Traditionally, craniotomy was thought to be less painful than other surgical procedures. Recent evidence has challenged this, with one study finding 55% of subjects reporting moderate to severe pain on Day 1 post-op. Pain delays recovery, prolongs hospital stay and increases rates of complications.

We aim to collect data on current practices in the perioperative management of pain in adult patients following elective supra-tentorial craniotomy under general anaesthesia (i.e. not awake craniotomy) .

Thank you for your assistance

Kate Arrow

Speciality Registrar and teaching fellow

Ben Ulyatt

Consultant Anaesthetist

Ninwells Hospital

Dundee

Which Neuroscience centre do you work in

   Answer                                                                  No Responses                       Percent

MIDDLESBROUGH                                                                     8                          3.36%

Other Answers:

brighton        iecpn

southend university nhs trust

238 response(s)

Are you a current member of the Neuroanaesthesia and Critical Care Society of Great Britain and Ireland (NACCS)?

   Answer                                                                  No Responses                       Percent

          Other Answers:           no

238 response(s)

Do you provide general anaesthesia to adult patients for elective supratentorial craniotomy at least once a month?

     Answer                  No Responses            Percent

Other Answers:

semi retired – no longer do neuro lists(after 20yrs)    yes

238 response(s)

Do you usually provide analgesic premedication to your craniotomy patients

   Answer                                                                  No Responses                       Percent

211 response(s) , 2 No Answer(s)

 Which agents do you routinely use for analgesic premedication for elective craniotomy

patients with normal renal function?

      Oral              IM                IV           Other route

17 response(s)

Which analgesic agents do you routinely administer intraoperatively (excluding remifentanil or dexmedetomidine)?

     Answer                  No Responses            Percent

Other Answers:

dipyrona       iv lignocaine

oxynorm parecoxib scalp block

208 respondent(s), showing percentage as a maximum of 100% per answer (multiple

checkbox selection)

Do these patients routinely receive local infiltration by the surgeon?

   Answer                                                                  No Responses                       Percent

Other Answers: but only lignocaine c adrenaline, which rarely outlasts theri surgery

yes, but all bar one uses lidocaine with adrenaline for vasoconstrictive effects

208 response(s)

Do these patients also routinely receive a scalp block

   Answer                                                                  No Responses                       Percent

Other Answers:

awake craniotomies get a scalp block; asleep craniotomies get local infiltration

occasionally             only awakes

sometimes

193 response(s) , 2 No Answer(s)

 Do these patients routinely receive a scalp block      Answer                    No Responses            Percent

15 response(s) , 4 No Answer(s)

Is this usually administered by..

   Answer                                                                  No Responses                       Percent

Other Answers                                                                            2                          7.69%

Other Answers:

in long cases pre-incision and at the end

surgeon administers pre incision lignocaine and at end of procedure bupivacaine

26 response(s)

Do you consider NSAIDs an acceptable option for perioperative use in uncomplicated supratentorial craniotomy patients?

   Answer                                                                  No Responses                       Percent

Other Answers: after 24 hours after 24hours post op.

although surgical group are not keen but not acceptable to neurosurgeons

cox 2’s are not completely non platelet dysfunctional depends on the operating surgeon and specifics of surgery i do, but surgeons don’t

i used to routinely use nsaid in spine and cranial surgery; i have no evidence of bleed due to this practice; a few years ago i decidedto stop administering the nsaid due to          concerns highlighted in literature

routinely a cox-2 nsaid intraoperatively and then non-selective nsaids from 24 hours postoperatively for a maximum of 3 days dosage tailored to age and renal function. tend to withold for 24 hrs

unsure

usually start 24hr postop and only after discussion with the surgeon yes after 24 hours yes after 6 hours

yes, but only if patient already taking them

206 response(s)

 At what stage do you usually introduce NSAIDs      Answer                      No Responses            Percent

Other Answers:

as directed by surgeon

at the end of surgery            only if needed

only in significant msv disease and then start intraoperatively single dose intraop

63 response(s) , 15 No Answer(s)

Do you routinely prescribe postoperative PCA or IV opioids for use in recovery / PACU or on the ward in this patient group?

     Answer                  No Responses            Percent

Other Answers:

iv in recovery only iv morphine in recovery iv morphine recovery iv opiods in recovery

not pca         not pca, iv administered by pacu staff only recovery recovery iv only, not pca recovery only

small amount of iv prn opioid in immediate post op recovery

206 response(s)

 Which is the usual first choice PCA or IV opioid that you prescribe for postoperative use,

assuming normal renal function in an otherwise healthy patient?

   Morphine    Fentanyl    Oxycodone    Other    None    No Answer

168 response(s)

Assuming your patient can swallow and there are no significant medical comorbidities, what analgesia and route do you routinely prescribe postoperatively for elective supratentorial craniotomy patients?

      Oral              IM                IV           Other route

     Ketamine                                        0              0              0              0                    

256 response(s)

If your patient is unable to swallow and the enteral route is not available to you, what analgesia and route do you/ would you prescribe postoperatively?

        IM                IV           Other route

176 response(s)

Do you have local / departmental guidelines for managing postoperative pain in this patient group in recovery / PACU ?

   Answer                                                                  No Responses                       Percent

Other Answers: for all post-op patients – morphine or fentanyl as per recovery room protocol             standard for all post op patients the guideline is for pca in pacu/ievel 1/ward               

192 response(s) , 10 No Answer(s)

Do you have local / departmental guidelines for managing postoperative pain in this

patient group on the ward / HDU ?

     Answer                  No Responses            Percent

          Other Answers:           

but we are unable to give intravenous opiates on the ward

192 response(s) , 10 No Answer(s)

Do you have an acute pain service that will visit your craniotomy patients postoperatively?

   Answer                                                                  No Responses                       Percent

Other Answers: and on request pca or requested

specialist nurses who manage these patients also manage their pain relief              we have an acute pain service in the hospital but not covering neurosurgical unit will visit patients identified pre-operatively as likely to have complex analgesic requirements, those with pcas, or on request. they are available 5 days/week

192 response(s) , 10 No Answer(s)

Thank you for taking the time to complete this survey. If you have any other comments you would like to make or share please feel free to enter in the box below.

Although I find the use of NSAIDs acceptable, surgical tradition means we do not use  them perioperatively following craniotomies.

Although I’m not involved in theatre with these cases on a regular basis I do run the Acute Pain Team here. I’m not sure what the questions in the survey would have asked but our regime for these craniotomies is 1) iv paracetamol qds x 24h, then oral 2)NSAID  at 6 h if all is Ok and no other contraindication (omit any functional neurosurgical case). Continue regular x 48h and then review 3)oramorph 5 mg qds + 3hourly prn 5-10 mg 4) big push to encourage scalp block at end of op

Departmental guidelines are just to avoid prescribing codeine and to stick to oral morphine at a dose of 5 or 10 mg qds along with paracetamol. There are no guideline with regards to prescribing non steroidals although most patients do not seem to need them      Filled in on behalf of my colleagues. We are a children’s hospital so don’t anaesthetise  enough patients over the age of 16 to qualify!

I dont understand why I keep on finding codeine prescribed for perioperative analgesia  by surgical teams many thanks, best wishes

I use a lot of the analgesics listed but not routinely for most cases so my answers to your questions are limited to Paracetamol & Morphine. Each patient is different and I’m  happy using to use clonidine, fentanyl,scalp blocks, IV lidocaine, ketamine depending on the individual patient.

If unable to swallow, codeine, i.m. or p.r., still works. It is not part of the culture in Cardiff to use NSAIDS because )I think) they are regarded as unnecessary, rather than      hazardous. Adding NSAIDS at/after 4-hours-postop would be acceptable to me.

many thanks, there are craniotomies and craniotomies of course ……               Most patients will receive dexamethasone(i.e. a steroidal anti-inflammatory drug) during  surgery, and many will have this started pre-op and continued post-op.

my main work seems to be complex backs so whilst I DO CRANIOTOMIES they are not  monthly but come like buses.

One aspect of postoperative craniotomy pain is related to the use of head bandages.       These are frequently uncomofrtable, hot and aggravating.

Rct’s and dosing studies on paracoxib show it is safe for use in craniotomy patients however there is no improvement in 24hr opioid use. I do use scalp blocks but not for all my patients. From metaanalysis, there is only significant improvement in the first 4-6hrs  post op when compared to short acting opioids. Gabapentin is useful in some patient groups. Since using oxynorm intraop and in recovery 24hr use of morphine pca dropped to less than 15mg hence I no longer use this.

Recent word from Pain team is that our craniotomy patients are rarely in pain after craniotomy and rarely need more than simple oral analgesics or med strength opioids        on ward.

Surprised by your finding re incidence of post op pain. Firm believer in pre-emptive analgesia – iv paracetamol, oxycodone (10mg+) in anaesth room, LA infiltratration w Bupiv 0.5% pre-incision – not at end of surgery. Rescue analgesia in recovery –        oxycodone. Don’t use NSAIDS for “political” reasons. If pt dev post op haematoma, surgeons will immediately blame NSAIDS!!

The survey didn’t differentiate between regular and PRN analgesia. I routinely prescribe regular paracetamol/NSAIDs. Opioids are PRN.Oxycodone only if oramorph contra-   indicated. Just in case my answers are confusing! Apologies.

Use IM dyhydrocodeine when nmb post op too

We are unable to give intravenous opiates on the ward and oxycodone can only be            given after discussion with Acute Pain Service

We completely an audit in our unit a few years ago that showed supretentorial craniotomy was managed successfully with PRN s/c morphine rather than PCA which was not used regularly in the first 24hrs unlike posterior fossa craniotomy. We have now  moved to regular oromorph which is dispensable by one nurse instead of two a big advantage on a busy ward.      we have no IV preparation of NSAID other than parecoxib on our hospital formulary       Why this obsession with adult patients? Children are an important patient group and  those >8 yrs are accurate reporters of pain.

You did not give the option of im codeine in the dysphagic patient question!