Preoperative Risk Assessment Before Elective Craniotomy: Are Aspirin, Arrhythmias, Deep Venous Thromboses, and Hyperglycemia Contraindications to Surgery?

OBJECTIVE: Perioperative risk assessment and stratification before craniotomy is necessary to identify and optimize modifiable risk factors. Due to the high costs of diagnostic testing and concerns for delaying surgery, some have questioned whether and when surgery delays are warranted and supported by the current body of literature. The objective of this scoping review was to evaluate the available evidence on the prognostic value of preoperative risk assessment before anesthesia for elective craniotomy. METHODS: In this scoping review, we reviewed 156 papers that assess preoperative risk assessment before elective craniotomy, of which 27 papers were included in the final analysis. RESULTS: There is little high-quality evidence to suggest significant risk reduction when 4 common preexisting abnormalities are present: preoperative chronic aspirin therapy, cardiac arrhythmias, deep vein thrombosis, or hyperglycemia. CONCLUSIONS: The risk of delaying craniotomy should ultimately be weighed against the perceived risks associated the patient's comorbid conditions and should be considered on an individualized basis.

Preoperative Versus Postoperative Scalp Block Combined With Incision Line Infiltration for Pain Control After Supratentorial Craniotomy.

OBJECTIVE: Postoperative pain after craniotomy is a significant clinical problem that is sometimes underestimated, although moderate or severe pain in early postoperative period complicates up to 60% of cases. The purpose of this prospective randomized multicenter trial was to determine the optimal timing for selective scalp block in patients undergoing general anesthesia for supratentorial craniotomy. MATERIALS AND METHODS: After ethics committee approval and informed consent, 56 adult patients were enrolled, and randomly assigned to receive a selective scalp block combined with incision line infiltration preoperatively or postoperatively. RESULTS: Postoperative pain at 24 hours after the procedure was recorded in all 56 enrolled patients. In patients assigned to receive a scalp block preoperatively, median VAS score at 24 hours after surgery was 0 (0 to 2), and in patients assigned to receive a scalp block postoperatively it was 0 (0 to 3) (P>0.05). There was no difference in severity of pain at 24, 12, 6, and 2 hours after surgery between the 2 study groups, but the amount of fentanyl administered intraoperatively was lower in patients assigned to the preoperative scalp block group (1.6±0.7 vs. 2.4±0.7 mkg/kg/h, P=0.01). DISCUSSION: This study confirms and extends available clinical evidence on the safety and efficacy of selective scalp blocks for the prevention of postoperative pain. Recorded data suggest that there is no difference in terms of occurrence and severity of postoperative pain regardless of whether the scalp block is performed preoperatively (after general anesthesia induction) or postoperatively (before extubation). Patients assigned to receive a scalp block combined with incision line infiltration preoperatively needed less intraoperative opioids than those assigned to postoperative scalp block.

A comprehensive analysis of patient satisfaction with anesthesia.

BACKGROUND: Patient satisfaction with anesthesia after surgical treatment is a complex concept that includes not only the level of satisfaction with the anesthesia itself but also the presence of fears, worries, depression, evaluation of the anesthesiologists' work, as well as cognitive dysfunction as a possible negative consequence of anesthesia. OBJECTIVE: Conducting a comprehensive analysis of patients' satisfaction with anesthesia. METHODS: Questionnaire of patients' satisfaction with anesthesia (Sinbukhova E.V., Lubnin A.Yu.), State-Trait Anxiety Inventory in the adaptation by Y.L. Hanin, Assessment of Depression, The Montreal Cognitive Assessment (MoCA), and Frontal Assessment Battery. Population consisted of 202 patients. RESULTS: Satisfaction with anesthesia: assessment "good and higher" with primary anesthesia - 59.7% of patients with repeated - 70% of patients. The most common factors that reduce the assessment of patients' satisfaction with anesthesia are: strong excitement before surgery about operation and anesthesia, no postoperative visit of the anesthesiologist, no visit of the anesthesiologist before the operation, not enough attention of anesthesiologist in the surgery room before anesthesia, nausea, vomiting, pain, dizziness, general discomfort, and thirst. MoCA cognitive assessment before and after anesthesia: P < 2.2 e-16 (significant decrease). Depression: major depression in 52% of patients, subclinical depression in 22.8%. CONCLUSION: Regular survey of patients' satisfaction should help to improve the quality of medical care. The strong excitement of the patient about the upcoming anesthesia and surgery, and the presence of a high level of anxiety and depression can be factors of reducing the patients' satisfaction with anesthesia. It requires psychological support of patients at the stage of surgical treatment.

Xenon anesthesia for awake craniotomy: safety and efficacy.

BACKGROUND: The asleep-awake-asleep (AAA) craniotomy is a technique that offers the opportunity of having a patient fully cooperative during the awake phase, and minimizes the possible discomfort, due to the asleep phase. The aim of this prospective observational study was to test the use of xenon in the first asleep phase of an AAA craniotomy, in patients undergoing craniotomy for brain tumor resection. METHODS: The data have been collected from 40 awake craniotomy procedures, performed in patients with cerebral tumor, treated with the AAA technique. Patients were treated with xenon during the asleep phase, and quality of mapping, complications and qualitative judgment of the experience given by the patients were recorded. RESULTS: The mapping was carried out as planned in 37 out of 40 cases. The doses of xenon administered during the first asleep phase of the anesthesia was 13±2 L. Time for awakening after xenon was switched off was 5±1 minute. A combination of xenon and regional anesthesia (with no need for additional systemic anesthetics) was adequate to accomplish craniotomy in 27/40 patients (67.5%). On the day after the operation, 37 patients recalled the testing procedure for mapping during the awake period, none had recollection of local anesthetic injections for regional anesthesia or sound associated with the neurosurgical drill. Five patients (12.5%) reported mild pain during tumor removal (VAS Score less than three). CONCLUSIONS: In this case series, xenon anesthesia was successfully used for the sedative phase of an awake craniotomy accomplished with an AAA approach.

Anesthesia for awake craniotomy.

PURPOSE OF REVIEW: The current review reports on current trends in the anesthetic management of awake craniotomy, including preoperative preparation, sedation schemes, pain management, and prevention of intraoperative complications. RECENT FINDINGS: Both approaches for anesthesia for awake craniotomy, asleep-awake-asleep and monitored anesthesia care (MAC), have shown equal efficacy for performing intraoperative brain mapping. Choice of the appropriate scheme is currently based mainly on the preferences of the particular anesthesiologist. Dexmedetomidine has demonstrated high efficacy and safety in MAC for awake craniotomy and has become a rational alternative to propofol. Despite the high efficacy of scalp block and opioids, pain remains a common compliant in awake craniotomy. Appropriate surgical tactics can reduce pain and even prevent postoperative neurological complications. Although the efficacy of prophylaxis of intraoperative seizures with anticonvulsants remains doubtful, levetiracetam can be superior to other drugs for this purpose. SUMMARY: Following a great deal of progress in anesthetic management, awake craniotomy, which had been a relatively rare approach, is now a commonly performed procedure for neurosurgical intervention. Modern anesthesia techniques can provide for successful brain mapping in almost any patient. Management of awake craniotomy in high-risk patients is a central task for future research.

'Scheduled' dosing of lornoxicam provides analgesia superior to that provided by 'on request' dosing following craniotomy.

BACKGROUND AND OBJECTIVES: The aim of this study was to compare the efficacy of 'scheduled' analgesia with analgesia 'on request in patients after craniotomy. PATIENTS AND METHODS: We performed a prospective randomized study comparing 'scheduled' analgesia with analgesia 'on request' on 126 patients aged 16-70 years undergoing craniotomy for a variety of reasons. Patients were randomized to one of two groups; group 1 (68 patients) received lornoxicam 'on request', and group 2 (58 patients) received 8 mg of lornoxicam preoperatively, immediately after intubation, then 8 mg again 6-8 h after the first injection and 8 mg repeated every 8 h for 48 h postoperatively. Subgroup analysis was performed for patients with supratentorial and infratentorial craniotomy. We measured pain scores (visual analogue scale), mean blood pressure and heart rate at 6, 18, 30, 42 and 54 h after surgery and compared differences in these parameters between groups and amongst subgroups. RESULTS AND DISCUSSION: Group 1 visual analogue pain scale scores were significantly higher than those in group 2 (P < 0.05). Group 1 patients with infratentorial craniotomy showed higher pain scores than supratentorial craniotomy patients (P < 0.05). No significant differences were observed in mean blood pressure between groups and subgroups (P > 0.05). We found no correlation between visual analogue scale scores, mean blood pressure and heart rate (P > 0.05). CONCLUSION: 'Scheduled' analgesia with lornoxicam was more effective for treating post-craniotomy pain than 'on request' analgesia with lornoxicam.