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STUDY DESIGN: Retrospective observational study. PURPOSE: To share our experience of multimodal intraoperative neurophysiological monitoring (IONM) used in Sakra World Hospital, Bengaluru in various spine surgeries. OVERVIEW OF LITERATURE: The development of new onset postoperative neurological deficits can be completely avoided. In order to avoid these, IONM has become a standard of care in recent times for early detection and manipulation of the surgical procedure to prevent postoperative neurological deficits. METHODS: This retrospective study was performed on 408 patients who had undergone spine surgeries with IONM during April 2014 to March 2020 at a single center. The operative report, anesthesia record, and IONM were reviewed. All the patients were reassessed for postoperative neurological deficits in the postoperative period and followed up based on the intraoperative findings and neurological deficits for 4 weeks. Signal changes in IONM were reviewed, and the obtained results were further categorized into true positive, true negative, false positive, or false negative. If changes were observed during the IONM, the patients were managed as per the algorithm. RESULTS: Of the 408 patients being monitored continuously during the intraoperative period, 38 showed changes in recordings, 28 developed postoperative neurological deficits, and one developed neurological deficit without any change in the IONM. Nine patients had transient neurological deficits, and the other 20 had permanent neurological deficits. Overall, the multimodal IONM used in our study had a sensitivity of 96.6%, specificity of 97.4%, a positive predictive value of 73.7%, and a negative predictive value of 99.7%. CONCLUSIONS: Use of decision algorithm and multimodal neuromonitoring consisting of motor evoked potentials, somatosensory evoked potentials, and electromyography complement each other in the detection of neurological injury during the course the surgery, improve intraoperative care, and prevent further damage and morbidity in patients.
RESUMEN
BACKGROUND: The effects of ketofol (a combination of ketamine and propofol) on systemic hemodynamics and requirement of opioids/Propofol have already been studied and published. However, there is paucity in the literature on the effects of ketofol on cerebral oxygenation. This study aims to compare the effects of ketofol (ketamine + propofol [1:5]) with propofol on cerebral oxygenation using jugular venous oxygen saturation (SjVO2), in patients undergoing surgical clipping of intracranial aneurysms. MATERIALS AND METHODS: A total of 40 World Federation of Neurosurgeons I and II patients were randomized into ketofol (n = 20) and propofol (n = 20) groups. Postinduction, SjVO2 catheter was inserted, and anesthesia was maintained with propofol and fentanyl in the propofol group and ketofol and fentanyl in the ketofol group. Jugular venous oxygen saturation (SjVO2) was obtained at baseline, 1 h and 2 h intraoperatively, and at 6 h after the surgery. Intraoperative hemodynamics and brain relaxation scores were also noted. RESULTS: Entire SjVO2 values in both groups were within the normal limits. Higher SjVO2 values were observed in ketofol group compared to propofol at 1 and 2 h after starting of the drug and at 6 h after surgery (P < 0.05). In propofol group, a significant fall in SjVO2 was recorded at 2 h after beginning the drug as compared to the baseline (P = 0.001). More than 20% fall in mean arterial pressure (MAP) compared to baseline MAP was noted in 75% of patients in propofol group and 15% of patients in ketofol group (P = 0.002). In propofol group, 55% of patients required rescue drug phenylephrine to treat hypotension, whereas only 15% of patients required it in ketofol group (P = 0.02). Fentanyl requirement in ketofol group was less as compared to the propofol group (P = 0.022). Brain relaxation scores were comparable in both the study groups (P = 0.887). CONCLUSION: Maintenance of anesthesia with ketofol provides better cerebral oxygenation and hemodynamic stability compared to propofol in neurosurgical patients.
