Spine tumor resection among patients who refuse blood product transfusion: a retrospective case series.

STUDY OBJECTIVE: To describe the perioperative blood conservation strategies and postoperative outcomes in patients who undergo complex spinal surgery for tumor resection and who also refuse blood product transfusion. DESIGN: A retrospective case series. SETTING: A single-center, tertiary care and academic teaching hospital in Canada. PATIENTS: All adult patients undergoing elective major spine tumor resection and refusing blood product transfusion who were referred to our institutional Blood Utilization Program between June 1, 2004, and May 9, 2014. MEASUREMENTS: Data on the use of iron, erythropoietin, preoperative autologous blood donation, acute normovolemic hemodilution, antifibrinolytic therapy, cell salvage, intraoperative hypotension, and active warming techniques were collected. Data on perioperative hemoglobin nadir, adverse outcomes, and hospital length of stay were also collected. MAIN RESULTS: Four patients who refused blood transfusion (self-identified as Jehovah's Witnesses) underwent non-emergent complex spine surgery for recurrent chondrosarcoma, meningioma, metastatic adenocarcinoma, and metastatic malignant melanoma. All patients received 1 or more perioperative blood conservation strategy including preoperative iron and/or erythropoietin, intraoperative antifibrinolytic therapy, and cell salvage. No patients experienced severe perioperative anemia (average hemoglobin nadir, 124 g/L) or anemia-related postoperative complications. CONCLUSIONS: Patients who decline blood product transfusion can successfully undergo major spine tumor resection. Careful patient selection and timely referral for perioperative optimization such that the risk of severe anemia is minimized are important for success.

Anesthetic management of patients with acute stroke.

Stroke is a major cause of death and disability. Anesthesiologists are likely to encounter patients with stroke and must be aware of the anesthetic considerations for these patients. Intravenous thrombolysis and intra-arterial thrombolysis are effective treatments for acuteischemic stroke as well as evolving endovascular techniques such as mechanical clot retrieval. Recent retrospective studies have found an association between general anesthesia and poor clinical outcome. The results of these studies have several limitations, and current evidence is inadequate to guide the choice of anesthesia in patients with acute stroke. The choice of anesthesia must be based on individual patient factors until further research is completed.

Acute and chronic pain following craniotomy.

PURPOSE OF REVIEW: The purpose of the review is to describe what is currently known about the mechanisms, incidence and risk factors for acute and chronic postcraniotomy pain. The review will also summarize the evidence supporting the prevention and management of acute and chronic postcraniotomy pain. RECENT FINDINGS: Current studies suggest acute and chronic pain is common in patients after craniotomy. Surgical and patient factors may influence the incidence and severity of pain and a multimodal approach to acute postcraniotomy pain is recommended. Although codeine and tramadol are frequently used in the postoperative period, research suggests morphine provides superior efficacy with a good safety profile. Local anesthesia with nerve blocks has not been shown to consistently reduce acute postoperative pain, though it has recently been demonstrated to dramatically reduce the incidence of chronic pain. Despite this, little is known about the mechanisms, prevention and treatment of chronic postcraniotomy pain. SUMMARY: Acute and chronic pain following craniotomy is frequent and underrecognized. Several surgical and patient risk factors predispose patients to pain following neurosurgery. Further research is needed to determine the mechanisms, predictors, prevention and optimal treatment of acute and chronic pain following craniotomy.