Influence of Levobupivacaine Regional Scalp Block on Hemodynamic Stability, Intra- and Postoperative Opioid Consumption in Supratentorial Craniotomies: A Randomized Controlled Trial

Abstract

Background: The anesthetic management of supratentorial craniotomy necessitates tight intraoperative hemodynamic control. This type of surgery may also be associated to substantial postoperative pain. We aimed at evaluating the influence of regional scalp block (SB) on hemodynamic stability during the noxious events of supratentorial craniotomies and total intravenous anesthesia, its influence on intraoperative anesthetic agents' consumption, and its effect on postoperative pain control.Methods: Sixty patients scheduled for elective craniotomy were prospectively enrolled. Patient, anesthesiologist, and neurosurgeon were blind to the random performance of SB with either levobupivacaine 0.33% (Group SB, n=30) or the same volume of saline (Group CO, placebo group, n=30). General anesthesia was induced and maintained using target-controlled infusions of remifentanil and propofol that were adjusted according to hemodynamic parameters and State Entropy of the electroencephalogram (SE), respectively. Mean arterial pressure (MAP), heart rate (HR), SE, and propofol and remifentanil effect-site concentrations (Ce) were recorded at the time of SB (Baseline), and 0, 1, 3, and 5 minutes after skull-pin fixation (SP), skin incision (SI), craniotomy (CR), and dura-mater incision (DM). Morphine consumption and postoperative pain intensity (0-10 visual analogue scale, VAS) were recorded 1, 3, 6, 24 and 48 hours after surgery. Propofol and remifentanil overall infusion rates were also recorded. Data were analyzed using two-tailed Student unpaired t-tests, two-way mixed-design ANOVA and Tukey's HSD tests for post-hoc comparisons as appropriate.Results: Demographics and length of anesthetic procedure of Group CO and SB were comparable. SP, SI and CR were associated with a significantly higher MAP in Group CO than in Group SB, at least at one of the time points of recording surrounding those noxious events. This was not the case at DM. Similarly, HR was significantly higher in Group CO than in Group SB during SP and SI, at least at one of the points of recording, but not during CR and DM. Propofol and remifentanil Ce and overall infusion rates were significantly higher in Group CO than in Group SB, except for propofol 4 Ce during SP. Postoperative pain VAS and cumulative morphine consumption were significantly higher in Group CO than in Group SB.Conclusions: In supratentorial craniotomies, SB improves hemodynamic control during noxious events, and provides adequate and prolonged postoperative pain control as compared to placebo.

Effect of scalp nerve block with ropivacaine on postoperative pain in pediatric patients undergoing craniotomy: A randomized controlled trial

“…In our study, we found that SNB with 0.2% ropivacaine provided preferable analgesia which relieved postoperative pain for up to 8 h postoperatively. The previous studies showed the persistent analgesic time of SNB on postoperative pain was 4-48 h in adult craniotomy patients (12,15). The reasons for the different duration of SNB on postoperative pain may be related to the type of local anesthetic, the dose of local anesthetic, and the compound application of epinephrine.…”

“…The theory was that preemptive analgesia prior to surgery can prevent central sensitization caused by noxious stimuli and inflammation ( 19 , 20 ). Previous studies demonstrated that preoperative SNB has beneficial to postoperative pain in adult craniotomy patients ( 12 , 13 ). In our study, we found that SNB with 0.2% ropivacaine provided preferable analgesia which relieved postoperative pain for up to 8 h postoperatively.…”

“…SNB has been widely used as the principal anesthetic in awake craniotomies or served as an adjuvant method to general anesthesia in adult supratentorial craniotomies ( 13 , 14 ). SNB can attenuate postoperative pain, decrease opioid and narcotic agent consumption and prevent intraoperative hemodynamic responses to noxious stimulation ( 12 , 15 ). However, over the past decade, the studies of SNB mostly focused on adult craniotomy patients, and there are few studies of SNB in pediatric patients undergoing craniotomy.…”

“…Given the side effects of opioids, it is necessary to minimize reliance on opioid analgesia in craniotomy patients. Multimodal analgesia which combines low doses of systemic analgesics with local anesthetics for scalp infiltration or regional scalp nerve block has been proposed to prevent postoperative pain in adult craniotomy patients (11)(12)(13). However, the optimal postoperative analgesic management for pediatric craniotomy patients remains elusive.…”

Perioperative Considerations for Revascularization and Non-Revascularization Surgeries in Moyamoya Disease

“…Also, scalp block has been proven to be superior over a sham group (with saline) in terms of hemodynamic stability and decreased anesthetic requirement during cranial fixation [55,56]. Scalp block's effect also extends into the postoperative period and has proved to decrease the incidence and severity of postoperative pain [57]. In summary, the incorporation of regional anesthesia has led to a smooth intraoperative course and improved postoperative patient comfort.…”