A Prospective, Randomized, Double-Blinded, Double-Dummy Pilot Study to Assess the Preemptive Effect of Triple Therapy with Aprepitant, Dexamethasone, and Promethazine versus Ondansetron, Dexamethasone and Promethazine on Reducing the Incidence of Postoperative Nausea and Vomiting Experienced by Patients Undergoing Craniotomy Under General Anesthesia.

INTRODUCTION: Postoperative nausea and vomiting (PONV) is among the most common distressing complications of surgery under anesthesia. Previous studies have demonstrated that patients who undergo craniotomy have incidences of nausea and vomiting as high as 50-70%. The main purpose of this pilot study is to assess the incidence of PONV by using two different prophylactic regimens in subjects undergoing a craniotomy. Thus, we designed this study to assess the efficacy and safety of triple therapy with the combination of dexamethasone, promethazine, and aprepitant versus ondansetron to reduce the incidence of PONV in patients undergoing craniotomy. MATERIALS AND METHODS: This is a prospective, single center, two-armed, randomized, double-dummy, double-blind, pilot study. Subjects were randomly assigned to one of the two treatment groups. Subjects received 40 mg of aprepitant pill (or matching placebo pill) 30-60 min before induction of anesthesia and 4 mg of ondansetron IV (or 2 ml of placebo saline solution) at induction of anesthesia. In addition, all subjects received 25 mg of promethazine IV and 10 mg of dexamethasone IV at induction of anesthesia. Assessments of PONV commenced for the first 24 h after surgery and were subsequently assessed for up to 5 days. RESULTS: The overall incidence of PONV during the first 24 h after surgery was 31.0% (n = 15) in the aprepitant group and 36.2% (n = 17) for the ondansetron group. The median times to first emetic and significant nausea episodes were 7.6 (2.9, 48.7) and 14.3 (4.4, 30.7) hours, respectively, for the aprepitant group and 6.0 (2.2, 29.5) and 9.6 (0.7, 35.2) hours, respectively, for the ondansetron group. There were no statistically significant differences between these groups. No adverse events directly related to study medications were found. CONCLUSION: This pilot study showed similar effectiveness when comparing the two PONV prophylaxis regimens. Our data showed that both treatments could be effective regimens to prevent PONV in patients undergoing craniotomy under general anesthesia. Future trials testing new PONV prophylaxis regimens in this surgical population should be performed to gain a better understanding of how to best provide prophylactic treatment.

Aprepitant versus ondansetron in preoperative triple-therapy treatment of nausea and vomiting in neurosurgery patients: study protocol for a randomized controlled trial.

BACKGROUND: The incidence of postoperative nausea and vomiting (PONV) is 50% to 80% after neurosurgery. The common prophylactic treatment for postoperative nausea and vomiting is a triple therapy of droperidol, promethazine and dexamethasone. Newer, more effectives methods of prophylaxis are being investigated. We designed this prospective, double-blind, single-center study to compare the efficacy of ondansetron, a neurokinin-1 antagonist, and aprepitant, as a substitute for droperidol, in the prophylactic treatment of postoperative nausea and vomiting after neurosurgery. METHODS: After obtaining institutional review board approval; 176 patients, 18 to 85 years of age with American Society of Anesthesiologists (ASA) classifications I to III, who did not receive antiemetics 24 h before surgery and were expected to undergo general anesthesia for neurosurgery lasting longer than 2 h were included in this study. After meeting the inclusion and exclusion criteria and providing written informed consent, patients were randomly assigned in a 1:1 ratio to one of two treatment groups: aprepitant or ondansetron. The objective of this study was to conduct a randomized, double-blind, double-dummy, parallel-group and single-center trial to compare and evaluate the efficacies of aprepitant versus ondansetron. Patients received oral aprepitant 40 mg OR oral dummy pill within 2 h prior to induction. At induction, a combination of intravenous dexamethasone 10 mg, promethazine 25 mg, and ondansetron 4 mg OR dummy injection was administered. Therefore, all patients received one dummy treatment and three active PONV prophylactic medications: dexamethasone 10 mg, promethazine 25 mg, and either aprepitant 40 mg OR ondansetron 4 mg infusion. The primary outcome measures were the episodes and severity of nausea and vomiting; administration of rescue antiemetic; and opioid consumption for 120 h postoperatively. Standard safety assessments included adverse event reports, physical and laboratory data, awakening time and duration of recovery from anesthesia. DISCUSSION: The results of this comparative study could potentially identify an improved treatment regimen that may decrease the incidence and severity of postoperative nausea and vomiting in patients undergoing neurosurgery. Also, this will serve to enhance patient recovery and overall satisfaction of neurosurgical patients in the immediate postoperative period. TRIAL REGISTRATION: Registered at The Ohio State University Biomedical Sciences Institutional Review Board: Protocol Number: 2007 H0053.

Current intraoperative devices to reduce visual loss after spine surgery.

Postoperative visual loss (POVL) after spine surgery performed with the patient prone is a rare but devastating postoperative complication. The incidence and the mechanisms of visual loss after surgery are difficult to determine. The 4 recognized causes of POVL are ischemic optic neuropathy (approximately 89%), central retinal artery occlusion (approximately 11%), cortical infarction, and external ocular injury. There are very limited guidelines or protocols on the perioperative practice for "prone-position" surgeries. However, new devices have been designed to prevent mechanical ocular compression during prone-position spine surgeries. The authors used PubMed to perform a literature search for devices used in prone-position spine surgeries. A total of 7 devices was found; the authors explored these devices' features, advantages, and disadvantages. The cause of POVL seems to be a multifactorial problem with unclear pathophysiological mechanisms. Therefore, ocular compression is a critical factor, and eliminating any obvious compression to the eye with these devices could possibly prevent this devastating perioperative complication.

Calcifying fibrous tumor of the spine.

OBJECTIVE: Calcifying fibrous tumor is a rare, benign soft-tissue tumor of unknown etiology, characterized by hyalinized collagenous fibrous tissue with psammomatous or dystrophic calcification and focal lymphoplasmacytic infiltrate known to involve different organ systems. Involvement of the spine and the presence of metaplastic ossification previously have not been reported. INTERVENTION: We report a 44-year-old female with progressive nontraumatic flank pain. Imaging revealed a left-sided retroperitoneal calcified mass attached to L5 body with no evidence of extension into the neural foramina, nearby vascular structures, or psoas muscle. The patient had an en bloc resection of the tumor via the transabdominal approach. A pathologic diagnosis of calcifying fibrosis with metaplastic ossification of the spine was reported. Postoperative recovery was uneventful and there is no recurrence after 18 months of follow-up. CONCLUSION: Calcifying fibrous tumor, a rare benign soft tissue tumor must be considered in the differential diagnosis of a retroperitoneal calcified mass closely associated with the spinal column. Spine surgeons should be aware of this rare pathologic disease entity and although its natural history is not clear, marginal excision is usually adequate.

Processed electroencephalogram response of patients undergoing carotid endarterectomy: a pilot study.

BACKGROUND: A risk during carotid endarterectomy (CEA) is cerebral ischemia as a result of clamping of the carotid artery. The Cerebral State Monitor is one of several electroencephalogram monitors that reflects level of consciousness of patients during anesthesia. The monitor reports level of consciousness with the empirical parameter Cerebral State Index (CSI) on a 0-100 scale. In this patient-controlled prospective pilot study, we compared the CSI measured from the surgical and control hemispheres of patients undergoing CEA surgery to determine whether the parameter is affected by presumed changes in cerebral blood flow. METHODS: Fifteen consenting CEA patients entered this institutionally approved study. We connected a separate Cerebral State Monitor to the left and right sides of the patient's head and recorded CSI intraoperatively. We compared the control-side data with the surgical-side data. RESULTS: Clamping caused the surgical-side CSI to drop below the control-side CSI. Shunt activation caused the CSI to rise above the control. The greatest difference between the surgical-side CSI and control-side CSI occurred at the completion of the CEA procedure. These observed trends were not statistically significant in this pilot project. CONCLUSION: Our preliminary results suggest that the CSI, and perhaps other similar indexes, may indicate changes in cerebral blood flow acutely during CEA. Our findings lend promise to a new use for these types of electroencephalogram monitors, which are prevalent in operating rooms today.

A retrospective cohort-matched comparison of conscious sedation versus general anesthesia for supratentorial glioma resection. Clinical article.

OBJECT: Glioma resection under conscious ("awake") sedation (CS) is used for eloquent areas of the brain to minimize postoperative neurological deficits. The objective of this study was to compare the duration of hospital stay, overall hospital cost, perioperative morbidity, and postoperative patient functional status in patients whose gliomas were resected using CS versus general endotracheal anesthesia (GEA). METHODS: Twenty-two cases in 20 patients who underwent surgery for cerebral gliomas under CS and a matched cohort of 22 cases in 19 patients who underwent surgery under GEA over a 3-year period were retrospectively evaluated. Criteria for inclusion in the study were as follows: 1) a single cerebral lesion; 2) gross-total resection as evidenced by postoperative Gd-enhanced MR imaging within 48 hours of surgery; 3) a WHO Grade II, III, or IV glioma; 4) a supratentorial lesion location; 5) a Karnofsky Performance Scale score ≥ 70; 6) an operation performed by the same neurosurgeon; and 7) an elective procedure. RESULTS: The average hospital stay was significantly different between the 2 groups: 3.5 days for patients who underwent CS and 4.6 days for those who underwent GEA. This result translated into a significant decrease in the average inpatient cost after intensive care unit (ICU) care for the CS group compared with the GEA group. Other variables were not significantly different. CONCLUSIONS: Patients undergoing glioma resection using CS techniques have a significantly shorter hospital stay with reduced inpatient hospital expenses after postoperative ICU care.

Hematuria masiva por fístula venosa ureteral: reporte de un caso: revisión de la literatura / Masive hematuria by uretral venous fistula: report of a case: review of literature

Se presenta un caso de hematuria masiva, debido a la existencia de una fístula entre la vena ilíaca Interna Derecha y el uréter derecho en una paciente de 35 años, la cuál es demostrada mediante: arteriografía selectiva, gammagrama con glóbulos rojos marcados con Tc99, tomografía abdómino pélvica y se demuestran los hallazgos intraoperatorios, así como la evolución de la paciente. Se revisa la literatura nacional e internacional