Guideline Adherence and Outcomes in Severe Adult Traumatic Brain Injury for the CHIRAG (Collaborative Head Injury and Guidelines) Study.

We examined the effect of early intensive care unit (ICU) adherence to 2007 Brain Trauma Foundation Guideline indicators after traumatic brain injury (TBI) on inpatient mortality at a level 1 trauma center in India (Jay Prakash Narayan Apex Trauma Center [JPNATC]) and Harborview Medical Center (HMC) in U.S. among adults older than 18 years with severe TBI. At each site, ICU Guideline adherence in first 72 hours for 17 indicators was determined and expressed as a percentage. Outcomes were in-hospital mortality and Glasgow Outcome Scale (GOS) scores at 3, 6, and 12 months after discharge. JPNATC and HMC Guideline adherence rates were 74.9% [11.0] and 71.6 % (SD ±10.4), and overall in-hospital mortality was 24% and 27%, respectively. At JPNATC, less than 65% ICU Guideline adherence was associated with higher inpatient mortality (adjusted relative risk [aRR], 1.92; 95% confidence interval [CI], 1.11-3.33) and an increase in ICU Guideline adherence rate by 1% was associated with a 3% lower in-hospital mortality (aRR, 0.97; 95% CI, 0.95-0.99). Among patients discharged with a GOS score of 2-4 at JPNATC, 67% improved at 12 months (R(2) = 0.991; P < 0.01; 99% follow-up rate) compared with discharge, but 35%, 25%, and 14% of patients discharged with a GOS score of 3-5 deteriorated at 3, 6, and 12 months to a lower GOS at home. Achieving early ICU adherence to guideline indicators was feasible and associated with significantly lower in-hospital mortality at JPNATC. Although the intracranial pressure (ICP) monitoring rates varied, in-hospitals deaths were similar between the two institutions. Although long-term outcomes generally improved, patients discharged with favorable GOS score often deteriorated at home.

Communication skills of anesthesiologists: An Indian perspective.

BACKGROUND: Communication failure is a risk factor for mishaps and complaints, which can be reduced by effective communication between operating room team members and patients. AIM: To conduct a survey among anesthesiologists regarding communications skills and related issues like stress in case of communication failure, need for training, music in operation theater, and language barrier at their work place. MATERIALS AND METHODS: We conducted a survey among anesthesiologists coming for a neuroanesthesia conference in India (n = 110) in February 2011 by questionnaire sent by e-mail to them. RESULTS: The response rate was 61.8% (68/110). Majority (95.5%) of the respondents agreed that good verbal communication leads to better patient outcome, better handling of crisis and is important between surgeons and anesthesiologists (98.5%). A total of 86% of the anesthesiologists felt that failure of communication caused stress to them. The idea of communication by e-mail or phone text messages instead of verbal communications was discouraged by 65.2%. A total of 82% of respondents felt that training of communication skills should be mandatory for all medical personnel and 77.6% were interested in participating in such course. Language barrier at work place was seen as hurdle by 62.7% of the respondents. A total of 80% of respondents felt that playing music in operating theater is appropriate. CONCLUSION: Results of the survey highlight the need for effective communication in the operating room between team members and need for formal training to improve it.

Ten years' experience in the management of spinal intramedullary tumors in a single institution.

We retrospectively reviewed the outcomes of 195 patients with intramedullary tumors who underwent surgery between January 2001 and December 2010 at a single institution. The symptomatology, neurological and neuroradiological findings, operative details, perioperative and postoperative complications, histopathological data and follow-up examinations of the 137 (70.2%) males and 58 (29.7%) females were studied and analyzed. Epidermoid was the most common intramedullary tumour in children (23%), whereas in adults, ependymomas were more common (46%). Ependymomas were more amenable to resection (total excision in 57.7% and near-total excision in 39.4%) as compared to astrocytomas (total excision in 29%; near total excision in 60.5%). At the final clinical follow-up, 24 patients (16.4%) had improved in McCormick grade, 112 patients (76.7%) remained unchanged and 11 patients (7.5%) had worsened. Complete removal of the lesion is the primary goal of surgery. We conclude that the strongest predictor of functional outcome was the preoperative neurological condition, beyond the histological differentiation of the intramedullary tumor.

Comparison of the effects of different anesthetic techniques on electrocorticography in patients undergoing epilepsy surgery - a bispectral index guided study.

AIM: It is well known that general anesthetics suppress/alter electrocorticography (ECoG) activity. However there are no randomized studies available, comparing various anesthetic techniques as regards their effects on ECoG. METHODS: The following is a double blind, randomized cross over study to compare the effects of isoflurane and propofol with or without nitrous oxide on electrocorticographic activity in patients undergoing epilepsy surgery. 40 patients suffering from medically intractable epilepsy scheduled to undergo resective surgery under ECoG guidance under general anesthesia, (March 2008-December 2010) were enrolled. Patients received either isoflurane or propofol (with air/oxygen or nitrous oxide/oxygen) as maintenance agents as per randomization and ECoG was recorded and quantified as per a scoring system (range 1-5, where 5 is most abnormal). RESULTS: The mean ECoG score in isoflurane group and propofol with nitrous oxide was 3.0(1.2), 3.2(1.2) [p=0.7] and with air was 3.9(1.0) and 3.4(1.1) [p=0.1] respectively. In both isoflurane group and propofol group addition of nitrous oxide depressed the ECoG score (p ≤ 0.01, 0.5 respectively). The total duration of anesthesia, surgery, emergence time, extubation time, and hospital stay was comparable in two groups. CONCLUSION: In our study optimal ECoG recordings were possible with use of either isoflurane or propofol. Addition of nitrous oxide to either of the anesthetic regimens suppressed the ECoG score.

Treatment of vertebral hemangiomas with absolute alcohol (ethanol) embolization, cord decompression, and single level instrumentation: a pilot study.

BACKGROUND: Vertebral hemangiomas (VH) are the most common lesions of the vertebral column. OBJECT: To evaluate the role of intraoperative ethanol embolization, surgical decompression, and instrumented fusion in VH presenting with myelopathy. METHODS: This is was a prospective study of single-level symptomatic VH with cord compression. Exclusions were as follows: pathological fractures, deformity, or multilevel pathologies. Surgery consisted of intraoperative bilateral pedicular absolute alcohol injection and laminectomy at the level of pathology followed by a short-segment instrumented fusion using pedicle screws. RESULTS: Ten patients (mean, 26.8 ± 18.11; range, 10-68 years; 8 females) were treated with use of this technique. Clinical features included myelopathy with motor and sensory involvement in all (4 paraplegic), sphincter involvement (8), and severe local pain (5). The preoperative American Spinal Injury Association (ASIA) scores were A (3), B (1), and C (6). All had pan vertebral body VH with severe cord compression. The mean surgical time was 102 ± 22 minutes; average blood, 296 ± 90.82 mL. Mean amount of absolute alcohol injected was 12.6 ± 4.7 mL (1 requiring 25 mL). Immediate embolization was achieved in all patients allowing laminectomy and soft-tissue hemangioma removal. Postsurgery, all patients showed improvement (sphincters improved in 4) at a follow-up ranging 12 to 26 months (transient neurological deterioration in 1). Postsurgery ASIA scores were D (5) and E (5) at last follow-up. Two patients showed evidence of bone sclerosis on follow-up CT scans at 1.2 and 1.5 years. CONCLUSION: This procedure seems to be a safe, efficient method to treat VH with severe cord compression. It seems to serve the purpose of providing embolization, cord decompression, and rigid fusion at the same sitting.

Does egress of cerebrospinal fluid during percutaneous retrogasserian glycerol rhizotomy influence long term pain relief?

BACKGROUND AND OBJECTIVES: To examine the effect of cerebrospinal fluid (CSF) flow during percutaneous retrogasserian glycerol rhizotomy (PRGR) on long term pain relief in patients with trigeminal neuralgia. METHODS: Eighty-nine patients with trigeminal neuralgia underwent 102 PRGR procedures. PRGR was conducted under fluoroscopy. After the egress of CSF, anhydrous glycerol (0.3-0.4 cc) was injected in the sitting position. In the absence of CSF flow, 0.25 mL 2% lidocaine was injected to elicit hypesthesia in the affected side. Once hypesthesia was elicited glycerol was injected. Patients were grouped as A (CSF flow present) or B (CSF flow absent), according to the egress of CSF at the time of needle placement. Patients were followed up for the recurrence of pain (average duration of follow up, 62 months). RESULTS: CSF flow was present in 54 patients (60.6%) and absent in 35 patients (39.4%). Thirty patients (56.6%) of group A had excellent pain relief, 18 patients (33.3%) had good pain relief, and 6 patients (11.1%) had no pain relief. However, in the absence of CSF flow, 14 patients (40%) each had excellent and good pain relief, and 7 patients (20%) were treatment failures. The pain relief was comparable between the groups. The median time to recurrence of pain needing further injection was 66 months in group A and 63 months in group B (not significant). CONCLUSIONS: Presence of CSF flow during needle placement does not influence the success rate and duration of pain relief following PRGR.