BackgroundMaintaining brain oxygenation status is the main goal of treatment in severe traumatic brain injury (TBI). Jugular venous oxygen saturation (SjvO2) monitoring is a technique to estimate global balance between cerebral oxygen supply and its metabolic requirement. Full Outline of Responsiveness (FOUR) score, a new consciousness measurement scoring, is expected to become an alternative for Glasgow Coma Scale (GCS) in evaluating neurologic status of patients with severe traumatic head injury, especially for those under mechanical ventilation.MethodsA total of 63 patients with severe TBI admitted to emergency department (ED) were included in this study. SjvO2 sampling was taken every 24 hours, until 72 hours after arrival. The assessment of FOUR score was conducted directly after each blood sample for SjvO2 was taken. Spearman’s rank correlation was used to determine the correlation between SjvO2 and FOUR score. Regression analysis was used to determine mortality predictors.ResultsFrom the 63 patients, a weak positive correlation between SjvO2 and FOUR score (r=0.246, p=0.052) was found upon admission. Meanwhile, strong and moderate negative correlation values were found in 48 hours (r=−0.751, p<0.001) and 72 hours (r=−0.49, p=0.002) after admission. Both FOUR score (p<0.001) and SjvO2 (p=0.04) were found to be independent mortality predictors in severe TBI.ConclusionThere was a negative correlation between the value of SjvO2 and FOUR score at 48 and 72 hours after admission. Both SjvO2 and FOUR score are independent mortality predictors in severe TBI.
PurposePostoperative urinary retention (POUR) is one of the most common complications following spinal anesthesia. Spinal anesthesia may influence urinary bladder function due to interruption of the micturition reflex. Urinary catheterization is the standard treatment of POUR. Urinary catheter insertion is an invasive procedure, which is associated with catheter-related infections, urethral trauma, and patient discomfort. The purpose of this study was to determine the effectiveness of intramuscular (IM) neostigmine to accelerate bladder emptying after spinal anesthesia.Patients and methodsA total of 36 patients undergoing lower abdominal (except for pelvic, urologic, anorectal, and hernia surgery) and lower extremity surgery under spinal anesthesia were divided into two groups randomly (n=18), to either neostigmine (N) group or control (C) group. Neostigmine 0.5 mg (N group) or NaCl 0.9% (C group) was administered intramuscularly when Bromage score 0 and sensory level sacral two have been achieved. The time to first voiding after IM injection and the time to first voiding after spinal anesthesia were measured.ResultsThe time to first voiding after IM injection was significantly faster (P≤0.05) in the N group than that in the C group, with median time as 40 minutes (20–70 minutes) and 75 minutes (55–135 minutes), respectively. Time to first voiding after spinal anesthesia was also significantly faster (P≤0.05) in the N group than that in the C group (mean of 280.8±66.6 minutes and 364.2±77.3 minutes, respectively).ConclusionIM neostigmine effectively accelerates bladder emptying after spinal anesthesia.
Object: Endotracheal intubation is the gold standard for ensuring a safe airway when applying general anesthesia. Endotracheal intubation can cause an increase in intracranial pressure (ICP). Ultrasound measurement of optic nerve sheath diameter (ONSD) is known as an accurate monitor of increased intracranial pressure. However, it is not known how the ICP fluctuations are caused by endotracheal intubation using various types of laryngoscopy. Therefore, the authors investigated the hemodynamic changes and intracranial pressure caused by the two types of laryngoscope used for endotracheal intubation in neurosurgical patients undergoing general anesthesia. Cases: The authors report 4 patients as a case series from the Central Operating Theatre (COT) of Sanglah General Hospital, Denpasar, Bali. We were performed optical nerve sheath diameter (ONSD) measurements on both eyeballs of those patients. All of the patients were performed general anaesthesia with endotracheal intubation. Correlation between ONSD and ICP measurements was determined, and changes were seen based on baseline data obtained from before intubation to 10 minutes after intubation. Sheath diameter more than 5.5 mm had a higher ICP value predicate than 15 mmHg with 100% sensitivity (95% CI, 100-100) and 100% specificity (95% CI, 100-100). Discussion: Our case series demonstrated a change in ICP in each patient endotracheal intubation with a McGrath video laryngoscope and a Macintosh laryngoscope, then the authors examined the optic nerve sheath by performing ultrasonography after induction before intubation (T0), 1 minute (T1), 3 minutes (T3), 5 minutes (T5) and 10 minutes after intubation (T10), which is known to increase ICP. In all patients ICP increased above normal values in baseline. There was a difference in diameter between the right and left eyes according to the location of each tumor. During tracheal manipulation, at first minute there was an increase in diameter in both eyes with ONSD increasing > 0,5 mm from the baseline value, and starting to decrease at 3, 5 minutes, and approaching or equal to the baseline value at 10 minutes. Conclusion: In neurosurgical patients undergoing general anesthesia with endotracheal intubation, laryngoscopy is unavoidable, the use of the type of laryngoscope should be carefully considered in order to select and use a better type of laryngoscope to prevent hemodynamic shock. Hemodynamic monitoring with patient monitors and ONSD ultrasonography is an accurate, simple, and rapid measure to detect ICP elevations and ICP changes in real time. Therefore, ONSD could be a useful tool for monitoring ICP, especially in conditions where invasive ICP monitoring is not available. Keywords: laryngoscope, hemodinamik, intracranial, ONSD, neurosurgery
Cerebellopontine angle (CPA) tumors are the most common neoplasms in the posterior fossa, accounting for 5-10% of intracranial tumors. Most CPA tumors are benign, with over 85% being vestibular schwannoma (acoustic neuromas). The preferred treatment for symptomatic vestibular schwannoma has been surgical excision. Craniotomy for vestibular schwannoma resections in lateral position gave better surgical field exposure, but also posed increased risk of ventilation-perfusion mismatch and atelectasis of the dependent lung in lengthy surgery. A 25 years old woman, with loss of hearing function, disturbed sense of balance, left hemiplegia, difficulties to swallow, on magnetic resonance imaging (MRI) examination had solid lesion in the cerebello-pontine angle size 5,6 cm x 5 cm x 4.5 cm which is diagnosed as Cerebello-pontine angle vestibular schwannoma sinistra. Patient underwent surgical resection in right lateral position under general anesthesia and the surgical resection performed in 6 hour 40 minutes. The goals of anesthetic management in vestibular schwannoma tumor resection are to facilitate ideal surgical condition and provide brain protection by maintaining cerebral perfusion pressure, avoid hemodynamic instability, enable intraoperative neuro-monitoring and ensure the early detection and prompt management of potential complications.
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