Effect of different positive end expiratory pressure levels on optic nerve sheath diameter in patients with or without midline shift who are undergoing supratentorial craniotomy

PURPOSE

In general, high levels of PEEP application is avoided in patients undergoing craniotomy to prevent a rise in ICP. But that approach would increase the risk of secondary brain injury especially in hypoxemic patients. Because the optic nerve sheath is distensible, a rise in ICP is associated with an increase in the optic nerve sheath diameter (ONSD). The cutoff value for elevated ICP assessed by ONSD is between 5.6 and 6.3 mm. We aimed to evaluate the effect of different PEEP levels on ONSD and compare the effect of different PEEP levels in patients with and without intracranial midline shift.

METHODS

This prospective observational study was performed in aged 18-70 years, ASA I-III, 80 patients who were undergoing supratentorial craniotomy. After the induction of general anesthesia, the ONSD's were measured by the linear transducer from 3 mm below the globe at PEEP values of 0-5-10 cmH2O. The ONSD were compered between patients with (n = 7) and without midline shift (n = 73) at different PEEP values.

RESULTS

The increases in ONSD due to increase in PEEP level were determined (p < 0.001). No difference was found in the comparison of ONSD between patients with and without midline shift in different PEEP values (p = 0.329, 0.535, 0.410 respectively). But application of 10 cmH2O PEEP in patients with a midline shift increased the mean ONSD value to 5.73 mm. This value is roughly 0.1 mm higher than the lower limit of the ONSD cutoff value.

CONCLUSIONS

The ONSD in adults undergoing supratentorial tumor craniotomy, PEEP values up to 5 cmH2O, appears not to be associated with an ICP increase; however, the ONSD exceeded the cutoff for increased ICP when a PEEP of 10 cmH2O was applied in patients with midline shift.

Cerebral oxygenation assessed by near-infrared spectroscopy in the sitting and prone positions during posterior fossa surgery: a prospective, randomized clinical study

OBJECTIVES

Sitting position (SP) or prone position (PP) are used for posterior fossa surgery. The SP induced reduction in cerebral blood flow and cerebral oxygen saturation (rSO2) has been shown in shoulder surgeries, but there is not enough data in intracranial tumor surgery. Studies showed that PP is safe in terms of cerebral oxygen saturation in patients undergoing spinal surgery. Our hypothesis is that the SP may improve cerebral oxygenation in the patients with intracranial pathologies due to reduction in intracranial pressure. Therefore, we compared the effects of the SP and PP on rSO2 in patients undergoing posterior fossa tumor surgery.

METHODS

Data were collected patients undergoing posterior fossa surgery, 20 patients in SP compared to 21 patients in PP. The rSO2 was assessed using INVOS monitor. Heart rate (HR), mean arterial pressure (MAP), EtCO2, BIS, and bilateral rSO2 were recorded preoperatively, and at 5, 8, and 11.ßminutes after the intubation and every 3.ßminutes after patient positioning until the initial surgical incision.

RESULTS

Cerebral oxygenation slowly reduced in both the sitting and prone position patients following the positioning (p.ß<.ß0.002), without any difference between the groups. The HR and MAP were lower in the sitting SP after positioning compared to the PP.

CONCLUSION

Neurosurgery in the SP and PP is associated with slight reduction in cerebral oxygenation. We speculate that if we rise the lower limit of MAP, we might have showed the beneficial effect of the SP on rSO2.

Effects of propofol, desflurane, and sevoflurane on respiratory functions following endoscopic endonasal transsphenoidal pituitary surgery: a prospective randomized study

Background

General anesthesia with intravenous or inhalation anesthetics reduces respiratory functions. We investigated the effects of propofol, desflurane, and sevoflurane on postoperative respiratory function tests.

Methods

This single-center randomized controlled study was performed in a university hospital from October 2015 to February 2017. Ninety patients scheduled for endoscopic endonasal transsphenoidal pituitary surgery were randomly categorized into either of these three groups: propofol (n = 30, the Group TIVA), desflurane (n = 30, the Group D) or sevoflurane (n = 30, the Group S). We analyzed the patients before, after, and 24 h following surgery, to identify the following parameters: forced expiratory volume in 1 second (FEV₁) %, forced vital capacity (FVC) %, FEV₁/FVC, and arterial blood gases (ABG). Furthermore, we also recorded the intraoperative dynamic lung compliance and airway resistance values.

Results

We did not find any significant differences in FEV₁ values (primary outcome) among the groups (P = 0.336). There was a remarkable reduction in the FEV₁ and FVC values in all groups postoperatively relative to the baseline (P < 0.001). The FVC, FEV₁/FVC, ABG analysis, compliance, and airway resistance were similar among the groups. Intraoperative dynamic compliance values were lower at the 1st and 2nd hours than those immediately after intubation (P < 0.001).

Conclusions

We demonstrated that propofol, desflurane, and sevoflurane reduced FEV₁ and FVC values postoperatively, without any significant differences among the drugs.

Single-stage planning for total cure of grade III-V brain arteriovenous malformations by embolization alone or in combination with microsurgical resection

PURPOSE

There are no established guidelines for treatment of Spetzler-Martin grade III-V brain arteriovenous malformations (bAVMs). The purpose of this study is to report our institutional experience in total obliteration/eradication of grade III-V bAVMs by single-stage planning of embolization combined with microsurgical resection when necessary.

METHODS

All patients harboring Spetzler-Martin (S-M) grade III-V bAVMs treated with single-stage planning between January 2006 and January 2018 were retrospectively reviewed. This treatment paradigm is applicable only to surgically accessible bAVMs and does not include deep-seated bAVMs. Indications for treatment, clinical presentation, imaging characteristics, and treatment outcomes were analyzed. Outcomes were assessed based on modified Rankin Scale.

RESULTS

A total of 31 patients were identified. Seventeen patients (54.8%) presented with hemorrhage, 10 (32.3%) with seizures, 3 (9.7%) with headaches, and 1 (3.2%) with progressive neurological deficit. Based on S-M grading system, 25 patients (80.6%) harbored grade III bAVM, 5 patients had grade IV bAVMs (16.1%), and 1 patient (3.2%) had a grade V bAVM. There were no treatment-related complications in 24/31 (77.4%) patients. Of the total of seven patients with complications, four patients had clinical deterioration. The long-term (> 6-month), non-disabling morbidity (mRS ≤ 2) rate was 6.5%. The long-term, disabling morbidity rate was 3.2% with a mortality of 3.2%. Complete angiographic obliteration was achieved in 30/31 (96.8%) patients.

CONCLUSION

Single-stage treatment strategy can be considered as an alternative to multistage embolization prior to surgery in grade III-V bAVMs. In this study, a high rate of total obliteration with relatively low rates of permanent morbidity and mortality was achieved.

The role of "Integrated Pulmonary Index" monitoring during morphine-based intravenous patient-controlled analgesia administration following supratentorial craniotomies: a prospective, randomized, double-blind controlled study

OBJECTIVE

Morphine is commonly used in post-operative analgesia, but opioid-related respiratory depression causes a general reluctance for its use. The "Integrated Pulmonary Index" is a tool calculated from non-invasively obtained respiratory and hemodynamic parameters. The aim of this prospective, randomized, double blind, and placebo-controlled study is to determine a more safe and effective dose for morphine in patient-controlled analgesia following supratentorial craniotomy using the "Integrated Pulmonary Index".

METHODS

This study included 60 patients (ASA I, II, and III). All patients used iv PCA for 24 h following supratentorial craniotomy. The PCA was set to administer a bolus dose of 1 mg morphine in Group 1 and 0.5 mg morphine in Group 2. The PCA contained placebo in Group 3 and patients received dexketoprofen 50 mg iv after awakening, repeated every 8 h. The IPI and NRS scores, total morphine consumption, and morphine related side-effects were recorded at 10 min, 1, 2, 6, 12, and 24 h post-operatively. The lowest IPI score, count of apnea, and desaturation events were recorded during the study period.

RESULTS

The IPI scores were similar among the groups. Although a statistically significant difference was not observed among the groups the lowest IPI scores were observed in Group 1; apnea and desaturation counts were also higher in Group 1. Statistically significant differences were not observed among the groups in terms of pain scores, but were lower in Groups 1 and 2 compared to Group 3.

CONCLUSION

Patient controlled analgesia with 0.5 mg morphine may be safe and effective for pain management following supratentorial craniotomies. Integrated pulmonary index can be used for detecting opioid-induced respiratory depression. Clinical Trials registration number: NCT02929147.

Efficacy of continuous positive airway pressure and incentive spirometry on respiratory functions during the postoperative period following supratentorial craniotomy: A prospective randomized controlled study

STUDY OBJECTIVE

Volume controlled ventilation with low PEEP is used in neuro-anesthesia to provide constant PaCO₂ levels and prevent raised intracranial pressure. Therefore, neurosurgery patients prone to atelectasis formation, however, we could not find any study that evaluates prevention of postoperative pulmonary complications in neurosurgery.

DESIGN

A prospective, randomized controlled study.

SETTING

Intensive care unit in a university hospital in Istanbul.

PATIENTS

Seventy-nine ASAI-II patients aged between 18 and 70years scheduled for elective supratentorial craniotomy were included in the study.

INTERVENTIONS

Patients randomized into 3 groups after surgery. The Group IS (n=20) was treated with incentive spirometry 5 times in 1min and 5min per hour, the Group CPAP (n=20) with continuous positive airway pressure 10 cmH₂O pressure and 0.4 F_iO₂ via an oronasal mask 5min per hour, and the Group Control (n=20) 4L·min^-1O₂ via mask; all during the first 6h postoperatively. Respiratory functions tests and arterial blood gases analysis were performed before the induction of anesthesia (Baseline), 30min, 6h, 24h postoperatively.

MAIN RESULTS

The IS and CPAP applications have similar effects with respect to FVC values. The postoperative 30min FEV₁ values were statistically significantly reduced compared to the Baseline in all groups (p<0.0001). FEV₁ values were statistically significantly increased at the postoperative 24h compared to the postoperative 30min in the Groups IS and CPAP (p<0.0001). This increase, however, was not observed in the Group Control, and the postoperative 24h FEV₁ values were statistically significantly lower in the Group Control compared to the Group IS (p=0.015).

CONCLUSION

Although this study is underpowered to detect differences in FEV₁ values, the postoperative 24h FEV₁ values were significantly higher in the IS group than the Control group and this difference was not observed between the CPAP and Control groups. It might be evaluate a favorable effect of IS in neurosurgery patients. But larger studies are needed to make a certain conclusion.

Emergency bronchoscopy for foreign-body aspiration in a child with type I mucopolysaccharidosis: a challenging airway management experience

The mucopolysaccharidosis (MPS) is a rare lysosomal storage disease. Glycosaminoglycans (GAG) accumulate in musculoskeletal system, connective tissues. Enlarged tongue, short immobile neck, and limited mobility of the cervical spine and temporomandibular joints render the airway management potentially risky. MPS children have high anesthetic risks, especially in airway management of emergency situations. The foreign-body aspiration requiring intervention with rigid bronchoscopy is an urgent and risky clinical situation. We present our experience with a challenging airway management with a three-year-old child with MPS who needed emergency bronchoscopy due to peanut aspiration.

Surgical and anesthesiological considerations of awake craniotomy: Cerrahpasa experience

AIM

Awake craniotomy (AC) with electrical cortical stimulation has become popular during the last ten years although the basic principles were introduced almost 50 years ago. The aim of this paper is to share with the readers our experience in 25 patients who underwent AC with electrical stimulation.

MATERIAL AND METHODS

Twenty-five patients who underwent AC between 2010 and 2013 are the subjects of this paper. All patients were diagnosed with intraaxial lesions involving the functional area itself or very close to it by preoperative imaging. During surgery, the functional area was demonstrated by cortical electrical stimulation and resection aimed to preserve it in order to avoid an irreversible functional deficit.

RESULTS

Total resection was possible in 80% while in 20% subtotal resection had to be performed because of involvement of the functional area itself. The neurological complication rate was found to be 16% (4 patients) and all were transient. No complication regarding anesthesia was noted.

CONCLUSION

Awake craniotomy in selected patients is very effective, safe and practical for supratentorial lesions close to the eloquent area. Complications related to the surgery itself are uncommon and general anesthesia is avoided. The hospital stay including the intensive care unit is short which makes it very economical surgical procedure.

Testicular development of male mice offsprings exposed to acrylamide and alcohol during the gestation and lactation period

Acrylamide (Ac) in the foods and alcohol (Al) in the drinks are unavoidable. Several previous studies demonstrated that these substances which are taken into the body via diet may cause adverse effects in the cells. However, there is no study about how Ac and Al may affect the male reproductive system of the offspring when consumed by the mother during pregnancy and lactation. For this purpose, sexual development in male mice was evaluated after intake of 14 mg/kg Ac and 2 g/kg Al from gestation day 6 to postnatal day (PND) 21. The weight of the offspring was reduced at birth and PND 21 for those exposed to Ac and/or Al. The gonadosomatic index of male offsprings was reduced except for the Ac-treated lactation group. Both substances induced multinuclear giant cells, degenerative cells, atrophic tubules, and maturation-arrested tubules, while decreased Leydig, Sertoli, and spermatogenic cell numbers. Lipid peroxidation level and superoxide dismutase enzyme activity increased in both Al-treated and Ac and Al-treated groups. There was only reduction in the catalase activity during the gestation and lactation periods. These findings suggest that consumption of Ac together with Al may induce impairments on testicular spermatogenesis in male offsprings.

The effects of intravenous, enteral and combined administration of glutamine on malnutrition in sepsis: a randomized clinical trial

Our aim was to compare the effects of intravenous, enteral, and enteral plus intravenous supplemented glutamine on plasma transferrin, nitrogen balance, and creatinine/height index in septic patients with malnutrition. Blood and urine samples were collected for transferrin, urea and creatinine measurements. Samples, SOFA score and protein-calorie intake values were repeated on days 7 and 15. Patients (n:120) were randomly divided into 4 groups. Group I received 30 g/day IV glutamine, group II received 30 g/day enteral glutamine, group III received 15 g/day IV and 15 g/day enteral glutamine. Group IV received only enteral feeding as a control group. Transferrin levels decreased in group IV (p<0.01 0-7 days, p<0.01 7-15 days, p<0.01 0-15 days). Nitrogen balance levels were highest in group IV when compared with group I (p<0.05, p<0.001), group II (p<0.001), and group III (p<0.05, p<0.001) on days 7-15. Creatinine/height indexes increased in group I (p<0.001), group II (p<0.001), group III (p<0.001), and group IV (p<0.05) on day 15. In group III the creatinine/height index was higher than in groups I and II (p<0.05). In group IV, creatinine/height index was lower than in group I (p<0.01) and group II (p<0.001). Protein-calorie intake in group IV was higher than others on day 7 (p<0.05). SOFA scores of group IV were higher than the other groups on day 15 (p<0.05). This study demonstrated, that combined route of gln supplementation resulted in the most positive outcome to transferrin, creatine/height index and nitrogen balance (on days 7 and 15) during the catabolic phase of septic patients with malnutrition.

Neurosurgery in the sitting position: retrospective analysis of 692 adult and pediatric cases

AIM

The sitting position is routinely used in many centers, although its use remains controversial and appears to be diminishing because of the risk of venous air embolism (VAE).

MATERIAL AND METHODS

This is a retrospective analysis of 601 adult and 91 pediatric cases underwent neurosurgery from January 1995 through December 2010 in the sitting position. The incidence of VAE and other complications related to the sitting position has been determined. VAE was defined as a sudden and sustained decrease of end-tidal carbon dioxide (ETCO2) ≥0.7 kPa.

RESULTS

The incidence of VAE in children and adults were found to be 26.3% (n=24) and 20.4% (n=123) consecutively but the difference was not significant. The incidence of positioning induced hypotension was more in adults (37.6%) compared to children (18.6%, p=0.00001). The presence of COPD (p=0.04) and ASA status (p=0.03) showed a correlation with 'hypotension with positioning'. There was no peroperative mortality.

CONCLUSION

The study provides a significant body of data on neuroanesthesia for the sitting position and our results suggest that if the sitting position is a neurosurgical necessity it can be used with vigilant follow up throughout the procedure to detect any occurrence of VAE by ETCO2 monitoring if you do not have the chance to use more sensitive tools.

A meningitis case due to Stenotrophomonas maltophilia and review of the literature

Stenotrophomonas maltophilia (formerly Xanthomonas maltophilia) is a Gram-negative bacillus increasingly associated with serious nosocomial infections. Here, we describe a 30-year-old male patient who developed meningitis associated with this organism after several neurosurgical procedures. A review of the literature revealed only 15 previous reports. Most cases were associated with neurosurgical procedures. Antimicrobial therapy is complicated by multiple drug resistance of the organism, and trimethoprim-sulfamethoxazole is the recommended agent for treatment.

Relationship between DNA damage and total antioxidant capacity in patients with transitional meningioma

PURPOSE

The purpose of this study was to assess oxidative DNA damage and total antioxidant capacity (TAC) in patients with transitional meningioma (TM) and to compare the results with normal brain tissues.

PATIENTS AND METHODS

Oxidative DNA damage and TAC were evaluated in TM extracted from 22 patients and in normal brain tissues of 15 subjects who underwent autopsy within first 4h of death. Oxidative DNA damage was assessed by measuring 8-hydroxy-2-deoxyguanosine (8-OH-dG) using the 8-OH-dG enzyme immunoassay kit, a quantitative assay for 8-OH-dG, and TAC was analyzed using the ImAnOx colorimetric test system for the determination of antioxidative capacity. The results were compared between two groups and any correlation between 8-OH-dG and TAC was sought.

RESULTS

The median level of TAC in TM (135nmol/gwet tissue) was remarkably lower than in normal brain tissue (298nmol/gwet tissue). The difference was statistically significant (p=0.00001). In contrast, oxidative DNA damage was significantly higher in patients with TM (71.61ng/gwet tissue) than in controls (34.71ng/gwet tissue). Again, the difference was statistically significant (p=0.00001). We also found a negative correlation between oxidative DNA damage and TAC (p<0.001).

CONCLUSION

These findings show that the degree of oxidative DNA damage is increased and TAC is decreased in TM and oxidative DNA damage is negatively correlated with the levels of TAC.

Detection of Epithelial Cell Transfer in Spinal Areas by Light Microscopy and Determining Any Tissue Coring via Cell Culture During Combined Spinal-Epidural Interventions

BACKGROUND AND OBJECTIVES

Epithelial tissue coring by spinal needles during subarachnoid injections may cause intraspinal epidermal tumors. Previous studies have investigated tissue transfer with different needle types during subarachnoid or epidural injection. This study deals with the transfer of epithelial tissue during combined spinal-epidural (CSE) anesthesia.

METHODS

We studied 68 American Society of Anesthesiologists I to III adult patients. CSE anesthesia was induced under aseptic conditions at the L2-3 or L3-4 interspace with patients in the lateral decubitus position. Cerebral spinal fluid, spinal needle stylet, fluid used to flush the interior of the spinal needle, fluid used to wash the exterior of the spinal needle, fluid used to flush the interior of the epidural needle, and fluid used to wash the exterior tip of the epidural needle were examined under light microscopy (n = 30 patients) or incubated in a cell-culture medium (n = 38 patients). Samples were incubated in cell-culture medium alone (n = 13) or in a cell-culture medium for 3 weeks and then in a medium with epidermal growth factor (n = 25). As a positive control, skin tissue samples were taken by punch biopsy from 10 randomly chosen patients who underwent CSE interventions. These samples were incubated in an enriched medium serum.

RESULTS

Light microscopy revealed that there was cell transfer in all phases in various rates: samples 1, 2, 3, 4, 5, and 6 contained epithelial cells and debris in ratios of 6.9%, 20.7%, 6.9%, 20.7%, 26.7%, and 33.3%, respectively. Epithelial cell colonization was detected in the cell-culture samples taken from the control group but not in the samples taken from the CSE group.

CONCLUSIONS

We could not reproduce the cells or cell debris obtained during the CSE interventions in vivo, which can be explained by a possible structural deformation of cells or the inadequacy of the amount of cells that were transferred.

Intrathecal baclofen toxicity and deep coma in minutes

BACKGROUND/OBJECTIVE

In recent years, intrathecal baclofen (ITB) treatment in patients with refractory spasticity has been accepted as an effective therapy. However, this treatment modality may cause life-threatening complications. This report describes the clinical presentation, unfamiliar dilemmas, and treatment of a patient with ITB toxicity and raises awareness of problems that may arise.

METHODS

A 33-year-old man with refractory spasticity due to diffuse white matter injury was admitted for ITB treatment. The patient had respiratory difficulty followed by a generalized seizure and developed coma minutes after the drug administration. The patient was transferred into an intensive care unit immediately and managed accordingly.

RESULTS

After proper management, the patient was followed and continued to receive ITB treatment.

CONCLUSIONS

ITB therapy is a very effective method of rehabilitation and medication in patients with refractory spasticity, but physicians must be aware of the serious complications that may develop just minutes after the drug is administered. Although safe, baclofen pumps are nevertheless mechanical devices that may malfunction. Therefore, physicians should be mindful of the possibility of life-threatening complications that may develop and lead to a patient's death if proper treatment is not performed.

An experimental study on the relationship of intra-abdominal pressure and renal ischemia

This study was undertaken in order to determine whether or not the increased intra-abdominal pressure during laparoscopic procedures causes renal ischaemia and parenchymal pathology. Fifteen adult New Zealand rabbits were used in the study. Anaesthesia was maintained by 2% isoflurane, 50% O2 in air. Heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP), end-tidal carbon dioxide (PETCO2), airway pressure (Paw) and blood gases were monitored. Rabbits in control group (group C, n = 7) and study group (group S, n = 8) had a Veress needle placed supraumbilically. Group S was insufflated with CO2 sequentially at 5, 10 and 15 mmHg of intra-abdominal pressures (IAP); each pressure level was maintained for 20 minutes. At the end of the study, laparotomy was performed and blood was withdrawn from renal vein for measurements of renin and angiotensin I levels, and the other kidney was removed simultaneously for pathological evaluation. Haemodynamic and respiratory measurements were stable in group C and were variable in group S. The renin level was 7.27 +/- 0.34 ng.mL-1 and angiotensin I was 5.01 +/- 0.32 ng.mL-1 in group C. In group S, levels of renin and angiotensin I were 26.2 +/- 5.9 ng.mL-1 and 39.4 +/- 12.1 ng.mL-1 respectively, being significantly higher than group C (p < 0.05). Pathological scores were 0.02 +/- 0.008 in group C and 0.82 +/- 0.124 in group S (p < 0.05). There were significant histological changes in group S compared with group C. During prolonged laparoscopic operations high intra-abdominal pressures may result in intra-abdominal organ ischaemia.

The cardiorespiratory effects of laparoscopic procedures in infants

We assessed the cardiorespiratory effects of laparoscopic procedures in 27 infants aged between 36 and 365 days. Infants were monitored and anaesthetised in a standardised manner. Heart rate, mean arterial pressure, end-tidal carbon dioxide and oxygen saturation were recorded, and blood gases were measured at 5 min after intubation, 15 and 30 min after carbon dioxide pneumoperitoneum, 5 min after desufflation and after extubation. The pH, PaO2, base excess, SaO2 and SpO2 decreased, and PCO2 increased by insufflation of carbon dioxide intraperitoneally, and improved following deflation. Changes in pH and PaO2 during the study were statistically significant (p < 0.0001). The increase in PaCO2 30 min after pneumoperitoneum was statistically significant when compared with initial values. Transient arrhythmias were observed in 10 infants 1 min after pneumoperitoneum. There were no statistically significant alterations in heart rate and systolic blood pressure.

Histological changes following epidural injection of midazolam in the neonatal rabbit

Midazolam can produce antinociceptive effects when used via intrathecal or epidural routes. Neurotoxicity studies are scanty especially for neonates. The aim of this study was to carry out electron microscopic (EM) examinations in the neonatal rabbit to determine the histological effects of epidural midazolam on spinal cord. Twenty white New Zealand neonatal rabbits were randomly assigned to three groups receiving single dose of 0.9% saline (Group I; Control, n = 4), 0.9% saline titrated to pH = 3.9 by addition of hydrochloric acid (Group II; n = 6), midazolam 250 micrograms.kg-1 (Group III; n = 12) epidurally. Half of each group were sacrificed on the second day and the remainder on the seventh day and spinal cord sections were evaluated by EM. Control group displayed normal histology on grids. Group II and II showed a variable degree of neurotoxic effects such as degeneration of vacuoles, cytoplasm and neurofilaments, disruption of myelin sheaths, lysis of cell membranes, perivascular oedema, pyknosis of nuclei. The toxic effects of acidic saline and midazolam are similar, in view of these results the epidural use of acidic midazolam (commercially available preparations) in neonates should be avoided.