Surgical treatment and indications for surgery in patients with intracerebral hemorrhage are accurately determined and based on perennial researches in many countries. Currently, minimally invasive surgical treatment of hypertensive intracerebral hematomas (HIH) is actively used [1, 2]. However, data on anesthetic management are almost absent in numerous manuscripts devoted to surgical treatment of HIH. Importantly, previous stroke is associated with high anesthetic risk and the choice of anesthesia is also essential for the outcomes as adequate surgical treatment.
A significant number of patients is characterized by advanced age and severe comorbidities. Thus, general anesthesia under mechanical ventilation is associated with various complications: post-induction hypotension, hypertension at extubation, problems associated with weaning from ventilator in postoperative period, etc. Currently, regional anesthesia is used in neurosurgical patients with high anesthetic and surgical risk [3]. Regional anesthetic techniques in patients with hemispheric tumors and in functional neurosurgical interventions are well studied [4]. However, we did not find reports devoted to regional anesthesia in minimally invasive surgery of HIH in modern national and foreign literature. The aim of the study was to analyze application of regional anesthesia in minimally invasive surgery of hypertensive intracerebral hematomas.
Material and methods
Surgical interventions have been performed for the period from October 2017 to March 2019 at the neurosurgical department of the Emergency Hospital No. 1 of Omsk. Inclusion criteria: 1) age 55—85 years; 2) putaminal, subcortical, thalamic HIH 25—50 ml with or without intraventricular hemorrhage (IVH); 3) surgical intervention — endoscopic aspiration of HIH; 4) GCS score 9—15. Exclusion criteria: 1) GCS ≤ 8; 2) hematoma volume of more than 50 ml; 3) need for mechanical ventilation due to respiratory failure; 4) diabetes mellitus.
Patients were divided into 2 groups: total intravenous anesthesia with mechanical ventilation (n=45) and regional anesthesia (n=43). Patients of both groups were comparable by sex, age, duration of surgery and blood loss (Table 1).
Arterial hypertension was diagnosed in all patients. Concomitant diseases: chronic obstructive pulmonary disease (COPD) — 38% of patients in the 1st group and 43% of patients in the 2nd group; coronary artery disease with chronic heart failure — 45% of patients in the 1st group and 35% of patients in the 2nd group; heart rhythm disturbances — 14% and 10%, respectively; obesity grade I—II — 61% and 58% of patients, respectively.
In the 1st group, surgery was performed under intravenous anesthesia and mechanical ventilation. Induction of anesthesia was carried out using propofol 1—1.5 mg/kg and fentanyl 2—2.5 μg/kg. Tracheal intubation was performed after induction of anesthesia and muscle relaxation with pipecuronium 0.1 mg/kg or rocuronium 1 mg/kg. We did not use succinylcholine for muscle relaxation. Mechanical ventilation was carried out in controlled mechanical ventilation (CMV) mode (Chirana Venar ventilator) with semi-closed circuit and CO2 elimination by soda lime. Tidal volume was 6—8 ml/kg, respiratory rate — 12—14 per minute. Normocapnia was maintained by mechanical ventilation. Infusion of propofol and fentanyl was used to maintain anesthesia. Postoperative CT was carried out to control the quality of debridement of hematoma. Patients were transferred to the intensive care unit for awakening and further treatment.
Regional anesthesia was used in the second group (blockade of sensitive scalp nerves combined with infiltration by anesthetic solution). Ropivacaine 0.75% in a total dose of 225 mg was used as a local anesthetic. Blockade included unilateral right and left supraorbital nerve, auriculotemporal, posterior auricular, major and minor occipital nerves (Fig. 1).
Results
Conversion to open surgery and recurrent HIH were absent (Table 2).
In the 1st group, predominant intraoperative complication was arterial hypotension (n=3). Hypotension was post-induction as a rule and associated with depressive effect of propofol on the cardiovascular system. This complication was not observed in the second group. Severe drug-resistant arterial hypertension in the second group was observed in 1 patient during debridement of thalamic hematoma.
Pneumonia was 3 times more common in the first group (33%) that required long-term ventilation and tracheostomy. Thus, there were 9 tracheostomies (20%). In the second group, one patient required mechanical ventilation on the second postoperative day due to aggravation of respiratory failure associated with severe COPD. Tracheostomy was carried out in this patient.
Regional anesthesia was accompanied by intraoperative nausea and vomiting in 6 patients. In all cases, this event was caused by fast injection of irrigation fluid into the hematoma cavity that provoked increase of intracranial pressure and exacerbated general cerebral syndrome despite the preventive administration of antiemetics (metoclopramide 0.5% 2 ml or ondansentron 8 mg). There were no cases of aspiration of vomit.
Motor anxiety associated with fixed position (positional and emotional discomfort) was noted in 3 patients of the 2nd group. These patients needed deeper sedation.
Considering GOS data, regional anesthesia was associated with 4-fold decrease of mortality compared with the 1st group. Moreover, the number of patients with favorable recovery and moderate disabilities was 1.5 times more in the 2nd group.
Discussion
Hypertensive ICH is one of the most common complication of arterial hypertension. Minimally invasive surgery of HIH confirmed its advantage over conservative treatment [2, 5]. This technique is associated with smaller craniotomy, less injury of brain tissue, time of surgery and anesthesia, blood loss [1, 2, 6]. Thus, minimally invasive surgery is advisable in advanced age patients with multiple comorbidities. Epidemiological studies showed that pulmonary infectious complications are the most common in patients with HIH regardless type of surgical intervention [2, 7]. We obtained the same data in our trial. Pulmonary infectious complications (pneumonia, pleuritis) were diagnosed in 15 (33%) patients of the 1st group that required tracheostomy and prolonged mechanical ventilation. In the second group, pulmonary infectious complications were significantly less common (4 (9%) cases) and tracheostomy with prolonged mechanical ventilation was required in one patient. Theoretical opportunity of regional anesthesia in these patients and avoiding mechanical ventilation prompted us to use this technique. Regional anesthesia as a main method of intraoperative management solves some problems, but this approach also creates new ones. On the one hand, we completely eliminate stress associated with tracheal intubation and extubation and also solve the problem of postoperative weaning from ventilator. On the other hand, we can encounter inadequate intraoperative ventilation under spontaneous breathing and preserved consciousness [3]. Perhaps, solution of the problem of common pulmonary infectious complications in patients with hemorrhagic stroke is determined by optimal anesthetic management rather choosing of adequate surgical approach.
For a long time, there was an opinion that patients after neurosurgical interventions do not experience pain. Moreover, anesthesia was considered harmful [8]. There is significant variability of postoperative pain and need for anesthesia in neurosurgical patients. A recent review of 26 studies was devoted to various aspects of pain after craniotomy. According to 15 of these studies, analgesia within 2 postoperative days was necessary approximately in 60–96% of patients [9]. Careful balance between quick neurological assessment and optimal depth of sedation, prevention of hypercapnia and adverse effects of opiates such as vomiting and hypoventilation are required in the treatment of postoperative pain in neurosurgical patients. However, it should be recognized that opiates ensure postoperative comfort. Regional anesthesia in patients with HIH solves the problem of postoperative pain for 10-12 postoperative hours if modern local anesthetics (for example, ropivacaine 0.75%) are used. Perhaps, refusal of opiates in early postoperative period is also followed by reduced number of pulmonary infections.
Conclusion
1. Regional anesthesia is a feasible and effective method of anesthetic management of minimally invasive surgical interventions in patients with HIH.
2. Regional anesthesia is followed by reduced mortality, increased recovery rate with favorable neurological outcomes and reduced incidence of pulmonary infectious complications.
Authors’ participation:
V.G. Dashyan, S.S. Petrikov, S.V. Tsilina — concept and design of the study;
S.V. Tsilina, Ya.A. Shesterikov — surgeries, collection of data, analysis of data (including statistical processing), writing the text;
S.V. Tsilina, N.V. Govorova — review of the articles;
V.G. Dashyan, S.S. Petrikov, Ya.A. Shesterikov, S.V. Tsilina — writing the text;
V.G. Dashyan, S.S. Petrikov, N.V. Govorova — editing
The authors declare no conflicts of interest.
Commentary
I will note at once that this manuscript has made an extremely positive impression on me. Arterial hypertension is an extremely common clinical phenomenon among adults in Russia especially in males [1]. A consequence of this disease is a relatively high percentage of hypertensive intracerebral hematomas. Conventional clinical course of these patients is rather lamentable and includes neurosurgery (debridement of hematoma) under general anesthesia and mechanical ventilation, postoperative secondary complications (primarily, pulmonary ones) with prolonged ICU-stay, tracheostomy followed by death or disability. Amazingly, major anesthesiology with general anesthesia and mechanical ventilation designed to protect the patient becomes a significant factor of aggression per se. The authors’ clear merit is the fact that they tried to eliminate this factor of aggression via refusing general anesthesia, and they succeeded.
Study design is absolutely adequate. Two comparable groups of patients (by more than 40 patients) is a quite convincing material. The authors competently selected the end-points for evaluation of the results (incidence of postoperative pulmonary complications, postoperative mortality and disability). In my opinion, this is a brilliant example of a well-conducted clinical trial.
The results and conclusions are expectable, adequate and clinically important (3-fold decrease of the incidence of pulmonary complications and 4-fold decrease of mortality rate). Confucius wrote that the main thing is to understand the direction of life movement and in no case do not become across this movement. The authors of the article did so. The global trend to fast track surgical technologies including neurosurgery [2], refusal of mandatory use of general anesthesia [3] is now obvious.
In my opinion, there are several not principal remarks:
1. Exclusion of patients with diabetes mellitus. Probably, this decision was not really necessary. On the one hand, diabetes mellitus, especially type 2, is a common disease in advanced age patients. On the other hand, the authors could show another advantage of locoregional anesthesia (LRA) because exceptional endocrine and metabolic stability is one of the known characteristics of these anesthetic schemes [4].
2. Schemes of locoregional anesthesia. The authors list all the nerves used for blockade in the "methods" heading. However, it was hardly necessary in complete fashion in all patients because minimally invasive neurosurgery was applied. This moment is not clear.
3. Clofelin. Administration of central alpha-2 adrenergic agonist for sedation in the LRA group (clophelin) is certainly a reasonable solution. This measure potentiates analgesic effect of local anesthetics and ensures hemodynamic stability. However, bolus injection of clofelin, in my opinion, is not the most successful option. Now we have the best variant of intravenous infusion of dexmedetomidine [5—7]. Intravenous infusion is definitely more controllable, and dexmedetomidine differs from clofelin by its pharmacological properties due to subreceptor selectivity. The authors’ choice might be influenced by financial aspects.
4. The problem of post- and intraoperative nausea and vomiting. This problem was clear after LRA and there is nothing surprising here [8]. Acute changes of intracranial pressure (ICP) during endoscopic neurosurgery are a known phenomenon stimulating post- and intraoperative nausea and vomiting. This fact was confirmed in experimental and clinical trials [9—12]. In my opinion, solution to this problem lies in two planes: maximal prevention of acute ICP changes and more effective pharmacological prophylaxis of post- and intraoperative nausea and vomiting [13].
5. It would be desirable to point out solution of the problem of additional sedation and positional discomfort associated with LRA.
6. Postoperative pain relief. This is another advantage of anesthesia based on LRA. Surprisingly, this is a proven fact that postoperative pain remains significantly lower even after conventional craniotomy within 12 or even 24 hours after surgery. At the same time, effect duration of even local anesthetics such as ropivacaine and bupivacaine does not exceed 6 hours [14]. This is also of great clinical significance, although this aspect has not been quantified by the authors for some reason.
Conclusion. This is a well done and clinically relevant research. It is not so often that mortality rate in severe patients is reduced by 4 times. The authors managed to do it.
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A.Yu. Lubnin (Moscow, Russia)