Journal of Neurosurgical Anesthesiology Year in Review · 2019-11-05 · Posterior Fossa Craniotomy...

JournalofNeurosurgicalAnesthesiologyYearinReview

MartinSmithEditor-in-Chief

@JNeurosurgAnes

martin.smith@ucl.ac.uk

@ProfmartinJNA

https://journals.lww.com/jnsa/

Outline

• Journalupdates- newinitiatives

• Year-in-Review- journal clubstyle- presentationsby3authors

DrAmieHoefnagelDrPhillip VlisidesDrArnoleyAbcejo

• clinicalandlaboratoryinvestigations

• reviewarticles

• journalclub

• correspondence– researchletters:earlydatafrompilot/feasibility studies– correspondence totheeditor:commentaryonstudies published inJNA– correspondence toJNAreaders:clinicalobservations describing new

knowledge/clarify controversialissues – mustbenovelanddidactic

• invitededitorials– commentary:onco-published manuscripts– focus:shortstate-of–the-artreview

JournalofNeurosurgicalAnesthesiology publishesarticlesonallaspectsofneuroscienceinanesthesiologyandcriticalcare

• reviewarticles

• journalclub

• reviewarticles

• journalclub

• 5articlesperissue• freetoread

Editor’schoice

• accessible inacollection viaalinkonthehomepage• freetoreadinperpetuity

SNACCclinicalguidelines andconsensusstatements

Colorfigurescannowbeincludedinonlineversionofthemanuscriptatnocharge.

Colorfigures

SNACCTraineeEngagementCommitteewillproducepodcastsdiscussingJNAarticles

Podcasts

• notanexhaustivelist– topicalissues– breadthofthejournal– onesthatIliked

YearinReview

Journal of Neurosurgical Anesthesiology 2019; 31(1): 7-17

• cognitiveaidsandevidence-basedchecklistsarefrequentlyutilizedincomplexsituations

• notsimplyinstructionstocompleteatask- ensurethatallcontingenciesrelatedtothe

emergencyareconsideredandaccountedfor- taskathandiscompletedfully, despitepossible

distractions

• 11evidence-basedcriticaleventcognitiveaidsforneuroanaesthesiaemergencies

Standarddesignprocessfacilitatessampling

Quickreferenceguideforcliniciansfacinganeuroanesthesiaemergency

• ShobanaRajan• AdrianaMartin• VibhaMahendra• AmandaKnutson• JamieUejima• GuyKositratna

• MarkWeller• HuiYan• SanchitAhuja• CarylBailey• JohnBebawy

• ACGMEcompetency-basedassessments(milestones)forresidenteducationnotspecifictoneuroanesthesiology- interpretationnotstraightforward

• 12neuroanesthesiology-specificmilestonesin5majorACGMEdomainsarerecommended- patientcare(7milestones)- medicalknowledge(2milestones)- practice-basedlearningandimprovement(1milestone)- interpersonalandcommunication skills (2milestones)

• eachmilestonedescribedindetail,withclearoutlineofexpectationsatvariouslevelsoftraining

ExampleofamilestonePatientcare7:technicalskills: useandinterpretationofmonitoringandequipment

SNACCNeuroanesthesiologymilestonesprovideaframeworkforreviewingresidentperformance.Thetaskforcerecommendsthatthetargetshouldbetoaccomplishlevel4orhighermilestonesbytheendofresidencytraining.

• promising preclinicaltherapeuticstrategieslargelyfailedtotranslateintoimprovedoutcomesinRCTs

• observational studies

• datascience

• ‘alive’inonecountry‘dead’ inanother

• only outstandingissue inthetransatlanticdivide inthedeterminationofbraindeath

GiventhecostandlogisticburdensofconductingRCTS,…….prioritizewhichresearchmethodsareimportantfor

answeringthemyriadofresearchquestionsinsevereTBI.

Perceived divide between whole brain and brainstem death more to do with emotive concepts rather than hard neurobiological facts - represents a failure to accept the centrality of the brainstem in defining life or death.

Delirium:26% (Training) vs. 17% (Control);P=0.507

HospitalLOS:6.8d (Training)vs.6.4d (Control);P=0.696

Declined Participation

Non-Adherence

Withdrawals

Training: 5/30 (17%)

Control: 0/31 (0%)

P=0.024

Conclusions

• OptimizeStudyDesign

• ConsiderEffectSize

• InterimAnalysis,StoppageRules

• impossibletoidentifyasingleunderlyingcauseforpostoperativedelirium- pharmacologicaltreatmenteitherempirical(e.g.antibiotics) orsymptomoriented(e.g.anti-

psychotics)- primarypreventionusingmulti-component non-pharmacological strategiesasmarterapproach

• cognitivereserveintheperioperativesetting- surgery/anaesthesiaarethedamaging‘hit- postoperativedelirium themanifestationof

cognitiveimpairment

Cancognitivereservebeincreasedbybraintrainingand,inturn,preventperioperativeneurocognitive

disorders suchasdelirium?

Journal of Neurosurgical Anesthesiology 2019; May 22, Epub: doi: 10.1097/ANA.0000000000000609

• multipledisparatefactorscontributetoICPelevation- interpretationnotstraightforward

• evidencefordistinctconceptualsubsetsofintracranialhypertensionwithsupportivedatafrompublishedliteratureandinvasiveandnon-invasiveneuromonitoringdata

• 3majorpathophysiologicalsubsets- increasedcerebralbloodvolume- masses andedema- hydrocephalus

Reductioninbloodpressureproducesvasodilationwithincreasedcerebralbloodvolumeontheuninjuredsidewithacorresponding increaseinICP.

Dysautoregulationontheinjured sideandintactautoregulationonthecontralateral(uninjured) side

TheinjuryandassociatededemaincreaseICPsomewhatwithassociateddecrementinintracranialcompliance.

Increaseinbloodpressurecausesvasoconstrictionontheuninjuredside,butdysregulatedhyperemiaandincreasedcerebralbloodvolumeontheinjuredside.

SimilarelevationsinICPareproducedbydistinctly differentphysiological conditions

Journal of Neurosurgical Anesthesiology 2019; May 22, Epub: doi: 10.1097/ANA.0000000000000609

• narrativereviewoftheevidencefortheperioperativemanagementofDOACsinintracranialneurosurgery

• increaseduseofdirectactinganticoagulants- predictablepharmacokinetics- fewerdruginteractions- lowerrisk ofbleeding

• limitedevidencebase- currentguidelines extrapolatedfrompharmacologicaldataandclinicalstudies thatexcluded

neurosurgicalpatients

Journal of Neurosurgical Anesthesiology 2019; Jul 12 Epub: doi: 10.1097/ANA.0000000000000629

DOACsinelectiveintracranialsurgery

• timingofDOACinterruption

• bridgingtherapyandthrombosisrisk

• restartinganticoagulation

DOACsinemergencyintracranialsurgery

• establishtimingoflastDOACdose/checkrenalfunction

• considernatureandurgencyofsurgery

• non-specificapproachestoreversal,e.g.PCC

• specificDOACantidotes

Interdisciplinaryco-operationbetweenneuroanesthesiologist,neurosurgeonandhaematologistessentialforoptimal

patientoutcomes.

Journal of Neurosurgical Anesthesiology 2018; 31(4) : 413-421

• severeVAEisamajorconcernoftheseatedposition forneurosurgery

• rarely,severeVAEcancauseenoughgasexchangeimpairment,hemodynamiccollapse,orpersistentneurologicdeficitsnecessitatingemergentreturntothesupineposition

• wecharacterizedthesecasesof“extremeVAE,”studiedtheiroutcomes,andstudiedtheirintraoperativecourseandmanagement

Methods

• Retrospectivecaseseriesofseatedneurosurgicalprocedures• (404craniotomies,324DBSimplantations)

• DefinedExtremeVAE asaclinicallydiagnosedVAEthatnecessitatedemergentpositionfromtheseatedtoaflatposition

• 8CasesofExtremeVAEIdentified• 6CraniotomiesforPosteriorFossaTumorresection• 2DBSplacements

• Patientcomorbidities,intraoperativevariables/events/management,hemodynamic/neurologic/dispositionoutcomeswererecorded

Results

TherewerenoextremeVAEcasesinvolvingtortocollisdenervationsorcervicalspineprocedures.

Therewere6extremeVAEduringposteriorfossasurgeries,withatotalincidenceof1.5%.And2extremeVAEduringDBSplacement,0.6% incidence.

Inonepatient(C),careoflife-sustainingmeasureswaswithdrawnduetoinabilitytocontrolbleedingoffriablecerebralvasculature.

Therewere2instancesoftransientST-segmentchangesandventriculararrhythmiainpatientswithairappearingintheaorticroot,andinbothinstancesthisrapidlyresolved.

NonewneurologicaldeficitswereattributedtotheVAEandemergentsupinepositioninginanyofthepatients.

Nonewpostoperativecardiovascularorcardio-electrophysiologicderangementswereattributedanyVAE.

PatientA PatientB PatientG

Δ EtCO2MAP

* Supine

PosteriorFossaCraniotomyinBMI53patient

VAEassociatedwithsevere reductioninEtCO2andMAP.Intra-aorticairnoted.Sustainedectopyandventriculartachycardia.

30-40mLoffrothybloodaspirated(blackline).

Post-op:Unchangedneuroexam.Notropinemia,nohemodynamicinstability.

PosteriorFossaCraniotomywithoutCVCline

VAE inleftandrightcardiacchambers.Hyopotension,NewS-Tchanges.

Emergent leftlateral decubituspositioningwithalmostinstantaneousresolutionofhemodynamiccompromise.

DBSplacementinseatedposition

Patientbegan tocoughafterburrholewithsignificantreductioninEtCO2vianasalcannula.Severe chestpaindevelops.

SupinepositionwithgradualresolutionofEtCO2tobaseline.

Results (cont’d)Journal of Neurosurgical Anesthesiology 2018; 31(4) : 413-421

• extremeVAE(severeVAEnecessitatingemergentreturntosupineposition) isarareevent

• centralvenouscatheterizationandaspirationduring VAEplayednodemonstrableroleinpatientoutcomeswithnoappreciableairaspiratedinmajorityofcases

• itappearsthatthehemodynamic andneurologic sequelae,iftreatedrapidly,aretransient andresolveshortlyafterpositionchange

ConclusionsJournal of Neurosurgical Anesthesiology 2018; 31(4) : 413-421

• prospectivemulticenterstudy including36physicians(18left- &18right-handed)and7200patients

• patientsrandomizedtohaveLPsperformedbyleft- andrighthandedphysicians- eachphysician performed200LPsduringwhichthelateralityofrecumbentposition wasdecidedaftera

second randomization- successful LPdefinedbyfreeflowofCSFatfirstattempt

• right-handedphysicianshadhigherLPsuccessratewithpatients inthe leftlateralposition(1595/1800vs.1408/1800;P=0.006)

• left-handedphysicianshadhigherLPsuccessratewithpatientsinrightlateralposition(1424/1800vs.1593/1800;P=0.001)

• patientfactors(age,sex,height,weight)didnotaffectLPsuccessrate

Multivariable analysis of factors affecting success of LP

Physicians handedness andpatientlateralityaffectsthesuccess oflumbar.Right-handedphysicians haveagreaterchanceofperformingsuccessful LPswhenpatientsareintheleftLRP,andviceversa.

• singlecentrestudyof126patientshavingendovascularthrombectomy- 116(92%)receivedconscious sedation- guideline recommendsystolicBPbetween140and180mmHg

• systolicBP<140mmHgin30.2%and>180mmHgin14.3%ofpatientsonarrivalinneuroradiologysuite

• haemodynamicinstabilitywascommon- 77.8%hadatleastoneepisodeofhypotension (SBP<140mmHg)- 19.1%hadatleastoneepisodeofhypertension (SBP>180mmHg)- mostself-limiting

• haemodynamicinterventionrequiredin38.9%ofpatients- 15.1%forhypotension- 19.8%forhypertension

• hypotension- morecommon inpatientsreceivingsedation(80.2%vs.50%,p=0.043)- poorcontrol(SBP<140mmHgfor>15mindespite intervention)occurredin12.7%ofpatients- lowerbaselineBPassociatedwithahigherriskofintraproceduralhypotension

(OR,0.92;95%CI,0.89-0.96;P<0.001)

Thereisafrequentneedforhaemodynamic interventionduringendovascular thrombectomy,arguingfortheroutinepresenceofanaesthetists

• synopsisofinnovativeresearch,recurringthemesandnovelexperimentalfindings- intracranialsurgery- spine surgery- stroke- traumaticbraininjury- subarachnoid haemorrhage- neuromonitoring- anestheticneurotoxicity- perioperativecognitivedysfunction anddelirium

Comprehensivereviewofclinicalandbasicscienceinneuroanaesthesiaandcriticalcare,including162citations.

• 30,590anesthesiologistsand38,600surgeonsworkingintheUnitedStatesduring2017- 31journals categorizedunderAnesthesiology - medianImpactFactorof2.56- 200journals categorizedunderSurgery- medianImpactFactorof1.81.3

• adjustedfornumberofpractitioners,surgeonshadfivetimesmorejournalsthananesthesiologists,withanImpactFactordilutedby30%

• researchanditspublicationdrivenby- scientificendeavour- ambitionforstatus- answersratherthanquestions

• thereviewprocess- vastlymoreeffectivethanitappearstobe- integrityandcommitmentofreviewers- assessments basedonmanuscriptspresentedtoreviewers

• acceptanceofanabundanceofflawedmanuscripts- cleverrevisions ofpriorversions rejectedbytheirauthors’first-choicejournal- acceptedbyauthors’second, third,etc.choicejournal

…..upto90%ofmedicalresearchisseriouslyflawedbecausebiasinfavorofpreferredresults“isunavoidableandpeopleshouldtakethatforgrantedwhenthey…readotherscientists’work.JohnIoannidis

• centralclearinghouseformanuscriptreview- noevaluationofmanuscripts’ quality- trackedhistory, including allpriorversions, allreviewsofallpriorversions, andallprioreditorial

correspondence, foreverysubmission ofeachmanuscript forwardedtointendedjournal

• implications- coveringupdesign inadequacies in‘revisions’ becomesdifficult/impossible- likelyleadtoshrinkageofjournal portfolios- bigpay-offforscience

Imagine the rate of progress that would follow from reversing the ratio of good/bad science from 25/75 to 75/25!

547reviewsconductedby177reviewers

@JNeurosurgAnes

• JNAistheofficialjournalofSNACC– becomeareviewer– submitamanuscript– writeafocuseditorial– citeJNAmanuscriptsinyourwork– socialmedia

@JNeurosurgAnes

martin.smith@ucl.ac.uk

@ProfmartinJNA

Journal of Neurosurgical Anesthesiology Year in Review · 2019-11-05 · Posterior Fossa Craniotomy...

Documents

Modern Neurosurgical Giants 2011.ppt - … craniotomy- pituitary tumors yWith Foerster-Epppy g y yilepsy surgery in Germany yAcoustic neuromas- sitting position, intradural posterior

Awake Craniotomy: Role in Neurosurgical Management Christine Stewart University of Minnesota, MS4

Parietal Craniotomy

Professional Development: ETCO Monitoring reading.pdf6! CEPCP Spring 2011 ETCO2 Filter Advanced A/W ETCO2 Filter Mask Using the ETCO2 with an Advanced Airway This is the most typical

Deconstructing Post Craniotomy PainDeconstructing Post Craniotomy Pain Barbara Van de Wiele MD Clinical Professor, Vice Chair & Director of Neurosurgical Anesthesiology UCLA Department

Neurosurgical Research

Suboccipital Concentric Craniotomy as Variant for ... · The diagnosis of the neurosurgical lesions in the posterior fossa were 15 tumors (6 medulloblastomas, 4 pineal tumors, 3 pilocytic

Interhemispheric Craniotomyneurobicetre.com/wp-content/...Craniotomy-The-Neurosurgical-Atlas.pdf · This craniotomy is situated around the coronal suture (when using a frontal interhemispheric

Neurosurgical Forum

Kel. 16 Makalah Craniotomy

Follow Up Post Craniotomy

8862 Craniotomy Transducer 8863 Burr-Hole Transducer · 2020. 12. 17. · Craniotomy Transducer Type 8862 is designed for intraoperative neurosurgical imaging, as well as neonatal

6712 Craniotomy

Microbiology of the central nervous system · 2019-02-22 · • SDE is a medical emergency. Emergent neurosurgical evacuation of the empyema, either through craniotomy, craniectomy,

Supraorbital craniotomy

for Neurosurgical Patientsneurosurgery.ucla.edu/Workfiles/Site-Neurosurgery/Craniotomy-Brain-Tumor-SM.pdfDuring business hours, please call UCLA Neurosurgery: 310-825-5111. Ask to

End Tidal Carbon Dioxide (EtCO2

The Awake Craniotomy

CRANIOTOMY PACK-I

EtCO2 Linkedin