Immediate postoperative complications in transsphenoidal pituitary surgery: a prospective study

Considering the important role of pituitary gland in regulating various endocrine axes and its unique anatomical location, various postoperative complications can be anticipated resulting from surgery on pituitary tumors. We examined and categorized the immediate postoperative complications according to various tumor pathologies. We carried out a prospective study in 152 consecutive patients and noted various postoperative complications during neurosurgical intensive care unit stay [within 48 hrs of hospital stay] in patients undergoing transsphenoidal removal of pituitary tumors. In our series, various groups showed different postoperative complications out of which, cerebrospinal fluid leak was the commonest followed by diabetes insipidus, postoperative nausea and vomiting, and hematoma at operation site. Various immediate postoperative complications can be anticipated in transsphenoidal pituitary surgery even though, it is considered to be relatively safe

Pre-hospital and initial management of head injury patients: an update

Most of the bad outcomes in patients with severe traumatic brain injury [TBI] are related to the presence of a high incidence of pre-hospital secondary brain insults. Therefore, knowledge of these variables and timely management of the disease at the pre-hospital period can significantly improve the outcome and decrease the mortality. The Brain Trauma Foundation guideline on "Prehospital Management" published in 2008 could provide the standardized protocols for the management of patients with TBI; however, this guideline has included the relevant papers up to 2006. A PubMed search for relevant clinical trials and reviews [from 1 January 2007 to 31 March 2013], which specifically discussed about the topic, was conducted. Based on the evidence, majority of the management strategies comprise of rapid correction of hypoxemia and hypotension, the two most important predictors for mortality. However, there is still a need to define the goals for the management of hypotension and inclusion of newer difficult airway carts as well as proper monitoring devices for ensuring better intubation and ventilatory management. Isotonic saline should be used as the first choice for fluid resuscitation. The pre-hospital hypothermia has more adverse effects; therefore, this should be avoided. Most of the management trials published after 2007 have focused mainly on the treatment as well as the prevention strategies for secondary brain injury. The results of these trials would be certainly adopted by new standardized guidelines and therefore may have a substantial impact on the pre-hospital management in patients with TBI

General intensive care for patients with traumatic brain injury: an update

Traumatic brain injury [TBI] is a growing epidemic throughout the world and may present as major global burden in 2020. Some intensive care units throughout the world still have no access to specialized monitoring methods, equipments and other technologies related to intensive care management of these patients; therefore, this review is meant for providing generalized supportive measurement to this subgroup of patients so that evidence based management could minimize or prevent the secondary brain injury. Therefore, we have included the PubMed search for the relevant clinical trials and reviews [from 1 January 2007 to 31 March 2013], which specifically discussed about the topic. General supportive measures are equally important to prevent and minimize the effects of secondary brain injury and therefore, have a substantial impact on the outcome in patients with TBI. The important considerations for general supportive intensive care unit care remain the prompt reorganization and treatment of hypoxemia, hypotension and hypercarbia. Evidences are found to be either against or weak regarding the use of routine hyperventilation therapy, tight control blood sugar regime, use of colloids and late as well as parenteral nutrition therapy in patients with severe TBI. There is also a need to develop some evidence based protocols for the health-care sectors, in which there is still lack of specific management related to monitoring methods, equipments and other technical resources. Optimization of physiological parameters, understanding of basic neurocritical care knowledge as well as incorporation of newer guidelines would certainly improve the outcome of the TBI patients.

Specific intensive care management of patients with traumatic brain injury: present and future

Traumatic brain injury [TBI] is a major global problem and affects approximately 10 million peoples annually; therefore has a substantial impact on the health-care system throughout the world. In this article, we have summarized various aspects of specific intensive care management in patients with TBI including the emerging evidence mainly after the Brain Trauma Foundation [BTF] 2007 and also highlighted the scope of the future therapies. This review has involved the relevant clinical trials and reviews [from 1 January 2007 to 31 March 2013], which specifically discussed about the topic. Though, BTF guideline based management strategies could provide standardized protocols for the management of patients with TBI and have some promising effects on mortality and morbidity; there is still need of inclusion of many suggestions based on various published after 2007. The main focus of majority of these trials remained to prevent or to treat the secondary brain injury. The future therapy will be directed to treat injured neurons and may benefit the outcome. There is also urgent need to develop some good prognostic indicators as well.

Early brain injury and subarachnoid hemorrhage: where are we at present?

The current era has adopted many new innovations in nearly every aspect of management of subarachnoid hemorrhage [SAH]; however, the neurological outcome has still not changed significantly. These major therapeutic advances mainly addressed the two most important sequels of the SAH-vasospasm and re-bleed. Thus, there is a possibility of some different pathophysiological mechanism that would be responsible for causing poor outcome in these patients. In this article, we have tried to compile the current role of this different yet potentially treatable pathophysiological mechanism in post-SAH patients. The main pathophysiological mechanism for the development of early brain injury [EBI] is the apoptotic pathways. The macro-mechanism includes increased intracranial pressure, disruption of the blood-brain barrier, and finally global ischemia. Most of the treatment strategies are still in the experimental phase. Although the role of EBI following SAH is now well established, the treatment modalities for human patients are yet to be testified

Neuroanesthetic considerations for emergent extracranial surgeries: What to know?

Neuroanaesthetic considerations in non neurosurgical cases are utmost important for the optimal management of such cases. These considerations become even more challenging in patients undergoing emergency surgeries. We have highlighted the neuroanesthetic considerations for three broad categories. The two most important considerations in this type of surgery will be the avoidance of secondary brain insult and maintenance of optimal cerebral perfusion pressure

Comparison of propofol versus sevoflurane on thermoregulation in patients undergoing transsphenoidal pituitary surgery: a preliminary study

General anesthesia causes inhibition of thermoregulatory mechanisms. Propofol has been reported to cause more temperature fall, but in case of deliberate mild hypothermia, both sevoflurane and propofol were comparable. Thermoregulation is found to be disturbed in cases of pituitary tumors. We aimed to investigate which of the two agents, sevoflurane or propofol, results in better preservation of thermoregulation in patients undergoing transsphenoidal excision of pituitary tumors. Twenty-six patients scheduled to undergo transsphenoidal removal of pituitary adenomas were randomly allocated to receive propofol or sevoflurane anesthesia. Baseline esophageal temperature was noted. Times for temperature to fall by 1[degree sign] C or 35[degree sign] C and to return to baseline were also comparable [P>0.05]. After that warmer was started at 43[degree sign] C and time to rise to baseline was noted. Duration of surgery, total blood loss, and total fluid intake were also noted. If any, side effects such as delayed arousal and recovery from muscle relaxant were noted. The demographics of the patients were comparable. Duration of surgery and total blood loss were comparable in the two groups. The time for temperature to fall by 1[degree sign] C or 35[degree sign] C and time to return to baseline was also comparable [P>0.05]. No side effects related to body temperature were noted. Both propofol and sevoflurane show similar effects in maintaining thermal homeostasis in patients undergoing transsphenoidal pituitary surgery