Manejo anestésico de los procedimientos neuroquirúrgicos endovasculares en pacientes con accidente cerebrovascular isquémico: revisión sistemática de metaanálisis / Anesthetic management of endovascular neurosurgical procedures in acute ischemic stroke patients: A systematic review of meta-analyses

La restauración de la circulación cerebral en la zona de isquemia es la tarea más crítica dentro del tratamiento para reducir la lesión neuronal irreversible en pacientes con accidente cerebrovascular isquémico. La recanalización de la circulación cerebral en los pacientes seleccionados se ha vuelto indispensable para mejorar los resultados clínicos y ha dado lugar a las técnicas de revascularización generalizadas. No existe una respuesta clara sobre qué modalidad anestésica utilizar en pacientes con accidente cerebrovascular isquémico agudo sometidos a procedimientos neuroendovasculares. El propósito de esta revisión sistemática es realizar un análisis cualitativo de revisiones sistemáticas y metaanálisis (RS y MA) que comparen métodos de anestesia general y otros tipos de anestesia para intervenciones endovasculares cerebrales en pacientes con accidente cerebrovascular isquémico agudo. Desarrollamos un protocolo con los criterios de inclusión y exclusión para publicaciones coincidentes y realizamos una búsqueda bibliográfica en PubMed y Google Scholar. La búsqueda bibliográfica arrojó 52 publicaciones potenciales. En esta revisión se incluyeron y analizaron diez RS y MA relevantes. La decisión sobre qué método de anestesia utilizar para los procedimientos endovasculares en el manejo de pacientes con accidente cerebrovascular isquémico agudo debe tomarse en función de las características personales del paciente, fenotipos fisiopatológicos, características clínicas y la experiencia institucional.(AU)

Restoration of cerebral circulation in the ischemic area is the most critical treatment task for reducing irreversible neuronal injury in ischemic stroke patients. The recanalización of appropriately selected patients became indispensable for improving clinical outcomes and resulted in the widespread revascularization techniques. There is no clear answer as to which anesthetic modality to use in ischemic stroke patients undergoing neuro-endovascular procedures. The purpose of this systematic review is to conduct a qualitative analysis of systematic reviews and meta-analyses (RSs & MAs) comparing general anesthesia and non-general anesthesia methods for cerebral endovascular interventions in acute ischemic stroke patients. We developed a protocol with the inclusion and exclusion criteria for matched publications and conducted a literature search in PubMed and Google Scholar. The literature search yielded 52 potential publications. Ten relevant RSs & MAs were included and analyzed in this review. The decision about which anesthesia method to use for endovascular procedures in managing acute ischemic stroke patients should be made based on the patient's personal characteristics, pathophysiological phenotypes, clinical characteristics, and institutional experience.(AU)

Anesthetic management of endovascular neurosurgical procedures in acute ischemic stroke patients: A systematic review of meta-analyses.

Restoration of cerebral circulation in the ischemic area is the most critical treatment task for reducing irreversible neuronal injury in ischemic stroke patients. The recanalización of appropriately selected patients became indispensable for improving clinical outcomes and resulted in the widespread revascularization techniques. There is no clear answer as to which anesthetic modality to use in ischemic stroke patients undergoing neuro-endovascular procedures. The purpose of this systematic review is to conduct a qualitative analysis of systematic reviews and meta-analyses (RSs & MAs) comparing general anesthesia and non-general anesthesia methods for cerebral endovascular interventions in acute ischemic stroke patients. We developed a protocol with the inclusion and exclusion criteria for matched publications and conducted a literature search in PubMed and Google Scholar. The literature search yielded 52 potential publications. Ten relevant RSs & MAs were included and analysed in this review. The decision about which anesthesia method to use for endovascular procedures in managing acute ischemic stroke patients should be made based on the patient's personal characteristics, pathophysiological phenotypes, clinical characteristics, and institutional experience.

Side effects of continuous intra-arterial infusion of nimodipine for management of resistant cerebral vasospasm in subarachnoid hemorrhage patients: A systematic review.

BACKGROUND: Cerebral vasospasm is a common complication of subarachnoid hemorrhage. Nimodipine is the most frequently used drug for cerebral vasospasm management and is the only approved medication that has been demonstrated to reduce ischemic complications, infarct size and improve neurological outcome after aneurismal subarachnoid hemorrhage. The main purpose of this systematic review was to conduct a comprehensive analysis of the main cerebral and extracerebral side effects of continuous intra-arterial infusion of nimodipine in management of delayed cerebral ischemia in subarachnoid hemorrhage patients. MATERIALS AND METHODS: A protocol with the inclusion and exclusion criteria for matched cases and the method of analysis were established and agreed by all authors. We defined the scope of this review to include articles (prospective and retrospective) reporting the side effects of continuous intra-arterial infusion of nimodipine in human subjects. PRISMA guidelines were used to conduct this systematic review. RESULTS: A total of 8 articles reporting 136 patients were included in the review and analyzed. The side effects associated with continuous intra-arterial infusion of nimodipine were arterial hypotention, heparin-induced thrombocytopenia, atrial fibrillation or flutter, infections, acute kidney injury, hepatic and gastro-intestinal side effects. CONCLUSION: The most frequent side effects reported in the articles included in this systematic review associated with the continuous intra-arterial infusion of nimodipine were arterial hypotension and heparin-induced thrombocytopenia. Intracerebral hemorrhage, the elevation of ICP, heart rhythm disorders, infectious complications, and thrombosis of the catheter might be also associated with CIAN. Future prospective studies are warranted to establish the risks and incidence of procedure-related side effects.

Systematic review of clinical evidence on postoperative delirium: literature search of original studies based on validated diagnostic scales.

BACKGROUND: Postoperative delirium is a serious complication that can occur within the 5th postoperative day. In 2017, the European Society of Anesthesiologists delivered dedicated guidelines that reported the need for routine monitoring using validated scales. OBJECTIVE: Aim of this systematic review is to identify clinical studies related to postoperative delirium that included postoperative monitoring with validated scales. DESIGN: Systematic review METHODS: Searched keywords included the following terms: postoperative, postsurgical, post anesthesia, anesthesia recovery, delirium, and confusion. Two researchers independently screened retrieved studies using a data extraction form. RESULTS: Literature search led to retrieve 6475 hits; of these, 260 studies (5.6% of the retrieved), published between 1987 and 2021, included in their methods a diagnostic workup with the use of a postoperative delirium validated scale and monitored patients for more than 24 h, therefore are qualified to be included in the present systematic review. CONCLUSION: In conclusion, available clinical literature on postoperative delirium relies on a limited number of studies, that included a validated diagnostic workup based on validated scales, extracted from a large series of studies that used inconsistent diagnostic criteria. In order to extract indications based on reliable evidence-based criteria, these are the studies that should be selectively considered. The analysis of these studies can also serve to design future projects and to test clinical hypothesis with a more standardized methodological approach.

Temperature management in acute brain injury: A systematic review of clinical evidence.

Temperature alterations in neurocritical care settings are common and have a striking effect on brain metabolism leading to or exacerbating neuronal injury. Hyperthermia worsens acute brain injury (ABI) patients outcome. However conclusive evidence linking control of temperature to improved outcome is still lacking. This review article report an update -results from clinical studies published between March 2006 and March 2020- on the relationship between hyperthermia or Target Temperature Management and functional outcome or mortality in ABI patients. MATERIALS AND METHODS: A systematic search of articles in PubMed and EMBASE database was accomplished. Only complete studies, published in English in peer-reviewed journals were included. RESULTS: A total of 63 articles into 5 subchapters are presented: acute ischemic stroke (17), subarachnoid hemorrhage (14), brain trauma (14), intracranial hemorrhage (8), and mixed acute brain injury (10). This evidence confirm and extend the negative impact of hyperthermia in ABI patients on worse functional outcome and higher mortality. In particular "early hyperthermia" in AIS patients seems to have a protective role have as promoting factor of clot lysis but no conclusive evidence is available. Normothermic TTM seems to have a positive effect on TBI patients in a reduced mortality rate compared to hypothermic TTM. CONCLUSIONS: Hyperthermia in ABI patients is associated with worse functional outcome and higher mortality. The use of normothermic TTM has an established indication only in TBI; further studies are needed to define the role and the indications of normothermic TTM in ABI patients.

Awake fiberoptic intubation in patients with stenosis of the upper airways: Utility of the laryngeal nerve block.

Awake fiberoptic intubation (AFOI) is mandatory to manage difficult airways. Superior laryngeal nerve block (SLNB) could reduce risks and improve patient comfort. The aim of this study is to assess the procedural comfort of SLNB during AFOI in a population of patients undergoing upper airway oncological surgery. Forty patients were randomized into two groups and were treated with continuous infusion of remifentanil, topic anesthesia and intercricoid block. In the study group (=20), SLNB was performed with lidocaine (L-SLNB); in the control group (n=20) SLNB was performed using saline (S-SLNB). AFOI was more comfortable in the L-SLNB group compared to S-SLNB patients [FOICS ≤ 1 in 18 patients (90%) L-SLNB; 2 (10%) S-SLNB (P <0.001)]. Intubation was faster in L-SLNB (47.45 ±15.38 sec) than S-SLNB (80.15 ±37.91 sec) (p <0.001). The SLNB procedure during AFOI is a safe and comfortable procedure in a population of patients undergoing upper airways surgery. Time to intubation was shorter in L-SLNB than in S-SLNB.

Short Report - Medical nutrition therapy for critically ill patients with COVID-19.

No Abstract Available.

Insulin and the Brain: A Sweet Relationship With Intensive Care.

BACKGROUND: Insulin receptors (IRs) in the brain have unique molecular features and a characteristic pattern of distribution. Their possible functions extend beyond glucose utilization. In this systematic review, we explore the interactions between insulin and the brain and its implications for anesthesiologists, critical care physicians, and other medical disciplines. METHODS: A literature search of published preclinical and clinical studies between 1978 and 2014 was conducted, yielding 5996 articles. After applying inclusion and exclusion criteria, 92 studies were selected for this systematic review. RESULTS: The IRs have unique molecular features, pattern of distribution, and mechanism of action. It has effects on neuronal function, metabolism, and neurotransmission. The IRs are involved in neuronal apoptosis and neurodegenerative processes. CONCLUSION: In this systematic review, we present a close relationship between insulin and the brain, with discernible effects on memory, learning abilities, and motor functions. The potential therapeutic effects extend from acute brain insults such as traumatic brain injury, brain ischemia, and hemorrhage, to chronic neurodegenerative diseases such as Alzheimer and Parkinson disease. An understanding of the wider effects of insulin conveyed in this review will prompt anaesthesiologists and critical care physicians to consider its therapeutic potential and guide future studies.

Neurocritical care for intracranial haemorrhage: a systematic review of recent studies.

Intracerebral haemorrhage (ICH) is associated with significant early mortality (up to 50% at 30 days) and long-term morbidity (with permanent neurological deficits in 75-80% of patients) and represents a serious health issue worldwide. The past decade has seen a dramatic increase in clinical research on ICH diagnosis and treatment that has led to revision of the guidelines for the diagnosis and management of ICH from the American Heart Association and American Stroke Association in 2013. This systematic review reports recent clinical evidence (original studies published between September 2013 and July 2015) related to neurocritical care and intensive care unit management of patients with ICH. All but one publication included in this review report original studies related to managment of patients with intracerebral or subarachnoid haemorrhage. These include insights on risk stratification and neurocritical care or intensive care unit treatment, management of haemodynamic variables and mechanical ventilation (goal-directed fluid therapy, advanced haemodynamic monitoring, and avoidance of hyperoxia and hyperventilation), and pharmacological neuroprotection.

Pharmacological perioperative brain neuroprotection: a qualitative review of randomized clinical trials.

Perioperative cerebral damage may be associated with surgery and anaesthesia. Pharmacological perioperative neuroprotection is associated with conflicting results. In this qualitative review of randomized controlled clinical trials on perioperative pharmacological brain neuroprotection, we report the effects of tested therapies on new postoperative neurological deficit, postoperative cognitive decline (POCD), and mortality rate. Studies were identified from Cochrane Central Register and MEDLINE and by hand-searching. Of 5904 retrieved studies, 25 randomized trials met our inclusion criteria. Tested therapies were: lidocaine, thiopental, S(+)-ketamine, propofol, nimodipine, GM1 ganglioside, lexipafant, glutamate/aspartate and xenon remacemide, atorvastatin, magnesium sulphate, erythropoietin, piracetam, rivastigmine, pegorgotein, and 17ß-estradiol. The use of atorvastatin and magnesium sulphate was associated with a lower incidence of new postoperative neurological deficit. The use of lidocaine, ketamine, and magnesium sulphate was associated with controversial results on POCD. The POCD did not differ between treated patients and control group for other tested drugs (thiopental, propofol, nimodipine, GM1 ganglioside, lexipafant, glutamate/aspartate, xenon, erythropoietin, remacemide, piracetam, rivastigmine, pegorgotein, and 17ß-estradiol). None of the tested drugs was associated with a reduction in mortality rate. Drugs with various mechanisms of action have been tested over time; current evidence suggests that pharmacological brain neuroprotection might reduce the incidence of new postoperative neurological deficits and POCD, while no benefits on perioperative mortality are described. Of importance from this review is the need for shared methodological approach when clinical studies on pharmacological neuroprotection are designed.

Postoperative delirium: risk factors, diagnosis and perioperative care.

UNLABELLED: Postoperative delirium (PD) relates to increased morbidity -associated with prolonged hospital stay, institutionalization and persistent functional and cognitive decline- poor long term outcome and higher perioperative mortality. Aim of this literature review is to identify established risk factors for PD and to categorize them according timing of occurrence (pre, intra and post operative), and clinical impact (Odds ratio [OR], % increase in incidence of PD). SOURCE OF INFORMATION: medical literature databases (medline and embase) were searched for published manuscripts on "postoperative delirium". Predictors and preoperative risk factors for PD were categorized into 4 groups: demographics; co morbidities; surgery and anesthesia-related (age, education, laboratory anomalies, smoking habits, benzodiazepines premedication, cardiac and thoracic surgery, etc). Intra operative risk factors for PD were categorized into 2 groups: surgery and anesthesia-related (anemia, duration and type of surgery, selected opioid, intraoperative hypotension, etc). Post operative risk factors and precipitating factors include various pathophysiological and environmental conditions, (i.e., ICU admission, low cardiac output requiring inotropes infusion; new onset atrial fibrillation; persistent hypoxia or hypercarbia; use of narcotic analgesics, delayed ambulation, inadequate nutritional status; sensory deprivation, etc). In conclusion, the effective identification, prevention and treatment of pre, intra and postoperative risk factors are the cornerstones for the prevention of PD. A dedicated perioperative care path that encompasses a tailored selection of drugs used perioperatively, the appropriate anesthesia strategy, qualified nursing surveillance, systematic use of diagnostic tools and accurate staff communication reduces the incidence and clinical impact of PD.

Adrenaline through the endotracheal tube as an answer to severe bronchospasms caused by lidocaine.

The authors describe the effect of instilling adrenaline through the endotracheal tube in one case of severe bronchospasms due to intubation with an endotracheal tube lubricated with 10% lidocaine spray in a patient with no history of adverse respiratory or allergic reactions.

Risk index for peri-operative atrial fibrillation in patients undergoing open intracranial neurosurgical procedures.

The aim of this prospective study was to determine the prevalence of pre-operative atrial fibrillation and the incidence of postoperative atrial fibrillation in patients undergoing elective or emergency intracranial neurosurgical procedures and the relation to survival and neurological outcome at 6-months follow-up compared to patients with sinus rhythm. A total of 2020 patients were enrolled; 1540 patients underwent elective procedures and 480 underwent emergency procedures. Prevalence of pre-operative atrial fibrillation was 3.7% in elective and 7.2% in emergency procedures (p = 0.0012). In patients undergoing elective cerebral procedures with pre-operative atrial fibrillation, compared to patients with sinus rhythm, 6-month neurological outcome and survival rate are similar. In patients undergoing emergency neurosurgical cerebral procedures, the presence of pre-operative atrial fibrillation is related to an increased risk of poor neurological outcome but with similar survival rate.