Effect of bilateral scalp nerve blocks on postoperative pain and discharge times in patients undergoing supratentorial craniotomy and general anesthesia: a randomized-controlled trial.

PURPOSE: Post-craniotomy pain is a common clinical issue and its optimal management remains incompletely studied. Utilization of a regional scalp block has the potential advantage of reducing perioperative pain and opioid consumption, thereby facilitating optimal postoperative neurologic assessment. The purpose of this study was to assess the efficacy of regional scalp block on post-craniotomy pain and opioid consumption. METHODS: We performed a prospective randomized-controlled trial in adults scheduled to undergo elective supratentorial craniotomy under general anesthesia to assess the efficacy of postoperative bilateral scalp block with 0.5% bupivacaine with 1:200,000 epinephrine compared with placebo on postoperative pain and opioid consumption. The primary outcome was the visual analogue scale (VAS) for pain at 24 hr postoperatively. RESULTS: Eighty-nine patients were enrolled (n = 44 in block group; n = 45 in control group). There was no difference in the mean (standard deviation) VAS score at 24 hr postoperatively between the treatment group and the control group [31.2 (21.4) mm vs 23.0 (19.2) mm, respectively; mean difference, 6.6; 95% confidence interval, -2.3, 15.5; P = 0.15]. There was also no significant difference in postoperative opioid consumption. Distribution of individual VAS score and opioid consumption revealed that postoperative pain was highly variable following craniotomy. Time to hospital discharge was not different between treatment and placebo groups. No adverse events associated with scalp block were identified. CONCLUSION: These data show that bilateral scalp blocks using bupivacaine with epinephrine did not reduce mean postoperative VAS score or overall opioid consumption at 24 hr nor the time-to-discharge from the postanesthesia care unit or from hospital. TRIAL REGISTRATION: www.ClinicalTrials.gov, NCT00972790; registered 9 September, 2009.

Anesthetic approach to high-risk patients and prolonged awake craniotomy using dexmedetomidine and scalp block.

BACKGROUND: Awake craniotomy with intraoperative speech or motor testing is relatively contraindicated in cases requiring prolonged operative times and in patients with severe medical comorbidities including anxiety, anticipated difficult airway, obesity, large tumors, and intracranial hypertension. The anesthetic management of neurosurgical patients who possess these contraindications but would be optimally treated by an awake procedure remains unclear. METHODS: We describe a new anesthetic approach for awake craniotomy that did not require any airway manipulation, utilizing a bupivacaine-based scalp nerve block, and dexmedetomidine as the primary hypnotic-sedative agent. Using this technique, we provided optimal operative conditions to perform awake craniotomy facilitating safe tumor resection, while utilizing intraoperative electrocorticography for motor and speech mapping in a cohort of 10 patients at a high risk for airway compromise and complications associated with patient comorbidities. RESULTS: All patients underwent successful awake craniotomy, intraoperative mapping, and tumor resection with adequate sedation for up to 9 hours (median 3.5 h, range 3 to 9 h) without any loss of neurological function, airway competency, or the need to provide any active rescue airway management. We report 4 of these cases that highlight our experience: 1 case required prolonged surgery because of the complexity of tumor resection and 3 patients had important medical comorbidities and/or relative contraindication for an awake procedure. CONCLUSIONS: Dexmedetomidine, with concurrent scalp block, is an effective and safe anesthetic approach for awake craniotomy. Dexmedetomidine facilitates the extension procedure complexity and duration in patients who might traditionally not be considered to be candidates for this procedure.

Rehabilitation outcomes after anoxic brain injury: a case-controlled comparison with traumatic brain injury.

OBJECTIVE: To investigate the functional outcomes of patients with anoxic brain injury (AnBI) compared with control patients with traumatic brain injury (TBI) during inpatient rehabilitation. DESIGN: Matched case-controlled design. SETTING: Inpatient neurorehabilitation program. PARTICIPANTS: Fifteen patients with AnBI and 15 patients with TBI. METHODS: Data of 15 patients with a primary diagnosis of AnBI were retrospectively reviewed and matched to 15 patients with TBI admitted within the same time frame on age, acute care length of stay, and functional status at admission. MAIN OUTCOME MEASURE: Functional outcome was assessed by the use of the Functional Independence Measure (FIM). RESULTS: Compared with the control patients with TBI, patients with AnBI achieved significantly lower FIM motor gain (16.3+/-15.6 versus 5.7+/-10.7, respectively) and efficiency scores (0.27+/-0.28 versus 0.06+/-0.13), discharge FIM cognition scores (25.9+/-5.9 versus 21.7+/-7.3), total FIM gain (22.5+/-19.6 versus 9.1+/-12.1), and total FIM efficiency scores (0.39+/-0.38 versus 0.10+/-0.16; all P<.05). CONCLUSIONS: Results suggest a slower rate of recovery for patients with AnBI compared with TBI, with physical recovery being slower than cognitive recovery as measured by the FIM during inpatient rehabilitation when matched according to preinjury characteristics and functional status at rehabilitation admission. Future studies on larger samples of patients with AnBI and TBI that use a case-controlled design and longer-term outcome measurement are warranted to further clarify the differences in functional outcomes between these groups and to assess whether optimal rehabilitation interventions differ for these groups.

Are accurate witnesses more likely to make absolute judgments?

The present study tested the Two-Judgment Theory of Eyewitness Identification Accuracy. Specifically, the extent to which participants were able to engage in an absolute judgment strategy was manipulated by varying the time available to view a lineup. Providing a limited exposure to a lineup should "interrupt" decision making, whereby witnesses can only engage a relative strategy, thus leading to higher false positive responding given a target-absent lineup. Seventy-four adults viewed a 1-minute video that exposed them to an unknown target and subsequently viewed the lineup for a limited (2 s) or an unlimited amount of time. Although false positive rates were similar across conditions, accurate witnesses were more confident than inaccurate witnesses. Confidence was negatively correlated with response latency such that witnesses who took more time to make a decision were less confident in their decisions compared to witnesses who made more rapid decisions. Response latency did not differ for accurate and inaccurate witnesses. Limitations and suggestions for future research on the Two-Judgment Theory are discussed.

Does methodology matter in eyewitness identification research? The effect of live versus video exposure on eyewitness identification accuracy.

The present study examined the effect of mode of target exposure (live versus video) on eyewitness identification accuracy. Adult participants (N=104) were exposed to a staged crime that they witnessed either live or on videotape. Participants were then asked to rate their stress and arousal levels prior to being presented with either a target-present or -absent simultaneous lineup. Across target-present and -absent lineups, mode of target exposure did not have a significant effect on identification accuracy. However, mode of target exposure was found to have a significant effect on stress and arousal levels. Participants who witnessed the crime live had higher levels of stress and arousal than those who were exposed to the videotaped crime. A higher level of arousal was significantly related to poorer identification accuracy for those in the video condition. For participants in the live condition however, stress and arousal had no effect on eyewitness identification accuracy. Implications of these findings in regards to the generalizability of laboratory-based research on eyewitness testimony to real-life crime are discussed.