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Resumen: Introducción: Existe la creencia de que los pacientes no experimentan dolor intenso después de cirugía intracraneal. La estimulación simpática secundaria a dolor puede ocasionar hipertensión intracraneal y sangrado postoperatorio. Es controvertido el uso de opioides para analgesia postcraneotomías por temor a sus efectos colaterales que pueden enmascarar signos de alteración neurológica. En pediatría hay estudios limitados. Objetivo: Describir el nivel de control del dolor postcraneotomías al usar buprenorfina ketorolaco y ondansetrón en pacientes pediátricos. Métodos: Estudio de cohorte descriptivo. Incluimos niños de 0-17 años programados para cirugía intracraneal electiva. Para el control del dolor se administró buprenorfina, ketorolaco y ondansetrón en infusión por 30 horas. Se investigó dolor al iniciar la infusión a las cuatro, ocho, 12, 24 y 30 horas; variables hemodinámicas y grado de sedación. Resultados: 109 pacientes fueron incluidos. Se observó adecuado control del dolor en 71.56%, 28.4% tuvo control insuficiente con una diferencia estadísticamente significativa (p < 0.001). Hubo sedación moderada en 5.6% iniciando la infusión y a las 24 horas (4.5%) sin repercusión hemodinámica. Se detectó náusea en 8.2% y vómito en 6.64%; no se presentó sedación profunda, ni depresión respiratoria. Conclusiones: Estos hallazgos sugieren que es una opción efectiva para tratar el dolor postcraneotomías en pediatría.
Abstract: Introduction: There is still a belief that patients do not experience intense pain after intracranial surgery. Sympathetic stimulation associated with pain can lead to elevated intracranial pressure and postoperative haemorrhage. There is controversy about the use of opioids for postoperative analgesia in craniotomies, owing to fear of its side effects, which can mask signs of neurological alteration. There are limited studies in the pediatric patient for post-craniotomy analgesia. Objective: To describe the postcraneotomies pain control level, using buprenorphine in partnership with ketorolac and ondansetron in pediatric patients. Methods: Descriptive cohort study. For postoperative pain control, patients were given continuous infusion buprenorphine, ketorolac and ondansetron for 30 hours. The main variables to investigate were pain at beginning of infusion, at four, eight, 12, 24 and 30 hours, hemodynamic variables and depth of sedation. Results: 109 patients were included. Adequate control of pain was observed in 71.56% of patients, whereas in 28.4% insufficient control was found, with a statistically significant difference (p < 0.001). There was moderate sedation in 5.6% of the patients at the start of infusion and at 24 hours (4.5%), without significant impact on hemodynamic variables. Nausea was found in 8.2% and vomiting in 6.64%. No deep sedation, or respiratory depression was presented. Conclusions: These findings suggest that is an effective option to treat postcraneotomy pain in pediatric patients.
ABSTRACT
Background: Recovery from general anesthesia and extubation is a period of intense physiological stress for patients. The most feared complications after intracranial surgery are development of an intracranial hematoma and major cerebral edema. Both may result in cerebral hypoperfusion and brain injury. Thus, the anesthetic emergence of a neurosurgical patient should include maintenance of stable respiratory and cardiovascular parameters. Minimal reaction to the endotracheal tube removal prevents sympathetic stimulation and increases in venous pressure. In our study, we compared dexmedetomidine HCl, lignocaine HCl and placebo to blunt stress response and providing a smooth transition from extubation phase. Methods: 75 ASA Grade I and II patients aged 18-60 years scheduled for elective intracranial surgery for intracranial space occupying lesions were randomly divided into three groups of 25 each. Balanced general anesthesia was given. Inhalation anesthetic was discontinued and after return of spontaneous respiration patient in Group D received injection dexmedetomidine 0.5 μg/kg intravenous (IV), Group X received injection lignocaine 1.5 mg/kg IV and Group P received 10 ml normal saline IV over 60 sec. Heart rate (HR), mean arterial pressure (MAP), quality of extubation were measured at 1, 3, 5, 10, 15 mins interval after extubation. Emergence time and extubation time were noted and quality of extubation was evaluated on cough grading. Results: There was a signifi cant decrease in MAPs and HR in Group D as compared to Group L and Group P (p<0.05) at all-time interval after extubation. Extubation quality score of the majority of patients was 1 in Group D, 2 in Group X, and 3 in Group P (p<0.001). The duration of emergence and extubation were comparable in all three groups. Sedation score of the most patient was 3 (44%) in Group D and 2 (56%) in Group X. Six patients in Group D and 1 patient in Group X had bradycardia. Conclusion: Single bolus dose of IV dexmedetomidine HCl 0.5 mg/kg given before tracheal extubation effectively attenuates hemodynamic response to extubation as compared to 1.5 mg/kg lignocaine HCl.
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In most intracranial surgery cases, a drain catheter is inserted to prevent the collection of the wound hematoma or seroma. A drain catheter is also inserted to drain the hematoma or the cerebrospinal fluid. The drain catheter itself does not cause complications; but many complications occur during its removal, such as hematoma, seroma, air collection and pseudomeningocele formation. To prevent these complications, neurosurgeons perform a suture on the catheter to remove the site. In this study, an additional horizontal mattress suture and an anchoring suture to the drainage catheter are proposed. This method maintains negative pressure in the catheter insertion site during the catheter removal, compresses the catheter tunnel site and attaches the external wounds strongly. The technique is easy and safe to perform, and does not require an additional suture to remove the catheter.
Subject(s)
Catheters , Cerebrospinal Fluid , Drainage , Hematoma , Seroma , Sutures , Wounds and InjuriesABSTRACT
Background: The time to extubation in neurosurgical patients depends on a number of various factors, including patient, surgical and anesthetic factors. Objective: To determine the factors influencing the time to extubation in neurosurgical patients. Methods: This study is a prospective study including all patients who underwent intracranial surgery from October 2008 to April 2009 at Siriraj Hospital. We excluded patients who were under the age of 18 years, intubated or had undergone tracheostomy prior to the surgery and had a history of difficult intubation. Demographic data and various factors expected to involve the extubation were collected and analyzed. Results: There were 171 (89.1%) patients suitable for the early extubation and 21 (10.9%) patients remained in the intubated condition. A univariate analysis revealed 10 factors influencing failure of the extubation, including age >65 years, ASA physical status > class II, Glasgow coma score (GCS) <13, emergency surgical condition, anesthetic time >300 minutes, estimated blood loss >700 ml, use of cerebral protective technique, total propofol dosage >1,000 mg, total fentanyl dosage >50 mcg/hour, and a completed operation time after 4 pm. In a multivariate analysis, the delayed extubation was associated with 3 factors, including GCS <13, emergency surgical condition and estimated blood loss >700 ml. Conclusion: The incidence of the early extubation in neurosurgical patients who underwent intracranial surgery was 89.1%. Factors associated with an increased risk of delayed extubation included low Glasgow coma score, emergency surgical status and a large amount of intra-operative blood loss.
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@#Objective To investigate the effects of muscle relaxants on motor evoked potentials (MEPs) monitoring during intracranial surgery. Methods 62 patients with neurological tumor were divided into 2 groups: muscle relaxant group (n=21) and non-muscle relaxant group (n=41). The incidence of successful MEPs monitoring was investigated. Results The incidence of successful MEPs monitoring was 76.2% in the muscle relaxant group and 41.5% in the non-muscle relaxant group (P<0.05). Conclusion Muscle relaxants can affect the MEP monitoring, which would not be administered as possible during anesthesia for intracranial surgery in functional area.