| Part Ⅰ The analysis of anesthesia advers effects related factors during brainstem tumors surgeryIntroductionThe development of anesthesia and mobitoring techniques greatly improved the development of neurosurgery. Brainstem, used to be the forbidden area of neurosurgery, is now undergoing surgery with great safty and better therapeutic outcome with the help of modern anesthesia techniques and intraoperative neurophysiological monitoring (IONM). However, is the regulator of respiratory, circulatory and physicial movement, brainstem may suffer reversible or irreversible damage by surgery operations, leading to sudden and dramatic changes of vital signs. So the risk of brainstem surgery is still extremely high Although IONM can help prevent the operation caused by injury, the monitoring effect can very easily, by anesthetic effect, be unable to provide reliable monitoring information. The result is that in brain stem surgery, once losing reliable neural electrophysiological monitoring information, the possibility of losing nerve function will be greatly increased. Therefore, in brainstem tumor operations, the rate of adverse events occurring is high, anesthesia management is very complex, especially the change of related operations caused by cardiovascular and respiratory function, and anesthesia related factors leading to failure of IONM monitoring. Only the anesthesiologists with a full understanding of the related factors of the adverse events and mechanisms can develop reasonable and effective anesthesia management measures and ensure the patient’s safety and quality of surgery. These are a direct threat to patients during the anesthesia period.In recent years, there are a lot of brain stem and related research reports at home and abroad. All kinds of adverse events occurred around the brain stem surgery anesthesia. Most researchers believe that because these adverse events often happened suddenly and they lead to serious consequences, if not detected and received treatment in time, it will be a serious threat to the patient’s safety and prognosis. Therefore, in brain stem surgery treatments, prevention is more important than treatment. Thus, the primary focus of managing the anesthesia period of brain stem tumor surgery is to fully understand the correlative factors of adverse events and to take appropriate preventive measures to reduce the incidence of adverse events. However, the related research at home and abroad are mostly case reports, which mainly describe the brainstem and confining concrete manifestation of brainstem tumor operation concerning respiratory and circulatory system of adverse events. Even though the possible mechanism is analyzed and the corresponding way to deal with the problem is put forward, the analysis of the related factors of brainstem tumor operation in all kinds of adverse events is rare. This study collected data from nine clinics in the Affiliated Hospital of Jinan University Guangdong brain hospital from January 2011 to June 2015 the implementation of the craniotomy for brain stem tumor surgery. I investigate the operative cardiovascular and respiratory changes and IONM monitoring failure and adverse events such as the occurrence, severity, manifestation, treatment methods and effects and the possible predisposing factors. This study also evaluates the analysis of brainstem tumor operation during anesthesia and the incidence of adverse events, related factors and recovery. This could help improve accumulation of clinical experience for anaesthetic management of brain stem tumor surgery reasonable selection of anesthetic drugs and anesthetic methods and improve the success rate of clinical reference monitoring the quality of anesthesia and surgery.Materials and methods:1 patient dataCollection of Medical College of Jinan University; Guangdong 999 brain hospital from January 2011 to June 2015 implemented during craniotomy resection of brain stem tumor surgery clinical data. 2 criteria of adverse events2.1 adverse events of circulatory systemHeart rate slows abruptly/gain is more than or equal to 20% of the rate, with or without the change of blood pressure; intraoperative appear but preoperative electrocardiogram examination found no arrhythmia rates.Blood pressure is suddenly reduced/increased more than or equal to 20% of the basic value, with or without changes in heart rate as defined by blood pressure fluctuations (if 20% of the value of the heart rate variability is larger than or equal to that of the base, then judged as arrhythmia).2.2 respiratory adverse eventsThe increase of anesthesia inductions and maintenance of respiratory secretions and the increase of the airway pressure needs suction to keep the airway unobstructed. The recovery period ceiling times of sputum is more than or equal to 3 times the initial period. The follow-up period could be heard and the clear sound of phlegm accumulating accompanied by new coughs as defined as coughing with phlegm.The anesthesia recovery period, due to a not ideal result in resting in the deoxidized state, cannot sustain SpO2 above 95%. A pipe to ICU within 24 hours is still unable to extubate in after reintubation or tracheotomy defined for delayed removal of tube.2.3 electrophysiological monitoring of adverse eventsIntraoperative neurophysiological monitoring project of one or more is unable to monitor the waveform (preoperative monitoring project to collect the waveform is good), even after excluding the impact of equipment failure and surgery. This is defined as monitoring failure.3 data collection method3.1 general data acquisitionHospital number, gender, age, whether there are other system complications.3.2 anesthesia data acquisitionPreoperative American Society of anesthesiologists (ASA) tracheal intubation, anesthesia way, anesthesia type and dose of drug use, the fluctuation range of the heart rate and blood pressure, changes in the BIS values, intraoperative body temperature and blood gas analysis of monitoring results, intraoperative transfusion volume and the volume of urine, intraoperative hemorrhage and the amount of blood transfusion, and duration of anaesthesia.3.3 operation data collection(the midbrain, pons and medulla oblongata) lesions, hydrocephalus, surgical approach, posture, pathological results (cavernous hemangioma, hemangioblastoma, glioma) and the nature of the lesions (hemorrhagic, non hemorrhagic). All collected at the time of surgery.3.4 intraoperative electrophysiological monitoring data acquisition:Types of monitoring items, the corresponding project before operation, type, parameters and monitoring physician monitoring equipment.3.5 kinds of adverse events in the collection3.5.1 cycle systemSurgery for circulatory system adverse events, event types, degrees, inducement, duration, effective intervention measures, whether or not to grant vasoactive drug control, drug use.3.5.2 respiratory systemThe recovery period of respiratory systems is poor regardless of increased secretion, suction of sputum, respiratory recovery, a pipe, a tube with tolerance or use of sedations.24 hours after extubation, whether re-intubation is required or not, re-intubation should be performed as it increases secretions.3.5.3 electrophysiological monitoring of adverse eventsWaveform monitoring is ideal (waveform compared with the preoperative difference or cannot be collected waveform), excluding the possible influencing factors of monitoring equipment and operating personnel.4 factors related to the choice ofAccessing the relevant literature, the following 10 possible and brainstem tumor surgeries and the factors associated with the occurrence of adverse events during anaesthesia were analyzed:General information:gender, age (<14,>14 years), whether the complications of pneumonia.Anesthesia:preoperative ASA grade (Ⅰ-Ⅱ, Ⅲ-Ⅳ), anesthesia (intravenous anesthesia, general anesthesia, anesthesia time).Operation:(midbrain, pons, medulla) lesions, lesions (hemorrhage lesions including cavernous hemangioma, hemangioblastoma, non bleeding lesions including glioma), whether comorbidities hydrocephalus. At the time of surgery.5 statistical analysisStatistical analysis was performed using SPSS 18 software.95% confidence interval by the frequency of occurrence of adverse events (confidence interval CI) said. The adverse events judgment criteria were classified as the positive group while the others were classified as the control group.10 possible related factors were analyzed by univariate analysis, initially identified possible risk factors, the count data using chi square test, measurement data for normal distribution test, comply with the normal distribution using two independent samples t test, does not meet the normal distribution using two independent samples rank sum test. The P value is less than 0.05 risk factors as standard screening will have statistical significance in Logistic regression analysis, the correlation with the relative risk value and 95%CI evaluation factors associated with adverse events.Result1 general situationJinan University Medical College; Guangdong 999 brain hospital during the period from January 2011 to 2015 June performed in 107 cases of craniotomy for resection of brainstem tumor surgery, surgery for the first time,96 cases in the TIVA the remaining 11 cases by CIIA. Average operative time for 162.7111.22+minutes, average duration of anesthesia 9.89 minute 293.17+.62 cases of male patients,45 cases of female patients, with an average age of 29.43 years+11.14 (from 4 to 64 years), which is less than or equal to 14 of 39 cases> 14 in 68 cases. Preoperative ASA grade 6 cases of grade Ⅰ,Ⅱ grade 18 cases,Ⅲ grade 81 cases,2 cases of grade Ⅳ,12 cases with hydrocephalus,4 cases complicated with pneumonia. The postoperative pathological diagnosis of 46 cases of brainstem glioma,58 cases of brainstem cavernous hemangioma,3 cases of brainstem hemangioblastomas.8 cases of lesions located in the midbrain, pons in 78 cases,21 cases were located in the medulla oblongata.2 The incidence of adverse eventsFrom the collection of 107 cases, Wai arrhythmia during anesthesia occurred in 48 cases, incidence rate was 44.0%; peri anesthesia period fluctuation of blood pressure in 36 patients, rate was 33.0%; postoperative delayed extubation in 10 cases, incidence was 9.2%; postoperative cough phlegm has 22 cases, incidence rate of 20.2%; 24 cases of failure monitoring in the operation, the occurrence of 22.0%.3 adverse eventsAbnormal heart rate or blood pressure fluctuations during operation, immediately halted all related operations, close observation of vital signs change and cause investigation and other possible (such as stretching stimulation of the trigeminal nerve and brainstem, etc.). In this group of cases with 41 cases after the stop operation and removal of incentives, vital signs returned to the operation of forward-looking and effective for the treatment,7 cases in the treatment has yet to recover before the operation, or recurrent symptoms and no obvious improvement, select corresponding vasoactive drugs, such as atropine, urapidil and other symptomatic treatment,7 cases were treated with drugs were restored to the pre operation.Postoperative cough should first be fully suction, then according to the condition of specific treatment. In this group of patients,22 patients had obvious cough phlegm, among them 7 cases recovery of consciousness and respiratory recovered well and the after evaluation of the surgical group cranial nerve injury is unknown significantly be pull tube processing, strengthening postoperative expectoration of sputum aspiration nursing. There was no complications of respiratory system; and recovery the remaining 15 cases recovery of consciousness or breathing is not ideal, consider the brain stem and posterior group of cranial nerve harass larger instead of after nasotracheal intubation with tube into ICU continue to observe. With tube cases in 6 cases within 24 hours after the operation of consciousness and respiratory recovery well and be extubation, except 1 case pull tube due to aspiration leads to hypoxia and tracheotomy outside, the remaining 5 patients without respiratory complications; tube with the rest of 9 cases due to postoperative 24 hours after consciousness or respiratory recovery has not been ideal, hence the trachea incision treatment.Intraoperative neurophysiological monitoring failure ruled out first fault monitoring equipment, and to inform the surgery doctors to determine whether caused by surgery operation, these reasons were excluded after anesthesia doctors according to the anesthetic depth and drug use to determine whether due to the failure of anesthesia related factors (such as blood pressure, body temperature caused by monitoring, and in ensuring the premise of anesthesia quality adjusted anesthesia methods (such as reducing the amount of sevoflurane or propofol but also ensure BIS values below 60). If the monitoring effect is still not improved, notice the surgeon decided by the operation process. In this group of cases there were 24 cases of failure monitoring, monitoring project and the failure was SEP. There are 11 cases in the adjustment of anesthesia monitoring effect of SEP after treatment significantly improved, the remaining 13 cases in order to ensure the safety of anesthesia is not given special treatment. After 24 hours of follow-up of poor recovery of consciousness has 9 cases, intraoperative SEP monitoring failure occurred. 4 single factor analysisSingle factor analysis showed that the correlation between the four factors of gender, age, operation time and duration of anesthesia and adverse events of all kinds, positive group and control group data was not statistically significant (P>0.05). Effect of different incidence of adverse events between the incidence of adverse events, and there were significant differences in the factors related to the results of the analysis are described as follows:(1) the preoperative ASA, lesion location and nature of the lesions with hydrocephalus and positive group and the control group of the circulatory system, the influence of difference was statistically significant (P< 0.05); (2) the preoperative ASA, lesion site and whether complicated with pneumonia, the positive group and control group on the respiratory system the influence of difference was statistically significant (P<0.05); (3) anesthesia group of intraoperative electrophysiological monitoring failure rate difference was statistically significant (P<0.05).5 Multivariate factosr analysisFurther multivariate logistic regression analysis results showed that:(1) preoperative ASA Ⅲ-Ⅳ, lesion nature of the hemorrhagic lesion, preoperative combined with hydrocephalus are risk factors for the occurrence of adverse reaction of circulatory system; (2) preoperative ASA for Ⅲ-Ⅳ, the location of disease spread to the medulla oblongata, preoperative pneumonia is the emergence of the risk factors of adverse reactions of the respiratory system; (3) total intravenous anesthesia is intraoperative electrophysiological monitoring failure of protective factors.ConclusionMany factors can lead to the occurrence of brainstem tumor operations during adverse events in anesthesia operations. The preoperative ASA score, lesion location and nature, as well as whether preoperative hydrocephalus or pneumonia is a risk factor for major adverse events. The anesthesiologist should have a comprehensive evaluation in patients with preoperative conditions. According to these risk factors, take some positive and effective preventive measures and the total intravenous anesthesia may reduce the occurrence of adverse events.Part II The effects of stellate ganglion block on cerebrovascular vasodilation in elderly patients and patients with subarachnoid hemorrhageIntroductionCerebral vasospasm (CVS) is a condition of morphologic narrowing of cerebral arteries most commonly found after subarachnoid hemorrhage (SAH). CVS leads to cerebral ischemia and infarction, and thus to disability or even death. Although advances in diagnosis and surgical and/or interventional treatment have improved the prognosis for these CVS patients, outcomes still remain disappointing. Age is a major risk factor for a poor outcome in patients with cerebral vascular disease including SAH. Recent studies have shown that the incidence of SAH in the elderly, especially those older than 60 years of age, is increasing with the increased age of the general population. In the aged brain, there is a reduction in the angiogenesis response due to decreased responsiveness to HIF-1. While the biological and medical consequences of a stroke are significant at any age, the incidence and severity of a stroke is significantly increased with age.Leriche and Fontaine first called attention to the fact that stellate ganglion block (SGB) caused a’striking regression of symptoms in two cases of postoperative hemiplegia’. Since then, numerous studies have emphasized the usefulness of SGB to reduce the vascular spasm associated with cerebral thrombosis and embolism. SGB causes vasodilatation in the skin of the head and neck. Its effects on cerebral hemodynamics, in aging or in SAH, are not clear. Thus, the present study was designed to clarify age-related or SAH-related differences in vasospasm, as well as the efficacy of SGB in relation to the responses of basilar arteries.MaterialsThe study was conducted with the approval of the Institutional Ethics Review Board of GuangDong 999 Brain Hospital. Written informed consent was obtained from all patients before surgery. All patients were diagnosed with ischemic encephalopathy or cerebral vascular disease and underwent total cerebral angiography or interventional embolization therapy using digital subtraction angiography (DSA). For undergoing total cerebral angiography, patients aged no less than 18 years old, with ASA levels I or II and GCS score of no less than 13 and WFNS levels of I to III. No SAH was found using CT examination before surgery. For undergoing interventional embolization therapy, patients aged no less than 18 years old, with ASA levels II or III, GCS score of no less than 13 and WFNS levels of I to III. Exclusion criteria were hemostatic disorders, cardiovascular disorders, disorders of the bronchus or lung, chronic administration of opioid analgesics, coagulation dysfunction or anticoagulant therapy, local anesthetic allergy, the structural abnormalities of the neck, such as scar or tumor, severe anxiety, and disagreement with consent.Methods1. Study protocolFor undergoing total cerebral angiography, patients were assigned to 2 groups. The elderly group consisted of 20 patients no less than 65 years old. The adult group consisted of 20 patients who were≥18 and<65 years old. For undergoing interventional embolization therapy, patients were randomly assigned to 2 groups, the non-SGB group (n=41) and the SGB group (n=34). For SGB treatment, patients were assigned to 2 groups, non-SAH group (n=15) and SAH group (n=19).To determine effect of SGB on cerebral vasospasm in adult and elderly patients, the caliber of ipsilateral middle cerebral artery (MCA), vertebral artery (VA) and arteriae basilaris (BA) was examined 15 min before and after SGB using digital subtraction angiography (DSA) methods.To determine effect of SGB on cerebral vasospasm in patients with SAH, the caliber of MCA, VA and BA was examined 15 min before and after SGB using DSA methods.2. Stellate Ganglion BlockThe stellate ganglion block (SGB) was performed under ultrasound guidance. At the C7 level, a 10 MHz linear probe was placed at 45 degrees of neck flexion in the sagittal plane and located between the carotid sheath and the brachial plexus. A 25-gauge,6 cm needle (Kovax) was inserted laterally,2 mm from the probe. The needle tip was placed posterior to the carotid artery, anterior to the longus colli muscle under the transverse short axis for the in-plane approach. Then,8 ml of 2% lidocaine was administered and a bandage was applied after removal of the needle. After 10-15 min, onset of SGB was established by the presence of an ipsilateral Homer’s syndrome along with pain relief.3. Cerebral Digital Subtraction AngiogramAll 115 patients had diagnostic angiography with the standard transfemoral Seldinger technique, including a 6F guiding catheter and DSA. Preoperative embolization was carried out in the same session with an additional Tracker 18 microcatheter system. The Tracker 18 catheter was introduced into the main feeding vessels, which, in most cases, originated from the external carotid artery. There was no provocative testing prior to embolization, as the risk of complications after embolization within the external carotid artery is very low. The contrast media (320 Iodixanol; Omnipaque, GE, China) was injected in the internal carotid artery (ICA) and the vertebral arteries. For the ICA, the rate of injection was 15 mL/s for a total of 25 mL, whereas for the vertebral arteries, the injection rate was 3 mL/s for a total volume of 6 mL. MCA diameter was measured at a distance of 2mm from the circle of Willis, at the peak systole. VA diameter was measured at a distance of 2 mm from ascends posterior to the internal carotid artery in the transverse foramina of the cervical vertebrae. BA diameter was measured at a distance of 2 mm from ascends superior in the central gutter (sulcus basilaris) ventral to the pons. All DSA examinations were performed by the same staff radiologist, who was blinded to status of SGB treatment. All measurements were performed 3 times, and an averaged was calculated.4. Three-dimensional transcranial DopplerAll of the patients to SGB were respectively monitored MCA, VA and BA’s average blood flow velocity (Vm) of block side before the block and after block for 15 minutes. TCD monitoring was used DWL BOX type maked in Germany, application of handheld 2 MHZ pulse probe, probe the MCA from temporal window, peering into the VA and BA from the pillow window, all operations are performed by the same professional and technical personnel.5. Observation of postoperative complicationsConventional CT scan and CT angiography were examed 12 hour after operation, determine whether happened complications such as bleeding and significant vasospasm.6. Statistical AnalysesStatistical analyses were performed with SPSS version 19.0 software (SPSS Inc, Chicago, IL). The paired or independent-test was used for continuous variables. The χ2 test were conducted for categorical variables. Results are presented as mean ± SD and median (minimum-maximum). The level of statistical significance was set at P ≤.05 for all tests for both sides.ResultsThe 17 adult and 20 elderly patients who underwent total cerebral angiography and completed the study had a median (interquartile range) age of 28± yr or of 65± and BMI of 25.8±3.7 or of 25.8±3.7. The 15 patients without SAH and 19 patients with SAH who underwent interventional embolization therapy and completed the study had a median (interquartile range) age of 37.4±11.7 yr or of 37.2±12.0 and BMI of 25.1±3.4 or of 23.9±3.3. The SGB was successful in all the patients. The presence of successful block was established between 10 and 20 min, and all the measurements during established block were taken between 15 and 30 min after the injection of local anaesthetic.1. SGB increases cerebral blood vessel caliber in elderly patientsNo significant changes of ASA and GCS measurements and average operation time were noted in the adult and elderly patients. SGB caused a significant increase (P<0.05) in caliber of MCA from a median (inter-quartile range) of 2.471±0.184 mm to 2.780±0.270 mm, and VA from 3.375±0.337 mm to 3.596±0.362 mm, and BA from 2.433±0.259 mm to 2.699±0.352 mm, in adult patients. The block induced a significant increase (P<0.05) in caliber of MCA from 2.441±0.187 mm to 2.558±0.265 mm, and VA from 3.332±0.178 mm to 3.382±0.188 mm, and BA from 2.699±0.352 mm to 2.482±0.261 mm in elderly patients. Table 5 showed no significant difference in blood vessel caliber between adult patients and elderly patients. Interestingly, caliber of MCA, VA and BA in adult patients was increased by 3.89±2.18%,2.68±1.87% and 3.62±2.48%, respectively, which is higher than that in elderly patients (P<0.05).2. SGB increases cerebral blood vessel caliber in patients with SAHNo significant changes in ASA, GCS, WFNS and average operation time were noted in patients with or without SAH. The block caused a significant increase (P<0.05) in caliber of MCA from a median (inter-quartile range) of 2.455±0.129 mm to 2.555±0.186 mm, BA from 2.420±0.915 mm to 2.429±0.089 mm, and VA from 3.387±0.152 mm to 3.391±0.155 mm in non-SAH patients. The block induced a significant increase (P<0.05) in caliber of MCA from 2.296±0.076 mm to 2.472±0.129 mm, VA from 3.259±0.102 mm to 3.274±0.096 mm and BA from 2.238±0.108 mm to 2.252±0.107 mm in SAH patients. Before SGB, caliber of cerebral blood vessels was decreased in SAH patients compared to that in non-SAH patients. Importantly, after SGB, caliber of MCA, VA and BA in patients with SAH was increased by 6.34±1.02%,4.21±1.63%, and 4.94±1.81%, respectively, which is higher than that in patients without SAH (P<0.05).3. SGB improved cerebral vasospasm in patients with cerebral vascular diseaseNo significant changes in ASA, GCS, WFNS and average operation time were noted in patients with or without SGB. As shown in Table 8, in non-SGB group, five patients suffered apparent cerebral vasospasm. Three of them went on with the operation after treatment with papaverine. The two most severe patient were ineligible for operation. A larger sample is needed to verify the therapeutic effect of SGB on severe cerebral vasospasm.4. Result for TCDThe adult group and elderly group, Non-SAH group and SAH group, block side of MCA and BA Vm of all patients with SGB increased significantly (P<0.005) after block, VA also increase after SGB but not obvious than before (P>0.005).ConclusionOur data suggest that SGB-increased caliber of MCA, VA and BA in both elderly patients and patients with SAH may help decrease cerebral vasospasm. SGB is a promising therapy for cerebral vascular accidents in both elderly patients and patients with SAH. |
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