-
[show abstract]
[hide abstract]
ABSTRACT: The year 2012 marks the 40th anniversary of the Society of Neuroscience in Anesthesiology and Critical Care (SNACC). To celebrate this occasion, we provide a review, speculative synthesis, and commentary addressing research relevant to neurosurgical anesthesiology in 1973 and 1974-the early years of SNACC. We address topics such as effects of anesthetic drugs, neuroprotection, cerebral physiology, and monitoring as they relate to the perioperative care of neurosurgical patients or patients experiencing or at risk for neurological disorders. Our hypothesis is that a review of these publications will identify the foundations of research and practice concepts that persist until today and will also identify concepts that have dwindled or outright disappeared.
Journal of neurosurgical anesthesiology 10/2012; 24(4):300-11. · 2.41 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Mayo Clinic has been involved in an ongoing effort to prevent the diversion of controlled substances from the workplace and to rapidly identify and respond when such diversion is detected. These efforts have found that diversion of controlled substances is not uncommon and can result in substantial risk not only to the individual who is diverting the drugs but also to patients, co-workers, and employers. We believe that all health care facilities should have systems in place to deter controlled substance diversion and to promptly identify diversion and intervene when it is occurring. Such systems are multifaceted and require close cooperation between multiple stakeholders including, but not limited to, departments of pharmacy, safety and security, anesthesiology, nursing, legal counsel, and human resources. Ideally, there should be a broad-based appreciation of the dangers that diversion creates not only for patients but also for all employees of health care facilities, because diversion can occur at any point along a long supply chain. All health care workers must be vigilant for signs of possible diversion and must be aware of how to engage a preexisting group with expertise in investigating possible diversions. In addition, clear policies and procedures should be in place for dealing with such investigations and for managing the many possible outcomes of a confirmed diversion. This article provides an overview of the multiple types of risk that result from drug diversion from health care facilities. Further, we describe a system developed at Mayo Clinic for evaluating episodes of potential drug diversion and for taking action once diversion is confirmed.
Mayo Clinic Proceedings 07/2012; 87(7):674-82. · 5.70 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: With a focus on landmark investigations, common themes, and unique and innovative contributions to the literature, we provide a synopsis of the 2011 literature pertaining to general advances in neurosurgical procedures and perioperative care and anesthetic management of neurosurgical patients.
Journal of neurosurgical anesthesiology 04/2012; 24(2):85-112. · 2.41 Impact Factor
-
Anesthesiology 11/2011; 115(5):1135-7. · 5.36 Impact Factor
-
Mayo Clinic Proceedings 11/2011; 86(11):1038-41. · 5.70 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: We provide a summary of the 2010 literature pertinent to the care of neurosurgical patients and those requiring neurocritical care. In addition, we address topics in the basic neurosciences as they relate to neuroanesthesiology. This review incorporates studies not only from both neuroanesthesiology and general anesthesiology-focused journals, but also from neurology, neurosurgery, critical care, and internal medicine journals and includes articles published after January 1, 2010, through those available on-line by November 31, 2010. We will review the broad categories of general neuroanesthesiology, with particular emphasis on cerebral physiology and pharmacology, intracranial hemorrhage, carotid artery disease, spine surgery, traumatic brain injury, neuroprotection, and neurotoxicity. When selecting articles for inclusion in this review, we gave priority to those publications that had: (1) new or novel information, (2) clinical utility, (3) a study design possessing appropriate statistical power, and/or (4) meaningful, unambiguous conclusions.
Journal of neurosurgical anesthesiology 04/2011; 23(2):67-99. · 2.41 Impact Factor
-
Anesthesiology 02/2011; 114(4):729-31. · 5.36 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To address controversial issues surrounding the use of nitrous oxide as a component of anesthesia in neurosurgical and neurologically at-risk patients.
Nitrous oxide has been used as a component of general anesthesia for over 160 years and has contributed to countless apparently uneventful anesthetics in neurologically at-risk patients. Avoidance of nitrous oxide in specific circumstances, such as pre-existing pneumocephalus, during acute venous air embolism, and in patients with disorders of folate metabolism, is warranted. However, various controversies exist regarding the use of this drug in the general neurosurgical population. Specifically, some suggest a possible association between nitrous oxide and the postoperative development of tension pneumocephalus despite lack of data to support this notion. Additionally, data describing alterations of cerebral hemodynamics and metabolism and exacerbation of ischemic neurologic injury by nitrous oxide are inconsistent. Recent data derived from humans having cerebral aneurysm clipping failed to show any long-term adverse effect from the use of nitrous oxide on gross neurologic or cognitive function.
Except in a few specific circumstances, there exists no conclusive evidence to support the dogmatic avoidance of nitrous oxide in neurosurgical patients.
Current opinion in anaesthesiology 10/2010; 23(5):544-50.
-
William L Lanier
Anesthesiology 08/2010; 113(2):268-70. · 5.36 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Recent literature contains many reports of value to clinicians providing anesthetic or intensive care for neurosurgical patients or patients experiencing, or at risk for, neurological impairment. We will review many of these articles, focusing on those that address intracranial hemorrhage, intracranial procedures, carotid endarterectomy, spine surgery, and the determinants of outcome in patients with evolving or new-onset neurologic disease. Additionally, we will review articles addressing neurotoxicity, neuroprotection, and nervous system monitoring.
Journal of neurosurgical anesthesiology 04/2010; 22(2):86-109. · 2.41 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To characterize the safety of general anaesthesia, used to facilitate MRI in children with clinical hypotonia, and to determine whether this technique could be performed safely as an outpatient procedure.
All children (age <or=12 years) who underwent MRI with general anaesthesia as a part of their diagnostic work-up for hypotonia at Mayo Clinic, Rochester, Minnesota, USA, between 1 January 2000 and 31 December 2006, were identified. Demographics, medical history, anaesthetic details, postanaesthetic disposition and the disease state identified as the cause of hypotonia, if available, were recorded.
Thirty-seven children underwent 38 general anaesthetics. Age was 2.7 +/- 2.3 years (range, 8 days-9 years). A volatile anaesthetic was employed in 37 out of 38 instances and nitrous oxide was used in 31. Three children experienced minor intraprocedural adverse events, and three children experienced minor adverse events in the postanaesthesia recovery room. No child required an unanticipated hospital admission or was re-admitted following discharge due to adverse events. A specific causative disease process was eventually identified in 17 children and represented a diverse group of disorders; a final diagnosis was never obtained in the remaining 20 children.
Use of general anaesthesia to facilitate MRI in children with clinical hypotonia appears to be a well tolerated practice. No major peri-procedural adverse events were noted, and all minor adverse events were either easily treated or resolved spontaneously.
European Journal of Anaesthesiology 03/2010; 27(6):514-20. · 2.23 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Progressive airway compromise from neck hematoma and edema is a feared complication of carotid endarterectomy (CEA). Despite this, the relationship of airway management technique to patient outcome has not been systematically studied in this population. We report the rate of successful airway management using various techniques in post-CEA patients.
A 10-year retrospective analysis was conducted to identify patients requiring airway management for neck exploration within 72 hours after CEA at Mayo Clinic, Rochester, MN.
Three thousand two hundred twenty-five patients underwent CEA over a 10-year period at our institution. Forty-four (1.4%) required neck exploration for hematoma, and 42 of these required airway management immediately before neck exploration surgery. (The tracheal tube had not been removed after CEA in the remaining 2 patients.) The average interval between the completion of CEA and return to the operating room for hematoma evacuation was 6.0 +/- 6.0 hours (mean +/- SD; range, <1-32 hours). Fiberoptic airway management, performed before the induction of anesthesia, was successful in 15 of 20 patients (75%) and, in patients in whom fiberoptic tracheal intubation failed, direct laryngoscopy (DL) was successful in all 5 (3 before and 2 after the induction of general anesthesia). In the remaining 22 patients, DL was used as the initial management technique without a trial of fiberoptic intubation. DL was successful in 5 of 7 patients (71%) when performed before induction of general anesthesia and was successful in 13 of 15 patients (87%) when performed after induction of general anesthesia. Hematoma decompression facilitated DL in 3 of 4 failures of DL; tracheostomy was performed in the remaining patient. An arterial site of bleeding was subsequently identified in 36% of patients in whom no difficulty was encountered during laryngoscopy for hematoma evacuation versus 6% in whom difficulty was noted (P = 0.03). In 36 of 44 patients (82%), the tracheal tube was removed within 24 hours of surgery for neck exploration. No adverse events related to airway management were noted. There were no deaths at 2 weeks after hematoma evacuation.
Multiple techniques resulted in successful airway control both before and after the induction of general anesthesia. Tracheal intubation was accomplished with both fiberoptic visualization and DL. In instances of poor direct visualization of the glottis, decompression of the airway by opening of the surgical incision may facilitate intubation of the trachea.
Anesthesia and analgesia 12/2009; 110(2):588-93. · 3.08 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Our goal was to test the hypothesis that-given the barbiturates' novel ability to reduce brain temperature-the high prevalence of reports describing cerebral protection by barbiturates in animal models are, in part, the result of inadvertent cerebral hypothermia. We reviewed all published reports evaluating barbiturate protection in animal models of focal cerebral ischemia where functional or anatomic endpoints were assessed. Presence or absence of protection, and additionally the year of publication, were tabulated. Temperature monitoring was categorized as: (a) not monitored, (b) inadequately monitored (ie, temperature monitored, but not at appropriate sites or times), or (c) adequately monitored (brain or cranial temperature monitored at appropriate times, with or without core temperature). Twenty eight references published between 1974 and 2008 described 57 separate protocols. Cerebral protection by barbiturates was reported in 35 of 57 (61%) protocols. Temperature was not monitored in 10 protocols (18%), inadequately monitored in 32 (56%), and adequately monitored in 15 (26%). Although the majority (32 of 57; 56%) of the protocols were published before December 1987, none of these properly monitored temperature. In the protocols published in 1988 or later, 15 of 25 (60%) had proper temperature monitoring and 9 of the 15 (60%) reported protection by the barbiturates. Very few (ie, 15 of 57; 26%) protocols were capable of distinguishing between direct cerebral protection by the barbiturates and an artifactual, hypothermia-related, effect. However, among those protocols having proper temperature monitoring, there remained considerable evidence of barbiturate protection.
Journal of neurosurgical anesthesiology 10/2009; 21(4):307-17. · 2.41 Impact Factor
-
Mayo Clinic Proceedings 08/2009; 84(7):572-5. · 5.70 Impact Factor
-
Anesthesiology 07/2009; 110(6):1426-8. · 5.36 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Phosphorylated fructose compounds have been reported to lessen neuronal injury in in vitro models of hypoxia and in vivo models of ischemia. Although a variety of mechanisms have been proposed to account for this finding, it is unknown if intracellular uptake and incorporation of these compounds into the glycolytic pathway contribute to the benefit. We evaluated phosphorylated fructose administration in an adult rat model of transient, near-complete cerebral ischemia to determine its impact on brain metabolism before, during, and after ischemia. Fifty-four pentobarbital anesthetized rats were randomly assigned to receive IV infusions of either fructose-1,6-bisphosphate, fructose-2,6-bisphosphate, or 0.9% saline. After 2 hours of infusion, 18 rats (6/treatment group) were subjected to brain harvesting before any ischemia, 18 additional rats had brain harvesting at the completion of 10 minutes of forebrain ischemia (2-vessel occlusion plus induced hypotension), and 18 rats had harvesting after ischemia and 15 minutes of reperfusion. Cortical brain samples were analyzed for ATP, ADP, AMP, phosphocreatine, glucose, and glycogen. When compared with placebo, neither phosphorylated fructose compound altered preischemic, intraischemic, or postischemic concentrations of brain high-energy phosphates, glucose, glycogen, or lactate, nor did they influence the intraischemic metabolism of endogenous brain glucose or glycogen. On the basis of these results, we conclude that mechanisms other than augmented carbohydrate metabolism are responsible for previous reports of neuronal protection by the bisphosphonates.
Journal of neurosurgical anesthesiology 02/2009; 21(1):31-9. · 2.41 Impact Factor
-
Anesthesiology 12/2008; 109(5):762-4. · 5.36 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Reconstitution of a watertight dural closure at the conclusion of most neurosurgical operations is a very important step to prevent cerebrospinal fluid leak, encephalocele formation, or infection. If sufficient native dura is not available to accomplish this goal, a dural substitute is required.
We have developed a system of single-person fascia lata harvest that is fast, safe, and easily mastered. Through a standard incision along the iliotibial band, the fascia lata is dissected from the underlying muscle, and with the use of a simple system of stainless steel plates, a tray, and 2 nonperforating towel clips, a large volume of fascia is harvested.
We have used this technique on 23 patients in the past 12 months, with good results. We have had fewer postoperative pain complaints and less seroma formation compared with the standard technique.
This technique requires only simple instrumentation and, because the harvesting is done by 1 person, it can proceed independently of the main operation, thus eliminating any added operative time and inconvenience. It reliably produces a large volume of high-quality fascia that can be used in a variety of neurosurgical procedures.
Neurosurgery 11/2008; 63(4 Suppl 2):359-61; discussion 361. · 2.79 Impact Factor
-
Diana G McGregor, William L Lanier,
Jeffrey J Pasternak,
Deborah A Rusy,
Kirk Hogan,
Satwant Samra,
Bradley Hindman,
Michael M Todd,
Darrell R Schroeder,
Emine Ozgur Bayman,
William Clarke,
James Torner,
Julie Weeks
[show abstract]
[hide abstract]
ABSTRACT: Laboratory studies suggest that nitrous oxide augments brain injury after ischemia or hypoxia. The authors examined the relation between nitrous oxide use and outcomes using data from the Intraoperative Hypothermia for Aneurysm Surgery Trial.
The Intraoperative Hypothermia for Aneurysm Surgery Trial was a prospective randomized study of the impact of intraoperative hypothermia (temperature = 33 degrees C) versus normothermia (temperature = 36.5 degrees C) in patients with aneurysmal subarachnoid hemorrhage undergoing surgical clipping. Anesthesia was dictated by a limited-options protocol with the use of nitrous oxide determined by individual anesthesiologists. All patients were assessed daily for 14 days after surgery or until hospital discharge. Neurologic and neuropsychological testing were conducted at 3 months after surgery. Outcome data were analyzed via both univariate tests and multivariate logistic regression analysis correcting for factors thought to influence outcome. An odds ratio (OR) greater than 1.0 denotes a worse outcome in patients receiving nitrous oxide.
Outcome data were available for 1,000 patients, of which 373 received nitrous oxide. There was no difference between groups in the development of delayed ischemic neurologic deficit. At 3 months after surgery, there were no significant differences between groups in any outcome variable: Glasgow Outcome Score (OR, 0.84; 95% confidence interval [CI], 0.63-1.14; P = 0.268), National Institutes of Health Stroke Scale (OR, 1.29; 95% CI, 0.96-1.73; P = 0.087), Rankin Disability Score (OR, 0.84; 95% CI, 0.61-1.15; P = 0.284), Barthel Activities of Daily Living Index (OR, 1.01; 95% CI, 0.68-1.51; P = 0.961), or neuropsychological testing (OR, 1.26; 95% CI, 0.85-1.87; P = 0.252).
In a population of patients at risk for ischemic brain injury, nitrous oxide use had no overall beneficial or detrimental impact on neurologic or neuropsychological outcomes.
Anesthesiology 05/2008; 108(4):568-79. · 5.36 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The 2007 literature pertaining to perioperative care of neurosurgical patients contains a wealth of articles. In this review, we provide a synopsis of common themes and unique contributions that are relevant to the care of patients with neurologic disorders who require either neurosurgical intervention or care in a neurosurgical-based intensive care unit.
Journal of neurosurgical anesthesiology 05/2008; 20(2):78-104. · 2.41 Impact Factor
