Dexmedetomidine for craniotomy under general anesthesia: A systematic review and meta-analysis of randomized clinical trials.

STUDY OBJECTIVE: To assess the efficacy and safety of dexmedetomidine as an adjunct to general anesthesia for craniotomy. DESIGN: A meta-analysis after systematically searching PubMed, Medline, EMBASE, and Cochrane library for randomized trials (RCTs). Relative risk (RR) and weighted mean difference (WMD) were calculated using random-effects meta-analysis. SETTING: Perioperative setting. PATIENTS: Twenty-two RCTs (1348 patients) with craniotomy under general anesthesia were included. INTERVENTIONS: Dexmedetomidine as an adjunct to general anesthesia versus placebo or other anesthetics. MEASUREMENTS: Primary outcomes included procedure success and postoperative pain; Secondary outcomes included cardiac adverse events, postoperative nausea and vomiting (PONV) and other clinically important outcomes. MAIN RESULTS: Dexmedetomidine vs. Placebo: High to moderate quality evidence suggested that dexmedetomidine reduced postoperative pain (WMD -0.25 cm, 95%CI -0.43 to -0.07 cm on a 10 cm visual analogue scale), postoperative nausea and vomiting (PONV, RR 0.57, 95%CI 0.39 to 0.84), hypertension (RR 0.37, 95%CI 0.22 to 0.61) and tachycardia (RR 0.32, 95%CI 0.12 to 0.85) with no significant increase of hypotension and bradycardia. Moderate quality evidence suggested no significant difference in procedural success. Dexmedetomidine vs. Active Comparators (including remifentanil, fentanyl, or propofol): Moderate quality evidence showed no difference in procedural success and postoperative pain. CONCLUSIONS: Dexmedetomidine as an adjunct to general anesthesia shows small benefits in reduction of pain, PONV, and maintains more stable hemodynamics with comparable effects on procedural success versus placebo. Very limited evidence explored comparative effects between dexmedetomidine and active controls. Further evidence is required to evaluate patient-important outcomes and optimal dosing strategies, particularly versus active comparators.

Establishment of epilepsy surgery in Peru.

Epilepsy surgery is a well-established treatment for certain types of intractable epilepsy. While there is a relatively high number of epilepsy surgery centers in Canada and the United States, the same cannot be said about many other parts of the world, such as South America. Although there are notable exceptions, such as Brazil and Colombia, formal epilepsy surgery centers have been lacking in many South American countries, including Peru. Although sporadic cases have been performed in Peru, there was no formal epilepsy surgery center in the country as of 2011. Beginning in 2008, with the support of the Partnering Epilepsy Centers in America program of the North American Commission of the International League Against Epilepsy, the Epilepsy Program at Western University in London, Canada, was partnered with the Department of Epilepsy at the Instituto Nacional de Ciencias Neurologicas in Lima. This was the beginning of a long-term relationship that culminated in the establishment of the first 2 formal epilepsy surgery centers in Peru. The purpose of this communication is to briefly summarize the establishment of 2 independent epilepsy surgery programs in Peru and to document the methods with which this accomplishment was achieved.

Multilevel, ultra-large-volume epidural blood patch for the treatment of neurocognitive decline associated with spontaneous intracranial hypotension: case report.

Spontaneous intracranial hypotension (SIH) is a progressive clinical syndrome characterized by orthostatic headaches, nausea, emesis, and occasionally focal neurological deficits. Rarely, SIH is associated with neurocognitive changes. An epidural blood patch (EBP) is commonly used to treat SIH when conservative measures are inadequate, although some patients require multiple EBP procedures or do not respond at all. Recently, the use of a large-volume (LV) EBP has been described to treat occult leak sites in treatment-refractory SIH. This article describes the management of a patient with profound neurocognitive decline associated with SIH, who was refractory to conservative management and multiple interventions. The authors describe the successful use of an ultra-LV-EBP of 120 ml across multiple levels, the largest volume reported in the literature, and describe the technical aspects of the procedure. This procedure has resulted in dramatic and sustained symptom resolution.

Comparison of Registered and Reported Outcomes in Randomized Clinical Trials Published in Anesthesiology Journals.

BACKGROUND: Randomized clinical trials (RCTs) provide high-quality evidence for clinical decision-making. Trial registration is one of the many tools used to improve the reporting of RCTs by reducing publication bias and selective outcome reporting bias. The purpose of our study is to examine whether RCTs published in the top 6 general anesthesiology journals were adequately registered and whether the reported primary and secondary outcomes corresponded to the originally registered outcomes. METHODS: Following a prespecified protocol, an electronic database was used to systematically screen and extract data from RCTs published in the top 6 general anesthesiology journals by impact factor (Anaesthesia, Anesthesia & Analgesia, Anesthesiology, British Journal of Anaesthesia, Canadian Journal of Anesthesia, and European Journal of Anaesthesiology) during the years 2007, 2010, 2013, and 2015. A manual search of each journal's Table of Contents was performed (in duplicate) to identify eligible RCTs. An adequately registered trial was defined as being registered in a publicly available trials registry before the first patient being enrolled with an unambiguously defined primary outcome. For adequately registered trials, the outcomes registered in the trial registry were compared with the outcomes reported in the article, with outcome discrepancies documented and analyzed by the type of discrepancy. RESULTS: During the 4 years studied, there were 860 RCTs identified, with 102 RCTs determined to be adequately registered (12%). The proportion of adequately registered trials increased over time, with 38% of RCTs being adequately registered in 2015. The most common reason in 2015 for inadequate registration was registering the RCT after the first patient had already been enrolled. Among adequately registered trials, 92% had at least 1 primary or secondary outcome discrepancy. In 2015, 42% of RCTs had at least 1 primary outcome discrepancy, while 90% of RCTs had at least 1 secondary outcome discrepancy. CONCLUSIONS: Despite trial registration being an accepted best practice, RCTs published in anesthesiology journals have a high rate of inadequate registration. While mandating trial registration has increased the proportion of adequately registered trials over time, there is still an unacceptably high proportion of inadequately registered RCTs. Among adequately registered trials, there are high rates of discrepancies between registered and reported outcomes, suggesting a need to compare a published RCT with its trial registry entry to be able to fully assess the quality of the study. If clinicians base their decisions on evidence distorted by primary outcome switching, patient care could be negatively affected.

Ultra-High Field Template-Assisted Target Selection for Deep Brain Stimulation Surgery.

BACKGROUND: Template and atlas guidance are fundamental aspects of stereotactic neurosurgery. The recent availability of ultra-high field (7 Tesla) magnetic resonance imaging has enabled in vivo visualization at the submillimeter scale. In this Doing More with Less article, we describe our experiences with integrating ultra-high field template data into the clinical workflow to assist with target selection in deep brain stimulation (DBS) surgical planning. METHODS: The creation of a high-resolution 7T template is described, generated from group data acquired at our center. A computational workflow was developed for spatially aligning the 7T template with standard clinical data and furthermore, integrating the derived imaging volumes into the surgical planning workstation. RESULTS: We demonstrate that our methodology can be effective for assisting with target selection in 2 cases: unilateral internal pallidum DBS for painful dystonia and bilateral subthalamic nucleus DBS for Parkinson's disease. CONCLUSIONS: In this article, we have described a workflow for the integration of high-resolution in vivo ultra-high field templates into the surgical navigation system as a means to assist with DBS planning. The method does not require any additional cost or time to the patient. Future work will include prospectively evaluating different templates and their impact on target selection.

Magnesium for acute traumatic brain injury.

BACKGROUND: Acute traumatic brain injury is a leading cause of death and disability in young adults. Numerous pharmacological and non-pharmacological tools have been investigated and considered as potential mechanisms for improving neurological outcome. Magnesium has been considered as one of these potential therapeutic tools because of its activity on NMDA-receptors, calcium channels and neuron membranes. Animal studies have indicated a beneficial effect of magnesium on outcome after brain injury, but its efficacy in humans is unknown. OBJECTIVES: To quantify the effect of magnesium administration on mortality and morbidity in patients with acute traumatic brain injury. SEARCH STRATEGY: We searched the Cochrane Injuries Group's specialised register, Cochrane Central Register of Controlled Trials, CENTRAL (The Cochrane Library issue 2, 2008), MEDLINE (and PubMed to 28 May, 2008: last 60 days), EMBASE, National Research Register, Current Controlled Trials, SIGLE, LILACS, and Zetoc. Searches were initially conducted in July 2005. The latest search was conducted in May 2008. SELECTION CRITERIA: We included all randomized controlled trials comparing any magnesium salt with no magnesium or with placebo, in patients following acute traumatic brain injury. DATA COLLECTION AND ANALYSIS: Two authors independently screened search results and assessed the full texts of potentially relevant studies for inclusion. Data were extracted and methodological quality was examined. MAIN RESULTS: Four studies met the inclusion criteria; one of which is an ongoing study. Data from three studies were included in the analysis. Data on mortality were only available in one study; RR 1.48 [1.00, 2.19], Test for overall effect: Z = 1.96 (P = 0.05). Glasgow Outcome Score at six months was described in the three studies. The Mean Difference = 0.02 (95% CI -0.38 to 0.041), Test for overall effect: Z = 0.08 (P = 0.94). AUTHORS' CONCLUSIONS: There is currently no evidence to support the use of magnesium salts in patients with acute traumatic brain injury.

Extubación temprana (fast-track) en neuroanestesia: ¿Una alternativa segura? / Extubación early (fast-track) in neuroanestesia: A sure alternative?

Las técnicas de transito rápido (fast y track) han impactado la práctica de la disciplina, desde áreas tan diversas como cardioanestesia a anestesia ambulatoria sin quedar fuera de este movimiento la neuroanestesia. Teniendo en este contexto una repercusión aun mayor, fundamentada en que la evaluación de la condición neurológica en un paciente despierto, es el método mejor y menos costoso de neuromonitoreo disponible; pero a pesar de la premisa anterior la aplicación de este tipo de protocolos en neurocirugía debe ser vista como un trabajo en equipo, para que la ejecución de la técnica no sea detrimente para el resultado final. Por eso durante esta revisión pretendemos evaluar el papel del fast y track en neuroanestesia, teniendo en cuenta las repercusiones fisopatològicas y por ende los pros y contras del despertar temprano vs. tardío; generando las bases para la elaboración de un posible plan anestésico para tránsito rápido, por que finalmente la emergencia anestésica y extubación temprana en neuroanestesia es deseable y posible en la mayoría de los casos, lo cual es esencial para detectar complicaciones postoperatorias a la llegada a recuperación...

Neurosurgery for the treatment of epilepsy.

PURPOSE OF REVIEW: Epilepsy is a common condition that is estimated to afflict 0.5-1.0% of the world's population. Frequently commencing in childhood, it is often associated with life-long disability. Approximately one-third of patients with epilepsy are refractory to antiepileptic drug therapy and many of these patients are candidates for surgical treatment. A growing body of evidence supports the safety and efficacy of surgery for the treatment of selected patients with epilepsy. Little information is available in the anesthesia literature regarding the presurgical assessment of candidates for surgical treatment. RECENT FINDINGS: The presurgical identification of suitable candidates involves a multidisciplinary approach to assessment. Recent advances, particularly in neuroimaging techniques, are dramatically enhancing the capacity to accurately identify patients who are most likely to benefit from surgery. Epilepsy surgery is underused worldwide and in developed countries. In view of current efforts to increase opportunities to provide surgical treatment to more patients and to offer surgery earlier in the course of the disorder, the number of patients requiring specialized perioperative anesthetic care is expected to increase. SUMMARY: This article provides anesthesiologists with an overview of the assessment process, investigation techniques and current rationale that influence the selection of appropriate candidates for surgical treatment and the associated need for specialized anesthetic care.

Testigos de Jehova con placenta previa total: alternativas de manejo / Placenta praevia in Jehovah's witness patients: two different therapeutics approaches

La mortalidad materna a nivel local esta determinada por fenómenos hemorrágicos mayores. Las pacientes con placenta previa total representan un grupo de altísimo riesgo para desarrollar el síndrome. Describimos dos casos de pacientes con placenta previa total que a su vez son Testigos de Jehová. Se describen dos aproximaciones terapéuticas diferentes para el ahorro de producto sanguíneo en esta subpoblación, discutiendo además la información entregada en el contexto de la nueva tendencia de esta comunidad religiosa sobre el uso o no de producto sanguíneo

Técnica combinada espinal epidural en paciente obstétrica de alto riesgo / Epidural spine combined technique in obstetric patient of high risk

Las técnicas combinadas espinales epidurales se han convertido en una alternativa a las intervenciones neuroaxiales tradicionales, fusionando las ventajas del bloqueo subaracnoideo con la flexibilidad de la técnica epidural, utilizandose tanto en alivio del dolor en el trabajo de parto como en cesáarea electiva o urgente. El uso de las mismas se ha introducido en población de alto riesgo. En esta serie de casos describimos el uso de técnicas combinadas espinales epidurales en la población materna críticamente enferma y discutiendo además los beneficios y los problemas potenciales y reales con el uso de las mismas.