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| Year : 2017 | Volume
: 65
| Issue : 5 | Page : 1059-1060 |
The art of waking up a neurosurgical patient: It is time to hone our skills
Hemant Bhagat, Ankur Luthra
Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| Date of Web Publication | 6-Sep-2017 |
Correspondence Address:
Hemant Bhagat
Division of Neuroanesthesia, Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/neuroindia.NI_674_17
How to cite this article:
Bhagat H, Luthra A. The art of waking up a neurosurgical patient: It is time to hone our skills. Neurol India 2017;65:1059-60 |
The word ‘emergence’ comes from a Latin word ‘emergere’ which means to move out of or away from something. Emergence from anaesthesia refers to the process of moving away from deliberate unconsciousness and awakening of patient following surgery and cessation of anaesthetic drugs. Emergence from anaesthesia is viewed by most physicians, patients and their relatives as a successful indicator of return to the preanaesthetic physiological state following a surgery. Consequently, the conduct of anaesthesia in any patient demands great attention. The concept of awakening becomes especially important in patients undergoing intracranial surgeries as both anaesthesia and surgical manoeuvres have a direct influence on the brain and its recovery. This leaves room for doubt in neurosurgical patients as to whether the anaesthetics or the surgery could be the culprit in an event of failure of the patient to wake up following neurosurgery. Hence, the understanding of the neuropharmacology of the administrated drugs and the skills of the anaesthesiologists need to be synchronized to facilitate a predictable and fast-track emergence from anaesthesia. An awake patient following neurosurgery is the best neuromonitor that helps in the detection of neurosurgical complications. Early awakening, early detection and intervention for a postoperative neurological malady can influence the outcome of the patient.
Paul et al., in a well-designed study observed statistically significant difference in the emergence time from anesthesia when they used desflurane in patients undergoing a supratentorial craniotomy.[1] The patients who received isoflurane had a slightly prolonged response to commands when compared to desflurane.[1] This is expected due to the low blood gas partition coefficient of desflurane when compared to isoflurane. Isoflurane has been shown to delay the emergence from anesthesia in neurosurgical patients.[2] However, when we weigh this emergence from anesthesia in terms of its clinical significance, which has been assigned a threshold of 15 minutes, the time-to-emergence (eye opening) was acceptable in both the groups.[1] The role of anaesthesia on awakening in neurosurgical patients has been widely evaluated. The data comparing various anaesthetics have observed statistical significance using desflurane without much clinical difference in the time-to-awakening.[3],[4] The present study and the existing literature support the fact that all the commonly used anaesthetics in neurosurgical patients have reasonable and acceptable recovery profile.[1],[2],[3],[4],[5] Similarly, the choice of opioids may not be consequential in affecting the emergence from anaesthesia.[6] This brings in a pertinent observation that it is not ‘what you use', but ‘how you use’ that is important for awakening following the conduct of anaesthesia. Consequently, you need to plan the emergence in neurosurgical patients so as to fast-track awakening but at the same time maintain the quality of emergence. It is time to develop the art of an early and a safe awakening following neurosurgery.
Following a neurosurgical procedure, the traditional concept has been to switch off the anaesthetics and watch for the respiratory efforts. Once the patient has significant spontaneous respiration, the residual neuromuscular blockage is reversed. Following adequacy of respiration and the return of consciousness, the patients are extubated. The flip side of this technique in neurosurgical patients is that reversal of neuromuscular blockage prior to return of consciousness may provoke sympathetic stimulation as well as coughing due to the presence of the endotracheal tube. Excessive coughing can lead to an increase in the intra-thoracic pressure and increased cerebral venous pressure.[3] This can jeopardise the venous haemostasis following surgery leading to formation of an intracranial haematoma. Similarly, sympathetic stimulation leads to hypertension which may predispose to the formation of an intracranial haematoma.[5] This has led the clinicians to think in terms of “ReversalFirst” or “ResponseFirst” in neurosurgical patients. Failure of return of consciousness following neurosurgery is representative of a unstable cerebral physiology. Consequently, reversal of residual neuromuscular blockade prior to return of consciousness may add on to the ongoing cerebral instability. The patient's ability to respond following cessation of anaesthesia may actually represent reversal of both unconsciousness and neuromuscular blockage. Reversal of residual neuromuscular blockage at this stage can lead to fast-track extubation with minimal coughing and limited sympathetic stimulation. However, there is a belief that return of consciousness prior to reversal of neuromuscular blockage can lead to awareness and may predispose to the psychological distress. In our clinical studies, we did not observe any incidence of awareness in neurosurgical patients with the “ResponseFirst” technique.[3],[4] The study by Paul et al., used the ” Reversal first” technique.[1] However, they extubated the patients prior to awakening them. This technique is advocated in some centres across the globe with reasonable advantage of avoiding coughing and haemodynamic fluctuations. An issue that needs attention is the risk of aspiration in case of regurgitation of stomach contents and the need to reintubate if the patient does not wake up. The emphasis at present is not just on awakening and extubation following anaesthesia, but to achieve a reasonable quality of emergence. The key components of a good quality of emergence are early awakening, limitation of haemodynamic changes, minimization of coughing, a reasonable level of alertness and avoidance of agitation during the phase of emergence.
How safe are these anaesthetics in terms of neurological and cognitive functions are questions that we need to answer. The important observation which the study of Paul et al., highlight is that both desflurane and isoflurane did not have significant bearing on the short term neurological outcome of the patients.[1] The next decade will probably witness research focussed on understanding the neuroprotective and neurotoxic effects of the anaesthetics. The future lies in understanding the influence of human genetics and molecular mechanisms of the anaesthetic drugs on the long term recovery profile of the patients.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| » References | |  |
| 1. | Paul AP, Vedantam A, Korula G, Chacko AG. A comparison of the recovery profiles of desflurane and isoflurane anesthesia in patients undergoing elective supratentorial craniotomy: A randomized controlled trial. Neurol India 2017;65:1053-58.  [Full text] |
| 2. | Prabhakar H, Singh GP, Mahajan C, Kapoor I, Kalaivani M, Anand V. Intravenous versus inhalational techniques for rapid emergence from anaesthesia in patients undergoing brain tumour surgery. Cochrane Database Syst Rev 2016;9:CD010467. [ PUBMED] |
| 3. | Bastola P, Bhagat H, Wig J. Comparative evaluation of propofol, sevoflurane and desflurane for neuroanaesthesia: A prospective randomised study in patients undergoing elective supratentorial craniotomy. Indian J Anaesth. 2015;59:287-94. [ PUBMED] |
| 4. | Bhat M, Bhagat H, Bhukal I, Sahani N, Khanna P, Gupta SK. Prospective randomized evaluation of propofol and desflurane in patients undergoing surgery for cerebellopontine angle tumors. Anaesth Pain & Intensive Care 2015;19:478-84. |
| 5. | Bhagat H, Dash HH, Bithal PK, Chouhan RS, Pandia MP. Planning for early emergence in neurosurgical patients: A randomized prospective trial of low-dose anesthetics. Anesth Analg 2008;107:1348-55. [ PUBMED] |
| 6. | Bhagat H, Bhukal I, Bastola P, Bithal PK, Dash HH. Does morphine prolong emergence in neurosurgical patients. Eur J Anaesthesiol 2012;29:S14. |
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