Anaesthetic considerations and challenges during awake craniotomy.

ABSTRACT: This article summarises the key anaesthetic considerations and challenges surrounding the perioperative management of a patient undergoing awake craniotomy. The main goals include patient comfort, facilitation of patient cooperation during the critical awake phase and maintenance of optimal operating conditions. These are achieved through appropriate patient selection and preparation, familiarity with the complexity of each surgical phase and potential complications that may arise, as well as maintenance of close communication among all team members. Challenges such as loss of patient cooperation, loss of airway, intraoperative nausea and vomiting, seizures, cerebral oedema, hypertension, blood loss and use of intraoperative magnetic resonance imaging are discussed. The importance of teamwork, competence, vigilance and clear management strategies for potential complications to maximise patient outcomes is also highlighted.

Non-anesthetist-administered moderate sedation with midazolam and fentanyl for outpatient MRI-aided hybrid intracavitary and interstitial brachytherapy in cervix cancer: a single-institution experience.

PURPOSE: The aim of the study was to determine the feasibility of interstitial brachytherapy under non-anesthetist-administered moderate sedation, to identify factors influencing the insertion, and the total procedural time. MATERIAL AND METHODS: A total of 47 insertions with hybrid intracavitary and interstitial applicators were performed in 23 patients from March 2017 to March 2020. Moderate sedation was achieved with intravenous midazolam and fentanyl administered by non-anesthetist. Insertion time and procedural time was recorded. Univariate and multivariate analysis were performed to evaluate the impact of different factors on insertion and procedural time. RESULTS: A total of 238 needles (range, 2-8 per insertion) were implanted, with an average insertion depth of 30 mm (range, 20-40 mm). The mean doses for midazolam and fentanyl were 3 mg (standard deviation [SD] = 1) and 53.3 mcg (SD = 23.9) per insertion, respectively. The median insertion time was 30 minutes (interquartile range [IQR] = 22-40), and the median total procedural time was 4.3 hours (IQR = 3.6-5.2). First time insertion, insertions performed before 2019, and higher midazolam dose were associated with significantly longer insertion time, whereas longer insertion time, MRI-based planning, and insertions performed before 2019 were associated with significantly longer total procedural time. CONCLUSIONS: Outpatient interstitial brachytherapy with non-anesthetist-administered sedation is achievable and well-tolerated. This method may significantly lessen the burden on hospital resources and has the potential to be cost-effective.

Medical student mistreatment by patients in the clinical environment: prevalence and management.

INTRODUCTION: Medical students rely on patients and their families as teachers during the learning journey. However, ill patients and their families may not welcome having students participating in their care, and anecdotal instances of abuse against clinical medical students are not uncommon. We aimed to determine the prevalence of medical student mistreatment by patients and their families and describe students' self-reported responses to such incidents. METHODS: An email link to an anonymised electronic survey form was sent to all clinical students (n = 184) at a Singapore medical school. The first part of the survey sought information on whether the student had previous experiences of mistreatment by patients and their families. If so, the frequency of mistreatment, circumstances when mistreatment happened and students' reactions were collected. In the second part, the students were asked if they knew how to handle such mistreatment incidents. RESULTS: There were a total of 91 respondents, 14.3% of whom had experienced mistreatment by patients and their families in our institution. One-third of the affected students felt fearful or humiliated. However, the majority chose to be passive by saying nothing or moving away. Less than half of the students knew how to handle such incidents or where to seek help. CONCLUSION: Incidents of mistreatment in our school are not uncommon. Our study revealed a need for more clarity and guidance about how students can manage such situations. This is an important topic because such mistreatment is known to inflict emotional disturbance in students. We proposed a workflow to help students deal with mistreatment.

Postoperative nausea and vomiting after craniotomy for tumor surgery: a comparison between awake craniotomy and general anesthesia.

STUDY OBJECTIVE: To assess the frequency of postoperative nausea and vomiting (PONV) in patients following an awake craniotomy compared to general anesthesia for tumor surgery. DESIGN: Prospective observational and chart review of all patients having a craniotomy for tumor during one year. SETTING: Postanesthesia care unit (PACU) and intensive care unit (ICU) of a university hospital. PATIENTS: 187 patients were reviewed. 107 patients who had a craniotomy for supratentorial tumor that was less than six hours in duration were analyzed and compared (50 awake craniotomy vs. 57 general anesthesia). INTERVENTIONS: Medical records were reviewed for events after the first four hours until discharge. The occurrence and the time of any nausea, vomiting; the administration of antiemetics and analgesic drugs; and complications were documented. MEASUREMENTS: Frequency of nausea, vomiting, administration of antiemetics and analgesia, and outcome between the two groups were compared using Chi-square and Student's t-test. MAIN RESULTS: The frequency of nausea (4% vs. 23%; p = 0.012) and vomiting (0% vs. 11%; p = 0.052) were less in patients having an awake craniotomy compared to general anesthesia, but only during the first four hours. The administration of postoperative analgesia was not different between the two groups and did not influence the frequency of PONV. CONCLUSION: The frequency of PONV during the initial recovery phase was less in patients having an awake craniotomy for tumor surgery than in patients having a similar procedure with general anesthesia.