Feasibility of Nonintubated Anesthesia for Lumboperitoneal Shunt Implantation.

Lumboperitoneal shunt (LPS) implantation is a cerebrospinal fluid diversion therapy for the communicating type of normal-pressure hydrocephalus (NPH); NPH mainly affects older adults. However, endotracheal intubation for mechanical ventilation with muscle relaxant increases perioperative and postoperative risks for this population. Based on knowledge from nonintubated thoracoscopic surgery, which has been widely performed in recent years, we describe a novel application of nonintubated anesthesia for LPS implantation in five patients. Anesthesia without muscle relaxants, with a laryngeal mask in one patient and a high-flow nasal cannula in four patients, was used to maintain spontaneous breathing during the surgery. The mean anesthesia time was 103.8 min, and the mean operative duration was 55.8 min. All patients recovered from anesthesia uneventfully. In our experience, nonintubated LPS surgery appears to be a promising and safe surgical technique for appropriately selected patients with NPH.

Neuroprotective effects of intraoperative dexmedetomidine versus saline infusion combined with goal-directed haemodynamic therapy for patients undergoing cranial surgery: A randomised controlled trial.

BACKGROUND: By inhibiting neuroinflammation dexmedetomidine may be neuroprotective in patients undergoing cranial surgery, but it reduces cardiac output and cerebral blood flow. OBJECTIVE: To investigate whether intra-operative dexmedetomidine combined with goal-directed haemodynamic therapy (GDHT) has neuroprotective effects in cranial surgery. DESIGN: A double-blind, single-institution, randomised controlled trial. SETTING: A single university hospital, from April 2017 to April 2020. PATIENTS: A total of 160 adults undergoing elective cranial surgery. INTERVENTION: Infusion of dexmedetomidine (0.5 µg kg-1 h-1) or saline combined with GDHT to optimise stroke volume during surgery. MAIN OUTCOME MEASURES: The proportion who developed postoperative neurological complications was compared. Postoperative disability was assessed using the Barthel Index at time points between admission and discharge, and also the 30-day modified Rankin Scale (mRS). Postoperative delirium was assessed. The concentration of a peri-operative serum neuroinflammatory mediator, high-mobility group box 1 protein (HMGB1), was compared. RESULTS: Fewer patients in the dexmedetomidine group developed new postoperative neurological complications (26.3% vs. 43.8%; P = 0.031), but the number of patients developing severe neurological complications was comparable between the two groups (11.3% vs. 20.0%; P = 0.191). In the dexmedetomidine group the Barthel Index reduction [0 (-10 to 0)] was less than that in the control group [-5 (-15 to 0)]; P = 0.023, and there was a more favourable 30-day mRS (P = 0.013) with more patients without postoperative delirium (84.6% vs. 64.2%; P = 0.012). Furthermore, dexmedetomidine induced a significant reduction in peri-operative serum HMGB1 level from the baseline (222.5 ±â€Š408.3 pg ml-1) to the first postoperative day (152.2 ±â€Š280.0 pg ml-1) P = 0.0033. There was no significant change in the control group. The dexmedetomidine group had a lower cardiac index than did the control group (3.0 ±â€Š0.8 vs. 3.4 ±â€Š1.8 l min-1 m-2; P = 0.0482) without lactate accumulation. CONCLUSIONS: Dexmedetomidine infusion combined with GDHT may mitigate neuroinflammation without undesirable haemodynamic effects during cranial surgery and therefore be neuroprotective. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT02878707.

Scalp Block Is Associated With Improved Recurrence Profiles in Patients Undergoing Primary Glioma Resection Surgery.

BACKGROUND: Glioma is associated with high recurrence and poor survival, despite the success of tumor resection surgery. This may be partly because the immune microenvironment within a glioma is susceptible to perioperative immunosuppression. Therefore, intraoperative anesthesia-related immunomodulators, such as scalp block, intravenous anesthesia, the opioid dosage administered, and transfusions, may influence oncological outcomes among patients with glioma. The aim of this retrospective study was to investigate the influence of anesthetic techniques on oncological outcomes after craniotomy for glioma resection, particularly the effects of scalp block, intravenous anesthesia, and inhalation anesthesia. METHODS: Consecutive patients who underwent primary glioma resection surgeries between January 2010 and December 2017 were analyzed to compare postcraniotomy oncological outcomes (progression-free survival [PFS] and overall survival) by using the Kaplan-Meier method and multivariate Cox regression analysis. A propensity score-matched regression analysis including prognostic covariates was also conducted to analyze the selected relevant anesthetic factors of the unmatched regression model. RESULTS: A total of 230 patients were included in the final analysis. No analyzed anesthetic factor was associated with overall survival. Patients who received scalp block had a more favorable median (95% confidence interval [CI]) PFS (55.37 [95% CI, 12.63-62.23] vs. 14.07 [95% CI, 11.27-17.67] mo; P=0.0053). Scalp block was associated with improved PFS before (hazard ratio, 0.465; 95% CI, 0.272-0.794; P=0.0050) and after (hazard ratio, 0.367; 95% CI, 0.173-0.779; P=0.0091) propensity score-matched Cox regression analysis. By contrast, intravenous anesthesia, amount of opioid consumed, and transfusion were not associated with PFS. CONCLUSIONS: The study results suggest that the scalp block improves the recurrence profiles of patients receiving primary glioma resection.

Mini-fluid challenge test predicts stroke volume and arterial pressure fluid responsiveness during spine surgery in prone position: A STARD-compliant diagnostic accuracy study.

The study was designed to verify if mini-fluid challenge test is more reliable than dynamic fluid variables in predicting stroke volume (SV) and arterial pressure fluid responsiveness during spine surgery in prone position with low-tidal-volume ventilation.Fifty patients undergoing spine surgery in prone position were included. Fluid challenge with 500 mL of colloid over 15 minutes was given. Changes in SV and systolic blood pressure (SBP) after initial 100 mL were compared with SV, pulse pressure variation (PPV), SV variation (SVV), plethysmographic variability index (PVI), and dynamic arterial elastance (Eadyn) in predicting SV or arterial pressure fluid responsiveness (15% increase or greater).An increase in SV of 5% or more after 100 mL predicted SV fluid responsiveness with area under the receiver operating curve (AUROC) of 0.90 (95% confidence interval [CI], 0.82 to 0.99), which was significantly higher than that of PPV (0.71 [95% CI, 0.57 to 0.86]; P = .01), and SVV (0.72 [95% CI, 0.57 to 0.87]; P = .03). A more than 4% increase in SBP after 100 mL predicted arterial pressure fluid responsiveness with AUROC of 0.86 (95% CI, 0.71-1.00), which was significantly higher than that of Eadyn (0.52 [95% CI, 0.33 to 0.71]; P = .01).Changes in SV and SBP after 100 mL of colloid predicted SV and arterial pressure fluid responsiveness, respectively, during spine surgery in prone position with low-tidal-volume ventilation.

Pretreatment serum lactate level as a prognostic biomarker in patients undergoing supratentorial primary brain tumor resection.

INTRODUCTION: Malignant primary brain tumors are one of the most aggressive cancers. Pretreatment serum nonneuronal biomarkers closely associated with postoperative outcomes are of high clinical relevance. The present study aimed to identify potential pretreatment serum biomarkers that may influence oncological outcomes in patients with primary brain tumors. METHODS: A total of 74 patients undergoing supratentorial primary brain tumor resection were enrolled. Before tumor resection, serum neuronal biomarkers, namely neuron-specific enolase (NSE), S100ß, and glial fibrillary acidic protein (GFAP), and serum nonneuronal biomarkers, namely neutrophil gelatinase-associated lipocalin (NGAL), lactate dehydrogenase (LDH), and lactate, were measured and associated postoperative oncological outcomes, including brain tumor grading, progression-free survival (PFS), and overall survival (OS), were compared. RESULTS: Patients with high-grade brain tumors had significantly higher pretreatment serum lactate levels (p = 0.011). By contrast, other biomarkers were comparable between patients with high-grade and low-grade brain tumors. Receiver operating characteristic curve analysis of serum lactate levels yielded an area under the curve of 0.71 for differentiating between high-grade and low-grade brain tumors. Kaplan-Meier survival analysis revealed patients with high serum lactate levels (≧2.0 mmol/L) had shorter PFS and OS (p = 0.021 and p = 0.093, respectively). In a multiple regression model, only elevated serum lactate levels were associated with poor PFS and OS (p = 0.021 and p = 0.048, respectively). CONCLUSIONS: An elevated pretreatment serum lactate level is a prognostic biomarker of high-grade primary brain tumors and is significantly associated with poor PFS in patients with supratentorial brain tumors undergoing tumor resection. By contrast, other serum biomarkers are not significantly associated with oncological outcomes.

Chlorhexidine-related refractory anaphylactic shock: a case successfully resuscitated with extracorporeal membrane oxygenation.

IMPORTANCE: We report a patient with a life-threatening anaphylactic reaction to a chlorhexidine-coated central venous catheter, confirmed with a high serum level of chlorhexidine-specific IgE. To our knowledge, this is the first case successfully resuscitated using extracorporeal membrane oxygenation (ECMO). Great caution is required when using chlorhexidine and chlorhexidine-impregnated catheters, given that its widespread use has the potential to sensitize certain patients and may result in life-threatening anaphylaxis on subsequent exposure. OBSERVATIONS: A case report of a single patient with life-threatening anaphylactic shock to chlorhexidine, who was successfully resuscitated using ECMO. CONCLUSIONS: We have designed a flowchart for the diagnosis and management of severe anaphylaxis. This case report highlights the potential for chlorhexidine to be a source for the development of refractory anaphylactic shock. We suggest that ECMO may save the lives of patients with severe bronchospasm and refractory anaphylactic shock secondary to chlorhexidine.

Emergency airway management with fiberoptic intubation in the prone position with a fixed flexed neck.

We describe emergency airway management with fiberoptic intubation in a patient in the prone position with her neck flexed by a head pin holder during a neurosurgical procedure. Laryngeal mask airway is suggested in emergency difficult airway algorithms; however, this was not feasible in this patient because of her edematous upper airway and limited mouth opening resulting from extreme neck flexion by a head pin holder. The case illustrates the role of fiberoptic intubation in emergency airway management in this critical situation. Maneuvers to facilitate fiberoptic technique are also described.

Prolonged retraction on the normal common carotid artery induced lethal stroke after cervical spine surgery.

STUDY DESIGN: Case report. OBJECTIVE: To report a previously undescribed complication of prolonged retraction on the normal common carotid artery after anterior cervical spine surgery. SUMMARY OF BACKGROUND DATA: Previous study showed that prolonged retraction could decrease the blood flow of the common carotid artery during anterior cervical spine surgery. A case report revealed that prolonged retraction could induce the formation of thrombosis in the atherosclerotic common carotid artery. METHODS: Notes review. Computed tomography of the brain was performed on the first and the fourth postoperative day. Carotid Doppler ultrasound and transcranial Doppler ultrasound were performed to evaluate the left common carotid artery and the left intracranial cerebral arteries. RESULTS: After lengthy anterior cervical spinal surgery, the patient did not regain his consciousness during the stay in the postoperative care unit. Large infarction of left cerebral hemisphere was revealed by computed tomography. The patient died on the seventh postoperative day of perioperative lethal stroke. CONCLUSION: We suggest that prolonged retraction, even on the normal common carotid artery, could induce lethal stroke after anterior cervical spine surgery. We recommend that retractor should be placed carefully and cerebral perfusion should be maintained adequately.