Training anesthesiology residents in providing anesthesia for awake craniotomy: learning curves and estimate of needed case load

Patient-reported intraoperative experiences during awake craniotomy for brain tumors: a scoping review

Awake craniotomy (AC) is a neurosurgical procedure that may be used to excise tumors located in eloquent areas of the brain. The techniques and outcomes of AC have been extensively described, but data on patient-reported experiences are not as well known. To determine these, we performed a scoping review of patient-reported intraoperative experiences during awake craniotomy for brain tumor resection. A total of 21 articles describing 534 patients were included in the review. Majority of the studies were performed on adult patients and utilized questionnaires and interviews. Some used additional qualitative methodology such as grounded theory and phenomenology. Most of the evaluation was performed within the first 2 weeks post-operatively. Recollection of the procedure ranged from 0 to 100%, and most memories dealt with the cranial fixation device application, cranial drilling, and intraoperative mapping. All patients reported some degree of pain and discomfort, mainly due to the cranial fixation device and uncomfortable operative position. Most patients were satisfied with their AC experience. They felt that participating in AC gave them a sense of control over their disease and thought that trust in the treatment team and adequate pre-operative preparation were very important. Patients who underwent AC for brain tumor resection had both positive and negative experiences intraoperatively, but overall, majority had a positive perception of and high levels of satisfaction with AC. Successful AC depends not only on a well-conducted intraoperative course, but also on adequate pre-operative information and patient preparation.

Awake Craniotomy in Low-Resource Settings: Findings from a Retrospective Cohort in the Philippines

BACKGROUND

Awake craniotomy is a technique used to maximize resection of lesions in eloquent areas of the brain and preserve function. Although its use in high-income centers is well documented for tumors and vascular lesions, reports of its use in low-middle-income countries are limited. There are no published series from the Philippines.

METHODS

We performed a retrospective review of all patients who underwent awake craniotomy at a tertiary referral center in Manila, Philippines from 2010 to 2019. Data on demographics, clinical features, diagnoses, intraoperative and postoperative complications, and outcomes were collected. Regression analyses were performed to correlate use of intraoperative adjuncts with outcome measures (extent of resection, complication rate, neurologic status after surgery and on last follow-up, and in-hospital mortality).

RESULTS

A total of 65 patients were included in the cohort, who had a male predilection (60%) and a mean age at diagnosis of 40.4 years. The most common indication was tumor excision (90%), followed by excision of arteriovenous malformations (5%) and cavernomas (3%). Of the tumors, the most common histopathologic diagnosis was low-grade glioma (48%). The intraoperative complication rate was 13.8%, with the most common complication being patient intolerance. Gross total excision rate for tumors was 78.3%. Univariate analysis showed that use of a cortical stimulator was associated with improved neurologic status on last follow-up (P = 0.0471).

CONCLUSIONS

Our experience shows that awake craniotomy is feasible in low-middle-income country settings and is safe and effective for excision of tumors, arteriovenous malformations, and cavernomas.

Anesthesia assessment in the era of competences: state of the art

Introduction: Anesthesiology requires procedure fulfillment, problem, and real-time crisis resolution, problem, and complications forecast, among others; therefore, the evaluation of its learning should center around how students achieve competence rather than solely focusing on knowledge acquisition. Literature  shows that despite the existence of numerous evaluation strategies, these are still underrated in most cases due to unawareness. Objective: The present article aims to explain the process of competency-based anesthesiology assessment, in addition to suggesting a brief description of the learning domains evaluated, theories of knowledge, instruments, and assessment systems in the area; and finally, to show some of the most relevant results regarding assessment systems in Colombia. Methodology: The results obtained in “Characteristics of the evaluation systems used by anesthesiology residency programs stakeholders in the educational process, a fact that motivated the publishing of this discussion around the topic of competency-based assessment in anesthesiology. Following a bibliography search with the keywords through PubMed, OVID, ERIC, DIALNET, and REDALYC, 110 articles were reviewed and 75 were established as relevant for the research’s theoretical  framework. Results and conclusion: Anesthesiology assessment should be conceived from the competency’s multidimensionality; it must be longitudinal and focused on the learning objectives.

Simulator training and residents' first laparoscopic hysterectomy: a randomized controlled trial

BACKGROUND

Hysterectomy rates are decreasing in many countries, and virtual reality simulators bring new opportunities into residents' surgical education. The objective of this study was to evaluate the effect of training in laparoscopic hysterectomy module with virtual reality simulator on surgical outcomes among residents performing their first laparoscopic hysterectomy.

METHODS

This randomized study was carried out at the Department of Obstetrics and Gynecology in Helsinki University Hospital and Hyvinkää Hospital. We recruited twenty residents and randomly signed half of them to train ten times with the laparoscopic hysterectomy module on a virtual reality simulator, while the rest represented the control group. Their first laparoscopic hysterectomy was video recorded and assessed later by using the Objective Structured Assessment of Technical Skills (OSATS) forms and Visual Analog Scale (VAS). The scores and surgical outcomes were compared between the groups.

RESULTS

The mean OSATS score for the Global Rating Scale (GRS) was 17.0 (SD 3.1) in the intervention group and 11.2 (SD 2.4) in the control group (p = 0.002). The mean procedure-specific OSATS score was 20.0 (SD 3.3) and 16.0 (SD 2.8) (p = 0.012), and the mean VAS score was 55.0 (SD 14.8) and 29.9 (SD 14.9) (p = 0.001). Operative time was 144 min in the intervention group and 165 min in the control group, but the difference did not reach statistical significance (p = 0.205). There were no differences between the groups in blood loss or direct complications.

CONCLUSION

Residents training with a virtual reality simulator prior to the first laparoscopic hysterectomy seem to perform better in the actual live operation. Thus, a virtual reality simulator hysterectomy module could be considered as a part of laparoscopic training curriculum.

Education in neuroanesthesia and neurocritical care: trends, challenges and advancements

PURPOSE OF REVIEW

We summarize the latest evidence in neuroanesthesia and neurocritical care (NCC) training. In addition, we describe the newer advancements that clinical educators face in these subspecialties. Lastly, we highlight educational approaches that may lead to an enhanced learning experience and development of necessary skills for neurosciences trainees.

RECENT FINDINGS

Current neuroanesthesia and NCC training requires acquisition of specific skills for increasing complex surgical cases, specialized neurosurgical practice and new perioperative technologies. Furthermore, there is increasing international interest for standardization and accreditation of neuroanesthesia fellowship programs. Recent evidence has demonstrated that well structured training using high-fidelity simulation improves cognitive and technical skills in acute neurological crises.

SUMMARY

High-fidelity simulation in perioperative care of neurosurgical patients can be part of formal neuroanesthesia and NCC curricula, and potentially impact trainees' proficiency. A research agenda is needed to validate the assessment of most effective educational interventions in neurosciences trainees with diverse medical backgrounds. Creative combinations of cost-effective interventions including traditional teaching, specific technical skills workshops, low and high-fidelity simulation deserve to be assessed in future studies.

Xenon anesthesia for awake craniotomy: safety and efficacy

BACKGROUND

The asleep-awake-asleep (AAA) craniotomy is a technique that offers the opportunity of having a patient fully cooperative during the awake phase, and minimizes the possible discomfort, due to the asleep phase. The aim of this prospective observational study was to test the use of xenon in the first asleep phase of an AAA craniotomy, in patients undergoing craniotomy for brain tumor resection.

METHODS

The data have been collected from 40 awake craniotomy procedures, performed in patients with cerebral tumor, treated with the AAA technique. Patients were treated with xenon during the asleep phase, and quality of mapping, complications and qualitative judgment of the experience given by the patients were recorded.

RESULTS

The mapping was carried out as planned in 37 out of 40 cases. The doses of xenon administered during the first asleep phase of the anesthesia was 13±2 L. Time for awakening after xenon was switched off was 5±1 minute. A combination of xenon and regional anesthesia (with no need for additional systemic anesthetics) was adequate to accomplish craniotomy in 27/40 patients (67.5%). On the day after the operation, 37 patients recalled the testing procedure for mapping during the awake period, none had recollection of local anesthetic injections for regional anesthesia or sound associated with the neurosurgical drill. Five patients (12.5%) reported mild pain during tumor removal (VAS Score less than three).

CONCLUSIONS

In this case series, xenon anesthesia was successfully used for the sedative phase of an awake craniotomy accomplished with an AAA approach.

Local anesthetics for brain tumor resection: current perspectives

This review summarizes the added value of local anesthetics in patients undergoing craniotomy for brain tumor resection, which is a procedure that is carried out frequently in neurosurgical practice. The procedure can be carried out under general anesthesia, sedation with local anesthesia or under local anesthesia only. Literature shows a large variation in the postoperative pain intensity ranging from no postoperative analgesia requirement in two-thirds of the patients up to a rate of 96% of the patients suffering from severe postoperative pain. The only identified causative factor predicting higher postoperative pain scores is infratentorial surgery. Postoperative analgesia can be achieved with multimodal pain management where local anesthesia is associated with lower postoperative pain intensity, reduction in opioid requirement and prevention of development of chronic pain. In awake craniotomy patients, sufficient local anesthesia is a cornerstone of the procedure. An awake craniotomy and brain tumor resection can be carried out completely under local anesthesia only. However, the use of sedative drugs is common to improve patient comfort during craniotomy and closure. Local anesthesia for craniotomy can be performed by directly blocking the six different nerves that provide the sensory innervation of the scalp, or by local infiltration of the surgical site and the placement of the pins of the Mayfield clamp. Direct nerve block has potential complications and pitfalls and is technically more challenging, but mostly requires lower total doses of the local anesthetics than the doses required in surgical-site infiltration. Due to a lack of comparative studies, there is no evidence showing superiority of one technique versus the other. Besides the use of other local anesthetics for analgesia, intravenous lidocaine administration has proven to be a safe and effective method in the prevention of coughing during emergence from general anesthesia and extubation, which is especially appreciated after brain tumor resection.

Anaesthesia Management for Awake Craniotomy: Systematic Review and Meta-Analysis

BACKGROUND

Awake craniotomy (AC) renders an expanded role in functional neurosurgery. Yet, evidence for optimal anaesthesia management remains limited. We aimed to summarise the latest clinical evidence of AC anaesthesia management and explore the relationship of AC failures on the used anaesthesia techniques.

METHODS

Two authors performed independently a systematic search of English articles in PubMed and EMBASE database 1/2007-12/2015. Search included randomised controlled trials (RCTs), observational trials, and case reports (n>4 cases), which reported anaesthetic approach for AC and at least one of our pre-specified outcomes: intraoperative seizures, hypoxia, arterial hypertension, nausea and vomiting, neurological dysfunction, conversion into general anaesthesia and failure of AC. Random effects meta-analysis was used to estimate event rates for four outcomes. Relationship with anaesthesia technique was explored using logistic meta-regression, calculating the odds ratios (OR) and 95% confidence intervals [95%CI].

RESULTS

We have included forty-seven studies. Eighteen reported asleep-awake-asleep technique (SAS), twenty-seven monitored anaesthesia care (MAC), one reported both and one used the awake-awake-awake technique (AAA). Proportions of AC failures, intraoperative seizures, new neurological dysfunction and conversion into general anaesthesia (GA) were 2% [95%CI:1-3], 8% [95%CI:6-11], 17% [95%CI:12-23] and 2% [95%CI:2-3], respectively. Meta-regression of SAS and MAC technique did not reveal any relevant differences between outcomes explained by the technique, except for conversion into GA. Estimated OR comparing SAS to MAC for AC failures was 0.98 [95%CI:0.36-2.69], 1.01 [95%CI:0.52-1.88] for seizures, 1.66 [95%CI:1.35-3.70] for new neurological dysfunction and 2.17 [95%CI:1.22-3.85] for conversion into GA. The latter result has to be interpreted cautiously. It is based on one retrospective high-risk of bias study and significance was abolished in a sensitivity analysis of only prospectively conducted studies.

CONCLUSION

SAS and MAC techniques were feasible and safe, whereas data for AAA technique are limited. Large RCTs are required to prove superiority of one anaesthetic regime for AC.

Awake craniotomy for brain tumor: indications, technique and benefits

Increasing interest in the quality of life of patients after treatment of brain tumors has led to the exploration of methods that can improve intraoperative assessment of neurological status to avoid neurological deficits. The only method that can provide assessment of all eloquent areas of cerebral cortex and white matter is brain mapping during awake craniotomy. This method helps ensure that the quality of life and the neuro-oncological result of treatment are not compromised. Apart from the medical aspects of awake surgery, its economic issues are also favorable. Here, we review the main aspects of awake brain tumor surgery. Neurosurgical, neuropsychological, neurophysiological and anesthetic issues are briefly discussed.