Search

Purpose: Uncertainties remain about the safety and efficacy of therapies for managing intracranial hypertension in acute brain injured (ABI) patients. This study aims to describe the therapeutical approaches used in ABI, with/without intracranial pressure (ICP) monitoring, among different pathologies and across different countries, and their association with sixmonths mortality and neurological outcome. Methods: A preplanned subanalysis of the SYNAPSE-ICU study, a multicentre, prospective, international, observational cohort study, describing the ICP treatment, graded according to Therapy Intensity Level (TIL) scale, in patients with ABI during the first week of intensive care unit (ICU) admission. Results: 2320 patients were included in the analysis. The median age was 55 (I-III quartiles = 39-69) years, and 800 (34.5%) were female. During the first week from ICU admission, no-basic TIL was used in 382 (16.5%) patients, mild-moderate in 1643 (70.8%), and extreme in 295 cases (eTIL, 12.7%). Patients who received eTIL were younger (median age 49 (I-III quartiles = 35-62) vs 56 (40-69) years, p

Microsurgical aneurysm clipping under general anesthesia is considered a definitive procedure for the obliteration of unruptured and ruptured aneurysms. Aneurysm clipping can present with postoperative neurological complications, which can be missed under general anesthesia even with intraoperative neurophysiological monitoring. Real-time monitoring with awake patients can help prevent and treat these complications very early. The anesthesiologist has a vital role in awake aneurysm surgery from providing adequate surgical conditions to patient satisfaction and managing intraoperative complications. We report the first-hand experience as a neuroanesthesiology team managing awake craniotomy and aneurysm clipping.

Percutaneous nephrolithotomy and placement of nephrostomy tube are performed for renal stones2 cm in diameter. Attempts have been made to infiltrate local anesthetics with or without adjuvants into the surgical site to reduce pain. We hypothesized that there would be a significant prolongation of the analgesic effect of local anesthetic instillation along the nephrostomy tube due to the adjuvant dexamethasone.After ethical approval and Clinical Trials Registry - India registration (CTRI/2020/03/024332), 64 American Society of Anesthesiologists classification 1 and 2 adult patients were enrolled in this randomized double-blinded prospective study divided into Group R-received 20 mL 0.2% Ropivacaine and Group R + D-received 20 mL 0.2% Ropivacaine with dexamethasone 8 mg, injected through a multi-lumen wound infiltration catheter.The demographic profile of patients was similar in both groups. The mean duration of analgesia was longer in Group R + D (21.3 ± 2.1 hrs) versus Group R (10 ± 1.9 hrs, P = 0.001). The mean numeric rating scale scores of Group R + D were significantly lower at all time intervals (P = 0.001). Also, the cumulative dose of ropivacaine and the total use of fentanyl postoperatively in Group R was much higher (70 ± 10.4 vs 56 ± 8.9 μg, P = 0.02). The C-reactive protein levels were significantly lower in Group R + D (13.8 ± 1.5 vs 23.1 ± 1.2 mg/L, P = 0.001 and 16.5 ± 1.3 vs 28.5 ± 1.7 mg/L, P = 0.001, at 24 and 48 hrs, respectively).We conclude that dexamethasone can be used as a suitable adjuvant to intermittent local anesthetic infiltration after percutaneous nephrolithotomy with a nephrostomy tube for the prolongation of analgesia.

Coffee is the most popular beverages consumed all over the world. Coffee arabica belongs to the family Rubiaceae. The adventure of Indian espresso started on a modest note, with planting of 'Seven seeds' of 'Mocha' during 1600 AD. Espresso development requires a lot of modest and gifted work for different activities including planting, relocating, pruning, culling, drying, reviewing and pressing of espresso. Espresso in India is become under a shelter of thick normal shade in biologically touchy districts of the Western and Eastern Ghats. This is one of the 25 biodiversity hotspots of the world. India is the solitary nation on the planet where the whole espresso development is developed under shade, hand-picked and sun dried. Tamil Nadu is the third biggest maker where India's 6 percent of the espresso is created. India is the third-biggest maker and exporter of espresso in Asia, and the 6th biggest maker and fifthbiggest exporter of espresso on the planet. How coffee is processed plays a tremendous role in determining the final taste, and choosing a particular processing method

Background and objectives Inadvertent perioperative hypothermia is expected in the elderly during central neuraxial anesthesia. We aimed to compare the incidence of intraoperative hypothermia (36-degree celsius) between preoperative forced-air warming for 30 minutes and non-warming groups. Also, we compared the time to develop hypothermia, perioperative shivering, duration of intraoperative active warming, metabolic acidosis, surgical site infections, coagulation derangements, and post-anesthesia care unit (PACU) stay. Material and methodology A total of 100 American Society of Anesthesiologists (ASA) I-III (Age60 years) patients scheduled to undergo femur fracture surgeries under central neuraxial anesthesia were enrolled in this single-blinded prospective randomized study. They were randomly allocated into Group A (active forced-air warming for 30 minutes in the preoperative period) and Group B (without forced-air warming). Then, patients were transferred to the operation theatre, where central neuraxial anesthesia was administered for surgery. An infrared tympanic membrane thermometer measured the core body temperature during the different study points. Results The intraoperative hypothermia incidences were 26.0% and 68.0% in groups A and B, respectively. The mean time for developing hypothermia was found to be 143.08 ± 26.26 min and 25.88 ± 9.25 min in groups A and B, respectively. The mean duration of intraoperative active warming was observed to be 15.6 minutes and 103.6 minutes in groups A and B, respectively. The shivering and surgical site infection (SSI) grades were lower in group A. Conclusion A preoperative forced-air warming strategy for 30 minutes helps in reducing the incidence of intraoperative hypothermia and shivering in elderly patients undergoing femur fracture surgeries under central neuraxial anesthesia.

Background Acromegaly patients have a very high incidence of difficult endotracheal intubation. The Modified Mallampatti grading (MMPG) in the sitting position is a common test performed preoperatively to predict difficult intubation. It has been suggested that supine MMPG is possibly a better predictor of difficult tracheal intubation (DTI) rather than the sitting MMPG in normal individuals. Objective We wanted to determine if the supine MMPG had a better diagnostic accuracy than the sitting MMPG in predicting DTI in acromegaly patients. Methods This was a single-centre prospective observational study conducted in 70 adult acromegaly patients undergoing pituitary adenoma surgery requiring general anaesthesia and endotracheal intubation. MMPG in the sitting position was recorded during the pre-anaesthesia consultation. An independent observer recorded the MMPG in the supine position and the ease of intubation prior to surgery. The diagnostic performance of the MMPG for the prediction of DTI was evaluated in the sitting and supine positions through the area under the receiver operating characteristic (ROC) curve. The Naguib score was also calculated and its ability to predict DTI was tested. Results Thirty-five patients (50%) out of a total of 70 patients had difficult tracheal intubation. The area under the ROC curve for MMPG in supine position 0.708 (0.587–0.810) was greater than that for the MMPG in the sitting position 0.616 (0.492–0.729) ; p = 0.0146∗). Conclusion MMPG performed in the supine position was possibly a superior predictor of difficult tracheal intubation in adult acromegaly patients compared with MMPG performed in the sitting position.

Stellate ganglion block (SGB) causes blockage of sympathetic nerve activity, which may lead to intracerebral vessel dilatation and relieve cerebral vasospasm in patients of aneurysmal subarachnoid hemorrhage (aSAH).The aim of this study was to evaluate the efficacy and safety of SGB to relieve cerebral vasospasm on clinicoradiological parameters.We prospectively included 20 patients with clinical and angiographic evidence of vasospasm post aneurysmal clipping. Cerebral blood flow velocity and Lindegaard ratio were assessed using transcranial Doppler (TCD). Location of vasospasm, vessel diameter, vasospasm severity, parenchymal filling time, and venous sinus filling time were assessed on digital subtraction angiography (DSA). Patients received ultrasound-guided SGB with 10 mL of 0.5% bupivacaine on the ipsilateral side of the vasospasm. After 30 minutes, the neurological status, TCD, and DSA parameters were reevaluated.After SGB, there was statistically significant reduction in the middle cerebral artery (MCA) peak systolic velocity (P = 0.005), mean flow velocity (P = 0.025), and Lindegaard ratio (P = 0.022) on TCD. We observed significant dilatation in the mean vessel diameter measured at the mid-M1 segment of MCA (P = 0.003) and mid-A1 segment of ACA (P = 0.002) on DSA. The mean parenchymal filling time and mean venous sinus filling time decreased nonsignificantly after SGB (P = 0.163/0.104). Neurological improvement was observed in five (25%) patients.SGB has positive clinicoradiological influence in the management of cerebral vasospasm of large vessels. However, its effect on cerebral microvasculature is limited and needs a larger database for further analysis.

Study Design: This was a prospective, randomized, and double-blind study. Purpose: Thoraco-lumbar spine surgery is associated with severe postoperative pain and can cause chronic pain. We aimed to compare the impact of epidural ropivacaine with and without dexmedetomidine on postoperative analgesia after thoracolumbar spine instrumentation wherein an epidural catheter was placed by the surgeon intraoperatively. Overview of Literature: Very few studies have reported the use of epidural dexmedetomidine in spine surgeries. When used via the epidural route, dexmedetomidine is safe and efficacious and is associated with reduced rescue analgesia consumption, increased duration of analgesia, reduced pain scores, but not with major hemodynamic adverse effects. Methods: Total 60 American Society of Anesthesiologists I–III adult patients aged 18–65 years who were scheduled to undergo thoraco-lumbar spine instrumentation were randomly allocated into group RD (epidural ropivacaine+dexmedetomidine) or group R (epidural ropivacaine plus saline). We aimed to compare the total rescue analgesic consumption on postoperative day 0, 1, and 2. Moreover, we studied the time to first rescue analgesia with visual analogue scale score

Background: The maintenance of hemodynamic stability is of pivotal importance in aneurysm surgeries. While administering anesthesia in these patients, the fluctuations in blood pressure may directly affect transmural pressure, thereby precipitating rupture of aneurysm and various other associated complications. We aimed to compare the effects of ketofol with propofol alone when used as an induction and maintenance anesthetic agent during surgical clipping of intracranial aneurysms. Materials and Methods: Forty adult, good-grade aneurysmal subarachnoid hemorrhage patients posted for aneurysm neck clipping were included in the study. The patients were randomized into two groups. One group received a combination of ketamine and propofol (1:5 ratio) and the other group received propofol for induction and maintenance of anesthesia. Intraoperative hemodynamic stability, intraventricular pressure, and quality of brain relaxation were studied in both the groups. Results: The patients were comparable with respect to demographic profile, Hunt and Hess grade, world federation of neurological surgeons (WFNS) grade, Fisher grade, duration of anesthesia, duration of surgery, optic nerve sheath diameter, and baseline hemoglobin. Intraoperative hemodynamics were better maintained in the ketofol group during induction, with only 15% of patients having >20% fall in mean arterial pressure (from baseline) intraoperatively, compared to 45% of patients receiving propofol alone (P = 0.038). The mean intraventricular pressure values in both the groups were in the normal range and the quality of brain relaxation was similar, with no significant difference (P > 0.05). Conclusion: Ketofol combination (1:5) as compared to propofol alone provides better hemodynamic stability on induction as well as maintenance anesthesia without causing an increase in intracranial pressure. Effect of ketofol on cerebral oxygenation and quality of emergence need to be evaluated further by larger multicentric, randomized control trials.

Background: Traumatic brain injury (TBI) induces major insult to the normal cerebral physiology. The anesthetic agents may infrequently produce deleterious effects and further aggravate damage to the injured brain. This study was conducted to evaluate the effects of propofol and sevoflurane on cerebral oxygenation, brain relaxation, systemic hemodynamic parameters and levels of interleukin-6 (IL-6) in patients with severe TBI undergoing decompressive craniectomy. Methods: A prospective randomized comparative study was conducted on 42 patients undergoing surgery for severe TBI. Patients were randomized into two groups, Group P received propofol and Group S received sevoflurane for maintenance of anesthesia. All patients were induced with fentanyl, propofol, and vecuronium. The effect of these agents on cerebral oxygenation was assessed by jugular venous oxygen saturation (SjVO2). Hemodynamic changes and quality of intraoperative brain relaxation were also assessed. The serum levels of IL-6 were quantitated using enzyme-linked immunosorbent assay technique. Results: SjVO2 values were comparable and mean arterial pressure (MAP) was found to be significantly lower in Group P as compared to those in Group S (P < 0.05). Brain relaxation scores were comparable between the groups. The level of IL-6 decreased significantly at the end of surgery compared to baseline in patients receiving sevoflurane (P = 0.040). Conclusions: Cerebral oxygenation measured by SjVO2 was comparable when anesthesia was maintained with propofol or sevoflurane. However, significant reduction in MAP by propofol needs attention in patients with severe TBI. The decrease in IL-6 level reflects anti-inflammatory effect and probable neuroprotective potential of propofol and sevoflurane.

Studies have evaluated the effects of volatile and intravenous anesthetic agents on the cerebral vasculature with inconsistent results. We used digital subtraction angiography to compare the effects of propofol and sevoflurane on the luminal diameter of cerebral vessels and on cerebral transit time in patients with aneurysmal subarachnoid hemorrhage (aSAH).This prospective preliminary study included adult patients with good-grade aSAH scheduled for endovascular coil embolization; patients were randomized to receive propofol or sevoflurane anesthesia during endovascular coiling. The primary outcome was the luminal diameter of 7 cerebral vessel segments measured on the diseased and nondiseased sides of the brain at 3 time points: awake, postinduction of anesthesia, and postcoiling. Cerebral transit time was also measured as a surrogate for cerebral blood flow.Eighteen patients were included in the analysis (9 per group). Baseline and intraoperative parameters were similar between the groups. Propofol increased the diameter of 1 vessel segment at postinduction and postcoiling on the diseased side and in 1 segment at postcoiling on the nondiseased side of the brain (P0.05). Sevoflurane increased vessel diameter in 3 segments at postinduction and in 2 segments at postcoiling on the diseased side, and in 4 segments at postcoiling on the nondiseased side (P0.05). Cerebral transit time did not change compared with baseline awake state in either group and was not different between the groups.Sevoflurane has cerebral vasodilating properties compared with propofol in patients with good-grade aSAH. However, sevoflurane affects cerebral transit time comparably to propofol.

Background: The effects of ketofol (a combination of ketamine and propofol) on systemic hemodynamics and requirement of opioids/Propofol have already been studied and published. However, there is paucity in the literature on the effects of ketofol on cerebral oxygenation. This study aims to compare the effects of ketofol (ketamine + propofol [1:5]) with propofol on cerebral oxygenation using jugular venous oxygen saturation (SjVO2), in patients undergoing surgical clipping of intracranial aneurysms. Materials and Methods: A total of 40 World Federation of Neurosurgeons I and II patients were randomized into ketofol (n = 20) and propofol (n = 20) groups. Postinduction, SjVO2 catheter was inserted, and anesthesia was maintained with propofol and fentanyl in the propofol group and ketofol and fentanyl in the ketofol group. Jugular venous oxygen saturation (SjVO2) was obtained at baseline, 1 h and 2 h intraoperatively, and at 6 h after the surgery. Intraoperative hemodynamics and brain relaxation scores were also noted. Results: Entire SjVO2 values in both groups were within the normal limits. Higher SjVO2 values were observed in ketofol group compared to propofol at 1 and 2 h after starting of the drug and at 6 h after surgery (P < 0.05). In propofol group, a significant fall in SjVO2 was recorded at 2 h after beginning the drug as compared to the baseline (P = 0.001). More than 20% fall in mean arterial pressure (MAP) compared to baseline MAP was noted in 75% of patients in propofol group and 15% of patients in ketofol group (P = 0.002). In propofol group, 55% of patients required rescue drug phenylephrine to treat hypotension, whereas only 15% of patients required it in ketofol group (P = 0.02). Fentanyl requirement in ketofol group was less as compared to the propofol group (P = 0.022). Brain relaxation scores were comparable in both the study groups (P = 0.887). Conclusion: Maintenance of anesthesia with ketofol provides better cerebral oxygenation and hemodynamic stability compared to propofol in neurosurgical patients.

To compare the efficacy of CoolSense and EMLA cream on pain reduction during intravenous cannulation in the pediatric population.A total of 140 American Society of Anesthesiologist I/II children of 6-12 y requiring intravenous cannulation before induction of anesthesia were randomized into two groups of 70 each. Before intravenous cannulation, group I received CoolSense pretreatment while group II received EMLA cream pretreatment. The primary outcome was to assess the efficacy of CoolSense and EMLA cream on pain reduction during intravenous cannulation. The secondary outcomes included the anxiety level of children, successful first attempt at cannulation, technical difficulties faced, adverse reactions, and parents' satisfaction score.There was a significant reduction in pain scores during intravenous cannulation in the CoolSense group compared to the EMLA cream group (mean pain score 7.14 ± 4.322 versus 29.32 ± 8.95, p value 0.001). Comparison of pre- and postprocedural anxiety levels showed a decrease in the anxiety level in the CoolSense group (p value = 0.003) as compared to the EMLA group. The duration of application of CoolSense was significantly less than EMLA cream.CoolSense was more efficacious in reducing the pain of intravenous cannulation than the EMLA cream. In the pediatric population, CoolSense appears to be a simple and rapid means of providing adequate analgesia for venous cannulation.

Background: This is a prospective observational study to evaluate the changes in middle cerebral artery flow velocities and cerebral perfusion pressure in the various positions used for posterior cranial fossa surgery and to correlate these changes with postoperative recovery characteristics and complications. Methods: Sixty patients were included in the study – 33 patients with CPA tumors were placed in the supine with head tilt position and the rest 27 with tumors in other locations of posterior fossa were placed in the prone position. The primary aim was to study the changes in middle cerebral artery blood flow velocity related to various positions of the patients used during posterior fossa surgery. The secondary aim was to compare the changes in pulsatility index, resistance index, and effective cerebral perfusion pressure in different position and to correlate these findings with postoperative recovery and the complications associated with these positions. Results: The systolic and mean flow velocities were higher in the supine with head tilt group than the prone group after positioning and post repositioning, but these values were within normal limits, and the changes with positioning from baseline were comparable between the groups. Furthermore, these changes did not affect the effective cerebral perfusion pressure or the outcomes of the patients. Conclusion: The current results do not determine whether the supine with head tilt position is better than the prone position during posterior fossa surgery.

Background: The indications for intracranial pressure (ICP) monitoring in patients with acute brain injury and the effects of ICP on patients’ outcomes are uncertain. The aims of this study were to describe current ICP monitoring practises for patients with acute brain injury at centres around the world and to assess variations in indications for ICP monitoring and interventions, and their association with long-term patient outcomes. Methods: We did a prospective, observational cohort study at 146 intensive care units (ICUs) in 42 countries. We assessed for eligibility all patients aged 18 years or older who were admitted to the ICU with either acute brain injury due to primary haemorrhagic stroke (including intracranial haemorrhage or subarachnoid haemorrhage) or traumatic brain injury. We included patients with altered levels of consciousness at ICU admission or within the first 48 h after the brain injury, as defined by the Glasgow Coma Scale (GCS) eye response score of 1 (no eye opening) and a GCS motor response score of at least 5 (not obeying commands). Patients not admitted to the ICU or with other forms of acute brain injury were excluded from the study. Between-centre differences in use of ICP monitoring were quantified by using the median odds ratio (MOR). We used the therapy intensity level (TIL) to quantify practice variations in ICP interventions. Primary endpoints were 6 month mortality and 6 month Glasgow Outcome Scale Extended (GOSE) score. A propensity score method with inverse probability of treatment weighting was used to estimate the association between use of ICP monitoring and these 6 month outcomes, independently of measured baseline covariates. This study is registered with ClinicalTrial.gov, NCT03257904. Findings: Between March 15, 2018, and April 30, 2019, 4776 patients were assessed for eligibility and 2395 patients were included in the study, including 1287 (54%) with traumatic brain injury, 587 (25%) with intracranial haemorrhage, and 521 (22%) with subarachnoid haemorrhage. The median age of patients was 55 years (IQR 39–69) and 1567 (65%) patients were male. Considerable variability was recorded in the use of ICP monitoring across centres (MOR 4·5, 95% CI 3·8–4·9 between two randomly selected centres for patients with similar covariates). 6 month mortality was lower in patients who had ICP monitoring (441/1318 [34%]) than in those who were not monitored (517/1049 [49%]; p