Comparison of propofol and desflurane for postoperative neurocognitive function in patients with aneurysmal subarachnoid hemorrhage: A prospective randomized trial.

Background: Following aneurysmal subarachnoid hemorrhage, 40-50% of survivors experience cognitive dysfunction, which affects their quality of life. Anesthetic agents play a pivotal role in aneurysm surgeries. However, substantial evidence regarding their effects on neurocognitive function is lacking. This study evaluated the effects of propofol and desflurane on postoperative neurocognitive function and serum S-100B levels. Methods: One hundred patients were equally randomized to receive either propofol (Group P) or desflurane (Group D). Cognitive function was assessed using the Montreal Cognitive Assessment scale at three different time points: Preoperatively, at the time of discharge, and one month after surgery. Perioperative serum levels of S-100B were also measured. Results: The preoperative mean cognitive score in Group P was 21.64 + 4.46 and in Group D was 21.66 + 4.07 (P = 0.79). At discharge, a significant decrease in cognitive scores was observed compared to preoperative scores (Group P- 20.91 + 3.94, P = 0.03 and Group D-19.28 + 4.22, P = 0.00); however, scores were comparable between the two groups (P = 0.09). One month following surgery, mean cognitive scores were 22.63 + 3.57 in Group P and 20.74 + 3.89 in Group D, and the difference was significant (P = 0.04). Higher memory and orientation scores were observed in Group P than in Group D at one month (P < 0.05) in the subgroup analysis. Both groups had similar serum S-100B levels. Conclusion: The mean cognitive scores one month after surgery improved significantly with propofol compared with desflurane, but without clinical significance. Individual domain analysis demonstrated that orientation and memory scores were better preserved with propofol.

Comparison of the effects of opioid-free anesthesia (OFA) and opioid-based anesthesia (OBA) on postoperative analgesia and intraoperative hemodynamics in patients undergoing spine surgery: A prospective randomized double-blind controlled trial.

Background: Opioids form the basis of perioperative pain management but are associated with multiple side effects. In opioid-free anesthesia (OFA), several non-opioid drugs or neuraxial/regional blocks are used as substitutes for opioids. Ketamine, a N-methyl-d-aspartate antagonist, provides intense analgesia. However, there is a shortage of literature on the effects of ketamine-based OFA on hemodynamics (HD) and postoperative analgesia in patients undergoing thoracolumbar spine surgery. Materials and Methods: This prospective randomized controlled trial included 60 adult patients. The patients in Group OFA (n = 30) received OFA with ketamine and ketofol (1:5) infusion, and those in Group OBA (n = 30) received opioid-based anesthesia (OBA) with fentanyl and propofol infusion. The postoperative pain-free period, pain scores, rescue analgesia, intraoperative HDs, and postoperative complications were assessed. Results: The mean pain-free period in Group OFA (9.86 ± 1.43 hr) was significantly higher than that in Group OBA (6.93 ± 1.93 hr) (P = 0.002). During the postoperative 48 hours, the total requirement of fentanyl was considerably lower in Group OFA (P < 0.05). There was a significantly higher incidence of hypertension in Group OFA (46%) and hypotension (43%) in Group OBA (43%), respectively. Postoperative nausea vomiting (PONV) was more common in Group OBA at the 2nd and 6th hr (P = 0.046 and P = 0.038). Conclusion: OFA with ketamine and ketofol provided adequate postoperative analgesia with a lower incidence of PONV after spine surgery. However, hypertension in the ketamine group and hypotension in the propofol group required fine titration of the infusion rate of drugs during the intraoperative period.

Hyperosmolar Therapy in Elderly Neurosurgical Patients: Comparison of the Effect of Mannitol (20%) and Hypertonic Saline (3%) on Advanced Cardiovascular Parameters using Transesophageal Echocardiography - A Preliminary Randomized Controlled Trial.

OBJECTIVE: Osmotherapeutic agents increase the intravascular volume by withdrawing water from the brain followed by relative hypovolemia due to diuresis leading to significant changes in systemic hemodynamics which might have adverse consequences in the elderly. We studied the effect of mannitol (20%) and hypertonic saline (3%) on left ventricle outflow tract velocity-time integral (LVOT-VTI) and cardiac output in elderly patients undergoing supratentorial neurosurgical procedures using transesophageal echocardiography. METHODS: We recruited twenty-eight patients aged above 65 years undergoing supratentorial craniotomy who received equiosmolar solutions of 5.35 ml/kg of 3% hypertonic saline (Group HS, n=14) or 5 ml/kg of 20% mannitol (Group M, n=14). LVOT-VTI was recorded at baseline, 15, 30, 45, 60 and 90 minutes post-infusion and cardiac output (CO) was derived. We also recorded heart rate, blood pressure, fluid balance, brain relaxation, vasopressor use, complications and neurological outcome. RESULTS: We found a significant decrease in LVOT-VTI at 45, and 60 mins in Group M as compared to Group HS [mean(SD), 16.76(1.81) v/s 20.78(1.87), P <0.001, 17.4(2.38) v/s 19.16(2), P = 0.044, respectively]. We also found a corresponding significant fall in CO [3863.16(845.87) v/s 4745.59 (1209.33) ml/min, P = 0.034] and systolic blood pressure (P = 0.039), at 45 mins in Group M. Urine output was higher in Group M (P <0.001). All other parameters were comparable. CONCLUSION: Hypertonic saline appears to be associated with better systemic hemodynamics (LVOT-VTI, CO) while providing equivalent brain relaxation as mannitol in elderly patients. A future larger study is required to confirm our preliminary findings.

Effect of Peri-operative Blood Transfusion on Neurological Outcome Following Aneurysmal Subarachnoid Hemorrhage: A Prospective Observational Study.

BACKGROUND: Anemia is a common complication of aneurysmal subarachnoid hemorrhage and is associated with unfavorable outcomes. Whether the physiological benefits of transfusion for anemia surpass the risk of blood transfusion remains to be determined. OBJECTIVES: The primary outcome was to evaluate the impact of peri-operative blood transfusion on the long-term neurological outcome, assessed by Glasgow Outcome Scale Extended at 3 months. The secondary outcomes included the impact of transfusion on the short-term neurological outcome, assessed by Modified Rankin Score at discharge/7 days, and on the incidence of vasospasm, infarction, re-exploration, tracheostomy, and length of hospital stay. MATERIAL AND METHODS: This prospective observational study was conducted on 185 patients with aneurysmal subarachnoid hemorrhage undergoing clipping of the aneurysmal neck. In our study, blood transfusion was administered to keep the target Hb around 10 g/dL. RESULTS: Unfavorable long-term outcome was found in 27/97 (28%) of patients who received a blood transfusion as compared to 13/74 (18%) of patients who did not receive a transfusion (P = 0.116). Patients receiving transfusion had more chances of an unfavorable outcome at discharge/7 days as compared to those not transfused [44/103 (43%) versus 22/80 (27%)], P = 0.025. There were increased chances of vasospasm, infarction, re-exploration, tracheostomy, and increased length of hospital stay in patients receiving transfusion (P < 0.05). CONCLUSIONS: The use of blood transfusion in patients with aneurysmal subarachnoid hemorrhage was associated with increased neurological complications and hence an unfavorable short-term outcome. However, when used judiciously as per the clinical requirements, blood transfusion did not have a significant effect on long-term neurological outcome.

The Role of Serum Matrix Metalloproteinase-9 as a Predictor of Delayed Cerebral Ischemia in Patients with Aneurysmal Subarachnoid Hemorrhage.

Delayed cerebral ischemia (DCI) is one of the major causes of a poor neurological outcome following aneurysmal subarachnoid hemorrhage (aSAH). Several biomarkers, including matrix metalloproteinase-9 (MMP-9), have been evaluated to predict the development of DCI for timely management. This prospective cohort study was done on 98 patients with aSAH presenting within 72 h of the ictus. Serum samples were collected preoperatively, 7 days after ictus, 10 days after ictus, or when the patient developed DCI, whichever was earlier. The primary objective was to correlate the serum MMP-9 levels with the development of DCI. The secondary objectives were to correlate the serum MMP-9 levels with sonographic vasospasm and the neurological outcome. There was no correlation between the serum MMP-9 levels and the development of DCI (p = 0.37). Similarly, there was no correlation between the serum MMP-9 levels and the sonographic vasospasm (0.05) nor with the modified Rankin Scale (mRS) at discharge (p = 0.27), mRS at 3 months (p = 0.22), and Glasgow Outcome Scale Extended (GOSE) at 3 months (p = 0.15). Serum MMP-9 levels do not predict the development of DCI following aSAH.

Complex cyanotic congenital heart disease and cervical spine surgery: Ticking all the right boxes.

Although complex congenital heart disease (CHD) patients usually present in childhood, it is not rare to see adults well past middle age. These patients undergo continuous pathophysiological changes in their heart and blood vessels, making anesthetic management more challenging if surgery is required. Herein, we report a case in which understanding the anatomy and pathophysiology helped optimally manage a patient with a double outlet right ventricle (DORV) who underwent plating and fixation for a hangman's fracture in the prone position.

Assessment of impaired cerebral autoregulation and its correlation with neurological outcome in aneurysmal subarachnoid hemorrhage: A prospective and observational study.

Background: Cerebral autoregulation (CA) is crucial for the maintenance of cerebral homeostasis. It can be assessed by measuring transient hyperemic response ratio (THRR) using transcranial Doppler (TCD). We aimed at assessing the incidence of impaired CA (ICA) and its correlation with the neurological outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). Methods: One hundred consecutive patients with aSAH scheduled for aneurysmal clipping were enrolled in this prospective and observational study. Preoperative and consecutive 5-day postoperative THRR measurements were taken. Primary objective of the study was to detect the incidence of ICA and its correlation with vasospasm (VS) postclipping, and neurological outcome at discharge and 1, 3, and 12 months was secondary objectives. Results: ICA (THRR < 1.09) was observed in 69 patients preoperatively, 74 patients on the 1st and 2nd postoperative day, 76 patients on 3rd postoperative day, and 78 patients on 4th and 5th postoperative day. Significant VS was seen in 13.4% and 61.5% of patients with intact THRR and deranged THRR, respectively (P < 0.000). Out of 78 patients who had ICA, 42 patients (53.8%) at discharge, 60 patients (76.9%) at 1 month, 54 patients (69.2%) at 3 month, and 55 patients (70.5%) at 12 months had unfavorable neurological outcome significantly more than those with preserved CA. Conclusion: Incidence of ICA assessed in aSAH patients varies from 69% to 78% in the perioperative period. The deranged CA was associated with significantly poor neurological outcome. Therefore, CA assessment using TCD-based THRR provides a simple, noninvasive bedside approach for predicting neurological outcome in aSAH.

Ketofol as an Anesthetic Agent in Patients With Isolated Moderate to Severe Traumatic Brain Injury: A Prospective, Randomized Double-blind Controlled Trial.

BACKGROUND: The effects of ketofol (propofol and ketamine admixture) on systemic hemodynamics and outcomes in patients undergoing emergency decompressive craniectomy for traumatic brain injury (TBI) are unknown and explored in this study. METHODS: Fifty patients with moderate/severe TBI were randomized to receive ketofol (n=25) or propofol (n=25) for induction and maintenance of anesthesia during TBI surgery. Intraoperative hemodynamic stability was assessed by continuous measurement of mean arterial pressure (MAP) and need for rescue interventions to maintain MAP within 20% of baseline. Brain relaxation scores, serum biomarker-glial fibrillary acidic protein levels, and extended Glasgow Outcome Scale (GOSE) at 30 and 90 days after discharge were also explored. RESULTS: MAP was lower and hemodynamic fluctuations more frequent in patients receiving propofol compared with those receiving ketofol (P<0.05). MAP fell >20% below baseline in 22 (88%) patients receiving propofol and in 10 (40%) receiving ketofol (P=0.001), with a greater requirement for vasopressors (80% vs. 24%, respectively; P=0.02). Intraoperative brain relaxation scores and GOSE at 30 and 90 day were similar between groups. Glial fibrillary acidic protein was lower in the ketofol group (3.31±0.43 ng/mL) as compared with the propofol (3.41±0.17 ng/mL; P=0.01) group on the third postoperative day. CONCLUSION: Compared with propofol, ketofol for induction and maintenance of anesthesia during decompressive surgery in patients with moderate/severe TBI was associated with improved hemodynamic stability, lower vasopressor requirement, and similar brain relaxation.

Does Cricoid Pressure Increase the Laryngoscopy Force During Rapid Sequence Induction?-A Randomized Study.

OBJECTIVE: Cricoid pressure, a manoeuver used to prevent pulmonary aspiration during rapid sequence induction, can result in deterioration of laryngeal view and increased haemodynamic changes. Its effect on laryngoscopy force remains unevaluated. The study aimed to assess the impact of cricoid pressure on laryngoscopy force and intubation characteristics during rapid sequence induction. METHODS: Seventy American Society of Anaesthesiologists I/II patients, both sexes, aged 16-65, having non-obstetric emergency surgery were randomly assigned to the cricoid group, which received 30 N cricoid pressure during rapid sequence induction, and the sham group, which received 0 N pressure. Propofol, fentanyl, and succinylcholine were used to produce general anaesthesia. The primary outcome was the peak force of laryngoscopy. Secondary outcomes were the laryngoscopic view, time to execute endotracheal intubation, and intubation success rate. RESULTS: With the application of cricoid pressure, the peak forces of laryngoscopy increased significantly, with a mean difference (95% CI) of 15.5 (13.8-17.2) N. With and without CP, the mean peak forces were 40.758 (4.2) and 25.2 (2.6) N, respectively, P < .001. Without cricoid pressure, the intubation success rate was 100%, compared to 85.7% with cricoid pressure, P = .025. The proportions of CL1/2A/2B patients with and without cricoid pressure were 5/23/7 and 17/15/3, respectively, with P = .005. With cricoid pressure, there was a considerable increase in intubation duration, with a mean difference (95% CI) of 24.4 (2.2-19.9) seconds. CONCLUSION: Cricoid pressure increases peak forces during laryngoscopy, resulting in worse intubation characteristics. This demonstrates the need of exercising care while performing this manoeuver.

DEX, Delirium and Dilemma.

Dexmedetomidine has been subjected to an extensive evaluation for its' role in the prevention of postoperative delirium following cardiac surgery. In striking contrast to the preexisting meta-analysis supporting postoperative delirium-reduction with dexmedetomidine, few recently concluded multicentric large scale randomized controlled trials suggest otherwise. This article aims to present a nuanced perspective of the evolving controversy by attempting to decode the apparent incongruences in the literature accumulating off-late, which is particularly pertinent amidst an ever-escalating heterogeneity in the current research ecosystem.

Comparison of Effects of Propofol and Sevoflurane on the Cerebral Vasculature Assessed by Digital Subtraction Angiographic Parameters in Patients Treated for Ruptured Cerebral Aneurysm: A Preliminary Study.

BACKGROUND: Studies have evaluated the effects of volatile and intravenous anesthetic agents on the cerebral vasculature with inconsistent results. We used digital subtraction angiography to compare the effects of propofol and sevoflurane on the luminal diameter of cerebral vessels and on cerebral transit time in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS: This prospective preliminary study included adult patients with good-grade aSAH scheduled for endovascular coil embolization; patients were randomized to receive propofol or sevoflurane anesthesia during endovascular coiling. The primary outcome was the luminal diameter of 7 cerebral vessel segments measured on the diseased and nondiseased sides of the brain at 3 time points: awake, postinduction of anesthesia, and postcoiling. Cerebral transit time was also measured as a surrogate for cerebral blood flow. RESULTS: Eighteen patients were included in the analysis (9 per group). Baseline and intraoperative parameters were similar between the groups. Propofol increased the diameter of 1 vessel segment at postinduction and postcoiling on the diseased side and in 1 segment at postcoiling on the nondiseased side of the brain ( P <0.05). Sevoflurane increased vessel diameter in 3 segments at postinduction and in 2 segments at postcoiling on the diseased side, and in 4 segments at postcoiling on the nondiseased side ( P <0.05). Cerebral transit time did not change compared with baseline awake state in either group and was not different between the groups. CONCLUSIONS: Sevoflurane has cerebral vasodilating properties compared with propofol in patients with good-grade aSAH. However, sevoflurane affects cerebral transit time comparably to propofol.

DEX, Delirium and Dilemma

ABSTRACT Dexmedetomidine has been subjected to an extensive evaluation for its' role in the prevention of postoperative delirium following cardiac surgery. In striking contrast to the preexisting meta-analysis supporting postoperative delirium-reduction with dexmedetomidine, few recently concluded multicentric large scale randomized controlled trials suggest otherwise. This article aims to present a nuanced perspective of the evolving controversy by attempting to decode the apparent incongruences in the literature accumulating off-late, which is particularly pertinent amidst an ever-escalating heterogeneity in the current research ecosystem.

Airway Management in a Patient with Retrosternal Goiter: A Context-Sensitive Airway Management Strategy.

Retrosternal extension of the goiter can cause compression of the trachea, esophagus and major blood vessels. Airway management is indeed a challenge in patients with airway obstructive signs and symptoms and it is based on the severity of the patient's clinical symptoms, availability of airway equipments, familiarity and expertise. We encountered a patient with retrosternal goiter with tracheal compression, presented for surgery required pediatric Fiber-Optic Bronchoscope (FOB) for securing the airway. A 45 year female patient presented with a swelling in front of the neck for 6 months. Recently, she developed intermittent stridor which was aggravated by lying supine. In computed tomography, there was a retrosternal extension of thyroid gland into superior mediastinum causing tracheal compression and narrowing (80%). Awake fiber-optic intubation with paediatric FOB was used to secure the airway before induction of anaesthesia. Paediatric FOB can be useful to secure airway in patients with tracheal compression and narrowing.

The predictors of hyperglycemia and its effects on neurological outcome in the patients with aneurysmal subarachnoid hemorrhage undergoing surgical clipping: A prospective observational study.

Background: Following intracranial aneurysm rupture, 70-90% of patients have hyperglycemia as a stressful response. Uncontrolled hyperglycemia is deleterious if not controlled well. The objectives of the study were to assess the prevalence, risk factors of hyperglycemia, and its effect on outcome in aneurysmal subarachnoid hemorrhage (aSAH) patients who underwent aneurysmal clipping. Methods: Following intracranial aneurysm rupture, 70-90% of patients have hyperglycemia as a stressful response. Uncontrolled hyperglycemia is deleterious if not controlled well. The objectives of the study were to assess the prevalence, risk factors of hyperglycemia, and its effect on outcome in aSAH patients who underwent aneurysmal clipping. Results: At admission, the prevalence of hyperglycemia and severe hyperglycemia was 31.8% and 6.8%, respectively. Perioperative hyperglycemia and severe hyperglycemia were seen in 75.7% and 27%, respectively. History of diabetes mellitus (DM), higher admission random blood sugar, and higher admission mean blood pressure were predictors of perioperative hyperglycemia (P- 0.046, 0.00, and 0.004, respectively) and severe hyperglycemia (P- 0.048, 0.00, and 0.031). In addition, female sex, prolonged duration of anesthesia, and surgery were also found to be the predictors of hyperglycemia (P- 0.025, 0.07, and 0.012). Increased ventilator, intensive care unit, and hospital days were associated with perioperative hyperglycemia and severe hyperglycemia, respectively (P ≤ 0.006/0.00, P ≤ 0.007/0.00, and P ≤ 0.038/0.00). Poor Glasgow Outcome Score at 1 and 3 months after discharge was associated with admission and perioperative hyperglycemia ([P ≤ 0.000/0.000 and P ≤ 0.000/0.000], respectively). However, no association was seen between mortality and hyperglycemia or severe hyperglycemia. Conclusion: A higher prevalence of hyperglycemia is present in aSAH patients. A higher incidence of perioperative hyperglycemia is associated with poor neurological outcomes. Hence, the identification of risk factors and meticulous perioperative control of hyperglycemia will help in preventing poor neurological outcomes.

Anesthetic Considerations for a Patient with Autosomal Dominant Polycystic Kidney Disease, Having a Ruptured Intracranial Aneurysm for Endovascular Coiling: A Case Report.

Autosomal dominant polycystic kidney disease (ADPKD) is a genetic disorder affecting 1 in 1,000 people worldwide. Intracranial aneurysms are an important extrarenal complication with a prevalence of 9 to 12%. The definitive management of an aneurysm includes surgical clipping or endovascular coiling. There is a paucity of literature regarding the anesthetic management of such patients. The pre-existing renal condition is an additional challenge in the management of these patients as the complications associated with chronic kidney disease are superimposed on those due to subarachnoid hemorrhage. Here, we describe anesthetic management of a patient with ADPKD who had a ruptured anterior communicating artery aneurysm, for which endovascular coiling was done.