Patient Satisfaction with Awake Craniotomy for Tumor Surgery: A Comparison of Remifentanil and Fentanyl in Conjunction with Propofol

Manninen, Pirjo; Balki, Mrinalini; Lukitto, Karolinah; Bernstein, Mark

doi:10.1213/01.ane.0000181287.86811.5c

Cited by 137 publications

(101 citation statements)

References 14 publications

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“…Advantages include increased patient comfort and tolerance during craniotomy and a secured airway with the ability to hyperventilate. The advantage of remifentanil is a rapid reversal of narcosis when intraoperative consciousness is required [10]. Advantages of propofol include short duration of action, amnesia, antiemetic action, reduced incidence of seizures, minimal effects on ECoG recordings and minimal effects on ventilation in low doses.…”

Section: Discussionmentioning

confidence: 99%

Awake Craniotomy for Tumour Excision

Prabhakaran

Mohan

Tripathy

et al. 2008

Medical Journal Armed Forces India

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A wake craniotomy literally means performing a craniotomy on an awake patient. It allows A A intraoperative assessment of the patient's neurological status. It is mainly used for mapping the resection margins during epilepsy surgery, accurate location of electrodes in surgery for movement disorders, and excision of tumours from eloquent areas of the cortex [1]. Eloquent areas are specialized areas of brain which control important functions, like movement, sensation, speech etc. Intraoperative neurological testing allows optimal tumour resection with minimal postoperative neurological dysfunction. Different anaesthetic techniques for awake craniotomy have been described in the literature [2][3][4][5][6][7]. Some have used conscious sedation, while others have used 'asleep-awake-asleep' technique. This is the first case series of awake craniotomies published from the Indian armed forces. Material and MethodsThis procedure was carried out in Command Hospital (SC), Pune during the ten month period. The inclusion criteria were supra tentorial, intra-axial tumours located close to eloquent areas of the brain and patients willing to co-operate. The exclusion criteria was posterior fossa tumours, non-willing patients, large tumours with midline shift and raised intracranial tension. Confused, demented or agitated patients are poor candidates. Patient was assessed for his fitness and psychological make up to undergo awake craniotomy. After history and physical examination the patient was subjected to detailed counselling. Patient was explained about the advantages of remaining awake during operation and the sequence of events in the operation theatre. Patient was educated about different tasks like moving the toes/ fingers on command, identification of picture cards, speaking etc. which he was supposed to perform during the surgery. It was re-emphasized that he will be conscious and he had to lie down still during the surgery. Option of general anaesthesia was also kept open and an informed consent was taken.In the operation theatre intravenous line was started and sedation in the form of injection midazolam 1-2 mg and injection fentanyl 50-75 mcg was given. The scalp was painted with 10% betadine lotion. The supraorbital,supratrochlear, auriculotemporal, zygomaticotemporal, greater occipital and lesser occipital nerves (Fig. 1) were blocked bilaterally with local anaesthetic (LA) solution.We used a mixture of 20 ml of 0.5% bupivacaine, 20 ml of 2% plain lignocaine, 0.4 ml (400 mcg) of adrenaline and 40 ml of saline adding upto a total of 80 ml of solution. This solution has a concentration of 0.125% bupivacaine, 0.5% of lignocaine and 5 mcg/ml of adrenaline. Adrenaline helps in hemostasis, reduces absorption of LA, thereby reducing its toxicity and prolongs the duration of action. About 25-30 ml of this solution was used for the nerve blocks. A band (Fig. 2) of subcutaneous and subfascial injection was given with 20-25 ml of this solution, around the head passing above the ears through forehead and occiput [8]. The rema...

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Section: Discussionmentioning

confidence: 99%

Awake Craniotomy for Tumour Excision

Prabhakaran

Mohan

Tripathy

et al. 2008

Medical Journal Armed Forces India

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“…The risk of complications either anesthesiarelated or caused by surgical stimulation has been clearly outlined by many authors 7,10,24,27,38,39,42 . Seizures are reported to be a common intraoperative complication during awake craniotomy for tumour resection 7,27 and can be seen both in awake and in asleep patients. As reported by Conte et al, intraoperative seizures' incidence can be as high as 30% in an asleep-awake technique, but those requiring medical intervention are 6-7% 8 .…”

Section: Complications and Their Treatmentmentioning

confidence: 99%

“…This high variability might also be explained by differences in seizures definition, by different level of intraoperative electrophysiological monitoring, current intensity and stimulator used, by different anesthesia or underlying patients pathology (tumour vs. intractable epilepsy or both), and seizure control 8,24 . Usually, seizures occur during mapping or tumour resection and are of short duration and self-limiting 27 . It can be the case of focal seizures, whose therapy mainly consists of the irrigation of the surgical field with ice cold Ringer's lactate solution 40 .…”

Section: Complications and Their Treatmentmentioning

confidence: 99%

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Anesthesiologic Management for Awake Craniotomy

Zoppellari¹,

Ferri²,

Pellegrini³

2012

Explicative Cases of Controversial Issues in Neurosurgery

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“…One patient suffered a transient episode of hypoxaemia (S p O 2 < 90%). The technique requires close supervision and as others have described [12], airway rescue equipment and skills must be immediately available. While well tolerated by ASA 1 and 2 patients, it may not suitable for patients at risk of rapidly developing significant hypoxia, such as the morbidly obese, or those in whom a reduction in S p O 2 (with CO 2 retention) may be poorly tolerated.…”

Section: ó 2008 the Authorsmentioning

confidence: 99%

An evaluation of conscious sedation using propofol and remifentanil for tension‐free vaginal tape insertion

Winton¹,

Eastwood²,

Powell³

et al. 2008

Anaesthesia

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Tension-free vaginal tape insertion is a recommended treatment for stress incontinence. There is evidence that intra-operative testing of continence by asking patients to cough may improve outcomes, but an optimal sedation regimen has not been determined. We prospectively evaluated the effectiveness of propofol and remifentanil infusions in 25 patients using pre-and postsedation peak cough pressures and pain scores. Patient satisfaction was assessed using the Iowa Satisfaction with Anaesthesia Score (ISAS). Post-sedation cough pressures were improved compared to baseline, with a mean peak pressure increase of 24 mmHg (95% CI 15.5-32.5; p < 0.001). Tension-free vaginal tape (TVT) insertion is a surgical treatment for genuine stress incontinence. It involves insertion of a prolene tape (Ethicon TVT, Ethicon, Edinburgh, UK) using 7-mm needles attached at either end. The tape is positioned to form a U-shaped sling at the level of the mid-urethra and is brought out behind the pubis symphysis through two small abdominal incisions. In the original description of the procedure, after the tape is positioned, the bladder is filled via a cystoscope which is then removed, and the patient asked to cough forcibly. This allows the tape to be adjusted until continence is just achieved.In traditional suspension procedures, or with a TVT performed under general or regional anaesthesia, the surgeon must estimate the degree of suspension required to relieve incontinence. This can lead to increased postoperative complications including failure to relieve incontinence or urinary retention. There have been no prospective studies comparing incontinence outcomes following TVT insertion performed under general anaesthesia versus sedation, though one paper did report improved results with local anaesthesia [1]. Published data has shown rates of urinary retention following TVT insertion under general anaesthesia to be high. One study quoted 56% of patients required an indwelling catheter for more than 24 h postoperatively [2].There are few published descriptions of sedation for TVT insertion. An optimal regimen would provide complete analgesia and anxiolysis during insertion of the tape, and an orientated patient able to co-operate with incontinence testing. It would also aim to minimise effects on urodynamics, with minimal respiratory depression and impairment of cough effectiveness. The authors previously described a method using a midazolam and fentanyl combination [3], which provided good analgesia and anxiolysis, but further improvement in emergence and cooperation with continence testing was proposed with a combination of propofol and remifentanil. The aim of this study was to evaluate the efficacy of a propofol and remifentanil regimen in terms of patient acceptance, co-operation with continence testing and cough effectiveness.

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Patient Satisfaction with Awake Craniotomy for Tumor Surgery: A Comparison of Remifentanil and Fentanyl in Conjunction with Propofol

Cited by 137 publications

References 14 publications

Awake Craniotomy for Tumour Excision

Awake Craniotomy for Tumour Excision

Anesthesiologic Management for Awake Craniotomy

An evaluation of conscious sedation using propofol and remifentanil for tension‐free vaginal tape insertion

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