Early Postoperative Outcomes of Normal Pressure Hydrocephalus: Results of a Service Evaluation.

BACKGROUND: Patients with normal pressure hydrocephalus (NPH) are often elderly, frail and affected by multimorbidity. Treatment is surgical with cerebrospinal diversion shunts. The selection of patients that are of an acceptable level of risk to be treated surgically has been a matter of debate for years and has deprived some patients of life-changing surgery. The aim of this service evaluation was to investigate the preoperative risk factors and early postoperative morbidity of patients with NPH using a standardized postoperative survey. MATERIALS AND METHODS: Consecutive NPH patients admitted for neurosurgical management of NPH between May 2017 and May 2018 were included in this prospective service evaluation. In addition to the collection of traditional outcome measures, the cardiac version of the Postoperative Morbidity Survey (C-POMS) was conducted on postoperative days 4, 7, and 10 to identify postoperative morbidity. RESULTS: Eighty-eight patients (63 males, age mean±SD, 75±7 y) underwent 106 surgical procedures (61 lumbar drains, 45 ventriculoperitoneal shunts). There was no 30-day mortality and no unexpected return to the operating room or admission to intensive care unit. There was 1 conservatively managed surgical complication. On postoperative day 4, the C-POMS identified no postoperative morbidity in 72% of the patients, and mild morbidity (postoperative nausea and mobility issues) in 28%. There was a delay in discharge in 50% of the patients with no postoperative morbidity on day 4, highlighting areas of our service requiring improvement. CONCLUSIONS: Early postoperative outcomes of NPH patients are good after both ventriculoperitoneal shunt insertion and lumbar drainage. This evaluation provides initial evidence on the utility of the C-POMS as a service evaluation tool in the standardized assessment postoperative outcomes in neurosurgery patients.

Experience with awake throughout craniotomy in tumour surgery: technique and outcomes of a prospective, consecutive case series with patient perception data.

BACKGROUND: Awake craniotomy is the standard of care in surgery of tumours located in eloquent parts of the brain. However, high variability is recorded in multiple parameters, including anaesthetic techniques, mapping paradigms and technology adjuncts. The current study is focused primarily on patients' level of consciousness, surgical technique, and experience based on a cohort of 50 consecutive cases undergoing awake throughout craniotomy (ATC). METHODS: Data was collected prospectively for 46 patients undergoing 50 operations over 14-month period, by the senior author, including demographics, extent of resection (EOR), adverse intraoperative events, surgical morbidity, surgery duration, levels of O2 saturation and brain oedema. A prospective, patient experience questionnaire was delivered to 38 patients. RESULTS: The ATC technique was well tolerated in all patients. Once TCI stopped, all patients were immediately assessable for mapping. Despite > 75% of cases being considered inoperable/high risk, gross total resection (GTR) was achieved in 68% patients and subtotal resection in 20%. The average duration of surgery was 220 min with no episodes of hypoxia. Early and late severe deficits recorded in 12% and 2%, respectively. No stimulation-induced seizures or failed ATCs were recorded. Patient-recorded data showed absent/minimal pain during (1) clamp placement in 95.6% of patients; (2) drilling in 94.7% of patients; (3) surgery in 78.9% of patients. Post-operatively, 92.3% of patients reported willingness to repeat the ATC, if necessary. CONCLUSIONS: The current ATC paradigm allows immediate brain mapping, maximising patient comfort during self-positioning. Despite the cohort of challenging tumour location, satisfactory EOR was achieved with acceptable morbidity and no adverse intraoperative events.

Knowledge and perceptions about perioperative stroke: a cross-sectional survey of patients scheduled for non-neurologic and non-cardiac surgery.

PURPOSE: Perioperative stroke is associated with significant morbidity and mortality yet patients may not be aware of their risk or receive appropriate counselling. Our objectives were to 1) compare patient's perceived vs calculated risk of stroke; 2) determine level of worry; and 3) assess prior discussion about perioperative stroke risk amongst elective patients undergoing non-cardiac, non-neurologic surgery. METHODS: Over a consecutive four-week period, surveys were distributed at two pre-anesthetic clinics to adult patients scheduled for non-cardiac, non-neurologic surgery. The survey included questions about demographics, perioperative stroke risk factors, patient perception of their quantitative and qualitative stroke risk, level of worry about stroke, and risk discussions. We identified independent predictors of risk underestimation amongst medium- and high-risk patients. RESULTS: Six hundred patients completed the survey (response rate 78%). Of these, 479, 104, and 15 patients were classified as low-, medium-, and high-risk, respectively (with two patients missing this data point). Most medium- (86%) and high-risk (80%) patients did not identify their elevated risk. Amongst medium- and high-risk patients, independent predictors of risk underestimation were lower education and absence of kidney disease. Medium- and high-risk patients were more worried than low-risk patients about perioperative stroke (median [interquartile range] visual analogue scale score 2 [0.5-4] vs 1 [0-2], P = 0.001). Fewer than half of patients had discussed perioperative stroke previously (40%, 23%, and 12% of high-, medium-, and low-risk patients, respectively). CONCLUSIONS: Patients at higher risk of stroke frequently underestimate their risk of perioperative stroke. The majority of patients had not discussed perioperative stroke prior to anesthetic consultation.

Awake craniotomy: anesthetic considerations based on outcome evidence.

PURPOSE OF REVIEW: This review highlights anaesthesia management options for awake craniotomy and discusses the advantages and disadvantages of different approaches, intraoperative complications and future directions. RECENT FINDINGS: For lesions located within or adjacent to eloquent regions of the brain, awake craniotomy allows maximal tumour resection with minimal consequences on neurological function. Various techniques have been described to provide anaesthesia or sedation and analgesia during the initial craniotomy, and rapid return to consciousness for intraoperative testing and tumour resection; there is no evidence that one approach is superior to another. Although very safe, awake craniotomy is associated with some well recognized complications; most are minor and self-limiting or easily reversed. In experienced hands, failure of awake craniotomy occurs in fewer than 2% of cases, irrespective of anaesthesia technique. Although brain tumour surgery remains the most common indication for awake craniotomy, the technique is finding utility in other neurosurgical procedures. SUMMARY: Several anaesthetic approaches are available for the management of patients during awake craniotomy. The choice of technique should be based on individual patient factors, location and duration of surgery, and anaesthesiologist expertise and experience. Appropriate patient selection and excellent multidisciplinary team working is associated with high levels of procedural success and patient satisfaction.

Internet-Based Resources Frequently Provide Inaccurate and Out-of-Date Recommendations on Preoperative Fasting: A Systematic Review.

Preoperative fasting is important to avoid morbidity and surgery delays, yet recommendations available on the Internet may be inaccurate. Our objectives were to describe the characteristics and recommendations of Internet resources on preoperative fasting and assess the quality and readability of these websites. We searched the Internet for common search terms on preoperative fasting using Google® search engines from 4 English-speaking countries (Canada, the United States, Australia, and the United Kingdom). We screened the first 30 websites from each search and extracted data from unique websites that provided recommendations on preoperative fasting. Website quality was assessed using validated tools (JAMA Benchmark criteria, DISCERN score, and Health on the Net Foundation code [HONcode] certification). Readability was scored using the Flesch Reading Ease score and Flesch-Kincaid Grade Level. A total of 87 websites were included in the analysis. A total of 48 websites (55%) provided at least 1 recommendation that contradicted established guidelines. Websites from health care institutions were most likely to make inaccurate recommendations (61%). Only 17% of websites encouraged preoperative hydration. Quality and readability were poor, with a median JAMA Benchmark score of 1 (interquartile range 0-3), mean DISCERN score 39.8 (SD 12.5), mean reading ease score 49 (SD 15), and mean grade level of 10.6 (SD 2.7). HONcode certification was infrequent (10%). Anesthesia society websites and scientific articles had higher DISCERN scores but worse readability compared with websites from health care institutions. Online fasting recommendations are frequently inconsistent with current guidelines, particularly among health care institution websites. The poor quality and readability of Internet resources on preoperative fasting may confuse patients.

Can hospital transfusion committees change transfusion practice?

Blood and blood products are commonly over-used in hospital practice. We investigated whether the introduction of a red-cell transfusion trigger (haemoglobin <8 g dL(-1)) influenced transfusion practice in surgery. Coronary artery bypass grafts (CABGs, n=400), total hip replacements (n=107), colectomies (n=85) and transurethral prostatectomies (TURPs, n=158) were reviewed over two periods of six months, before and after the introduction of the policy by the local hospital transfusion committee. After introduction of the policy, the proportion of patients transfused fell from 57% to 45% with CABGs (P=0.02) and from 52% to 26% with hip replacements (P=0.006); for colectomies and TURPs there was no change. Hospital stay did not increase in any of the groups. In the second period, haemoglobin concentration on discharge was lower after total hip replacement, by a mean (95% CI) of 0.7 (0.3-1.2) g dL(-1) (P=0.002) and after colectomy, by a mean of 0.6 (0.1-1.1) g dL(-1) (P=0.03). Although other factors cannot be excluded, we suggest that the reductions in red-cell transfusion were in large part attributable to the new transfusion policy.