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Ketamine has a number of clinical uses and properties that suggest a role for the drug in neuroanestheisa practice. “Dogma” and “myths” persist with regard to its effects on cerebral hemodynamics and intracranial pressure which have limited its use in Neuroanesthesia and care of the critically ill brain-injured patient. This review aims to educate the clinician on the possible role of ketamine in modern neuroanesthesia practice. A number of systemic reviews support the use of ketamine in patients with acute brain injury and raised intracranial pressure (ICP). Pre-clinical work suggests that ketamine may have mechanisms of action compatible with neuroprotection including modifying glutamate excitatory-driven mechanisms of brain injury. There is emerging clinical evidence to suggest that ketamine may inhibit spreading depolarizations (SDs), a cortical electrical phenomenon associated with brain injury. Ketamine is no longer contraindicated in the care of the brain-injured patient, and its properties of potent analgesia, dissociative anesthesia, and minimal effects on both the hemodynamic and respiratory system are being utilized in the pre-hospital and emergency room setting. Good grade data on meaningful clinical outcomes is presently lacking to support the use of ketamine as a drug with neuroprotection properties but is an area of ongoing interest.

STUDY DESIGN The enhanced perioperative care (EPOC) program is an institutional quality improvement initiative. We used a historically controlled study design to evaluate patients who underwent major spine surgery before and after the implementation of the EPOC program. OBJECTIVE To determine whether multidisciplinary EPOC program was associated with an improvement in clinical and financial outcomes for elective adult major spine surgery patients. SUMMARY OF BACKGROUND DATA The enhanced recovery after surgery (ERAS) programs successfully implemented in hip and knee replacement surgeries, and improved clinical outcomes and patient satisfaction. METHODS We compared 183 subjects in traditional care (TRDC) group to 267 intervention period (EPOC) in a single academic quaternary spine surgery referral center. One hundred eight subjects in no pathway (NOPW) care group was also examined to exclude if the observed changes between the EPOC and TRDC groups might be due to concurrent changes in practice or population over the same time period. Our primary outcome variables were hospital and intensive care unit lengths of stay and the secondary outcomes were postoperative complications, 30-day hospital readmission and cost. RESULTS In this highly complex patient population, we observed a reduction in mean hospital length of stay (HLOS) between TRDC versus EPOC groups (8.2 vs. 6.1 d, standard deviation [SD] = 6.3 vs. 3.6, P

This chapter discusses the common cerebrovascular disorders that present for surgical intervention, which include intracranial aneurysms, vascular malformations (arteriovenous malformation, dural arteriovenous fistula, cavernoma), occlusive cerebrovascular diseases (moyamoya, atherosclerotic vascular occlusion), and cranial vascular compression syndromes (trigeminal neuralgia, hemifacial spasm). It covers the critical goals of peri-operative management of cerebrovascular surgery, including maintenance of adequate cerebral perfusion, optimization of haemodynamic and ventilation parameters to avoid cerebral ischaemia and hyperaemia, creation of favourable surgical conditions, and facilitation of intra-operative neurophysiological monitoring and brain protection. Anaesthetic management of cerebrovascular surgery involves integrating the implications of intracranial as well as extracranial manifestations of the neurological pathology with the principles of anaesthetic neuropharmacology in the context of planned surgical procedure and neuromonitoring. Careful pre-operative evaluation, selection of suitable anaesthetic agents and monitors, and preparedness to deal with potential complications are the key to successful outcome of cerebrovascular surgery.