Perioperative Care of Patients Undergoing Major Complex Spinal Instrumentation Surgery: Clinical Practice Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care

An Overview of Adult Acute Traumatic Neurologic Injury for the Anesthesiologist: What is Known, What is New, and Emerging Concepts

Purpose of Review

We examine what is known, what is new, and what is emerging in acute neurotrauma relevant to the anesthesiologist.

Recent Findings

Timely and goal-directed care is critical for all patients requiring urgent/emergent anesthesia care. Anesthesia care for acute neurological injury should incorporate understanding the evolution of traumatic brain injury and spinal cord injury that translates to preoperative preparation, hemodynamic resuscitation, prevention of second insults, and safe transport between care settings. Anesthesia care should support optimizing patient outcomes.

Summary

Best practices involve extrapolating data from the intensive care unit setting since there is a lack of research addressing anesthesia care for acute neurological injury. There are opportunities to generate data to support evidence-based anesthetic care.

Perioperative Methadone for Spine Surgery: A Scoping Review

Complex spine surgery is associated with significant acute postoperative pain. Methadone possesses pharmacological properties that make it an attractive analgesic modality for major surgeries. This scoping review aimed to summarize the evidence for the perioperative use of methadone in adults undergoing complex spine surgery. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). A search was performed using MEDLINE, CINAHL, Cochrane Library, Scopus, Embase, and Joanna Briggs between January 1946 and April 2023. The initial search identified 317 citations, of which 12 met the criteria for inclusion in the review. There was significant heterogeneity in the doses, routes of administration, and timing of perioperative methadone administration in the included studies. On the basis of the available literature, methadone has been associated with reduced postoperative pain scores and reduced postoperative opioid consumption. Though safety concerns have been raised by observational studies, these have not been confirmed by prospective randomized studies. Further research is required to explore optimal methadone dosing regimens, the potential synergistic relationships between methadone and other pharmacological adjuncts, as well as the potential long-term antinociceptive benefits of perioperative methadone administration.

Effect of Nicotine Replacement Therapy on Perioperative Pain Management and Opioid Requirement in Abstinent Tobacco Smokers Undergoing Spinal Fusion: A Double-blind Randomized Controlled Trial

BACKGROUND

Smoking negatively impacts postoperative outcomes but acute abstinence from smoking during hospitalization can increase postoperative pain, lower pain thresholds, disrupt pain management, and trigger hyperalgesia due to abrupt nicotine withdrawal in tobacco users. Nicotine replacement therapy has been recommended to minimize these complications. We hypothesized that a high dose (21 mg/24 h) transdermal nicotine (TDN) patch would reduce postoperative pain and opioid requirements.

METHODS

One hundred abstinent tobacco smokers undergoing single-level spinal fusion were randomized into placebo (n=50) and nicotine treatment (n=50) groups. Placebo and TDN patches were applied 24 hours before surgery until 48 hours after surgery. Primary outcomes were postoperative pain scores and opioid (morphine) consumption, and serum nicotine levels. The relationship between daily tobacco use and pain and opioid requirements, and between serum nicotine levels and morphine consumption, were assessed.

RESULTS

Postoperative pain scores at rest and on movement were lower in the nicotine group than in the placebo group at 6 hours, 12 hours, and 24 hours after surgery (P<0.05). Postoperative morphine consumption was lower in the nicotine group than in the placebo group (9.92 ± 4.0 vs. 15.9 ± 5.0 mg, respectively; P=0.0002). There was a positive correlation between the number of cigarettes smoked per day and postoperative pain scores at rest (r = 0.4553; P = 0.0001) and during movement and a negative correlation between serum nicotine concentration and postoperative morphine consumption (r =-0.3664; P = 0.0089).

CONCLUSIONS

TDN patches (21 mg/24 h) reduced postoperative pain and opioid requirements in abstinent tobacco smokes undergoing spinal fusion.

Effect of intravenous lidocaine on catheter‑related bladder discomfort, postoperative pain and opioid requirement in complex fusion lumbar spinal surgery: a randomized, double blind, controlled trial

BACKGROUND

Catheter-related bladder discomfort (CRBD) and pain commonly arises postoperatively in patients who undergo intra-operative urinary catheterization. The study aims to demonstrate the effectiveness of intravenous lidocaine to prevent CRBD and postoperative pain in complex lumbar spinal surgery.

METHODS

Eighty male patients, aged 20-79 years, scheduled for elective fusion spine surgery at least two levels were randomly assigned to receive either intravenous lidocaine (1.5 mg/kg followed by 2 mg/kg/h) (Group L) or a parallel volume of normal saline (Group C). The primary outcome was incidence of moderate to severe CRBD in a postanesthetic care unit (PACU) between the two groups. Secondary outcomes included postoperative pain, 24-hour post operative opioid requirement, mild and moderate to severe CRBD at 1, 2, 6 and 24 h postoperatively, patient satisfaction on Global Perceived Effect Scale (GPES), and the adverse effects of lidocaine and surgical complications.

RESULTS

Group L showed a significantly lower incidence of moderate-to-severe CRBD compared to Group C in the PACU (P = 0.002) and at 1 h postoperatively (P = 0.039). Additionally, Group L experienced a significantly lower average pain scores compared to Group C at all time points (P < 0.001, P < 0.001, P = 0.001, P < 0.001 and P < 0.001 at 0, 1, 2, 6 and 24 h, respectively) and demonstrated a significantly reduced postoperative morphine requirement across all time intervals (P < 0.05). Group L also reported significantly higher satisfaction on GPES compared to group C (P < 0.001). No adverse outcome was observed in either group.

CONCLUSION

Intravenous lidocaine administration significantly reduced the incidence of moderate-to-severe CRBD at PACU and at 1 h postoperatively. Additionally, its use in complex spine surgery led to reductions in postoperative pain, opioid requirement, and improved patient satisfaction, without any observed side effects.

Differences in Perioperative Management of Patients Undergoing Complex Spine Surgery: A Global Perspective

BACKGROUND

The aim of this survey was to understand institutional spine surgery practices and their concordance with published best practices/recommendations.

METHODS

Using a global internet-based survey examining perioperative spine surgery practice, reported institutional spine pathway elements (n=139) were compared with the level of evidence published in guideline recommendations. The concordance of clinical practice with guidelines was categorized as poor (≤20%), fair (21%-40%), moderate (41%-60%), good (61%-80%), or very good (81%-100%).

RESULTS

Seventy-two of 409 (17.6%) institutional contacts started the survey, of which 31 (7.6%) completed the survey. Six (19.4%) of the completed surveys were from respondents in low/middle-income countries, and 25 (80.6%) were from respondents in high-income countries. Forty-one incomplete surveys were not included in the final analysis, as most were less than 40% complete. Five of 139 (3.6%) reported elements had very good concordance for the entire cohort; hospitals with spine surgery pathways reported 18 elements with very good concordance, whereas institutions without spine surgery pathways reported only 1 element with very good concordance. Reported spine pathways included between 7 and 47 separate pathway elements. There were 87 unique elements in the reviewed pathways. Only 3 of 87 (3.4%) elements with high-quality evidence demonstrated very good practice concordance.

CONCLUSIONS

This global survey-based study identified practice variation and low adoption rates of high-quality evidence in the care of patients undergoing complex spine surgery.

Designing Enhanced Recovery After Surgery Protocols in Neurosurgery: A Contemporary Narrative Review

Enhanced Recovery After Surgery (ERAS) protocols have revolutionized the approach to perioperative care in various surgical specialties. They reduce complications, improve patient outcomes, and shorten hospital lengths of stay. Implementation of ERAS protocols for neurosurgical procedures has been relatively underexplored and underutilized due to the unique challenges and complexities of neurosurgery. This narrative review explores the barriers to, and pioneering strategies of, standardized procedure-specific ERAS protocols, and the importance of multidisciplinary collaboration in neurosurgery and neuroanesthsia, patient-centered approaches, and continuous quality improvement initiatives, to achieve better patient outcomes. It also discusses initiatives to guide future clinical practice, research, and guideline creation, to foster the development of tailored ERAS protocols in neurosurgery.

Perioperative Management for Complex Spine Fusion Surgery

Complex spine surgeries performed worldwide continue to increase in number, as do the age and comorbidity of patients undergoing these operations. Perioperative care protocols related to blood management, postoperative pain control, and intraoperative measures to mitigate morbidity may improve clinical workflows and patient outcomes.

Utilizing Artificial Intelligence and Chat Generative Pretrained Transformer to Answer Questions About Clinical Scenarios in Neuroanesthesiology

OBJECTIVE

We tested the ability of chat generative pretrained transformer (ChatGPT), an artificial intelligence chatbot, to answer questions relevant to scenarios covered in 3 clinical guidelines, published by the Society for Neuroscience in Anesthesiology and Critical Care (SNACC), which has published management guidelines: endovascular treatment of stroke, perioperative stroke (Stroke), and care of patients undergoing complex spine surgery (Spine).

METHODS

Four neuroanesthesiologists independently assessed whether ChatGPT could apply 52 high-quality recommendations (HQRs) included in the 3 SNACC guidelines. HQRs were deemed present in the ChatGPT responses if noted by at least 3 of the 4 reviewers. Reviewers also identified incorrect references, potentially harmful recommendations, and whether ChatGPT cited the SNACC guidelines.

RESULTS

The overall reviewer agreement for the presence of HQRs in the ChatGPT answers ranged from 0% to 100%. Only 4 of 52 (8%) HQRs were deemed present by at least 3 of the 4 reviewers after 5 generic questions, and 23 (44%) HQRs were deemed present after at least 1 additional targeted question. Potentially harmful recommendations were identified for each of the 3 clinical scenarios and ChatGPT failed to cite the SNACC guidelines.

CONCLUSIONS

The ChatGPT answers were open to human interpretation regarding whether the responses included the HQRs. Though targeted questions resulted in the inclusion of more HQRs than generic questions, fewer than 50% of HQRs were noted even after targeted questions. This suggests that ChatGPT should not currently be considered a reliable source of information for clinical decision-making. Future iterations of ChatGPT may refine algorithms to improve its reliability as a source of clinical information.

Value-based Care and Quality Improvement in Perioperative Neuroscience

Value-based care and quality improvement are related concepts used to measure and improve clinical care. Value-based care represents the relationship between the incremental gain in outcome for patients and cost efficiency. It is achieved by identifying outcomes that are important to patients, codesigning solutions using multidisciplinary teams, measuring both outcomes and costs to drive further improvements, and developing partnerships across the health system. Quality improvement is focused on process improvement and compliance with best practice, and often uses "Plan-Do-Study-Act" cycles to identify, test, and implement change. Validated, standardized core outcome sets for perioperative neuroscience are currently lacking, but neuroanesthesiologists can consider using traditional clinical indicators, patient-reported outcomes measures, and perioperative core outcome measures. Several examples of bundled care solutions have been successfully implemented in perioperative neuroscience to increase value; for example, enhanced recovery for spine surgery, delirium reduction pathways, and same-day discharge craniotomy. This review proposes potential individual- and system-based solutions to address barriers to value-based care and quality improvement in perioperative neuroscience.

[Perioperative management of the brain-dead organ donor : Anesthesia between ethics and evidence]

Hintergrund

Die Anzahl postmortal gespendeter Organe ist in Deutschland weit geringer als der Bedarf. Dies unterstreicht die Wichtigkeit einer optimalen Versorgung während des gesamten Prozesses der Organspende.

Fragestellung

Es existieren internationale Leitlinien und nationale Empfehlungen zu intensivmedizinischen organprotektiven Maßnahmen beim Organspender. Für das anästhesiologische Management fehlen evidenzbasierte Empfehlungen. Ziel dieser Übersichtsarbeit ist es, anhand der vorhandenen Evidenz die pathophysiologischen Veränderungen des irreversiblen Hirnfunktionsausfalls zu rekapitulieren und sich kritisch mit den empfohlenen Behandlungsstrategien und therapeutischen Zielgrößen auseinanderzusetzen. Auch auf ethische Aspekte der Betreuung des postmortalen Organspenders wird eingegangen.

Methode

Diese Übersichtsarbeit basiert auf einer selektiven Literaturrecherche in PubMed (Suchwörter: „brain dead donor“, „organ procurement“, „organ protective therapy“, „donor preconditioning“, „perioperative donor management“, „ethical considerations of brain dead donor“). Internationale Leitlinien und nationale Empfehlungen wurden besonders berücksichtigt.

Ergebnisse

Insgesamt ist die Evidenz für optimale intensivmedizinische und perioperative organprotektive Maßnahmen beim postmortalen Organspender sehr gering. Nationale und internationale Empfehlungen zu Zielwerten und medikamentösen Behandlungsstrategien unterscheiden sich teilweise erheblich: kontrollierte randomisierte Studien fehlen. Der Stellenwert einer Narkose zur Explantation bleibt sowohl unter pathophysiologischen Gesichtspunkten als auch aus ethischer Sicht ungeklärt.

Schlussfolgerungen

Die Kenntnisse über die pathophysiologischen Prozesse im Rahmen des irreversiblen Hirnfunktionsausfalls und die organprotektiven Maßnahmen sind ebenso Grundvoraussetzung wie die ethische Auseinandersetzung mit dem Thema postmortale Organspende. Nur dann kann das Behandlungsteam in dieser herausfordernden Situation sowohl dem Organempfänger als auch dem Organspender und seinen Angehörigen gerecht werden.