II.2.B. Total Intravenous Anesthesia (TIVA)
Despite of the advantages of propofol use in neurosurgery such as reduce of CMRO2 and ICP, increase of cerebral perfusion pressure (CPP), and antiemetic effect,9,22-25 adverse events like shivering, high blood pressure, and postoperative nausea and vomiting (PONV) are not uncommon.26
The effects and outcomes of several combinations of opioids and propofol infusions have been compared during neuorsurgery with different results. Gerlach et al, compared propofol/remifentanil versus propofol/sufentanil in supratentorial surgeries finding a reduced time for extubation in remifentanil group (6.4 min versus 14.3 min).27 SOMCT and Rancho Los Amigos Scale (RLAS) are comparable to baseline in a shorter time …show more content…
Dexmedetomidine
Some adjuvants such as the alpha-2 adrenoreceptor agonist dexmedetomidine have been widely used in neuroanesthesia with potential intra and postoperative advantages. Dexmedetomidine produces dose-dependent sedation, anxiolysis, and analgesia without any concomitant respiratory depression, and decreasing other anesthetics requirements.32,33 These characteristics make it a very suitable drug for neuroanesthesia.32,33
Smoother arousal and recovery after neurological surgery has been reported with the use of dexmedetomidine as an adjunct during neuroanesthesia. Bekker et al, carried out a prospective, randomized, double-blinded study, where patients who received dexmedetomidine as an adjuvant during sevoflurane/remifentanil general anesthesia, were associated with less use of antihypertensive drugs during the surgery and postoperatively when compared with placebo (43% versus 86%).32
Among other effects of dexmedetomidine are a reduction in cerebral blood volume leading to minimize intraoperative brain retraction, optimization of oxygen supply/demand relation, and inhibition of hypercapnia-induced cerebral …show more content…
Planned Delayed Emergence
Risks of early extubation may outweigh the benefits in patients with compromised clinical condition. Patients with impaired baseline level of consciousness, poor airway control, prolonged (> 6hours) or complicated surgery, unstable intraoperative hemodynamics or ventilation difficulties, and increased brain swelling are some of the clinical situations where planed delayed recovery should be considered.17 Other considerations may include surgery involving eloquent areas of the brain, significant brain ischemia, and posterior fossa lesions.
Cai et al reported a rate of 49.8% of delayed extubation out of 800 patients.46 Although data may be limited, the criteria for delayed extubation after intracranial surgery have been described in reviews and observational prospective studies.37,46
If a planned delay of the emergence has been decided, the possibility of a brief awakening in order to perform a short neurological assessment is a common practice among physicians. Performing a postoperative CT scan or placing an ICP monitor are complementary options to an early neurologic
Despite of the advantages of propofol use in neurosurgery such as reduce of CMRO2 and ICP, increase of cerebral perfusion pressure (CPP), and antiemetic effect,9,22-25 adverse events like shivering, high blood pressure, and postoperative nausea and vomiting (PONV) are not uncommon.26
The effects and outcomes of several combinations of opioids and propofol infusions have been compared during neuorsurgery with different results. Gerlach et al, compared propofol/remifentanil versus propofol/sufentanil in supratentorial surgeries finding a reduced time for extubation in remifentanil group (6.4 min versus 14.3 min).27 SOMCT and Rancho Los Amigos Scale (RLAS) are comparable to baseline in a shorter time …show more content…
Dexmedetomidine
Some adjuvants such as the alpha-2 adrenoreceptor agonist dexmedetomidine have been widely used in neuroanesthesia with potential intra and postoperative advantages. Dexmedetomidine produces dose-dependent sedation, anxiolysis, and analgesia without any concomitant respiratory depression, and decreasing other anesthetics requirements.32,33 These characteristics make it a very suitable drug for neuroanesthesia.32,33
Smoother arousal and recovery after neurological surgery has been reported with the use of dexmedetomidine as an adjunct during neuroanesthesia. Bekker et al, carried out a prospective, randomized, double-blinded study, where patients who received dexmedetomidine as an adjuvant during sevoflurane/remifentanil general anesthesia, were associated with less use of antihypertensive drugs during the surgery and postoperatively when compared with placebo (43% versus 86%).32
Among other effects of dexmedetomidine are a reduction in cerebral blood volume leading to minimize intraoperative brain retraction, optimization of oxygen supply/demand relation, and inhibition of hypercapnia-induced cerebral …show more content…
Planned Delayed Emergence
Risks of early extubation may outweigh the benefits in patients with compromised clinical condition. Patients with impaired baseline level of consciousness, poor airway control, prolonged (> 6hours) or complicated surgery, unstable intraoperative hemodynamics or ventilation difficulties, and increased brain swelling are some of the clinical situations where planed delayed recovery should be considered.17 Other considerations may include surgery involving eloquent areas of the brain, significant brain ischemia, and posterior fossa lesions.
Cai et al reported a rate of 49.8% of delayed extubation out of 800 patients.46 Although data may be limited, the criteria for delayed extubation after intracranial surgery have been described in reviews and observational prospective studies.37,46
If a planned delay of the emergence has been decided, the possibility of a brief awakening in order to perform a short neurological assessment is a common practice among physicians. Performing a postoperative CT scan or placing an ICP monitor are complementary options to an early neurologic