Day 2 :
Johns Hopkins Bayview Medical Center, USA
Keynote: Awake craniotomy anesthesia: A comparison between the monitored anesthesia care (MAC) versus the asleep-awake-asleep (AAA) technique
Time : 09:30-10:00
Punita Tripathi was a practicing Cardiac Anesthesiologist at the All India Institute of Medical Sciences (AIIMS), New Delhi, before moving to USA in 1996. Thereafter, she completed her Residency in Anesthesiology from Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA in 2002. Since 2002, she is a Faculty at the Johns Hopkins University, Baltimore. For the past five years, she has been Director of Neurosurgical Anesthesia at Johns Hopkins Bayview Medical Center and has been actively involved in writing protocols for Awake Craniotomy and Anesthesia for neurosurgical cases. Her areas of research interests are as follows: Neurosurgical Anesthesia, Thoracic Anesthesia and Obstetric Anesthesia. She has authored papers in many reputed journals and has written book chapters.
Introduction: Awake craniotomy (AC) with intraoperative brain mapping, allows for maximum tumor resection while monitoring neurological function. It is used for lesions involving the eloquent areas of the brain, such as Broca's, Wernicke’s, or the primary motor area. Common techniques used are monitored anesthesia care (MAC), using an unprotected airway, or the asleep-awake-asleep (AAA) technique, using a partially or totally protected airway. Comparative analysis between the MAC and AAA technique in a consecutive series of patients undergoing the removal of an eloquent brain lesion is being presented.
Method: Approved by the appropriate Institutional Review Board (IRB), requirement for written informed consent was waived by the IRB. A prospective data collection and subsequent retrospective data analysis was conducted on 81 patients who underwent an awake craniotomy for an eloquent brain lesion over a nine year period. Fifty patients underwent anesthesia with the monitored anesthesia care (MAC) technique and 31 patients underwent the asleep-awake-asleep (AAA) technique by a single surgeon and a team of anesthesiologists. The monitored anesthesia care technique included, and was based on, no set protocol for sedation, different medications for MAC based on the comfort level of anesthesiologist, requirements of the patient and whether the scalp block is working well. Nose was sprayed with phenylephrine and the posterior pharynx was sprayed with lidocaine; the nasopharyngeal airway was coated with 5% lidocaine ointment which was then inserted into the more patent nostril, connected to the anesthesia circuit for oxygenation. For the AAA technique, propofol was used for induction, followed by laryngeal mask airway placement (LMA). An anesthesia circuit was attached to the LMA with the anesthesia being maintained with sevoflurane until the patient was spontaneously ventilating and asleep. A complete scalp block of the supraorbital, supratrochlear, auriculotemporal, zygomatico-temporal, greater occipital, lesser occipital and greater auricular nerves was performed by the neurosurgeon or anesthesiologist (Figure 1) in all patients. Infiltrative block was performed at the pinning site and also the incision site. After craniotomy, local anesthesia was infiltrated around the nerves supplying the dura mater by the surgeons.
Results: Similar preoperative patient characteristics were observed in the two groups (Table 1). Operative time was shorter in the MAC group (283.5 mins.) versus the AAA (313.3 mins, p=0.038), by about 30 minutes. Hypertension was the most common intraoperative complication (MAC: 8% vs. AAA: 9.7%, p=0.794). Intraoperative seizures incident were 4% in the MAC group and 3.2% in the AAA group (p=0.858). Awake cases conversion to general anesthesia occurred in none of the MAC groups and 3.2% of the AAA cohort (p=0.201). No cases were aborted in either of the cohorts (Table 2). Mean hospital stay was 3.98 and 3.84 days in the MAC and AAA group, respectively (p=0.833) (Table 3).
Conclusion: Successful awake craniotomy requires cooperation between the surgeon and anesthesiologists, a working scalp block and infiltrative block, a good understanding of airway management and sedation protocol, as well as the ability to manage adverse intraoperative issues. Both MAC and AAA provide safe and effective anesthetic management for awake craniotomy.
University of Saskatchewan, Canada
Time : 10:00-10:30
Samar Tabl is a Clinical Associate Professor at the University of Saskatchewan, Canada. She is a Graduate of the Faculty of Medicine, Ain Shams University, Cairo, Egypt, and has trained in both Egypt and Canada. She holds both Masters and PhD Degrees in Clinical Anaesthesia. She also did a Research Fellowship in Obstetric Anaesthesia at Mount Sinai Hospital, University of Toronto, Canada. Her areas of research interests include: Obstetric Anaesthesia, Ultrasound Guided Regional Techniques in Obstetric Anesthesia, Airway Management and Simulation Education.
Purpose: The purpose of the study was to compare the efficacy of two doses of carbetocin—20 mcg and 100 mcg—in women undergoing elective cesarean delivery.
Methods: The study was conducted as a randomized double-blinded, non-inferiority study in women undergoing elective cesarean delivery under spinal anesthesia. They were randomized into two groups to receive either 20 mcg or 100 mcg of carbetocin, intravenously upon delivery of the anterior shoulder of the baby. Uterine tone was assessed by obstetrician at two and five minutes after carbetocin administration, according to a numerical verbal scale of 0 to 10 (0=atonic uterus and 10=firm uterus). If the uterine tone was considered unsatisfactory by the obstetrician and additional uterotonic was deemed necessary, this was administered according to usual practice at our hospital (oxytocin and/or ergot and/or hemabate). The primary outcome was the uterine tone at two minutes after carbetocin administration. While, the secondary outcomes were uterine tone at five minutes, use of additional uterotonics within 24 hours, blood loss, hypo/hypertension, brady/tachycardia, nausea/vomiting, chest pain/shortness of breath, headache and flushing.
Results: There was no significant difference in the uterine tone [mean (SD)] at two minutes between 20 mcg [7.5 (1.9)] or 100 mcg [8.0 (1.5)] groups (p=0.06). Nine patients required additional uterotonics in the 20 mcg group, versus seven patients in the 100 mcg group (p=0.53). There was no significant difference in the uterine tone at five minutes in the two groups or the incidence of side effects. The mean (SD) estimated blood loss was 889.6 (536.2) mL in 20 mcg and 795.4 (428.8) mL in 100 mcg group (p=0.33).
Conclusion: Our study suggests carbetocin 20 mcg is not inferior to 100 mcg in producing adequate uterine tone in women undergoing elective cesarean delivery. Further studies are warranted in women at risk for postpartum hemorrhage.
Wake Forest University, USA
Keynote: The combined use of acellular urinary bladder matrix with negative pressure for treatment of complex lower extremity wound coverage
Time : 10:30-11:00
Claire Dillingham is a Board-Certified Plastic and Reconstructive Surgeon. She is currently, the Medical Director of Safety and Quality at her local hospital. She was the Medical Director of a wound care facility for five years. She teaches advanced techniques in wound care management to Surgery and Medicine residents. Her focus is on the patient as a whole for improving nutritional status, body dynamics, diabetic control, treatment of peripheral vascular disease, compression of lower extremities, and implementation of advanced wound care modalities.
Statement of the Problem: Patients with complex wounds can be a challenge to heal. The longer the wound is present the higher the complication rates which can lead to severe infections, loss of function, loss of a limb and even death. Traditional methods of wound healing have a place in initial wound care such as wet to dry saline gauze dressing changes. However, the implementation of this treatment requires an available and capable person to do the dressing change three times a day which is often not an option. The aging population also means higher rates of comorbid diseases which contribute to poor healing.
Purpose: The purpose of this study is to review the essentials in wound healing and describe the treatment modality of Acellular Urinary Bladder matrix (UBM) (MatriStem, ACell Inc. Columbia, MD, USA) with negative pressure therapy (KCI) for complex wounds.
Methodology & Theoretical Orientation: A retrospective review was performed of 4 patients with complex lower extremity wounds. All patients were treated with surgical debridement of the wound and placement of ACell (MiroMatrix powder and Multilayer Wound Matrix sheet) and negative pressure wound therapy. Two patients had traumatic wounds. One patient had diabetes and a previous contralateral below knee amputation. One patient had diabetes and pyoderma gangrenosum. The patients were evaluated weekly and the dressing changed weekly. Additional Acell was applied if there was a remaining deficit in the depth of the wound.
Findings: Closure was achieved in all four cases with the combined treatment of Acell and negative pressure therapy. Patients expressed pain relief and convenience with once a week dressing changes.
Conclusion & Significance: In the treatment of complex wounds, porcine urinary bladder matrix devices offer an option that has shown advantages to traditional modalities with successful closure and aesthetically acceptable results.