Journal of Neurosurgical Anesthesiology Year in Review · 2019-11-05 · Posterior Fossa Craniotomy in BMI 53 patient VAE associated with severe reduction in EtCO2 and MAP. Intra

JournalofNeurosurgicalAnesthesiologyYearinReview

MartinSmithEditor-in-Chief

@JNeurosurgAnes

[email protected]

@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

[email protected]

@ProfmartinJNA


Documents

Journal of Neurosurgical Anesthesiology Year in Review · 2019-11-05 · Posterior Fossa Craniotomy in BMI 53 patient VAE associated with severe reduction in EtCO2 and MAP. Intra