April CME is brought to you by Dr Ian Appleby, Hon Treasurer of NASGBI & Consultant at National Hospital for Neurology and Neurosurgery, Queen Square.
It is becoming ever clearer that complete or near-complete surgical resection of both low- and high-grade gliomas is generally recommended if possible. Where the tumour is adjacent to eloquent areas this usually necessitates an awake craniotomy. There is growing evidence that awake tumour resection is associated with a better outcome – a systematic review from 2013 showed shorter hospital stay (4 vs 9days), fewer neurological deficits (7% vs 23%) and comparable extent of resection and operative time. The authors postulate that while the surgeon’s ability to perform intra-operative cortical mapping in an awake, cooperative patient is crucial, the contribution of the anaesthesiologist is essential. They speculate whether the avoidance of general anaesthesia and the associated physiological disturbances and mechanical ventilation and effect on antitumor immunity and tumour progression may be the reason for this outcome benefit. They do also say that the greater attention given to an “awake patient” by both surgeon and anaesthetist should not be ignored!
With the increasing focus on the management of patients with subdural haematoma (the ongoing audit by the SBNS which NASGBI hopes to join as an example) and the likelihood that the management of especially chronic SDH will be used as a quality indicator for neurosurgical units, this study probably only serves to confirm what most of us already think – avoid intubation if possible and if necessary try and extubate at the end of the surgical procedure or as soon as possible afterwards. Factors associated with prolonged mechanical ventilation in this study were; history of alcohol abuse, GCS<15 on admission and surgery for SDH. Unfortunately, there is no detail about either the manner of surgery or the conduct of the anaesthesia and worryingly for me the suggestion of the authors is that further studies should look at the role of early tracheostomy in this patient group!
Many studies have looked at factors predictive of a poor outcome after aneurysmal SAH (aSAH). This study, from The Mayo Clinic, conversely, looked at predictors of an excellent functional outcome. In a retrospective review of some 373 patients with aSAH, 63% were noted to have an excellent outcome (score 0 or 1 on modified Rankin Scale at last follow-up). This is an improvement on ISAT which had approximately 50% excellent outcome and probably reflects advances in surgical and endovascular treatment and also neurocritical care. Multivariable analysis showed the 4 factors most strongly associated with a good outcome were; good clinical grade after resuscitation, absence of ICH on initial CT scan, not receiving a blood transfusion and not developing brain infarcts from delayed ischaemia.
Observational data have suggested that better fluid management for brain dead organ donors could increase organ recovery. This trial set out to determine whether protocolized fluid therapy, guided by cardiac index, mean arterial pressure and pulse pressure variation (obtained using a LiDCO) increased the number of usable organs per donor. The take home message is that protocolized fluid therapy did not increase the yield of organs per donor – indeed the trial was stopped early after recruiting 556 of a planned 960 patients. It is worth noting that only 76% of the patients randomized to the protocolized therapy actually received it due to logistical problems with the LiDCO.
Hospital readmissions are used as a quality indicator for hospital care. In the USA, Medicare and Medicaid have instituted payment penalties for hospitals with excessive readmission rates. This retrospective review of patients with glioblastoma, who underwent biopsy or tumour resection, looked at reasons for readmission and whether they were preventable. 27 (7.5%) of 362 patients were readmitted within 30 days with the reasons being neurological deterioration, surgical site infection and thromboembolic complications and 19(70%) were deemed to be preventable. Not surprisingly readmission had a significant effect on length of survival. Interestingly, when compared to practice at my own hospital and probably generally in the UK and Ireland, it seems that none of these patients received VTE chemoprophylaxis within 30 days of surgery because of the perceived risk of intracranial haemorrhage. And finally, a historical vignette and an interesting, contemporary description of how language is processed (useful for those awake craniotomies were as well as providing anaesthesia – or not – we are also testing speech);