Best practice & research. Clinical anaesthesiology
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Fear of the side effects of analgesic drugs frequently leads to the under-treatment of post-craniotomy pain. Nevertheless, this pain continues to be commonly observed, is frequently severe, and, if unrelieved, may cause distress for the neurosurgical patient and serious complications for the operative brain. We review recent evidence-based data on pain therapy after intracranial surgery. ⋯ If titrated properly, opioids do not increase serious side effects as compared with codeine. The non-narcotics ketoprofen, tramadol, and paracetamol may be useful as supplemental, opioid-sparing drugs. There is a need for larger trials to delineate safety and efficacy of analgesic therapies with a focus on short- and long-term outcomes.
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Best Pract Res Clin Anaesthesiol · Dec 2007
ReviewPrevention and control of postoperative nausea and vomiting in post-craniotomy patients.
Postoperative nausea and vomiting (PONV) are the most frequent side-effects in the postoperative period, impairing subjective well-being and having economic impact due to delayed discharge. However, emetic symptoms can also cause major medical complications, and post-craniotomy patients may be at an increased risk. A review and critical appraisal of the existing literature on PONV in post-craniotomy patients, and a comparison of these findings with the current knowledge on PONV in the general surgical population, leads to the following conclusions: (1) Despite the lack of a documented case of harm caused by retching or vomiting in a post-craniotomy patient, the potential risk caused by arterial hypertension and high intra-abdominal/intra-thoracic pressure leading to high intracranial pressure, forces to avoid PONV in these patients. (2) There is unclarity about a specifically increased (or decreased) risk for PONV in post-craniotomy patients compared with other surgical procedures. (3) The decision whether or not to administer an antiemetic should not be based primarily on risk scores for PONV but on the likelihood for potential catastrophic consequences of PONV. ⋯ This also impacts upon the meaning of meta-analyses performed with trials that showed marked heterogeneity and inconclusive results. (5) No studies on the treatment of established PONV are available. This highlights the need to transfer knowledge about PONV treatment from other surgical procedures. (6) Despite the possibility that PONV in post-craniotomy patients can be triggered by specific conditions (e.g. surgery near the area postrema at the floor of the fourth ventricle with the vomiting centre located nearby), recommendations based on trials in post-craniotomy patients may be flawed. Thus, general knowledge on prevention and treatment of PONV must adopted for craniotomy settings.
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Neurosurgical patients frequently develop respiratory complications, adversely affecting neurologic outcome and survival. The review summarizes current literature and management of respiratory complications associated with brain injury. ⋯ Further studies are warranted to elucidate an optimal oxygenation and ventilation in brain-injured patients, weaning strategies, predictors of the failed weaning and extubation, respiratory support in patients with difficulties to wean, and early tracheostomy.
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Recovery from general anaesthesia is a period of intense stress for patients: there is sympathetic activation, catecholamine release, and increase in blood pressure or heart rate. Stressful events increase cerebral blood flow and cerebral oxygen consumption, potentially producing elevation of intracranial pressure and thus, favouring cerebral insults. Measures to prevent agitation, hypertension, shivering, and coughing are therefore very well justified in neurosurgical patients. ⋯ An awake patient is the best and the cheapest neuromonitoring available. If, after surgery, a patient does not rapidly recover consciousness, or a focal neurological deficit becomes apparent, a head CT-scan should be performed as soon as possible to rule out a neurosurgical complication. Close monitoring during the first 24 hours after craniotomy is mandatory.
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Best Pract Res Clin Anaesthesiol · Dec 2007
ReviewPrevention and treatment of homeostatic disorders after central neurosurgical procedures.
Prevention and treatment of homeostatic disorders after central neurosurgical procedures requires a coordinated effort by the entire medical team caring for the patient. The goal of management is to optimize physiologic and metabolic variables so that patient outcome is improved. This chapter reviews current knowledge and clinical approaches to prevention and treatment of general homeostatic disorders that commonly complicate the postoperative course of neurosurgical patients after general anesthesia. Practice recommendations based on current clinical trials and experience will be made on the following topics: therapeutic approaches to optimal hemoglobin, cerebral blood flow and hemorrheology; prophylaxis and treatment of thrombosis; temperature management including rewarming and the control of shivering; use and side effects of anticonvulsants and corticosteroids; and therapeutic approaches to optimal serum glucose levels.