Awake Craniotomy: A New Airway Approach.

Awake craniotomies have been performed regularly at the University of Pennsylvania since 2004. Varying approaches to airway management are described for this procedure, including intubation with an endotracheal tube and use of a laryngeal mask airway, simple facemask, or nasal cannula. In this case series, we describe the successful use (i.e., no need for endotracheal intubation related to inadequate gas exchange) of bilateral nasopharyngeal airways in 90 patients undergoing awake craniotomies. The use of nasopharyngeal airways can ease the transition between the asleep and awake phases of the craniotomy without the need to stimulate the airway. Our purpose was to describe our experience and report adverse events related to this technique.

Anesthetic variation and potential impact of anesthetics used during endovascular management of acute ischemic stroke.

BACKGROUND: Many authors have reported that general anesthesia (GA), as a generic and uncharacterized therapy, is contraindicated for patients undergoing endovascular management of acute ischemic stroke (EMAIS). The recent American Heart Association update cautiously suggests that it might be reasonable to favor conscious sedation over GA during EMAIS. We are concerned that such recommendations will result in patients undergoing endovascular treatment without consideration of the effects of specific anesthetic agents and anesthetic dose, and without appropriate critical consideration of the individual patient's issues. We hypothesized that significant variation in anesthetic practice comprises GA, and that outcome differences among types of GA would arise. METHODS: With IRB approval, we examined the records of patients who underwent anterior circulation EMAIS at the University of Pennsylvania from 2010 to 2015. Patients were managed by different anesthesiologists with no specific protocol. We analyzed American Society of Anesthesiologists status, NIH Stroke Scale, type of stroke, procedure, different types of anesthetic, blood pressure control, and outcome metrics. Modified Rankin Scale (mRS) scores were determined from medical records. RESULTS: GA was used in 91% of patients. Several types of GA were employed: intravenous, volatile, and intravenous/volatile combined. mRS scores ≤2 at discharge were observed in 42.8% of patients receiving volatile anesthesia and were better in patients receiving only volatile agents after induction of anesthesia (p<0.05). CONCLUSIONS: Our data support the notion that anesthetic techniques and associated physiology used in EMAIS are not homogeneous, making any statements about the effects of generic GA in stroke ambiguous. Moreover, our data suggest that the type of GA may affect the outcome after EMAIS.

Perioperative management of undiagnosed placenta percreta: case report and management strategies.

Placenta percreta is a rare pregnancy disorder in which the placenta penetrates the uterine myometrium and can invade surrounding organs. Because the rate of cesarean sections is increasing in developed countries, the incidence of placenta percreta is also rising. This condition significantly increases the risk of maternal and fetal morbidity and mortality, and is currently the most common indication for peripartum hysterectomy. Multidisciplinary management in a specialized center capable of providing massive transfusions can improve outcomes for the mother and baby. This team should include a surgeon specialized in pelvic surgery, an anesthesiologist experienced in obstetrics, a skilled urologist, a neonatologist, a blood bank team capable of administering multiple blood products, and an intensive care facility where the patient can be monitored. In this report, we present the case of a patient with preoperatively undiagnosed placenta percreta and discuss the relevant management methods. We also discuss the relevant obstetric and anesthetic management methods, as well as diagnostic and transfusion protocols.

Anesthetic management of schwannoma mimicking carotid body tumor.

Schwannomas are rare and slow-growing neurogenic tumors for which surgery is the standard of care. However, the anesthetic management of these tumors can be challenging. This case report describes the anesthetic management of a patient who underwent carotid endarterectomy and excision of a presumed carotid body tumor. Histopathologic examination showed that the excised tissue was a schwannoma, which in this location can mimic a carotid body tumor. The relevant literature is also reviewed.