ABSTRACT
Purpose: To investigate the safety and feasibility of growth rod distraction procedure as 'daycare surgery' in early-onset scoliosis (EOS). EOS is an 'enigma' in spine surgery as early fusion and deformity correction will negatively affect truncal growth and pulmonary development. Likewise, delaying the treatment would lead to grotesque deformity with severe systemic implications. Therefore, worldwide we use 'Growth rods' for EOS and periodically distract it to allow for spinal growth in a 'controlled' manner. However, regular distraction every 6 months until definitive fusion would incur huge financial challenges and resource utilization . Our hypothesis is that the growth rod distraction procedure can be routinely used as a daycare procedure, thereby, cutting down the cost and resource utilization, especially in these pandemic times. Method(s): Hospital records and operation notes were retrospectively reviewed of 119 patients with a focus on details of neurological events/ complications during their index surgeries/lengthening procedures. Multimodality IONM was used as a mandatory protocol in all our index cases . However, for growth rod lengthening procedures we had well-defined indications-i) patients in whom intraoperative drop in signals were present during index case ii)patients who had intraspinal abnormality and had synchronous neurosurgical procedure iii) patients who underwent rod exchange/revision surgery concurrent with lengthening procedure. Except for these indications, none of our patients had IONM during the routine lengthening procedure.An amplitude drop of greater than 50% in trans cranial MEP or somatosensory evoked potentials (SSEP) was considered a neuromonitoring 'alert'. Result(s): 653 procedures involving primary growing rod surgeries (119 / 653) and lengthening procedures (534/653) were performed in 119 patients with EOS with a mean age of 7.3+/-2.3 years. Traditional growing rods (TGR-454/534) or magnetically controlled growing rods (MCGR-80/534) were implanted and subsequent lengthening procedures (Average -4.7 (range 2-9)) were done at stipulated intervals (TGR- 6.5 months, MCGR -3.8 mo). The mean anesthesia to surgical time for TGR (96.6+/-23 min vs 41.3 +/- 12 min) and MCGR was done as an outpatient procedure with mean average time of 26.2+/-9 minutes, respectively. The mean average blood loss in TGR vs MCGR was reported as 108+/-38 mL vs 0 mL.None of the patients with rod lengthening procedures required blood transfusion or experienced a neuromonitoring alert. On the morning of surgery these patients were admitted on short admission to Operating theatres and were not administered any pre-medication drugs. Induction was done using propofol (calm patients) or sevoflurane (restless patients) and BIS monitoring was done throughout the procedure. Intraoperative pain management was done using a fentanyl bolus. Furthermore, In the immediate post-operative period these patients were managed on fentanyl single bolus dose (0.5 microgram/kg) and later administered paracetamol injection (15 mg/kg - <30 kg) or ketorolac injection (0.1 mg/kg). At discharge, patients were managed on non-steroidal anti-inflammatory oral medications. Average reporting pain control (VAS-1.3+/-0.78) was satisfactory and mobilization was initiated within 4 hours, postoperatively. All our patients were discharged on the same evening with oral analgesics. Our 30-day readmission was noted in 2/119 secondary to superficial wound infection, which was managed on oral antibiotics. Conclusion(s): Growth rods (TGR, MCGR ) lengthening procedures can be safely undertaken as 'daycare surgery' under standardized anaesthesia and pain protocol. Secondly, intraoperative neuromonitoring can also be avoided in distraction procedures, thereby, helping in cost-cutting. This is especially relevant in changing paradigms of resource limitation in the COVID pandemic situation worldwide.
ABSTRACT
Background: Severe acute respiratory syndrome coronavirus 2 (SARSCoV- 2) or COVID-19 pandemic was a highly contagious virus that was first reported in the city of Wuhan, China in December 2019. COVID-19 pandemic has been a challenge to the global healthcare system and healthcare professionals including Indonesia. The first case found in Indonesia was in March 2020 and there were three peaks of the case, which were in January 2021, July 2021, and February 2022. Cipto Mangunkusumo Hospital, as a tertiary level and national referral hospital, was assigned as one of the biggest COVID-19 center hospitals in Indonesia. Throughout the pandemic, several policies regarding anesthesia practice were made, including the COVID-19 screening system and surgical patient pathway. Thus, there were two exclusive negative pressure operating rooms located in a centralized COVID-19 building and an emergency unit. Many surgical procedures were performed during the pandemic, including neurosurgical cases which involved neuro anesthesia practices that needed some adjustment due to the pandemic. There are two main questions that will be addressed in this research. First, Of all patients that undergo neurosurgery procedures how many have COVID-19. Second, Of all COVID- 19 patients that undergo surgery how many of them are neurosurgery. Method(s): This study was descriptive and involved a retrospective review of data collected from patients who underwent neurosurgeries between March 2020 and March 2022. Analyzes were performed according to COVID-19 status, age, classification case, type of surgery, and type of anesthesia. Result(s): A total of 933 neurosurgery cases and 488 COVID-19 surgery cases were identified. There were 26 neurosurgery cases with COVID 19. It was about 2.7% relative to all neurosurgery cases and about 5.3% relative to all COVID 19 surgery cases. General anesthesia was conducted in all of the cases. Fifty percent of the surgery was performed in centralized COVID-19 building operating room with elective setting, following 46% of cases was performed in emergency unit. There was one case was performed in catheterization lab. The population of cases was 65.3% in adult patients and 34.7% in pediatric population, consisted of eight vascular cases, seven oncology cases, seven infection cases, three trauma cases, and one congenital case. The procedure performed were 57.6% cerebrospinal fluid diversion, 34.6% craniotomy and 7,6% debridement.We followed our hospital established local COVID-19 guideline for surgical procedures, international guidelines, and recommendations, such as SNACC, to help deciding the risk stratification and time to perform the procedures. However, we have not performed transnasal procedure, awake craniotomy, and intraoperative neuromonitoring. All safety measures and infection control protocols were implemented. Conclusion(s): Neurosurgical procedures for patient with COVID-19 are considered uncommon with respect to all COVID-19 surgery cases and all neurosurgery cases. This information can be taken into consideration when making guidelines in the pandemic era. Further research are needed to explore impact of COVID-19 to neurosurgery patients.
ABSTRACT
Introduction: Neurological complications are frequent in patients with coronavirus disease-2019 (COVID-19). The use of non-invasive neuromonitoring in subjects without primary brain injury but with potential neurological derangement is gaining attention outside the intensive care unit (ICU). This systematic review and meta-analysis investigates the use of non-invasive multimodal neuromonitoring of the brain in non-critically ill patients with COVID-19 outside the ICU and quantifies the prevalence of abnormal neuromonitoring findings in this population. Methods: A structured literature search was performed in MEDLINE/PubMed, Scopus, Cochrane, and EMBASE to investigate the use of non-invasive neuromonitoring tools, including transcranial doppler (TCD); optic nerve sheath diameter (ONSD); near-infrared spectroscopy (NIRS); pupillometry; and electroencephalography (EEG) inpatients with COVID-19 outside the ICU. The proportion of non-ICU patients with CVOID-19 and a particular neurological feature at neuromonitoring at the study time was defined as prevalence. Results: A total of 6,593 records were identified through literature searching. Twenty-one studies were finally selected, comprising 368 non-ICU patients, of whom 97 were considered for the prevalence of meta-analysis. The pooled prevalence of electroencephalographic seizures, periodic and rhythmic patterns, slow background abnormalities, and abnormal background on EEG was.17 (95% CI 0.04-0.29), 0.42 (95% CI 0.01-0.82), 0.92 (95% CI 0.83-1.01), and.95 (95% CI 0.088-1.09), respectively. No studies investigating NIRS and ONSD outside the ICU were found. The pooled prevalence for abnormal neuromonitoring findings detected using the TCD and pupillometry were incomputable due to insufficient data. Conclusions: Neuromonitoring tools are non-invasive, less expensive, safe, and bedside available tools with a great potential for both diagnosis and monitoring of patients with COVID-19 at risk of brain derangements. However, extensive literature searching reveals that they are rarely used outside critical care settings.Systematic Review Registration: www.crd.york.ac.uk/prospero/display_record.php?RecordID=265617, identifier: CRD42021265617.
ABSTRACT
Purpose: The incidence and the clinical presentation of neurological manifestations of coronavirus disease-2019 (COVID-19) remain unclear. No data regarding the use of neuromonitoring tools in this group of patients are available. Methods: This is a retrospective study of prospectively collected data. The primary aim was to assess the incidence and the type of neurological complications in critically ill COVID-19 patients and their effect on survival as well as on hospital and intensive care unit (ICU) length of stay. The secondary aim was to describe cerebral hemodynamic changes detected by noninvasive neuromonitoring modalities such as transcranial Doppler, optic nerve sheath diameter (ONSD), and automated pupillometry. Results: Ninety-four patients with COVID-19 admitted to an ICU from February 28 to June 30, 2020, were included in this study. Fifty-three patients underwent noninvasive neuromonitoring. Neurological complications were detected in 50% of patients, with delirium as the most common manifestation. Patients with neurological complications, compared to those without, had longer hospital (36.8 ± 25.1 vs. 19.4 ± 16.9 days, p < 0.001) and ICU (31.5 ± 22.6 vs. 11.5±10.1 days, p < 0.001) stay. The duration of mechanical ventilation was independently associated with the risk of developing neurological complications (odds ratio 1.100, 95% CI 1.046-1.175, p = 0.001). Patients with increased intracranial pressure measured by ONSD (19% of the overall population) had longer ICU stay. Conclusions: Neurological complications are common in critically ill patients with COVID-19 receiving invasive mechanical ventilation and are associated with prolonged ICU length of stay. Multimodal noninvasive neuromonitoring systems are useful tools for the early detection of variations in cerebrovascular parameters in COVID-19.