The Effect of Goal-Directed Fluid Therapy versus Standard Fluid Therapy on the Cuff Leak Gradient in Patients Undergoing Complex Spine Surgery in Prone Position.

Objective Cuff leak test is an effective and established maneuver to predict airway edema. Standard fluid therapy (SFT) based on conventional monitoring is often associated with postoperative airway edema after complex spine surgeries. We conducted this prospective randomized controlled study to compare the effect of SFT versus goal-directed fluid therapy (GDFT) on the cuff leak gradient (CLG) in patients undergoing complex spine surgery in prone position. Our secondary objectives were to compare the effect of SFT and GDFT on sore throat, hoarseness, and length of intensive care unit (ICU) and hospital stay. Materials and Methods Thirty consecutive American Society of Anesthesiologists physical status I and II patients (18-60 years), of either sex, scheduled for spine surgery in prone position with expected duration of surgery more than 5 hours were included. The patients were randomized into two groups of 15 each. Group S patients ( n = 15) served as control group and received SFT intraoperatively, while patients in group G ( n = 15) received GDFT. Standard anesthetic protocol was followed in both the groups. The CLG was defined as the difference between the cuff leak volume (CLV) after intubation (CLV AI ) and before extubation (CLV BE ). Statistical Analysis and Results CLG was significantly less in group G (group S, 137.12 mL; group G, 65.52 mL; p -value <0.001). Intravenous fluids, blood loss, and postoperative sore throat were comparatively lesser in group G, though not statistically significant. Postoperative hoarseness was significantly lower in group G ( p -value = 0.003). Duration of ICU stay in group G (19.43 hours) was significantly lower ( p -value = 0.009) than group S (24.64 hours), but length of hospital stay was comparable. Conclusion GDFT significantly reduces airway edema and consequently reduces CLG as compared with SFT in patients undergoing complex spine surgery in prone position. Postoperatively, it also reduces sore throat, hoarseness of voice, and duration of ICU stay.

Incidence of Pressure-Related Skin Injuries in Patients Operated for Spine Surgery in Prone: A Retrospective Analysis of 307 Patients.

BACKGROUND: Spine surgery in prone position frequently results in pressure skin lesions (PSLs). No study from Arabic world has published their incidence in literature. METHODS: We retrospectively analyzed patients who underwent prone position spine surgery from December 1, 2017, to November 30, 2018. They received standardized anesthesia care and were made prone on Jackson table. The face was supported on a nonface contoured foam device, whereas the chest and pelvis were supported on soft cushions. Following completion of surgery, they were turned supine and their skin was inspected for any skin lesions. The lesions were categorized into five grades depending on severity. RESULTS: Data of 307 patients were analyzed. Their mean age and weight was 41.5 years and 71 kg, respectively. The mean duration of prone positioning was 470 min. One hundred and three PSLs were observed in 45 patients (14.7%), giving a PSL incidence of 43.7% in affected patients. Majority of patients (18, 40%) with lesions remained in prone position between 421 and 600 min. Multiple lesions were observed in 53.3% of the affected patients. The highest number of patients (21, 46.7%) had one lesion only and it was restricted to face. All lesions were of Grade I, II, or III. Body weight >71 kg was more prone to developing PSLs. Females were more prone to PSLs. CONCLUSION: PSLs in prone position spine surgery occur frequently, and their incidence is proportional to the duration of positioning and weight of the patients. Face is the most commonly affected area.

Effect of Stellate Ganglion Block on Intraoperative Propofol and Fentanyl Consumption in Patients with Complex Regional Pain Syndrome Undergoing Surgical Repair of Brachial Plexus Injury: A Randomized, Double-blind, Placebo-controlled Trial.

INTRODUCTION: Stellate ganglion block (SGB) is commonly performed to treat chronic painful conditions, such as complex regional pain syndrome (CRPS) and postherpetic neuralgia. However, whether it is effective in reducing anesthesia and analgesia requirement during surgery (acute pain) is not known. MATERIALS AND METHODS: Sixty American Society of Anesthesiologists (ASA) physical status I and II patients with CRPS type II undergoing surgery for repair of brachial plexus injury were randomized (1:1) to receive SGB with either 10 mL of 0.5% bupivacaine (Group B) or a matching placebo (Group S) before induction of anesthesia. RESULTS: There was a significant reduction in the requirement of total intraoperative propofol (1659.7 ± 787.5 vs. 2500.7 ± 740.9 mg, P = 0.0003) and fentanyl (190.0 ± 82.5 vs. 327.3 ± 139.3, P = 0.0001) in Group B compared with Group S. Similarly, in Group B, the time to first analgesic was much longer (328 ± 219 vs. 64 ± 116 min, P = 0.000) and postoperative fentanyl requirement for 24 h was lesser compared to Group S (0.6 ± 1.1 vs. 2.1 ± 1.3 µg/kg, P = 0.000). CONCLUSION: SGB is effective in reducing the requirement of intraoperative propofol and fentanyl as well as decreasing opioid requirement in the postoperative period in patients with CRPS type II undergoing surgery.

Effect of Two Regimens of Fluid Administration on Airway Edema in Prone-Position Surgery.

BACKGROUND: Surgeries in prone position expose a patient to multitude of complications including laryngeal edema which may be related to the volume of fluid administered. Administering larger volumes of fluid intraoperatively may contribute to significant tissue edema, leading many anesthesiologists to practice a restrictive fluid infusion strategy. Although previous studies have compared fluid infusion strategies, changes in airway dimensions leading to airway edema have not been extensively investigated. Here, we compared two fluid infusion regimens in patients undergoing spine surgery in the prone position, and assessed their association with airway edema by means of the cuff leak test (CLT). AIMS: The aim of this study was to test the hypothesis whether a larger volume of crystalloid administration in spine surgeries performed in prone position would result in greater chances of airway edema, than would a restricted infusion policy, utilizing the CLT. MATERIALS AND METHODS: After ethical committee approval, thirty patients, aged 21-60 years, American Society of Anesthesiologists Status I or II, scheduled for elective spine surgery in the prone position, were selected. Group 1 (restrictive group) received 3 mL.kg - 1.h - 1, whereas Group 2 (permissive group) received 5 mL.kg - 1.h - 1 of crystalloids plus urine output replacement. The airway edema was assessed by CLT which was performed soon after intubation (T1) and before extubation (T2). Cuff leak volume (CLV) was calculated from the difference in tidal volumes before (VT i) and after cuff deflation (VT e). Airway edema was evaluated by calculating the differences in the CLV at T1 and T2 (ΔCLV); the more the value of Δ CLV which means greater difference between these two points, the more the decrease in laryngeal lumen, signifying an increased risk of airway edema. RESULTS: Decrease in laryngeal lumen was observed in patients who received permissive fluid regimen than that of the restrictive group, signifying more chances of airway edema in the former group. In addition, a poor correlation was found between the duration of anesthesia and development of airway edema in our study group. CONCLUSIONS: Because surgeries in the prone position are at risk of airway edema, restrictive fluid regimen strategy should be preferred over the liberal one as there are more chances of reduction in laryngeal lumen dimensions with permissive fluid infusions.

Acute Transient Sialadenitis - "Anesthesia Mumps:" Case Report and Review of Literature.

Acute postoperative sialadenitis, called "anesthesia mumps," has been reported in different surgical procedures. It is usually benign in nature, and the swelling resolves spontaneously without any treatment in the majority of cases. The attending physician should be aware of this transient condition. Very rarely, serious complications can occur such as respiratory distress warranting urgent intervention. We report a case of acute transient sialadenitis in a 6-year-old child who underwent general anesthesia for upper gastrointestinal endoscopy, which resolved spontaneously without any treatment.

Anesthetic considerations for extracranial injuries in patients with associated brain trauma.

Patients with severe traumatic brain injury often presents with extracranial injuries, which may contribute to fatal outcome. Anesthetic management of such polytrauma patients is extremely challenging that includes prioritizing the organ system to be dealt first, reducing on-going injury, and preventing secondary injuries. Neuroprotective and neurorescue measures should be instituted simultaneously during extracranial surgeries. Selection of anesthetic drugs that minimally interferes with cerebral dynamics, maintenance of hemodynamics and cerebral perfusion pressure, optimal utilization of multimodal monitoring techniques, and aggressive rehabilitation approach are the key factors for improving overall patient outcome.

Incidence and predictors of postoperative pulmonary complications in patients undergoing craniotomy and excision of posterior fossa tumor.

BACKGROUND AND AIMS: Infratentorial neurosurgical procedures are considered high risk for the development of postoperative pulmonary complications (POPCs), prolonging hospital stay of patients with substantial morbidity and mortality. MATERIAL AND METHODS: Patients between the ages of 18 and 65 years, who underwent elective surgery for posterior fossa tumors over a period of two years, were reviewed. Data including American Society of Anesthesiologists physical status; comorbidities like hypertension, diabetes mellitus and hypothyroidism, history of smoking, obstructive sleep apnea, respiratory symptoms, lower cranial nerve (LCN) palsy; intraoperative complications such as hemodynamic alterations suggestive of brain stem or cranial nerve handling, tight brain as informed by the operating neurosurgeon, blood loss, and transfusion; and postoperative duration of mechanical ventilation, tracheostomy, POPCs, length of ICU and hospital stay, general condition of the patient at discharge, and cause of in-hospital mortality were collected. POPC was defined as the presence of atelectasis, tracheobronchitis, pneumonia, bronchospasm, respiratory failure, reintubation, or weaning failure. RESULTS: Case files of 288 patients fulfilling the study criteria were analyzed; POPCs were observed in 35 patients (12.1%). On multivariate analysis, postoperative blood transfusion, LCN palsy, prolonged ICU stay, and tracheostomy were found to be independent predictors of POPC. CONCLUSIONS: The incidence of POPC was 12.1% following infratentorial tumor surgery. The predictors for the occurrence of POPCs were postoperative blood transfusion, LCN palsy, prolonged ICU stay, and tracheostomy.

Comparison of Full Outline of UnResponsiveness (FOUR) score and the conventional scores in predicting outcome in aneurysmal subarachnoid haemorrhage patients.

BACKGROUND AND AIMS: Full Outline of UnResponsiveness (FOUR) score is a more comprehensive score used to assess eye response, motor response, brainstem reflexes, and respiration that was introduced to overcome the drawbacks of Glasgow coma scale (GCS) score. Our aim was to assess which score best predicts mortality and poor outcome in aneurysmal subarachnoid haemorrhage (aSAH) patients. METHODS: This cohort study, prospectively evaluated the use of FOUR score to assess the mortality and outcome in aSAH patients during the period from November 2015 to November 2016. For each patient of aSAH, GCS, FOUR score, Hunt and Hess (HH) score and World Federation of Neurological Surgeons (WFNS) score were determined at the time of admission to neurosurgical intensive care unit. All patients were followed till 28 days post-SAH and their outcome were assessed by Glasgow outcome scale (GOS). We calculated the sensitivity (Sn) and specificity (Sp) for each of these scores. We generated the receiver operating characteristic curve (ROC), quantified the accuracy by the area under curve (AUC), and also calculated their 95% confidence interval (95% CI). RESULTS: A total of 75 aSAH patients were enrolled for the study. The mortality was 24/75 (32%) with 23 in-hospital deaths. FOUR score was highly specific (86.27%) and sensitive (75%) for the prediction of mortality. However, for predicting 28-day outcome, WFNS and HH grade were most specific (92.5%), whereas FOUR and HH score was moderately specific (68.57%). CONCLUSION: FOUR score is among the most specific and moderately sensitive tool for prediction of mortality. However, WFNS and HH grade are more specific in predicting the 28-day outcome.

Perioperative Course of Transsphenoidal Pituitary Surgery through Endoscopic versus Microscopic Approach: Interim Concerns for Neurosurgical Anesthesiology.

BACKGROUND: Endonasal endoscopic approach for transsphenoidal excision of pituitary adenoma has undergone remarkable evolution in the last two decades. It is considered less invasive and less stressful, with results comparable to the previous "gold standard" technique of microscopic transsphenoidal excision of pituitary adenoma. The aim of this study was to compare the various perioperative anesthetic and surgical factors which differ in the two approaches (endoscopic vs. microscopic) for pituitary adenoma excision, during the period when surgeons increasingly started using endoscope at our center. MATERIALS AND METHODS: Data of 307 patients from January 2011 to December 2013 were reviewed in this retrospective study. Various parameters were divided and compared on the basis of the type of approach for pituitary tumor resection vis-à-vis microscope-assisted sublabial transsphenoidal (MSLTS) resection or microscope-assisted transnasal transsphenoidal (MTNTS) resection or endoscope-assisted endonasal transsphenoidal (ETSS) resection. RESULTS: Demographic variables (except age); tumor type, dimensions, and invasiveness; patients' comorbidities; postoperative nausea/vomiting, electrolyte imbalance, respiratory, and cardiovascular problems were comparable among three groups. Duration of surgery and anesthesia were shortest for MTNTS group and longest for ETSS group (P < 0.001). Blood loss was higher in ETSS technique (median 300 mL) and least in MTNTS (median 100 mL), and the difference was significant across all three groups (P = 0.0003). Postoperative cerebrospinal fluid rhinorrhea was 17% in the MSLTS group compared to 6.5% in MTNTS and 7.9% in ETSS (P = 0.047). CONCLUSION: ETSS with the expected advantage of being less invasive offers a better chance for complete resection of adenoma. Neuroanesthesiologist must be prepared for longer surgical time and more blood loss as compared to previous microscopic approach, at least till the surgeons expertise in this newer technique.

Efficacy and safety of dexmedetomidine infusion for patients undergoing awake craniotomy: An observational study.

BACKGROUND: The goal of awake craniotomy is to maintain adequate sedation, analgesia, respiratory, and hemodynamic stability and also to provide a cooperative patient for neurologic testing. An observational study carried out to evaluate the efficacy of dexmedetomidine sedation for awake craniotomy. MATERIALS AND METHODS: Adult patients with age >18 year who underwent awake craniotomy for intracranial tumor surgery were enrolled. Those who were uncooperative and had difficult airway were excluded from the study. In the operating room, the patients received a bolus dose of dexmedetomidine 1 µg/kg followed by an infusion of 0.2-0.7 µg/kg/h (bispectral index target 60-80). Once the patients were sedated, scalp block was given with bupivacaine 0.25%. The data on hemodynamics at various stages of the procedure, intraoperative complications, total amount of fentanyl used, intravenous fluids required, blood loss and transfusion, duration of surgery, Intensive Care Unit (ICU), and hospital stay were collected. The patients were assessed for Glasgow outcome scale (GOS) score and patient satisfaction score (PSS). RESULTS: A total of 27 patients underwent awake craniotomy during a period of 2 years. Most common intraoperative complication was seizures; observed in five patients (18.5%). None of these patients experienced any episode of desaturation. Two patients had tight brain for which propofol boluses were administered. The average fentanyl consumption was 161.5 ± 85.0 µg. The duration of surgery, ICU, and hospital stays were 231.5 ± 90.5 min, 14.5 ± 3.5 h, and 4.7 ± 1.5 days, respectively. The overall PSS was 8 and GOS was good in all the patients. CONCLUSION: The use of dexmedetomidine infusion with regional scalp block in patients undergoing awake craniotomy is safe and efficacious. The absence of major complications and higher PSS makes it close to an ideal agent for craniotomy in awake state.

Effect of nitrous oxide on bispectral index values at equi-minimum alveolar concentrations of sevoflurane and desflurane.

BACKGROUND AND AIMS: Bispectral index (BIS) values may be anaesthetic agent-specific, depending on their ability to suppress the electroencephalogram (EEG) signals. We carried out a prospective, randomised clinical trial to study the effect of nitrous oxide (N2O) on the BIS values at an equi-minimum alveolar concentration (MAC) of sevoflurane and desflurane. METHODS: Sixty adult patients undergoing spine surgery were randomised into two groups; Group S (sevoflurane; n = 30) and Group D (desflurane; n = 30) for the maintenance of anaesthesia in oxygen and air or oxygen and N2O mixture (FiO2-0.4) (Stage 1). BIS and fraction of inspired and end-tidal concentration of agents were noted at 1.0 MAC. In Stage 2, air or N2O was discontinued and the other carrier gas was introduced. At steady state of this carrier gas, values were again noted as in Stage 1. Statistical analysis was performed using two-way analysis of variance followed by Bonferroni correction, and Student's t-test for paired data. P<0.05 was considered statistically significant. RESULTS: With air-oxygen as the carrier gas, sevoflurane and desflurane resulted in comparable BIS values (P = 0.44). With addition of 60% N2O, there was a significant increase in BIS values at 1.0 MAC for both the agents. Furthermore, higher BIS values were observed with sevoflurane compared to desflurane (P = 0.01). CONCLUSION: Sevoflurane and desflurane at equi-MAC concentration exert similar effect on BIS values when used with air-oxygen. N2O results in higher BIS values; this effect is more pronounced in combination with sevoflurane.

Effect of tranexamic acid on intraoperative blood loss and transfusion requirements in patients undergoing excision of intracranial meningioma.

Surgical excision of meningioma is often complicated by significant blood loss requiring blood transfusion with its attendant risks. Although tranexamic acid is used to reduce perioperative blood loss, its blood conservation effect is uncertain in neurosurgery. Sixty adults undergoing elective craniotomy for meningioma excision were randomized to receive either tranexamic acid or placebo, initiated prior to skin incision. Patients in the tranexamic acid group received intravenous bolus of 20mg/kg over 20min followed by an infusion of 1mg/kg/h till the conclusion of surgery. Intraoperative blood loss, transfusion requirements and estimation of surgical hemostasis using a 5-grade scale were noted. Postoperatively, the extent of tumor excision on CT scan and complications were observed. Demographics, tumor characteristics, amount of fluid infusion, and duration of surgery and anesthesia were comparable between the two groups. The amount of blood loss was significantly less in tranexamic acid group compared to placebo (830mlvs 1124ml; p=0.03). The transfusion requirement was less in tranexamic acid group (p>0.05). The patients in tranexamic acid group fared better on a 5-grade surgical hemostasis scale with more patients showing good hemostasis (p=0.007). There were no significant differences between the groups with regards to extent of tumor removal, perioperative complications, hospital stay or neurologic outcome. To conclude, administration of tranexamic acid significantly reduced blood loss in patients undergoing excision of meningioma. Fewer patients in the tranexamic acid group received blood transfusions. Surgical field hemostasis was better achieved in patients who received tranexamic acid.

Perioperative problems in patients with brainstem tumors and their influence on patient outcome.

BACKGROUND AND AIMS: Patients with brainstem tumors have many associated systemic abnormalities and are prone to develop perioperative complications. We studied the problems associated with brainstem tumors and their influence on the postoperative neurological outcome. MATERIAL AND METHODS: Retrospective review of records of patients who underwent surgery for brainstem tumors over a period of 8 years was done. Preoperative variables, perioperative complications and neurological outcome as assessed by Glasgow Outcome Scale at the time of hospital discharge were noted. Association between perioperative factors and the unfavorable neurological outcome was evaluated. RESULTS: Data of 70 patients were retrieved, 7 patients were excluded from the study because of incomplete data and data analysis was carried out for 63 patients. We found that lower cranial nerve palsies (32%) and hydrocephalus (43%) were common preoperatively. Various intraoperative problems encountered were hemodynamic instability (56%), major blood loss requiring blood transfusion (40%) and venous air embolism (11%), and postoperative problems were meningitis (51%), hypokalemia (38%), chest infection (21%), seizure (11%), deterioration of Glasgow Coma Scale (GCS, 11%), hyponatremia (8%), hydrocephalus (6%), respiratory distress (3%) and operatives site hematoma (3%). Fifty-six (89%) patients had favorable outcome at hospital discharge whereas, 7 (11%) had an unfavorable outcome. There was no association between pre- and intra-operative factors and the neurological outcome. Deterioration of GCS, chest infection, and the need for reintubation and tracheostomy were associated with unfavorable neurological outcome. CONCLUSION: Patients of brainstem tumors are at increased risk of perioperative complications. Some of the postoperative complications were associated with unfavorable neurological outcome.

Comparison between sevoflurane and desflurane on emergence and recovery characteristics of children undergoing surgery for spinal dysraphism.

BACKGROUND AND AIMS: Rapid recovery is desirable after neurosurgery as it enables early post-operative neurological evaluation and prompt management of complications. Studies have been rare comparing the recovery characteristics in paediatric neurosurgical patients. Hence, this study was carried out to compare the effect of sevoflurane and desflurane anaesthesia on emergence and extubation in children undergoing spinal surgery. METHODS: Sixty children, aged 1-12 years, undergoing elective surgery for lumbo-sacral spinal dysraphism were enrolled. Anaesthesia was induced with sevoflurane using a face mask. The children were then randomised to receive either sevoflurane or desflurane with oxygen and nitrous oxide, fentanyl (1 µg/kg/h) and rocuronium. The anaesthetic depth was guided by bispectral index (BIS(®)) monitoring with a target BIS(®) between 45 and 55. Perioperative data with regard to demographic profile, haemodynamics, emergence and extubation times, modified Aldrete score (MAS), pain (objective pain score), agitation (Cole's agitation score), time to first analgesic and complications, thereof, were recorded. Statistical analysis was done using STATA 11.2 (StataCorp., College Station, TX, USA) and data are presented as median (range) or mean ± standard deviation. RESULTS: The demographic profile, haemodynamics, MAS, pain and agitation scores and time to first analgesic were comparable in between the two groups (P > 0.05). The emergence time was shorter in desflurane group (2.75 [0.85-12] min) as compared to sevoflurane (8 [2.5-14] min) (P < 0.0001). The extubation time was also shorter in desflurane group (3 [0.8-10] min) as compared to the sevoflurane group (5.5 [1.2-14] min) (P = 0.0003). CONCLUSION: Desflurane provided earlier tracheal extubation and emergence as compared to sevoflurane in children undergoing surgery for lumbo-sacral spinal dysraphism.

Anaesthesia for awake craniotomy: A retrospective study of 54 cases.

BACKGROUND AND AIMS: The anaesthetic challenge of awake craniotomy is to maintain adequate sedation, analgesia, respiratory and haemodynamic stability in an awake patient who should be able to co-operate during intraoperative neurological assessment. The current literature, sharing the experience on awake craniotomy, in Indian context, is minimal. Hence, we carried out a retrospective study with the aim to review and analyse the anaesthetic management and perioperative complications in patients undergoing awake craniotomy, at our centre. METHODS: Medical records of 54 patients who underwent awake craniotomy for intracranial lesions over a period of 10 years were reviewed, retrospectively. Data regarding anaesthetic management, intraoperative complications and post-operative course were recorded. RESULTS: Propofol (81.5%) and dexmedetomidine (18.5%) were the main agents used for providing conscious sedation to facilitate awake craniotomy. Hypertension (16.7%) was the most commonly encountered complication during intraoperative period, followed by seizures (9.3%), desaturation (7.4%), tight brain (7.4%), and shivering (5.6%). The procedure had to be converted to general anaesthesia in one of patients owing to refractory brain bulge. The incidence of respiratory and haemodynamic complications were comparable in the both groups (P > 0.05). There was less incidence of intraoperative seizures in patients who received propofol (P = 0.03). In post-operative period, 20% of patients developed new motor deficit. Mean intensive care unit stay was 2.8 ± 1.9 day (1-14 days) and mean hospital stay was 7.0 ± 5.0 day (3-30 days). CONCLUSIONS: 'Conscious sedation' was the technique of choice for awake craniotomy, at our institute. Fentanyl, propofol, and dexmedetomidine were the main agents used for this purpose. Patients receiving propofol had less incidence of intraoperative seizure. Appropriate selection of patients, understanding the procedure of surgery, and judicious use of sedatives or anaesthetic agents are key to the success for awake craniotomy as a procedure.

Causes of tracheal re-intubation after craniotomy: A prospective study.

BACKGROUND: Re-intubation of neurosurgical patients after a successful tracheal extubation in the operating room is not uncommon. However, no prospective study has ever addressed this concern. This study was aimed at analyzing various risk factors of re-intubation and its effect on patient outcome. METHODS: Patients aged between 18-60 yrs and of ASA physical status I and II undergoing elective craniotomies over a period of two yrs were included. A standard anesthetic technique using propofol, fentanyl, rocuronium, and isoflurane/sevoflurane was followed, in all these patients. 'Re-intubation' was defined as the necessity of tracheal intubation within 72 hrs of a planned extubation. Data were collected and analyzed employing standard statistical methods. RESULTS: One thousand eight hundred and fifty patients underwent elective craniotomy, of which 920 were included in this study. A total of 45 (4.9%) patients required re-intubation. Mean anesthesia duration and time of re-intubation were 6.3±1.8 and 24.6±21.9 hrs, respectively. The causes of re-intubation were neurological deterioration (55.6%), respiratory distress (22.2%), unmanageable respiratory secretion (13.3%), and seizures (8.9%). The most common post-operative radiological (CT scan) finding was residual tumor and edema (68.9%). Seventy-three percent of the re-intubated patients had satisfactory post-operative cough-reflex. The ICU and hospital stay, and Glasgow outcome scale at discharge were not significantly affected by different causes of re-intubation. CONCLUSION: Neurological deterioration is the most common cause of re-intubation following elective craniotomies owing to residual tumor and surrounding edema. A satisfactory cough reflex may not prevent subsequent re-intubation in post-craniotomy patients.

Advances in neuro-monitoring.

Neuromonitoring aims to detect harmful physiologic events, early enough to guide the treatment instituted. Evidences encourage us to implement multimodal monitoring, as no single monitor is capable of providing a complete picture of dynamic cerebral state. This review highlights the role of intracranial pressure monitoring, cerebral oxygenation (jugular venous oximetry, brain tissue oxygenation, near infrared oximetry, cerebral microdialysis) and cerebral blood flow monitoring (direct and indirect methods) in the management of neurologically injured patients. In this context, the recent developments of these monitors along with the relevant clinical implications have been discussed. Nevertheless, the diverse range of data obtained from these monitors needs to be integrated and simplified for the clinician. Hence, the future research should focus on identification of a most useful monitor for integration into multimodal system.

Local warming at injection site helps alleviate pain after rocuronium administration.

PURPOSE: Various strategies have been proposed to reduce discomfort of pain after rocuronium injection. These studies have shown pretreatment of drugs such as fentanyl and lidocaine to be effective. In a prospective randomized study, we evaluated whether pretreatment with local warming at injection site using an air-warming device could effectively alleviate pain induced by rocuronium. METHODS: Ninety patients undergoing spinal surgeries were randomly divided into two groups: group C (control) and group T (treatment). Patients in group T were subjected to warming at 40°C for 1 min prior to injecting 1 ml (10 mg) of rocuronium at the site of venous access. Patients were then assessed for any discomfort and to quantify their discomfort on a 5-point scale. RESULTS: Age, sex, and weight were comparable between the two groups. Pain on rocuronium administration was reported by 88.9% patient in group C versus 66.7% in group T (p < 0.05). Severe pain was significantly less in group T (35.6% vs. 8.9%). CONCLUSION: Application of warmth over the vascular access prior to rocuronium administration effectively reduces injection-related pain.