Preoperative Low-Dose Aspirin Exposure and Outcomes After Emergency Neurosurgery for Traumatic Intracranial Hemorrhage in Elderly Patients.

BACKGROUND: Antiplatelet medications are usually discontinued before elective neurosurgery, but this is not an option for emergent neurosurgery. We performed a retrospective cohort study to examine whether preoperative aspirin use was associated with worse outcomes after emergency neurosurgery in elderly patients. METHODS: We analyzed all cases of emergency neurosurgical procedures for traumatic intracranial hemorrhage from 2008 to 2012 at a level 1 trauma center. Demographics, comorbidities, and outcomes were compared for patients ≥65 years by preoperative aspirin exposure. Exclusion criteria were: (1) polytrauma, (2) concomitant use of other preoperative anticoagulants or antiplatelet agents, (3) surgical indication other than subdural, extradural, or intraparenchymal hemorrhage, and (4) repeat neurosurgical procedures within a single admission. Estimated intraoperative blood loss, postprocedural intracranial bleeding requiring reoperation, death in hospital, intensive care unit, and hospital lengths of stay and perioperative blood product transfusion from 48 hours before 48 hours after surgery were the study outcomes. We also examined whether platelet transfusion had an impact on outcomes for patients on aspirin. RESULTS: The cohort included 171 patients. Patients receiving preoperative aspirin (n = 87, 95% taking 81 mg/day) were the same age as patients not receiving aspirin (n = 84; 78.3 ± 7.8 vs 75.9 ± 7.9 years, P > .05), had slightly higher admission Glasgow Coma Scale scores (12.8 ± 3.4 vs 11.4 ± 4, P = .02) and tended to have more coronary artery disease (P< .05). Adjusted for Glasgow Coma Scale and coronary artery disease, patients receiving preoperative aspirin had a higher odds of perioperative platelet transfusion (adjusted odds ratio 9.89, 95% confidence interval, 4.24-26.25). There were no other differences in outcomes between the 2 groups. Preoperative or intraoperative platelet transfusion was not associated with better outcomes among aspirin patients. CONCLUSIONS: In patients age ≥65 years undergoing emergency neurosurgery for traumatic intracranial hemorrhage, preoperative low-dose aspirin treatment was not associated with increased perioperative bleeding, hospital lengths of stay, or in-hospital mortality.

The dosage of thiopental as pharmacological cerebral protection during non-shunt carotid endarterectomy: A retrospective study.

Background: Thiopental has been used as a pharmacological cerebral protection strategy during carotid endarterectomy surgeries. However, the optimal dosage required to induce burst suppression on the electroencephalogram (EEG) remains unknown. This retrospective study aimed to determine the optimal dosage of thiopental required to induce burst suppression during non-shunt carotid endarterectomy. Methods: The Neurological Institute of Thailand Review Board approved the study. Data were collected from 2009 to 2019 for all non-shunt carotid endarterectomy patients who received thiopental for pharmacological cerebral protection and had intraoperative EEG monitoring. Demographic information, carotid stenosis severity, intraoperative EEG parameters, thiopental dosage, carotid clamp time, intraoperative events, and patient outcomes were abstracted. Results: The study included 57 patients. Among them, 24 patients (42%) achieved EEG burst suppression pattern with a thiopental dosage of 26.3±10.1 mg/kg/hr. There were no significant differences in perioperative events between patients who achieved burst suppression and those who did not. After surgery, 33.3% of patients who achieved burst suppression were extubated and awakened. One patient in the non-burst suppression group experienced mild neurological deficits. No deaths occurred within one month postoperative. Conclusions: The optimal dosage of thiopental required to achieve burst suppression on intraoperative EEG during non-shunt carotid endarterectomy was 26.3±10.1 mg/kg/hr.

Nutrition support and deficiencies in children with severe traumatic brain injury.

OBJECTIVE: Adequate nutrition support is considered important to recovery after pediatric traumatic brain injury. The 2003 Pediatric Guidelines recommend initiation of nutrition within 72 hrs after traumatic brain injury. We examined our local experience with nutritional support in severe pediatric traumatic brain injury patients (cases) and non-traumatic brain injury patients (controls). DESIGN: A retrospective review of pediatric patients with severe traumatic brain injury over an 11-yr period (1997-2009) and without traumatic brain injury over a 3-yr period (2007-2009). SETTING: Level I pediatric trauma center pediatric intensive care unit. PATIENTS: Patients with severe pediatric traumatic brain injury (age <15 yrs, Glasgow Coma Scale score of <9) and admitted to the pediatric intensive care unit for >7 days and patients without traumatic brain injury (age <15 yrs, head Abbreviated Injury Scale score of 0) and admitted to pediatric intensive care unit. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data from 101 severe traumatic brain injury and 92 non-traumatic brain injury patients were analyzed. Traumatic brain injury patients: All received enteral nutrition while 13 (12%) also received parenteral nutrition. Nutrition was started 53 ± 20 hrs (range 12-162) after pediatric intensive care unit admission. Fifty patients (52%) received nutrition within the first 48 hrs, and 83 (82%) received nutrition support within the first 72 hrs. Caloric and protein intakes were 47% and 40% of the goals on pediatric intensive care unit day 7 and 76% and 70% of the goals on pediatric intensive care unit day 14. Caloric and protein goals were met in 26% ± 16% and 18% ± 19% of pediatric intensive care unit stay, respectively. Patients whose intake met nutritional goals on pediatric intensive care unit day 7 had earlier initiation of nutrition support at admission than patients who never met the goals (calorie goal met vs. unmet by day 7, 44 ± 23 hrs vs. 67 ± 31 hrs; p < .001; protein goal met vs. unmet by day 7, 43 ± 17 hrs vs. 65 ± 29 hrs; p = .001). Patients gained 0.6% ± 11% weight by pediatric intensive care unit day 7 and lost 7% ± 11% weight by pediatric intensive care unit day 14. Non-traumatic brain injury patients: The time to start of nutrition for the non-traumatic brain injury group was earlier only for patients with isolated orthopedic injuries (24 ± 6 hrs; p = .02). The average caloric and protein intakes were less for the traumatic brain injury (n = 20) group (caloric 52% ± 16% of goal and protein 42% ± 18% of goal) than for the non-traumatic brain injury (n = 23) group (65% ± 11% of goal and protein 51% ± 20% of goal; both p < .01) for pediatric intensive care unit days 0-7. For pediatric intensive care unit days 8-14, there was no difference in average caloric (82% ± 22% vs. 79% ± 18% of goal) or protein (77% ± 6% vs. 79% ± 7% of goal) between the traumatic brain injury (n = 12) and non-traumatic brain injury (n = 10) groups. Addition of a nutritionist was associated with earlier time to nutrition start (p = .02). CONCLUSIONS: Nutritional support was initiated in most patients within 72 hrs of pediatric intensive care unit admission. Although daily caloric and protein goals were not achieved in the first 2 wks of pediatric intensive care unit stay and nutritional deficiencies were common, earlier start of nutritional support was associated with involvement of a nutritionist and with meeting both caloric and protein goals by pediatric intensive care unit day 7.

Incidence and Risk Factors for Perioperative Cardiovascular Complications in Spine Surgery.

Background: An increasing number of patients are opting for spine surgery despite the associated risk of cardiovascular complications. The evidence regarding the incidence and risk factors of cardiovascular complications in spine surgery is insufficient. Therefore, we aimed to determine the incidence and risk factors for cardiovascular complications that occur perioperatively in spine surgery. Methods: This retrospective study included all patients who underwent spine surgery between January 2018 and December 2019 at a single center. Demographic, clinical, and operative data were collected from electronic medical records. The incidence of perioperative cardiac complications was determined. Univariate and multivariate analyses were performed to identify risk factors for the development of perioperative cardiovascular complications in the participants. Results: Of the 1,002 eligible patients enrolled in the study, six developed cardiac complications. Acute myocardial infarction, cardiac arrest, and congestive heart failure occurred in one, two, and three patients, respectively. Risk factors for cardiovascular complications included scoliosis surgery (odds ratios (OR): 18.61; 95% confidence interval (CI): 1.346-257.35) and a history of congestive heart failure (OR: 120.97; 95% CI: 2.12-6898.80). Conclusion: The incidence of perioperative cardiovascular complications in patients who underwent spine surgery was 0.6%. High-risk patients should be closely monitored optimally managed throughout the perioperative period.

Hyperglycemia during craniotomy for adult traumatic brain injury.

BACKGROUND: Hyperglycemia after traumatic brain injury (TBI) is associated with poor outcome, but previous studies have not addressed intraoperative hyperglycemia in adult TBI. In this study, we examined glucose value variability and risk factors for hyperglycemia during craniotomy in adults with TBI. METHODS: A retrospective cohort study of patients ≥18 years who underwent urgent or emergent craniotomy for TBI at Harborview Medical Center (level 1 adult and pediatric trauma center) between October 2007 and May 2010 was performed. Preoperative (within 24 hours of anesthesia start) and intraoperative (during anesthesia) glucose values for each patient were retrieved. The prevalence of intraoperative hyperglycemia (glucose ≥200 mg/dL), hypoglycemia (glucose <60 mg/dL), and glycemic trends was determined. Generalized Estimating Equations was used to determine the independent predictors of intraoperative hyperglycemia. Data are presented as adjusted odds ratio (AOR) (95% confidence interval [CI]), and P < 0.05 reflects significance. RESULTS: Intraoperative hyperglycemia was common (26 [15%]) and intraoperative hypoglycemia was not observed. Independent risk factors of intraoperative hyperglycemia were age ≥65 years (AOR 3.9 [95% CI: 1.4-10.3]; P = 0.007), Glasgow Coma Scale score <9 (AOR 4.9 [95% CI: 1.6-15.1]; P = 0.006), preoperative hyperglycemia (AOR 4.4 [95% CI: 1.7-11.6]; P = 0.003), and subdural hematoma (AOR 5.6 [95% CI: 1.4-22.2]; P = 0.02). Mean intraoperative glucose was highest in severe TBI patients (P = 0.02). There was both between-patient (79.5% variance; P < 0.001) and within-patient (20.5% variance; P < 0.001) intraoperative glucose value variability. Patients with intraoperative hyperglycemia had higher in-hospital mortality (8 [31%] vs 20 [13%]; P < 0.02). CONCLUSION: Intraoperative hyperglycemia was common in adults undergoing urgent/emergent craniotomy for TBI and was predicted by severe TBI, the presence of subdural hematoma, preoperative hyperglycemia, and age ≥65 years. However, there was significant variability in intraoperative glucose values.

Gender differences in cerebrovascular reactivity to carbon dioxide during sevoflurane anesthesia in children: preliminary findings.

BACKGROUND: Cerebrovascular reactivity to carbon dioxide (CO(2) R) is affected by age, gender and anesthetic agents. While gender differences in CO(2) R are described in adults, there are no such data in children. AIM: To examine the gender differences in CO(2) R in children during sevoflurane anesthesia. METHODS: Five girls and five boys <15 years of age and ASA physical status I, undergoing general anesthesia for elective surgery were enrolled. Under steady-state anesthesia with <1.0 MAC sevoflurane, middle cerebral artery blood flow velocity changes were monitored using Transcranial Doppler ultrasound while endtidal carbon dioxide (EtCO(2)) was adjusted from 40 to 30 mmHg (hypocapnia) and then from 40 to 50 mmHg (hypercapnia). CO(2)R was calculated between EtCO(2) ranges 30-40 and 40-50 mmHg. Cerebrovascular resistance (eCVR) was estimated as MAP/Vmca and the change in eCVR (ΔeCVR) between EtCO(2) 30 and 40 mmHg and between EtCO(2) 40 and 50 mmHg was calculated. RESULTS: There was no gender difference in CO(2)R. However, both CO(2)R and ΔeCVR were lower in the EtCO(2) 40-50 mmHg range compared to EtCO(2) 30-40 mmHg range only in girls (P = 0.01 and P = 0.01, respectively). Vmca increased significantly with increase in CO(2) (P < 0.001) for both boys and girls. The coefficient of nonlinear correlation (r) between Vmca and EtCO(2) was 0.88 in girls vs 0.66 in boys. CONCLUSION: While there were no gender differences in CO(2)R within the individual EtCO(2) ranges examined, girls but not boys had a significantly lower CO(2)R and ΔeCVR in the higher EtCO(2) range during <1.0 MAC sevoflurane anesthesia.

Vasopressor use and effect on blood pressure after severe adult traumatic brain injury.

BACKGROUND: We describe institutional vasopressor usage, and examine the effect of vasopressors on hemodynamics: heart rate (HR), mean arterial blood pressure (MAP), intracranial pressure (ICP), cerebral perfusion pressure (CPP), brain tissue oxygenation (PbtO(2)), and jugular venous oximetry (SjVO(2)) in adults with severe traumatic brain injury (TBI). METHODS: We performed a retrospective analysis of 114 severely head injured patients who were admitted to the neurocritical care unit of Level 1 trauma center and who received vasopressors (phenylephrine, norepinephrine, dopamine, vasopressin or epinephrine) to increase blood pressure RESULTS: Phenylephrine was the most commonly used vasopressor (43%), followed by norepinephrine (30%), dopamine (22%), and vasopressin (5%). Adjusted for age, gender, injury severity score, vasopressor dose, baseline blood pressure, fluid administration, propofol sedation, and hypertonic saline infusion, phenylephrine use was associated with 8 mmHg higher mean arterial pressure (MAP) than dopamine (P = 0.03), and 12 mmHg higher cerebral perfusion pressure (CPP) than norepinephrine (P = 0.02) during the 3 h after vasopressor start. There was no difference in ICP between the drug groups, either at baseline or after vasopressor treatment. CONCLUSIONS: Most severe TBI patients received phenylephrine. Patients who received phenylephrine had higher MAP and CPP than patients who received dopamine and norepinephrine, respectively.

Prediction of discharge outcome with the full outline of unresponsiveness (FOUR) score in neurosurgical patients.

To identify the diagnostic properties of the Full Outline of Unresponsiveness (FOUR) score and the discharge outcome, 318 patients were studied. The evaluators rated the patients on admission or when they had mental status alteration with the FOUR score. The course of treatment was determined based on the clinical. The mortality rate and Glasgow Outcome Scale were recorded. Adjusted regression models and prognostic performance were tested by calculation of the receiver operating characteristic curve. One-hundred and twenty-two patients (40.1%) had a poor outcome defined as a Glasgow Outcome Scale score from 3-5, and 38 patients (12.5%) died. The area under the characteristic curve (AUC) for poor outcome and in-hospital mortality were 0.88 (95% CI, 0.83-0.92) and 0.92 (95% CI, 0.87-0.97). The cut-off point of 14 showed sensitivity and specificity of the total FOUR score predicting poor outcomes at 0.77 (95% CI, 0.69-0.84) and 0.95 (95% CI, 0.90-0.97), while the cut-off point of 10 showed the values for in-hospital mortality at 0.71 (95% CI, 0.55-0.83) and 0.93 (95% CI, 0.90-0.96). The total FOUR score showed satisfactory prognostic value for predicting outcome. The cut-off points for the poor outcome and in-hospital mortality are 14 and 10, respectively.

What is new in pediatric traumatic brain injury?

PURPOSE OF REVIEW: Pediatric traumatic brain injury (TBI) is associated with significant morbidity and mortality. The purpose of this review is to discuss emerging concepts and to provide an update on the clinical evaluation, management, and predictors of outcome after pediatric TBI. RECENT FINDINGS: We review the epidemiology, patterns of injury, and pathophysiology of pediatric TBI and focus on selective 'hot topics' such as biomarkers, glucose control, and the potential benefits of hypothermia after pediatric TBI. SUMMARY: As TBI is the leading cause of death in children, research in this area is needed to advance our knowledge of the sequelae after and improve outcomes of children with TBI.

The Thai Anesthesia Incident Monitoring study (Thai AIMS): an analysis of 21 awareness events.

OBJECTIVE: To demonstrate the characteristics, outcomes, and the circumstances associated with intraoperative recall of awareness. MATERIAL AND METHOD: Relevant data of intra-operative recall of awareness were extracted from the Thai Anesthesia Incident Monitoring study (Thai AIMS) database of 1996 incident reports and 2537 incidents which were conducted among 51 hospitals throughout Thailand from January to June, 2007. Details regarding patients, surgical, anesthetic and systematic factors were recorded in a structured data record form. The completed record forms were reviewed independently by three anesthesiologists. The descriptive statistic was analyzed by using SPSS software version 11.5 and demonstrated in number and percent. RESULTS: Twenty-one incidents (21/1996 = 1.05%) of intra-operative recall of awareness were reported. Awareness was predominantly found in females (76.2%) and with ASA physical status I (47.6%). Most of the patients recalled events during the maintenance period and reported sound (71.4%), pain (52.4%), feeling operated (38.1%), paralysis (33.3%), recognizing intubated (4.8%) and panic (4.8%). Anxiety (33.3%), temporary emotional stress (19%), and post traumatic stress (4.8%) were found during immediate outcome assessment but scarcely sustained on the hospital discharged date. The factors associated with the incidents were anesthetic related in the majority especially ineffective monitoring (100%), pre-medication abandonment (100%) and light anesthesia (71.5%). CONCLUSION: Intra-operative recall of awareness in the Thai AIMS was 1.05% of all incident reports. Most of the events were considered as anesthesia related. The suggested corrective strategies were quality assurance activity, effective monitoring and equipment maintenance.

Cerebral autoregulation and CO2 reactivity before and after elective supratentorial tumor resection.

BACKGROUND: The effect of surgical decompression of tumor on autoregulation and CO2 reactivity is not known. We examined the effect of elective tumor resection on cerebral autoregulation and CO2 reactivity. METHODS: Patients with supratentorial tumors undergoing elective craniotomy for tumor resection under standard anesthesia underwent cerebral autoregulation and CO2 reactivity testing immediately before and between 6 and 24 hours after surgery. Transient hyperemic response of the middle cerebral artery after the release of 10 second compression of the ipsilateral common carotid artery was used to calculate the transient hyperemic response ratio (THRR). THRR>1.1 defined the normal autoregulation. Voluntary hyperventilation was titrated to reduce the ETCO2 by 10 mm Hg below baseline and CO2 reactivity was calculated. RESULTS: Thirty-five patients (26 male and 9 female) were studied. Overall, cerebral autoregulation was intact before and after tumor resection for the cohort (THRR 1.27+/-0.10 and 1.30+/-0.12, P=0.11). However, cerebral autoregulation was impaired preoperatively in 7 (20%) patients and remained impaired in all 7 patients after tumor resection. Larger tumor size (P=0.002), and midline shift more than 5 mm (P<0.001) were associated with impaired cerebral autoregulation. Twenty-eight (80%) patients who had intact preoperative cerebral autoregulation maintained autoregulation postoperatively. CO2 reactivity was within normal limits before and after surgery in all patients and did not change between the 2 periods (3.41+/-0.46/mm Hg and 3.60+/-0.63%/mm Hg, P=0.07). CONCLUSION: Preoperative cerebral autoregulation was impaired in a significant number of patients with large supratentorial tumor size and midline shift more than 5 mm and was associated with postoperative impaired cerebral autoregulation during the first 24 hours after the surgery.