Innovative (and Safe) Techniques With Supraglottic Airways.

ABSTRACT: Supraglottic airways have been utilized as an alternative to facemask ventilation and endotracheal intubation and thus have been essential to airway management since their introduction in the late 1980s. This chapter describes basic considerations in their use and an update on current clinical practice, with an emphasis on safe management. The devices have evolved to meet today's clinical airway challenges, and they provide benefits for patients and practitioners.

Scalp nerve blockade reduces pain after headframe placement in radiosurgery: a double blind, randomized clinical trial.

BACKGROUND: Patients undergoing stereotactic headframe placement for radiosurgery report that discomfort associated with the headframe often lasts for the duration of the treatment day (approximately 6 hours). We hypothesize that blockade of scalp nerves prior to headframe placement reduces the incidence of moderate to severe head pain during the entire treatment day. We describe a randomized, double-blind, placebo-controlled study of awake patients having radiosurgery for intracranial pathology that examines whether scalp nerve blockade and local anesthetic infiltration results in superior patient comfort versus infiltration alone. METHODS: Twenty seven adult patients undergoing stereotactic radiosurgery were randomized to receive a nerve block with placebo or bupivacaine 0.5% with epinephrine. Supraorbital and greater occipital nerve blocks using blinded syringes were performed by the anesthesiologist in addition to subcutaneous infiltration of pin sites with lidocaine 1% by the surgeon. Pain was reported using 10 cm visual analog scales (VAS) at pre-specified time points during the treatment day. The primary outcome measure was the presence of pain scores classified as "zero to mild pain (VAS <4)" or "moderate to severe pain (VAS > or = 4)". RESULTS: 27 patients were randomized to placebo (n = 14) and nerve block (n = 13) groups. The proportion of moderate to severe pain measurements were significantly less in the nerve block group than the placebo group (4.9% vs. 24.1%; odds ratio, 0.166; 95% confidence interval 0.029-0.955; p = 0.044). There were no adverse events. CONCLUSION: Scalp nerve block significantly decreased moderate to severe head pain in radiosurgery patients throughout the treatment day.

Younger age at intracranial aneurysms rupture among patients with opioid use disorders.

BACKGROUND: Association between opioid abuse and intracranial aneurysms rupture has been suggested in recent studies. However, these observations are limited to single center studies and could be benefited from validation in larger cohorts. Hence, we aimed to study the association between age at aneurysmal subarachnoid hemorrhage (aSAH) and opioid use disorders (OUD) using a large, national database. METHODS: This study was conducted using the 2016 and 2017 National Inpatient Sample (NIS) with ICD-10 codes. Cohorts were categorized as "Non-users", "OUD", and "Multi-drug users". Linear regression models were used to examine the association between OUD and multi-drug users with age at aneurysm rupture, and multiple logistic regression models were used for the association between in-hospital mortality and drug abuse. RESULTS: A total of 17,391 patients with aSAH were captured in the 2016 and 2017 NIS database. Out of these patients, 235 (1.4%) were included in the OUD group and 59 (0.3%) in the multi-drug users' group. Adjusted linear regression showed an unstandardized coefficient (UC) = -12.3 [95%CI = -14.4/-10.1, p < 0.001] for OUD patients and an UC = -16.8 [95%CI = -21.1/-12.5, p < 0.001] for multi-drug users, compared to non-users. The risk of in-hospital mortality was significantly increased in drug user, OR = 1.47 [95%CI: 1.1-2.01, p = 0.017] for OUD patients, and OR = 2.35 [95%CI: 1.35-4.11, p = 0.003] for multi-drug users. CONCLUSIONS: This is the first national study to examine the association between age at intracranial aneurysms rupture and opioid abuse. aSAH patients with history of OUD were 12 years younger compared to non-users, when OUD was combined with other drugs, the age at aneurysms rupture was 17 years younger. Further elucidation regarding the mechanisms by which opioids triggers aneurysms rupture and predispose to worsen outcomes following aSAH is required, as well as appropriate prevention, and management strategies for aSAH patients with OUD.

Jaw Elevation Device: Tool for Neck Immobilization to Facilitate Recovery in Endovascular Thrombectomy via Transcervical Access.

BACKGROUND: Acute stroke resolution via endovascular thrombectomy requires transcarotid access when transfemoral access is not possible. Although postoperative complications such as cervical hematoma and airway compression have been reported, an appropriate postprocedural management is largely unknown yet. We aim to provide new insights and learning points from our experience using the Jaw Elevation Device (JED) as a tool to facilitate recovery post surgery. CASE DESCRIPTION: A 79-year-old female underwent endovascular thrombectomy via transcervical, transcarotid access for a left internal carotid artery occlusion. No intraprocedural complications were reported. After successful thrombectomy, manual compression was applied in the carotid artery, and to achieve neck immobilization a JED was used for 4 hours after the procedure. No complications occurred. CONCLUSIONS: JED appears to be a reasonable option to facilitate patient recovery due to its capacity to maintain the airway, provide mild compression for hemostasis, and prevent cervical hematoma through a comfortable neck immobilization.

Neuroanesthesia at The Mount Sinai Hospital.

The practice of neuroanesthesia at the Mount Sinai Medical Center focused initially on clinical practice, followed by specialization. This article presents a brief history of the division and a description of the areas of interest, presentations, and publications that have originated there.

A prospective emergency department-based study of pattern and outcome of neurologic and neurosurgical diseases in Haiti.

OBJECTIVE: To perform the first prospective survey of neurologic and neurosurgical emergency department (ED) admissions in Haiti. METHODS: Data of all ED admissions at 3 Haitian hospitals for 90 consecutive days per site were collected prospectively. Patients who were given a diagnosis of a neurologic or neurosurgical disorder by the ED physician were entered in a deidentified database including demographics, presenting symptoms, brain imaging (when available), requests for neurosurgical consultation, and outcome. RESULTS: Of the 7628 patients admitted to the ED during this study, 1243 patients had a neurologic disorder, yielding an ED-based neurologic disease prevalence of 16%. The 3 most common neurologic diseases were cerebrovascular disease (31%), neurotrauma (28%), and altered mental status (12%). Neurosurgical pathologies represented 19% of all neurologic admissions with a combined ED-based disease prevalence of 3%. Mortality rate was 9%. The most common neurosurgical disease was neurotrauma (87%), caused by motor vehicle accidents (59%), falls (20%), and assault (17%). Neurosurgical procedures were performed in 14 of 208 patients with a mortality rate of 33%. CONCLUSIONS: This prospective survey represents the first study of neurosurgical or neurologic disease patterns in Haiti. The results suggest specific disease priorities for this population that can guide efforts to improve Haitian health care and conduct more comprehensive epidemiologic studies in Haiti.

Percutaneous radiofrequency ablation of hepatocellular lesions in segment II of the liver: a risk factor for cardiac tamponade.

Percutaneous radiofrequency ablation (PRFA) is a minimally invasive procedure used for the treatment of small hepatocellular carcinomas. PRFA is regarded as a much safer alternative to surgical resection or orthotopic liver transplantation. However, serious complications, including cardiac tamponade, have been reported. Two cases of severe cardiac tamponade during PRFA were successfully treated.

Neuroimaging for the anesthesiologist.

This article provides an overview of neuroimaging modalities of particular interest to the anesthesiologist caring for neurosurgical patients. Imaging characteristics of neuropathologies and considerations for anesthetic management of diagnostic procedures are discussed.

Pallidal deep brain stimulation for primary dystonia in children.

BACKGROUND: Deep brain stimulation (DBS) at the internal globus pallidus (GPi) has replaced ablative procedures for the treatment of primary generalized dystonia (PGD) because it is adjustable, reversible, and yields robust clinical improvement that appears to be long lasting. OBJECTIVE: To describe the long-term responses to pallidal DBS of a consecutive series of 22 pediatric patients with PGD. METHODS: Retrospective chart review of 22 consecutive PGD patients, ≤21 years of age treated by one DBS team over an 8-year period. The Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) was used to evaluate symptom severity and functional disability, pre- and post-operatively. Adverse events and medication changes were also noted. RESULTS: The median follow-up was 2 years (range, 1-8 years). All 22 patients reached 1-year follow-up; 14 reached 2 years, and 11 reached 3 years. The BFMDRS motor subscores were improved 84%, 93%, and 94% (median) at these time points. These motor responses were matched by equivalent improvements in function, and the response to DBS resulted in significant reductions in oral and intrathecal medication requirements after 12 and 24 months of stimulation. There were no hemorrhages or neurological complications related to surgery and no adverse effects from stimulation. Significant hardware-related complications were noted, in particular, infection (14%), which delayed clinical improvement. CONCLUSION: Pallidal DBS is a safe and effective treatment for PGD in patients <21 years of age. The improvement appears durable. Improvement in device design should reduce hardware-related complications over time.

"Scalp block" during craniotomy: a classic technique revisited.

Local anesthesia of the nerves of the scalp is referred to as "scalp block." This technique was originally introduced more than a century ago, but has undergone a modern rebirth in intraoperative and postoperative anesthetic management. Here, we review the use of "scalp block" during craniotomy with its anatomic basis, historical evolution, current technique, potential advantages, and pitfalls. We also address its current and potential future applications.

Anesthesia for pediatric deep brain stimulation.

In patients refractory to medical therapy, deep brain stimulations (DBSs) have emerged as the treatment of movement disorders particularly Parkinson's disease. Their use has also been extended in pediatric and adult patients to treat epileptogenic foci. We here performed a retrospective chart review of anesthesia records from 28 pediatric cases of patients who underwent DBS implantation for dystonia using combinations of dexmedetomidine and propofol-based anesthesia. Complications with anesthetic techniques including airway and cardiovascular difficulties were analyzed.

Magnetic resonance imaging anesthesia: new challenges and techniques.

PURPOSE OF REVIEW: The increasing use of magnetic resonance imaging as a diagnostic modality has led to increased demand for sedation and monitoring during the procedure. This review is to acquaint the reader with the most recent developments in magnetic resonance imaging diagnostics and to describe the evolving techniques and strategies for patient management. RECENT FINDINGS: Many centers are meeting the challenges of increasing demand by streamlining their sedation/anesthetic protocols to achieve greater efficiency. Some have enlisted the help of nursing staff who are trained to provide sedation for certain patients. Continued experience in magnetic resonance imaging anesthesia has led to a better understanding of patient needs and decreased the number of failed procedures. The scope of magnetic resonance imaging diagnostics has expanded to include urology, otolaryngology, and neonatal evaluation. Although infants and children constitute the majority of patients, many adults also require anesthesia for magnetic resonance imaging and present their own challenges. SUMMARY: Anesthesia and sedation during magnetic resonance imaging have a unique set of constraints. However, most of the standards of modern, safe anesthetic care can be met in this environment. The growing experience at many hospitals has demonstrated that a wide range of patients can receive safe care during magnetic resonance imaging.