Brain Regional Energy Metabolism in Patients with Traumatic Brain Injury: A Cerebral Microdialysis Guided Study.

BACKGROUND: In traumatic brain injuries (TBI), cerebral microdialysis (CMD)-derived parameters, especially the lactate to pyruvate ratio (LP ratio), have been utilized for cerebral perfusion optimization. The objectives were to identify cerebral ischemia as measured by CMD in TBI patients requiring decompressive craniectomy and to observe the correlation between cerebral perfusion pressure (CPP), intracranial pressure (ICP), and CMD variables in these patients. Our secondary aim was to observe the effect of CPP augmentation on ischemia biomarkers. METHODS: After the Institute Ethics Committee approvals, seven adult patients requiring decompressive craniectomy following TBI were enrolled and CMD data were obtained prospectively for 72 h. CPP was augmented by 20% with noradrenaline infusion if LP ratio >40. Correlations were done with bootstrapping (n = 500) to obtain the confidence intervals (CI) due to the small sample size. RESULTS: One patient had cerebral ischemia (median LP ratio of 265.5 and median pyruvate of 38 µmol/L), while another patient had non-ischemic mitochondrial dysfunction (median LP ratio 40.7 and median pyruvate 278.5). The coefficients of correlation between the LP ratio with CPP and ICP were r = -0.05 (CI = -0.14-0.03) and r = 0.09 (CI = -0.03-0.24), respectively. The coefficient of correlation between cerebral and blood glucose was r = 0.38, (CI - 0.35-0.14). Only two patients needed CPP augmentation, however, postaugmentation cerebral biochemistry did not change appreciably. CONCLUSION: CMD can identify cerebral ischemia, however, no correlations were observed between the LP ratio and CPP or ICP. CPP augmentation did not improve cerebral biochemistry. More studies are required to understand and treat cerebral metabolism in TBI.

Perioperative Management of Pediatric Brain Tumors: A Retrospective Analysis.

Background: Brain tumors are the second most common malignancy in childhood and the surgical excision remains the cornerstone of management. The objective of this study was to analyze the factors associated with the length of intensive care unit (ICU) and hospital stay, and postoperative outcome in such children. Materials and Methods: Three years of data were collected, retrospectively, by detailed review of medical records pertaining to pre-anesthetic evaluation and perioperative course of children less than 16 years of age who underwent excision of intracranial tumors. Results: One hundred sixty-eight medical records were analyzed. One third of the children were found to have developed various intraoperative adverse events; the most common were hemodynamic changes following brainstem handling and brain swelling. 58% of children required postoperative mechanical ventilation. 82.7% of patients had favorable neurologic outcome which was comparable between the two tumor locations (supratentorial vs infratentorial). On multivariate analysis, re-exploration surgery and electrolyte disturbances, such as serum sodium, were found to be the independent risk factors affecting hospital stay. The amount of intraoperative blood loss and postoperative pulmonary complications (POPCs) were independent risk factors affecting the neurologic outcome. Conclusions: Adverse events are fairly common after excision of brain tumors in children. Intraoperative complications did not affect the ICU stay or neurological outcome; however, the postoperative complications increased length of ICU and hospital stays. POPC was the single most important factor responsible for poor neurologic outcome and was more so in children who underwent infratentorial surgery, prolonged mechanical ventilation, and who had a lower cranial nerve palsy.

Effect of Goal-Directed Intraoperative Fluid Therapy on Duration of Hospital Stay and Postoperative Complications in Patients Undergoing Excision of Large Supratentorial Tumors.

Background: Optimal fluid management during neurosurgery is controversial. Evidences suggest that goal-directed fluid therapy (GDFT) can improve postoperative outcome. This study aimed to assess the intraoperative use of GDFT on the duration of hospital stay and postoperative complications in patients undergoing craniotomy for large supratentorial tumors. Materials and Methods: Forty patients of 18-65 years age undergoing large supratentorial tumor surgery were prospectively randomized into two groups. Control-group received fluid regimen based on routine hemodynamic monitoring, whereas patients belonging to GDFT group received fluid based on stroke volume variation (SVV)-guided therapy. A colloid bolus of 250 ml 6% hydroxyl ethyl starch was given, if the SVV was more than 12% in the GDFT group. Hemodynamic parameters, such as blood pressure and heart rate, and dynamic parameters, such as cardiac index, stroke volume index, and SVV, were recorded at different time intervals. Results: The total amount of fluid required was significantly lower in GDFT (P = 0.003) group as compared to the Control group. Intraoperative complications were significantly lower in GDFT group (P = 0.005), but the incidence of tight brain was significantly higher in the control group. The duration of hospital stay (P = 0.07) and incidence of postoperative complications (P = 0.32) were lower in GDFT group. Neurological outcomes at-discharge were similar in both the groups. Conclusions: This study did not show any benefit of GDFT over conventional intraoperative fluid therapy in terms of incidence of postoperative complications, hospital and ICU stay, and Glasgow outcome scores at-discharge in patients undergoing craniotomy for excision of large supratentorial tumors. However, the use of GDFT leads to better perioperative fluid management and brain relaxation scores. Clinical Trial Registry: CTRI/2016/10/007350.

Human errors and their prevention in healthcare.

Human errors form a significant portion of preventable mishaps in healthcare. Even the most competent clinicians are not immune to it. Errors in the perioperative period can often have grave consequences, and hence, perioperative clinicians need to be aware of the impact of human errors and how to minimize them. Errors are broadly classified into two kinds: latent and active errors. While active errors need to be addressed at the individual level, latent errors indicate organizational inadequacies. This review describes common errors in perioperative settings, the impact of such errors on healthcare, and preventive strategies to minimize such errors in daily patient care.

Brain Death Diagnosis for Potential Organ Donors During the Covid-19 Pandemic.

Formal brainstem reflex testing remains one of the most important procedures in identification and evaluation of patients who meet clinical criteria for brainstem death. Early identification of such patients is critical since willing donors may contribute to the organ donation process. During the first two waves of the coronavirus disease of 2019 (COVID-19) pandemic, organ transplantation from brainstem dead donors has declined significantly due to several reasons, including perceived increased risk of virus transmission to both physicians as well as patients as well as lack of awareness regarding donor workup in the context of the COVID-19 pandemic.

Neuroanesthesia Practice During the COVID-19 Pandemic: Recommendations From Society for Neuroscience in Anesthesiology and Critical Care (SNACC).

The pandemic of coronavirus disease 2019 (COVID-19) has several implications relevant to neuroanesthesiologists, including neurological manifestations of the disease, impact of anesthesia provision for specific neurosurgical procedures and electroconvulsive therapy, and health care provider wellness. The Society for Neuroscience in Anesthesiology and Critical Care appointed a task force to provide timely, consensus-based expert guidance for neuroanesthesiologists during the COVID-19 pandemic. The aim of this document is to provide a focused overview of COVID-19 disease relevant to neuroanesthesia practice. This consensus statement provides information on the neurological manifestations of COVID-19, advice for neuroanesthesia clinical practice during emergent neurosurgery, interventional radiology (excluding endovascular treatment of acute ischemic stroke), transnasal neurosurgery, awake craniotomy and electroconvulsive therapy, as well as information about health care provider wellness. Institutions and health care providers are encouraged to adapt these recommendations to best suit local needs, considering existing practice standards and resource availability to ensure safety of patients and providers.

Anesthetic Management of an Adolescent with Hypofibrinogenemia Posted for Cervical Deformity Correction!

A 15-year-old boy diagnosed as case of cervical kyphosis, atlantoaxial dislocation, and hypofibrinogenemia was posted for corrective surgery under general anesthesia. His preoperative plasma fibrinogen levels and other coagulation profile were deranged. He was diagnosed with type 1 congenital fibrinogen abnormality, that is, hypofibrinogenemia. Preoperative blood products including cryoprecipitates were transfused to correct fibrinogen levels and coagulation profile. Cryoprecipitate was transfused at the dose of 1 bag per 10kg body weight per day. During intraoperative period, blood products were transfused following blood loss of 1100mL. Postoperatively the repeat laboratory investigations after 20 h revealed normal PF levels (211 mg/dL) with normal coagulation profile. He was discharged five days later with the uncomplicated postoperative course.

The path to safe and accessible anaesthesia care.

The increasing focus on and importance of surgical care in achieving universal health coverage requires the development of safe and accessible anaesthesia services. Increasing access to care by supporting the necessary inputs to the anaesthesia system, including medications, equipment and personnel, must be accompanied by processes that support high-quality care, including support for education, and guidelines for standards, and training. As safe, high-quality care requires an integrated approach, each element must be supported together, i.e., in an integrated manner to ensure that anaesthesia care reaches those who need it, and in the safest possible manner. Several important efforts have been undertaken globally to address and foster these elements, and resources to guide these processes exist for low- and middle-income countries to improve them. This review highlights both the needs and resources for safe and high-quality care that patients deserve.

Intracranial Pressure Monitoring in Children with Severe Traumatic Brain Injury: A Retrospective Study.

INTRODUCTION: There is a paucity of literature on intracranial pressure (ICP) monitoring in children. The aim of this study was to ascertain whether ICP monitoring is useful in children with severe traumatic brain injury (TBI). MATERIALS AND METHODS: Medical records of children between 1 and 12 years, admitted to neurocritical care unit with severe TBI in 2 years, were reviewed. The children were divided into two groups: study group (ICP monitored) and control group (ICP not monitored). Admission demographics, vital parameters, and computed tomographic scan findings were recorded. In the study group, date of ICP catheter insertion/removal with ICP values and treatment carried out for increased ICP were noted. Data on tracheostomy, duration of mechanical ventilation, hospital stay, and outcome at discharge were noted. RESULTS: Demographic variables were comparable between the two groups. When adjusted for death, no significant difference was observed between the study and the control groups in median duration of mechanical ventilation: 35 days (95% confidence interval [CI]: 12-73) versus 55 days (95% CI: 29-55) (P = 0.96), hospital stay: 36 days (95% CI: 12-73) versus 58 days (95% CI: 29-58) (P = 0.96), and time to tracheostomy: 6 days (95% CI: 5-8) versus 5 days (95% CI: 4-7) (P = 0.49). Mortality rates, incidence of cranial surgeries, and outcome at discharge were also comparable. CONCLUSION: ICP monitoring did not reduce the incidence of death, cranial surgeries, duration of mechanical ventilation, hospital stay, or improve the outcome at discharge in children with severe TBI.

Non- Neurological Complications after Traumatic Brain Injury: A Prospective Observational Study.

INTRODUCTION AND AIMS: Recognizing and treating nonneurological complications occurring in traumatic brain injury (TBI) patients during intensive care unit (ICU) stay are challenging. The aim is to estimate various nonneurological complications in TBI patients. The secondary aim is to see the effect of these complications on ICU stay, disability, and mortality. MATERIALS AND METHODS: This was a prospective observational study at the neuro-ICU of a Level-I trauma center. A total of 154 TBI patients were enrolled. The period of the study was from admission to discharge from ICU or demise. Inclusion criteria were patients aged >16 years and patients with severe TBI (Glasgow coma score [GCS] ≤8). Nonneurological complications were frequent in TBI patients. RESULTS: We observed respiratory complications to be the most common (61%). Other complications, in the decreasing order, included dyselectrolytemia (46.1%), cardiovascular (34.4%), coagulopathy (33.1%), sepsis (26%), abdominal complications (17.5%), and acute kidney injury (AKI, 3.9%). The presence of systemic complications except AKI was found to be significantly associated with increased ICU stay. Most of the patients of AKI died early in ICU. Respiratory dysfunction was found to be independently associated with 3.05 times higher risk of worsening clinical condition (disability) (P < 0.018). The presence of cardiovascular complications during ICU stay (4.2 times, P < 0.005), AKI (24.7 times, P < 0.02), coagulopathy (3.13 times, P < 0.047), and GCS <6 (4.2 times, P < 0.006) of TBI was independently associated with significantly increased risk of ICU mortality. CONCLUSION: TBI patients tend to have poor outcome due to concomitant nonneurological complications. These have significant bearing on ICU stay, disability, and mortality.

Anesthetic Considerations for Ventriculoatrial Shunt Insertion in a Child with Cerebrospinal Fluid Ascites.

Cerebrospinal fluid (CSF) ascites is a rare complication of ventriculoperitoneal shunt, where CSF accumulates in the peritoneal cavity as a result of defective absorption. Alternate CSF diversion procedure such as ventriculoatrial (VA) shunt is another way of managing this complication. Although there are reports published on this condition, the scientific literature hardly discussed the anesthetic management in such scenario. Here, we describe such a case with particular attention to perioperative management during VA shunt insertion for CSF ascites.

Pediatric neuroanesthesia.

PURPOSE OF REVIEW: Pediatric neuroanesthesia is a fascinating, yet challenging branch of anesthesia. This review highlights some of the recent insights into pediatric neuroanesthesia from the past 18 months. RECENT FINDINGS: Although there are incontrovertible evidences in animals suggesting that prolonged exposure to general anesthesia causes long-term neurological impairment, the translational relevance of these findings in humans is debatable. Early surgery for pediatric drug-refractory epilepsy is supported by emerging literature, but poses unique perioperative problems for the treating neuroanesthesiologist. Similarly, minimizing intraoperative blood loss and blood transfusion concerns every anesthesiologist managing small children. The usefulness of tranexamic acid in children is further enhanced by some studies in spine surgeries. Some pertinent issues related to intraoperative neuromonitoring are also discussed in the text. SUMMARY: There are several logistical and ethical problems of carrying out high-quality prospective studies in children but important findings on prevention of anesthetic neurotoxicity; minimizing intraoperative blood loss, intraoperative neurophysiological monitoring, examining optimal doses and choices of anesthetic agents in epilepsy surgery have been published recently.

Complications related to sitting position during Pediatric Neurosurgery: An institutional experience and review of literature.

BACKGROUND: Sitting position is preferred during posterior fossa surgeries as it provides better anatomical orientation and a clear surgical field. However, its use has been declining due to its propensity to cause life-threatening complications. This study was carried out to analyze the perioperative complications and postoperative course of children who underwent neurosurgery in sitting position. MATERIALS AND METHODS: Medical records of 97 children (<18 years) who underwent neurosurgery in sitting position over a period of 12 years, were retrospectively analyzed. Data pertaining to the perioperative course such as demographics, hemodynamic changes, various complications, duration of intensive care unit (ICU) and hospital stay, and neurological status at discharge were recorded. Statistical analysis was done by chi-square and Mann-Whitney test, and a P value <0.05 was considered as significant. RESULTS: The median age of these children was 12 (3-18) years. Hemodynamic instability was observed in 12 (12.3%) children. A total of 38 episodes of venous air embolism (VAE) were encountered in 21 (21.6%) children; nine experienced multiple episodes. VAE was associated with hypotension in five (23.8%) and desaturation in four (19.1%) children. Six children presented with postoperative tension pneumocephalus; three were managed with twist drill burr-hole evacuation. Brainstem handling was the most common indication (42.5%) for the requirement of elective postoperative ventilation. The duration of ICU and hospital stays were comparable among the children who experienced VAE and those who did not (P > 0.05). Neurological status at discharge was also comparable between these two groups (P = 0.83). CONCLUSIONS: This study observed a lesser incidence of VAE and associated complications. Tension pneumocephalus was managed successfully without any adverse outcome. Hence, it is believed that with meticulous anesthetic and surgical techniques, sitting position can safely be practiced in children undergoing neurosurgery.