies over a 1-year period. There were 463 craniotomies over the time range (June 1, 2016 to May 31, 2017). Indications for craniotomy included tumors, arteriovenous malformations, aneurysms and seizures. Patients were separated into 2 groups; those that received midazolam 2mg at induction and those that did not receive midazolam. Demographic data and other medications administered were extracted from the anesthesia record. Administration of rescue antiemetics for the first 24 hours, was used to indicate the presence of postoperative nausea and vomiting. A statistical analysis was performed. Results: Administration of IV midazolam 2mg was not associated with reduced PONV (odds ratio [OR] = 1.2; 95% confidence interval [CI], 0.1-2.7; P = 0.43) within 24 hours. Variables accounted for included age, sex, BMI, smoking status, history of PONV, and other anesthetic drugs administered. Conclusions: Administration of midazolam 2mg intravenously at induction was not effective in reducing overall PONV in craniotomy patients. It is possible the midazolam dose was too small, or the operation was too long for midazolam at induction to make a statistical difference. Of note, the overall incidence of PONV was 31% which is considerably lower than expected after this surgery. This may be due to the high percentage of patients who received a propofol based anesthetic along with dexamethasone and ondansetron. The low overall incidence of PONV may have diminished the chance of detecting the antiemetic effect of midazolam. (Table Presented)
Searching for baseline blood pressure: A comparison of blood pressure at three different care points
A common approach to blood pressure management in the operating room is to keep the intraoperative, pressures within 20% of baseline blood pressure. One question that arises from this recommendation is; what is a patient's true baseline blood pressure? In order to get a more precise definition of baseline blood pressure, a comparison of the first operating room blood pressure was made with the blood pressure taken in a preoperative holding area before surgery, and the blood pressure taken in pre-surgical testing. (before day of surgery). A database of 2087 adult general anesthesia cases was generated, which contained the blood pressure (BP) in the pre-surgical testing clinic, the first BP in preoperative holding on the day of surgery, and the first BP in the operating room. Comparisons were made between the blood pressures taken at each phase of care. All components of BP taken in the OR were statistically significantly higher (p<0.001 for all comparisons) than in either PST or the holding area, while the BP in the latter locations were not significantly different. This blood pressure difference persists whether or not the patient is taking antihypertensive medications. The higher blood pressure measured in the operating rooms precludes using this measurement to determine baseline blood pressure. Blood pressures taken prior to arrival in the operating room are similar to blood pressures taken before the day of surgery. Blood pressure measurements taken prior to entrance in the operating room can be used to determine baseline blood pressure.
A Survey of the American Society of Anesthesiologists Regarding Environmental Attitudes, Knowledge, and Organization
Our planet is in the midst of an environmental crisis. Government and international agencies such as the Intergovernmental Panel on Climate Change urge radical and transformative change at every level of how we conduct our personal and professional lives. The health care industry contributes to climate change. According to a study from the University of Chicago, the health care sector accounts for 8% of the United States' total greenhouse gas emissions. In an effort to understand the current state of environmental practice, attitudes, and knowledge among anesthesiologists in the United States, we conducted a survey of American anesthesiologists regarding environmental sustainability. The environmental survey was sent out by e-mail to a random sampling of 5200 members of the American Society of Anesthesiologists. This process was repeated a second time. A total of 2189 anesthesiologists of 5200 responded to the survey, a 42% response rate. Of the survey respondents, 80.1% (confidence interval, 78.2%-81.9%) were interested in recycling. Respondents reported recycling in 27.7% of operating rooms where they work. The majority of respondents (67%; confidence interval, 64%-69%) reported there was insufficient information on how to recycle intraoperatively. Respondents supported sustainability practices such as reprocessing equipment, using prefilled syringes, and donating unused equipment and supplies. The affirmative response rate was 48.4% for reprocessing equipment, 56.6% for using prefilled syringes, and 65.1% for donating equipment and supplies to medical missions. Questions about hospital-wide organization of sustainability programs elicited many "I don't know" responses. Eighteen percent of responders indicated the presence of a sustainability or "green" task force. A total of 12.6% of responders indicated the presence of a mandate from hospital leadership to promote sustainability programs. Two important conclusions drawn from the survey data are a lack of hospital-wide organization of sustainability programs and a belief among survey responders that they lack adequate information on recycling and sustainability.
Is it better to perform a craniotomy for brain tumor resection awake?
Searching for baseline blood pressure: A comparison of blood pressure at three care points [Meeting Abstract]
Introduction: A common approach to blood pressure management in the operating room is to keep the intraoperative pressures within 20% of baseline blood pressure. One question that arises from this recommendation is; what is a patient's true baseline blood pressure? In order to get a more precise definition of baseline blood pressure, a comparison of the first operating room blood pressure was made with the blood pressure taken in a preoperative holding area before surgery, and the blood pressure taken in pre-surgical testing. (1 to 30 d prior to surgery, median of 8 d prior to surgery). How do these blood pressures compare? Methods: A database of 1907 adult general anesthesia cases was generated, which contained the blood pressure (BP) in the pre-surgical testing (PST) clinic, the first BP in preoperative holding on the day of surgery, and the first BP in the operating room (OR). Anxiolytic premedication is rarely used in this institution. Comparisons were made between the blood pressure taken at each phase of care using one-sided analysis of variance (ANOVA), followed by Tukey's Honestly Significant Difference. Subsequently, the mean average, standard deviation, and 95% confidence interval for the difference of blood pressures between each phase of care was determined. Results: All components of BP taken in the OR were statistically significantly higher (P<0.001 for all comparisons) than in either PST or the holding area, while the BP in the latter locations were not significantly different (P=0.4 for systolic, P=0.9 for diastolic, P=0.9 for MAP) (Figure 1). The mean and 95% confidence interval of differences between phases of care are detailed in Figure 2. When separated by gender, age, and presence of hypertensive medication, the same trend remained for MAP. Discussion: Blood pressure measured in the operating room is significantly higher than preoperative blood pressures. The higher blood pressure measured in the operating rooms precludes using this measurement to determine baseline blood pressure. Blood pressures taken prior to arrival in the operating room are similar to blood pressures taken before the day of surgery. Blood pressure measurements taken prior to entrance in the operating room can be used to determine baseline blood pressure. The caveat to this rule is the variability of blood pressure readings in general. The standard deviation for measurements at any time was large. This means that averaging multiple readings prior to entering the OR will likely give a more realistic picture of a patients "baseline" blood pressure. (Figure Presented)
Anesthesia for an adult with mucopolysaccharidosis I [Case Report]
We describe the anesthetic management difficulties of a man with mucopolysaccharidosis I. We also briefly review the anesthesia literature related to this disease
Dexmedetomidine in awake craniotomy: a technical note
BACKGROUND: Resection of lesions in eloquent areas of the brain are sometimes best done with the patient awake. An awake patient provides neurological feedback as the lesion is resected. This increases the chances of a complete resection without leaving a patient neurologically devastated. Unfortunately, this procedure is not always well tolerated by the patient. METHODS: We performed a case series of awake craniotomies using a dexmedetomidine infusion. RESULTS: All 17 patients included in our study tolerated the procedure well with no major complications. CONCLUSIONS: The addition of dexmedetomidine to our technique improves safety and comfort for patients undergoing awake craniotomy
Awake craniotomy with dexmedetomidine in pediatric patients [Case Report]
We present our experience with the use of dexmedetomidine, an alpha2 agonist, in two children undergoing awake craniotomy. General anesthesia with the laryngeal mask airway was used for parts of the procedure not requiring patient cooperation to reduce the duration of wakefulness and abolish the discomfort of surgical stimulation. Dexmedetomidine was used as a primary anesthetic for brain mapping of the cortical speech area. The asleep-awake-sleep technique provided adequate sedation and analgesia throughout the surgery and allowed the patient to complete the necessary neuropsychological tests. To our knowledge, ours is the first description of the use of dexmedetomidine in pediatric neurosurgery
Perioperative electrolyte and acid-base abnormalities
St. Louis : Mosby, 1999