Prevalence and predictors of preoperative cardiac autonomic dysfunction among elective neurosurgical patients: A prospective observational study.

Background and Aims: The autonomic nervous system (ANS) is cardinal for systemic homeostasis. Autonomic dysfunction is prevalent in as high as 65% of patients presenting for cardiac surgery in the Indian scenario. Pre-existing cardiac autonomic dysfunction (CAD) in surgical patients can accentuate perioperative haemodynamic fluctuations during stressful intraoperative events, predispose to adverse cardiac events, and contribute to morbidity and mortality. The prevalence and predictors of CAD in the elective neurosurgical population are unknown in the Indian scenario. The current study was conducted to bridge this knowledge gap. Methods: In this single-centre prospective observational study conducted at a tertiary care neurosciences centre, among 400 consenting adult patients of either gender, between 18 and 80 years of age, undergoing elective neurosurgery, the preoperative ANS function at the bedside was assessed as the primary outcome measure. The ANS status was evaluated using ANSiscope™-derived indices of heart rate variability. The diagnosis of CAD was made when the ANS index exceeded a threshold of 13.5. Data regarding predictors of CAD were collected from patient records as the secondary outcome measure. Statistical analysis was done using the R software. A P-value of <0.05 was considered statistically significant. Results: The prevalence of preoperative CAD in our study population was 79.7% (319/400 patients). None of the demographic and baseline clinical characteristics we studied predicted CAD in our study. Conclusion: We observed a significant prevalence of preoperative CAD among elective neurosurgical patients. None of the parameters we evaluated predicted CAD in our study.

Post-operative anemia in children undergoing elective neurosurgery: An analysis of incidence, risk factors, and outcomes.

Objectives: Pediatric neurosurgeries carry a considerable risk of intraoperative bleeding and, subsequently, anemia in the post-operative period. Postoperative anemia is often multifactorial with several factors contributing to its occurrence. The present study aims to quantify the incidence of postoperative anemia, identify potential risk factors, and assess the impact of post-operative anemia on clinical outcomes in the pediatric neurosurgery population. Materials and Methods: This was a single-center and retrospective cohort study which included children <18 years of age undergoing elective neurosurgery. The data were extracted from the electronic and physical patient health records. Post-operative anemia was defined for this study as a hemoglobin value below 10 g/dL at any time up to 3 days after surgery. Results: A total of 300 children were recruited during the study period. The incidence of post-operative anemia after elective pediatric neurosurgery was 21.33%. Children in the post-operative anemia group were younger (P = 0.004), had lower pre-operative hemoglobin values (P < 0.001), belonged to higher American Society of Anesthesiologists (ASA) physical status (P = 0.023), underwent predominantly supratentorial (P = 0.041) and non-tumor surgeries (0.004), and received lesser intraoperative blood transfusion (P = 0.010) compared to no post-operative anemia group. The factors that remained predictive of post-operative anemia on multivariate analysis were ASA physical status (P = 0.018, odds ratio [OR] = 1.94, 95% confidence interval [CI] of 1.12-3.36), pre-operative hemoglobin (P < 0.001, OR = 0.64, 95% CI of 0.50-0.82), and intraoperative transfusion (P = 0.028, OR = 0.45, 95% CI of 0.22-0.92). Conclusion: Optimization of modifiable risk factors is essential to reduce the occurrence of post-operative anemia and improve outcomes in pediatric neurosurgical patients.

Effect of remote ischemic preconditioning on cerebral oxygen saturation in aneurysmal subarachnoid hemorrhage: Secondary analysis of a randomized controlled trial.

Remote ischemic preconditioning (RIPC) can ameliorate cerebral vasospasm and delayed cerebral ischemia and improve neurological outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). Monitoring of regional cerebral oxygen saturation (rScO2) during the critical phase after aSAH can help detect ischemia and assess the effect of RIPC intervention. We investigated the effect of RIPC on rScO2 in patients with aSAH. Our study was a single-center, prospective, parallel-group, randomized pilot trial. After approval by institutional ethics committee, consenting patients (n = 25) with aSAH presenting within 72 h of ictus and scheduled for surgical clipping of cerebral aneurysm were randomized 1:1 to true RIPC (inflation of upper extremity blood pressure cuff thrice to 30 mmHg above systolic blood pressure for 5 min) or sham RIPC (inflation of blood pressure cuff thrice to 30 mmHg for 5 min). In this secondary analysis, our outcome measures assessed by a blinded observer were incidence of cerebral oxygen desaturation (COD) during 7-10 days after ictus and Glasgow outcome scale extended (GOSE) at discharge. The incidence of COD (decrease in rScO2 > 20% from baseline) was lower in the RIPC group (15.4% versus 33.3%); p = 0.378. The absence of ipsilateral COD resulted in a higher mean GOSE (estimate 1.15, p = 0.015). The RIPC group had a higher mean GOSE compared to sham group (estimate 0.8, p = 0.027). This pilot trial demonstrated that RIPC has the potential to prevent COD in patients with aSAH. Larger trials with cerebral oxygenation as the primary outcome are needed to confirm our findings.

Effect of remote ischemic preconditioning on cerebral vasospasm, biomarkers of cerebral ischemia, and functional outcomes in aneurysmal subarachnoid hemorrhage (ERVAS): A randomized controlled pilot trial.

BACKGROUND: Cerebral vasospasm can complicate aneurysmal subarachnoid hemorrhage (aSAH), contributing to cerebral ischemia. We explored the role of remote ischemic preconditioning (RIPC) in reducing cerebral vasospasm and ischemia and improving outcomes after aSAH. MATERIALS AND METHODS: Patients with ruptured cerebral aneurysm undergoing surgical clipping and meeting the trial criteria were randomized to true RIPC (n = 13) (inflating upper extremity blood pressure cuff thrice to 30 mmHg above systolic pressure for 5 min) or sham RIPC (n = 12) (inflating blood pressure cuff thrice to 30 mmHg for 5 min) after ethical approval. A blinded observer assessed outcome measures-cerebral vasospasm and biomarkers of cerebral ischemia. We also evaluated the feasibility and safety of RIPC in aSAH and Glasgow Outcome Scale-Extended (GOSE). RESULTS: Angiographic vasospasm was seen in 9/13 (69%) patients; 1/4 patients (25%) in true RIPC group, and 8/9 patients (89%) in sham RIPC group (P = 0.05). Vasospasm on transcranial Doppler study was diagnosed in 5/25 (20%) patients and 1/13 patients (7.7%) in true RIPC and 4/12 patients (33.3%) in sham RIPC group, (P = 0.16). There was no difference in S100B and neuron-specific enolase (NSE) levels over various time-points within groups (P = 0.32 and 0.49 for S100B, P = 0.66 and 0.17 for NSE in true and sham groups, respectively) and between groups (P = 0.56 for S100B and P = 0.31 for NSE). Higher GOSE scores were observed with true RIPC (P = 0.009) unlike sham RIPC (P = 0.847) over 6-month follow-up with significant between group difference (P = 0.003). No side effects were seen with RIPC. CONCLUSIONS: RIPC is feasible and safe in patients with aSAH and results in a lower incidence of vasospasm and better functional outcome.

KetaDex: A Saviour for Intraoperative Multimodal Neurophysiological Monitoring in Complex Neurosurgeries.

BACKGROUND: The anaesthetic mandate for a combination of electrocorticography (ECoG) and subcortical motor evoked potential mapping (SCMEPM) substantially differs from that required for each of these monitors in isolation. There is no current consensus defining the anaesthetic management for intraoperative multimodal monitoring combining these two modalities. CASE DESCRIPTION: We report our experience of anaesthetising a drug resistant epileptic patient for craniotomy and resection of his frontal gliotic lesion. We propose a novel anaesthetic technique to cater to the multiple goals of this surgery like optimal neuromonitoring under adequate depth of anaesthesia. We used balanced anaesthesia technique. Continuous intravenous (IV) infusions of Inj. Dexmedetomidine of 1.5 mcg/kg/hour and Inj. Ketamine at 0.5mg/kg/hour were used to supplement inhalational anaesthetic titrated to a MAC up to 0.5. Neuromuscular blockade was avoided after the initial tracheal intubation dose. CONCLUSION: To the best of our knowledge, this is the first case reporting the safety and efficacy of balanced anaesthetic technique for concurrent ECoG and SCMEPM. Successful intraoperative ECoG and SCMEPM monitoring with absent intraoperative awareness confirmed the safety of our anaesthetic technique. Through this, a composite of patient safety, surgeon satisfaction and adequate intraoperative monitoring could be achieved.

Craniotomy in Klippel-Trenaunay syndrome: Concerns and challenges.

Klippel-Trenaunay syndrome (KTS) is a rare congenital disorder characterised by cutaneous capillary malformations, soft tissue and bone hypertrophy and venous varicosities. The coexistence of Chiari 1 malformation and an intracranial tumour has been rarely reported in the literature. Multisystem involvement of this syndrome mandates adequate preparation and planning, with meticulous conduct of anaesthesia to achieve favourable outcomes. We report a case of KTS syndrome with Chiari 1 malformation who had presented for craniotomy, and thereby discuss the challenges faced during anaesthetic management of these patients for major surgeries.

Effect of remote ischemic preconditioning on cerebral vasospasm and biomarkers of cerebral ischemia in aneurysmal subarachnoid hemorrhage (ERVAS): A protocol for a randomized, controlled pilot trial.

INTRODUCTION: Cerebral vasospasm is a dreaded complication of aneurysmal subarachnoid hemorrhage (aSAH) predisposing to delayed cerebral ischemia. We intend to study the cerebroprotective effects of remote ischemic preconditioning (RIPC) in patients with aSAH. MATERIALS AND METHODS: This is a single-center, prospective, parallel group, randomized, pilot trial, approved by the Institutional Ethics Committee. Patients with aSAH admitted to our hospital for surgical clipping; fulfilling the trial inclusion criteria will be randomized to true RIPC (n = 12) (inflating upper extremity blood pressure cuff thrice for 5 min to 30 mmHg above systolic blood pressure) or sham RIPC (n = 12) (inflating blood pressure cuff thrice for 5 min to 30 mmHg) in 1:1 allocation ratio using a computerized random allocation sequence and block randomization. RESULTS: Our primary outcome measure is vasospasm on cerebral angiography and transcranial Doppler study, and concentration of serum S100B and neuron-specific enolase at 24 h after RIPC and on day 7 of ictus. Our secondary outcomes are safety of RIPC, cerebral oxygen saturation, and Glasgow coma score, and extended Glasgow outcome scale scores at discharge and at 1, 3, and 6 months following discharge. Outcome measures will be assessed by an observer blinded to the study intervention. CONCLUSION: If our preliminary results demonstrate a beneficial effect of RIPC, this would serve as a clinically applicable and safe preemptive method of protection against cerebral ischemia.