Intravenous dexmedetomidine sedation for magnetoencephalography: A retrospective study.

BACKGROUND: Magnetoencephalography (MEG) plays a preponderant role in the preoperative assessment of patients with drug-resistant epilepsy (DRE). However, the magnetoencephalography of patients with drug-resistant epilepsy can be difficult without sedation and/or general anesthesia. Our objective is to describe our experience with intravenous dexmedetomidine as sedation for magnetoencephalography and its effect, if any, on the ability to recognize epileptic spikes. METHODS: In this retrospective study, we reviewed the records of 89 children who presented for Magnetoencephalography/electroencephalography (EEG) scans between August of 2008 and May of 2015. Data analyzed included demographics and the frequency of epileptic spikes. Sedated magnetoencephalography recordings were compared to nonsedated video-electroencephalography (vEEG) recordings in the same patients to determine the impact of dexmedetomidine. RESULTS: Spike frequency between magnetoencephalography with sedation and video-electroencephalography without sedation was compared in 85 patients. Magnetoencephalography and video-electroencephalography were considered clinically concordant in 80 patients (94.1%) and discordant in 5 patients (5.9%), all with less spikes during Magnetoencephalography. The median (range) bolus dose of dexmedetomidine was 2 (1-2) mcg/kg. The median (range) infusion rate of dexmedetomidine was 2 (0.5-4) mcg/kg/h. All patients experienced reductions in heart rate after administration of dexmedetomidine; these reductions were statistically, but not clinically, significant. CONCLUSIONS: Our results suggest that dexmedetomidine-based protocol provides reliable sedation in children undergoing MEG scanning because of the high success rate, limited interictal artifacts, and minimal impacts on spike frequency.

Anesthetic considerations for stereotactic electroencephalography implantation.

The refractory seizures have significant impact on the quality of life and increase long term neurologic and non-neurologic complications. Implantation of Stereotactic Electroencephalography (SEEG) leads is one of the newer surgical techniques intended to localize seizure foci with higher accuracy than the conventional methods. Most of the commonly utilized anesthetic agents depress EEG waveforms affecting intra operative monitoring during these surgeries. Hence, the anesthetic goals include a stable induction and maintenance with agents which have minimal effect on EEG. This article discusses the peri-operative considerations of multiple anti-epileptic medications, recent advances in anesthetic management, and important post-operative concerns.

Intraoperative neurophysiological monitoring team's communiqué with anesthesia professionals.

BACKGROUND AND AIMS: Intraoperative neurophysiological monitoring (IONM) is the standard of care during many spinal, vascular, and intracranial surgeries. High-quality perioperative care requires the communication and cooperation of several multidisciplinary teams. One of these multidisciplinary services is intraoperative neuromonitoring (IONM), while other teams represent anesthesia and surgery. Few studies have investigated the IONM team's objective communication with anesthesia providers. We conducted a retrospective review of IONM-related quality assurance data to identify how changes in the evoked potentials observed during the surgery were communicated within our IONM-anesthesia team and determined the resulting qualitative outcomes. MATERIAL AND METHODS: Quality assurance records of 3,112 patients who underwent surgical procedures with IONM (from 2010 to 2015) were reviewed. We examined communications regarding perioperative evoked potential or electroencephalography (EEG) fluctuations that prompted neurophysiologists to alert/notify the anesthesia team to consider alteration of anesthetic depth/drug regimen or patient positioning and analyzed the outcomes of these interventions. RESULTS: Of the total of 1280 (41.13%) communications issued, there were 347 notifications and 11 alerts made by the neurophysiologist to the anesthesia team for various types of neuro/orthopedic surgeries. Prompt communication led to resolution of 90% of alerts and 80% of notifications after corrective measures were executed by the anesthesiologists. Notifications mainly related to limb malpositioning and extravasation of intravenous fluid. CONCLUSION: Based on our institutions' protocol and algorithm for intervention during IONM-supported surgeries, our findings of resolution in alerts and notifications indicate that successful communications between the two teams could potentially lead to improved anesthetic care and patient safety.

Intraoperative Neuromonitoring for Brachial Plexus Neurolysis During Delayed Fixation of a Clavicular Fracture Presenting as Thoracic Outlet Syndrome: A Case Report.

CASE: Brachial plexopathy is a rare complication of nonoperatively treated clavicular fractures. We describe a 68-year-old man who presented with fracture-callus-induced acute brachial plexopathy and dynamic thoracic outlet syndrome after 9 weeks of nonoperative management for a clavicular fracture. He underwent fracture fixation with brachial plexus decompression via callus excision; intraoperative neuromonitoring was used to evaluate brachial plexus function. Postsurgery, his neurologic function recovered completely. CONCLUSION: Intraoperative neuromonitoring is a useful tool for minimizing the risk of additional brachial plexus injury and determining the adequacy of neural decompression during delayed open reduction and internal fixation of clavicular fractures with fracture-callus-induced brachial plexus compression.

Anesthetic and pharmacologic considerations in perioperative care of obese children.

PURPOSE: Anesthetic management of obese pediatric patients is challenging. With increasing prevalence of childhood obesity, more severely obese children with comorbidities present for surgery every day. The purpose of this review is to provide an up-to-date comprehensive narrative review on the impact of pathophysiological changes imposed by pediatric obesity on the perioperative management of obese children, especially drug dosing. This knowledge is necessary to provide safe delivery of anesthesia for severely obese children. SOURCE: MEDLINE and PubMed peer-reviewed manuscripts in obesity and pediatric anesthesia. When there was no information in pediatric literature, we included adult studies in our review. PRINCIPAL FINDINGS: Defining obesity in a growing child is based on body mass index percentiles specific to age and sex. The precursors of adult obesity-related comorbidities are often seen in obese children. Respiratory and cardiovascular comorbidities increase perioperative risk in the severely obese child [>99th percentile]. Obstructive sleep apnea is highly prevalent and requires consideration of opioid sparing techniques and careful postoperative disposition. A detailed discussion on the effect of obesity on pharmacokinetics of different commonly used anesthetics and analgesics is presented, with current recommendations on dosing. CONCLUSION: Optimal and safe anesthetic management of an obese child requires thoughtful pre-procedure assessment and meticulous perioperative management tailored to associated comorbidities, with heightened awareness of potential perioperative complications. There remains a need for improved guidelines for risk stratification, drug dosing and postoperative disposition in this patient population.

Medication errors in anesthesia: unacceptable or unavoidable? / Erros de medicação em anestesia: inaceitável ou inevitável?

Abstract Medication errors are the common causes of patient morbidity and mortality. It adds financial burden to the institution as well. Though the impact varies from no harm to serious adverse effects including death, it needs attention on priority basis since medication errors' are preventable. In today's world where people are aware and medical claims are on the hike, it is of utmost priority that we curb this issue. Individual effort to decrease medication error alone might not be successful until a change in the existing protocols and system is incorporated. Often drug errors that occur cannot be reversed. The best way to ‘treat' drug errors is to prevent them. Wrong medication (due to syringe swap), overdose (due to misunderstanding or preconception of the dose, pump misuse and dilution error), incorrect administration route, under dosing and omission are common causes of medication error that occur perioperatively. Drug omission and calculation mistakes occur commonly in ICU. Medication errors can occur perioperatively either during preparation, administration or record keeping. Numerous human and system errors can be blamed for occurrence of medication errors. The need of the hour is to stop the blame - game, accept mistakes and develop a safe and ‘just' culture in order to prevent medication errors. The newly devised systems like VEINROM, a fluid delivery system is a novel approach in preventing drug errors due to most commonly used medications in anesthesia. Similar developments along with vigilant doctors, safe workplace culture and organizational support all together can help prevent these errors.

Resumo Os erros de medicação são as causas mais comuns de morbidade e mortalidade dos pacientes. Além disso, esses erros aumentam os encargos financeiros da instituição. Embora o impacto varie de nenhum dano a efeitos adversos graves, inclusive o óbito, é preciso estar atento à ordem de prioridades porque os erros de medicação são evitáveis. Na atualidade, com as pessoas cientes e os processos médicos em evidência, frear esse problema é de extrema prioridade. O esforço individual para diminuir os erros de medicação pode não obter sucesso até que uma mudança nos protocolos e sistemas existentes seja incorporada. Muitas vezes, os erros de medicação ocorridos não podem ser revertidos. A melhor maneira de "tratar" esses erros é impedi-los. Os erros de medicação (devido à troca de seringa), de overdose (devido a mal-entendido ou preconcepção da dose, mal uso de bomba e erro de diluição), de via de administração incorreta, de subdosagem e de omissão são causas comuns de erro de medicação que ocorrem no período perioperatório. A omissão e erros no cálculo de medicamentos ocorrem comumente em UTI. Os erros de medicação podem ocorrer no período perioperatório, tanto durante a preparação e administração quanto na manutenção de registros. Um grande número de erros humanos e do sistema pode ser responsabilizado pela ocorrência de erros de medicação. A necessidade do momento é parar o jogo da culpa, aceitar os erros e desenvolver uma cultura segura e "justa" para evitar os erros de medicação. Os sistemas recém-criados, como o Veinrom, um sistema de administração de líquidos, é uma nova abordagem na prevenção de erros de medicação devido aos medicamentos mais comumente usados em anestesia. Desenvolvimentos semelhantes, juntamente com médicos vigilantes, uma cultura de local de trabalho seguro e apoio organizacional, todos em conjunto podem ajudar a evitar esses erros.

Medication errors in anesthesia: unacceptable or unavoidable?

Medication errors are the common causes of patient morbidity and mortality. It adds financial burden to the institution as well. Though the impact varies from no harm to serious adverse effects including death, it needs attention on priority basis since medication errors' are preventable. In today's world where people are aware and medical claims are on the hike, it is of utmost priority that we curb this issue. Individual effort to decrease medication error alone might not be successful until a change in the existing protocols and system is incorporated. Often drug errors that occur cannot be reversed. The best way to 'treat' drug errors is to prevent them. Wrong medication (due to syringe swap), overdose (due to misunderstanding or preconception of the dose, pump misuse and dilution error), incorrect administration route, under dosing and omission are common causes of medication error that occur perioperatively. Drug omission and calculation mistakes occur commonly in ICU. Medication errors can occur perioperatively either during preparation, administration or record keeping. Numerous human and system errors can be blamed for occurrence of medication errors. The need of the hour is to stop the blame - game, accept mistakes and develop a safe and 'just' culture in order to prevent medication errors. The newly devised systems like VEINROM, a fluid delivery system is a novel approach in preventing drug errors due to most commonly used medications in anesthesia. Similar developments along with vigilant doctors, safe workplace culture and organizational support all together can help prevent these errors.

[Medication errors in anesthesia: unacceptable or unavoidable?] / Erros de medicação em anestesia: inaceitável ou inevitável?

Medication errors are the common causes of patient morbidity and mortality. It adds financial burden to the institution as well. Though the impact varies from no harm to serious adverse effects including death, it needs attention on priority basis since medication errors' are preventable. In today's world where people are aware and medical claims are on the hike, it is of utmost priority that we curb this issue. Individual effort to decrease medication error alone might not be successful until a change in the existing protocols and system is incorporated. Often drug errors that occur cannot be reversed. The best way to 'treat' drug errors is to prevent them. Wrong medication (due to syringe swap), overdose (due to misunderstanding or preconception of the dose, pump misuse and dilution error), incorrect administration route, under dosing and omission are common causes of medication error that occur perioperatively. Drug omission and calculation mistakes occur commonly in ICU. Medication errors can occur perioperatively either during preparation, administration or record keeping. Numerous human and system errors can be blamed for occurrence of medication errors. The need of the hour is to stop the blame - game, accept mistakes and develop a safe and 'just' culture in order to prevent medication errors. The newly devised systems like VEINROM, a fluid delivery system is a novel approach in preventing drug errors due to most commonly used medications in anesthesia. Similar developments along with vigilant doctors, safe workplace culture and organizational support all together can help prevent these errors.

Intraoperative Neurophysiological Monitoring of the Laryngeal Nerves During Anterior Neck Surgery: A Review.

Contributions to the literature on intraoperative neuro monitoring (IONM) during endocrine and head and neck surgery have increased over recent years. Organizational support for neural monitoring during surgery is becoming evident and is increasingly recognized as an adjunct to visual nerve identification. A comprehensive understanding of the role of IONM for prevention of nerve injuries is critical to maximize safety during surgery of the anterior compartment of the neck. This review will explore the potential advantages of IONM to improve the outcomes among patients undergoing anterior neck surgery.

Comparison of the combination of dexmedetomidine and ketamine to propofol or propofol/sevoflurane for drug-induced sleep endoscopy in children.

AIM: Examination of dynamic airway collapse in patients with obstructive sleep apnea (OSA) during drug-induced sleep endoscopy (DISE) can help identify the anatomic causes of airway obstruction. We hypothesized that a combination of dexmedetomidine and ketamine (Group DK) would result in fewer oxygen desaturations and a higher successful completion rate during DISE in children with OSA when compared to propofol (Group P) or sevoflurane/propofol (Group SP). METHODS: In this retrospective study, we reviewed the records of 59 children who presented for DISE between October 2013 and March 2015. Data analyzed included demographics, OSA severity, and hemodynamics (heart rate and blood pressure). The primary outcomes were airway desaturation during DISE to <85% and successful completion of DISE; these were compared between the three groups: DK, P, and SP. RESULTS: Preoperative polysomnography was available for 49 patients. There were significantly more patients with severe OSA in Group P as compared to the other two groups. The mean (±sd) bolus dose for ketamine, dexmedetomidine, and propofol were 2.0 ± 0.6 mg·kg(-1) , 1.9 ± 0.9 mcg·kg(-1) , and 1.8 ± 1.1 mg·kg(-1) , respectively. The mean (±sd) infusion rate for dexmedetomidine was 1.6 ± 0.7 mcg·kg(-1) ·h(-1) and for propofol was 248 ± 68 mcg·kg(-1) ·min(-1) in Group P and 192 ± 48 mcg·kg(-1) ·min(-1) in Group SP. Patients in Group DK had significantly fewer desaturations to <85% during DISE compared to Group P. Patients in Group DK had significantly more successful completion of DISE (100% Group DK, 92% Group P, and 79% Group SP) as compared to Group SP. CONCLUSIONS: These results suggest that the described dose regimen of propofol used alone or in combination with sevoflurane appears to be associated with more oxygen desaturations and a lower rate of successful completion than a combination of dexmedetomidine and ketamine during DISE in children with OSA.

Effect of clonidine and/or fentanyl in combination with intrathecal bupivacaine for lower limb surgery.

BACKGROUND AND AIMS: Various adjuncts to local anesthetics have been used with the purpose of improving the quality of subarachnoid block. This randomized double-blind study was conducted to evaluate the efficacy of adding clonidine to bupivacaine and bupivacaine-fentanyl combination. MATERIAL AND METHODS: A total of 100 patients scheduled for surgery under spinal anesthesia were randomly allocated into four groups (n = 25 each) to receive intrathecal bupivacaine 7.5 mg plus normal saline 0.5 ml (group BS), intrathecal bupivacaine 7.5 mg, and fentanyl 25 µg (group BF), intrathecal bupivacaine 7.5 mg and clonidine 75 µg (group BC), intrathecal bupivacaine 7.5 mg, clonidine 37.5 µg, and fentanyl 12.5 µg (group BCF). The time of onset and duration of sensory block, highest dermatome level of sensory block, time of onset of motor block, time to complete motor block recovery and duration of spinal anesthesia, intraoperative and postoperative hemodynamics and side effects if any were recorded. VAS, total number of patients who were administered supplemental analgesic in each group and the total amount of supplemental analgesic administered in the next 24 h was quantified and documented in all the groups. RESULTS: The time of onset of sensory block (min) in groups BS, BC, BCF, and BF was 10.80 ± 2.26, 10.20 ± 1.00, 10.00 ± 0.00, and 13.80 ± 2.61 respectively, thus onset of sensory block was significantly earlier in groups BC and BCF. Similarly, onset of motor block was also quicker in groups BC and BCF. Time of requirement of supplemental analgesia was 135.20 ± 12.70 min, 199.2 ± 21.92 min, 209.80 ± 26.32 min, and 208.00 ± 26.58 min in groups BS, BF, BC, and BCF respectively. Intraoperative and postoperative changes in heart rate, mean arterial blood pressure, oxygen saturation, and respiratory rate were comparable. Sedation scores were significantly higher in group BC. Pruritus was only observed in groups BF and BCF. Mean nausea vomiting scores were comparable in all groups. CONCLUSION: We conclude that the addition of clonidine in doses of 75 µg and 37.5 µg to low-dose bupivacaine and bupivacaine-fentanyl prolongs the sensory and motor block while increasing the duration of postoperative analgesia without significant side-effects.

Effect of intravenous esmolol on analgesic requirements in laparoscopic cholecystectomy.

BACKGROUND AND AIMS: Perioperative beta blockers are also being advocated for modulation of acute pain and reduction of intraoperative anesthetic requirements. This study evaluated the effect of perioperative use of esmolol, an ultra short acting beta blocker, on anesthesia and modulation of post operative pain in patients of laproscopic cholecystectomy. MATERIAL AND METHODS: Sixty adult ASA I & II grade patients of either sex, scheduled for laparoscopic cholecystectomy under general anesthesia, were enrolled in the study. The patients were randomly allocated to one of the two groups E or C according to computer generated numbers. Group E- Patients who received loading dose of injection esmolol 0.5 mg/kg in 30 ml isotonic saline, before induction of anesthesia, followed by an IV infusion of esmolol 0.05 µg/kg/min till the completion of surgery and Group C- Patients who received 30 ml of isotonic saline as loading dose and continuous infusion of isotonic saline at the same rate as the esmolol group till the completion of surgery. RESULTS: The baseline MAP at 0 minute was almost similar in both the groups. At 8th minute (time of intubation), MAP increased significantly in group C as compared to group E and remained higher than group E till the end of procedure. Intraoperatively, 16.67% of patients in group C showed somatic signs as compared to none in group E. The difference was statistically significant. 73.33% of patients in group C required additional doses of Inj. Fentanyl as compared to 6.67% in group E. CONCLUSIONS: We conclude that intravenous esmolol influences the analgesic requirements both intraoperatively as well as postoperatively by modulation of the sympathetic component of the pain i.e. heart rate and blood pressure.

Awake craniotomy: A qualitative review and future challenges.

Neurosurgery in awake patients incorporates newer technologies that require the anesthesiologists to update their skills and evolve their methodologies. They need effective communication skills and knowledge of selecting the right anesthetic drugs to ensure adequate analgesia, akinesia, along with patient satisfaction with the anesthetic conduct throughout the procedure. The challenge of providing adequate anesthetic care to an awake patient for intracranial surgery requires more than routine vigilance about anesthetic management.

A comparative study evaluating the prophylactic efficacy of oral clonidine and tramadol for perioperative shivering in geriatric patients undergoing transurethral resection of prostate.

BACKGROUND AND AIMS: Perioperative shivering, in geriatric patients undergoing urological surgery under central neuraxial blockade is a common complication. Prophylactic measures to reduce shivering are quintessential to decrease the morbidity and mortality. Believing that oral formulation will bring down the cost of treatment, we decided to compare the efficacy of oral clonidine and tramadol, as premedication, in prevention of shivering in patients undergoing transurethral resection of prostate (TURP) under spinal anesthesia in a prospective and double-blind manner. MATERIALS AND METHODS: The patients were randomly allocated into three groups (40 patients each). Group I received oral clonidine 150 µg, Group II received oral tramadol 50 mg, while Group III received a placebo. Number of patients having shivering, their grades and duration, hemodynamic changes, and side-effects in the form of sedation were recorded. Data were analyzed using analysis of variance, Student's t-test, Z test as and when appropriate. RESULTS: In group I and II, 38 patients (95%) and 37 patients (92.5%) did not shiver, respectively. Although in the group III, 24 patients (60%) exhibited no grade of shivering, the shivering was of significantly severe intensity and lasted for a longer duration. No, clinically significant collateral effects were observed in patients who were administered clonidine or tramadol. CONCLUSIONS: Oral clonidine and tramadol were comparable in respect to their effect in decreasing the incidence, intensity, and duration of shivering when used prophylactically in patients who underwent TURP under subarachnoid blockade.

Anesthetic challenges for deep brain stimulation: a systematic approach.

Ablative intracranial surgery for Parkinson's disease has advanced to embedding electrodes into precise areas of the basal ganglia. Electrode implantation surgery, referred to as deep brain stimulation (DBS), is preferred in view of its reversibility, adjustability, and capability to be safely performed bilaterally. DBS is been increasingly used for other movement disorders, intractable tremors epilepsy, and sometimes chronic pain. Anesthesiologists need to amalgamate the knowledge of neuroanatomical structures and surgical techniques involved in placement of microelectrodes in defined cerebral target areas. Perioperative verbal communication with the patient during the procedure is quintessential and may attenuate the need for pharmacological agents. This review will endeavor to assimilate the present knowledge regarding the patient selection, available/practiced anesthesia regimens, and perioperative complications after our thorough search for literature published between 1991 and 2013.

Antioxidants: The new frontier for translational research in cerebroprotection.

It is important for the anesthesiologist to understand the etiology of free radical damage and how free-radical scavengers attenuate this, so that this knowledge can be applied to diverse neuro-pathological conditions. This review will concentrate on the role of reactive species of oxygen in the pathophysiology of organ dysfunction, specifically sub arachnoid hemorrhage (SAH), traumatic brain injury (TBI) as well as global central nervous system (CNS) hypoxic, ischemic and reperfusion states. We enumerate potential therapeutic modalities that are been currently investigated and of interest for future trials. Antioxidants are perhaps the next frontier of translational research, especially in neuro-anesthesiology.

VEINROM: A possible solution for erroneous intravenous drug administration.

Erroneous intravenous drug administration has a high probability of causing substantial financial consequences along with patient morbidity or mortality. Anesthesiologists and hospital administrators need to be cognizant of the problem. National and international anesthesiology bodies should be involved with the medical device manufacturing industry to alleviate this long standing enigma. We propose our concept Vassopressors, Emergency drugs, Induction agents, Reversal agents, Opioids and Miscellaneous (VEINROM) as a conceivable solution to this paradox.

Use of oral tramadol to prevent perianesthetic shivering in patients undergoing transurethral resection of prostate under subarachnoid blockade.

CONTEXT: Under regional anesthesia, geriatric patients are prone to shivering induced perioperative complications that Anesthesiologists should prevent rather than treat. AIM: We investigated the prophylactic efficacy of oral tramadol 50 mg to prevent the perioperative shivering after transurethral resection of prostate (TURP) surgery under subarachnoid blockade (SAB). Shivering is usually overlooked in patients undergoing urological surgery under spinal anesthesia and may result in morbidity, prolonged hospital stay and increased financial burden. Use of prophylactic measures to reduce shivering in geriatric patients who undergo urological procedures could circumvent this. Oral formulation of tramadol is a universally available cost-effective drug with the minimal side-effects. SETTINGS AND DESIGN: Prospective, randomized, double-blinded, placebo-controlled study. PATIENTS AND METHODS: A total of 80 patients who were scheduled for TURP surgery under subarachnoid block were randomly selected. Group I and II (n = 40 each) received oral tramadol 50 mg and placebo tablet respectively. After achieving subarachnoid block, the shivering, body temperature (tympanic membrane, axillary and forehead), hemodynamic parameters and arterial saturation were recorded at regular intervals. STATISTICAL ANALYSIS USED: T-test, analysis of variance test, Z-test and Fisher exact test were utilized while Statistical Product and Service Solutions, IBM, Chicago (SPSS statistics (version 16.0)), software was used for analysis. RESULTS: Incidence of shivering was significantly less in patients who received tramadol (7.5% vs. 40%; P < 0.01). The use of tramadol was associated with clinically inconsequential side-effects. CONCLUSION: We conclude that the use of oral tramadol 50 mg is effective as a prophylactic agent to reduce the incidence, severity and duration of perioperative shivering in patients undergoing TURP surgery under SAB.