Anesthesiology

Neurological complications after cardiac surgery: anesthetic considerations based on outcome evidence Purpose of review Neurological complications after cardiac surgery remain prevalent. This review aims to discuss the modifiable and outcome-relevant risk factors based on an up-to-date literature review, with a focus on interventions that may improve outcomes. Recent findings There is a close relationship between intraoperative blood pressure and postoperative neurological outcomes in cardiac surgical patients based on cohort studies and randomized controlled trials. Adopting an optimal and personalized blood pressure target is essential; however, the outstanding issue is the determination of this target. Maintaining cerebral tissue oxygen saturation at least 90% patient's baseline during cardiac surgery may be beneficial; however, the outstanding issues are effective intervention protocols and quality outcome evidence. Maintaining hemoglobin at least 7.5 g/dl may be adequate for cardiac surgical patients; however, this evidence is based on the pooled results of thousands of patients. We still need to know the optimal hemoglobin level for an individual patient, which is of particular relevance during the decision-making of transfusion or not. Summary The available evidence highlights the importance of maintaining optimal and individualized blood pressure, cerebral tissue oxygen saturation and hemoglobin level in improving neurological outcomes after cardiac surgery. However, outstanding issues remain and need to be addressed via outcome-oriented further research. Correspondence to Wei Mei, MD, Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Road, Wuhan 430030, China. Tel: +86 27 83662673; e-mail: wmei@hust.edu.cn Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Anesthesia and brain tumor surgery: technical considerations based on current research evidence Purpose of review Anesthetics may influence cancer recurrence and metastasis following surgery by modulating the neuroendocrine stress response or by directly affecting cancer cell biology. This review summarizes the current evidence on whether commonly used anesthetics potentially affect postoperative outcomes following solid organ cancer surgery with particular focus on neurological malignancies. Recent findings Despite significant improvement in diagnostic and therapeutic technology over the past decades, mortality rates after cancer surgery (including brain tumor resection) remains high. With regards to brain tumors, interaction between microglia/macrophages and tumor cells by multiple biological factors play an important role in tumor progression and metastasis. Preclinical studies have demonstrated an association between anesthetics and brain tumor cell biology, and a potential effect on tumor progression and metastasis has been revealed. However, in the clinical setting, the current evidence is inadequate to draw firm conclusions on the optimal anesthetic technique for brain tumor surgery. Summary Further work at both the basic science and clinical level is urgently needed to evaluate the association between perioperative factors, including anesthetics/technique, and postoperative brain tumor outcomes. Correspondence to Daqing Ma, Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital 369 Fulham Road, London SW10 9NH, UK. Tel: +44 203315 8495; fax: +44 203315 5109; e-mail: d.ma@imperial.ac.uk Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Neuroanesthesia and outcomes: evidence, opinions, and speculations on clinically relevant topics Purpose of review The objective of this review is to identify outstanding topics most relevant to neuroanesthesia practice and patient outcomes. We discuss the role of awake craniotomy, choice of general anesthetic agents, monitoring of anesthetic 'depth', mannitol-induced diuresis, neurophysiological monitoring, hyperventilation, and cerebral hypoperfusion. Recent findings Awake craniotomy, although a technique likely underused, is associated with enhanced recovery after surgery and prolonged survival after brain tumor resection compared with surgery under general anesthesia. The choice of general anesthetic must balance patient and surgical factors. Although propofol may be associated with favorable oncologic outcomes, currently available retrospective evidence does not specifically address neurosurgical patients. Both the definition and monitoring of anesthetic 'depth' remains elusive. Neuroanesthesiologists need to recognize and manage intraoperative light anesthesia in a timely fashion. Further evidence related to the optimal management of mannitol-induced diuresis and hyperventilation in neurosurgical patients is needed. Contemporary neurophysiological monitoring can reasonably detect intraoperative neurologic injury; however, its effect on patient outcome is unclear. Finally, cerebral hypoperfusion without stroke may be common; however, the clinical significance requires further investigation. Summary We provide an overview of several topics that are relevant to neuroanesthesia practice and patient outcomes based on evidence, opinions, and speculations. Our review highlights the need for further outcome-oriented studies to specifically address these clinically relevant issues. Correspondence to Lingzhong Meng, MD, Professor and Division Chief, Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, TMP 3, PO Box 208051, New Haven, CT 06520, USA. Tel: +1 203 785 2802; e-mail: lingzhong.meng@yale.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Anaesthesia for stroke thrombectomy: technical considerations based on outcome evidence Purpose of review Stroke is the second leading cause of death and the third leading cause of disability worldwide. Treatment is time limited and delays cost lives. This review discusses modern stroke management, during a time when treatments and guidelines are rapidly evolving. Recent findings Stroke thrombectomy has become the therapy of choice for large vessel occlusion (LVO) strokes. Perfusion imaging techniques, both computed tomography (CT) and MRI, now allow treatment beyond a set time window in specific patients. Both general anaesthesia and conscious sedation are options for patients undergoing stroke thrombectomy. Summary An individualized approach to the patient's anaesthetic management is optimal, and depends on close communication with the neurointerventionalist regarding patient and procedure-specific variables. No specific anaesthetic agent is preferred. Guiding principles are minimization of time delay, and maintenance of cerebral perfusion pressure. Correspondence to David L. McDonagh, MD, 5323 Harry Hines Blvd., Dallas, TX, USA. Tel: +1 214 648 6400; e-mail: David.mcdonagh@utsouthwestern.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Neurophysiological monitoring during neurosurgery: anesthetic considerations based on outcome evidence Purpose of review This article reviews the recent outcome studies that investigated intraoperative neurophysiological monitoring (IONM) during spine, neurovascular and brain tumor surgery. Recent findings Several recent studies have focused on identifying which types of neurosurgical procedures might benefit most from IONM use. Despite conflicting literature regarding its efficacy in improving neurological outcomes, many experts have advocated for the use of IONM in neurosurgery. Several themes have emerged from the recent literature: the entire perioperative team must always work together to ensure adequate communication and intervention; systems and checklists, in which each member of the perioperative team has a clearly defined role, can be useful in the event of a sudden intraoperative changes in electrophysiological signals; regardless of the IONM modality used, any sudden change in electrophysiological signal should prompt an immediate and appropriate intervention; a multimodal IONM approach is often, but not always, advantageous over a single IONM approach. Summary For neurosurgical procedures that can be complicated by neural injury, the use of IONM should be considered according to specific patient and surgical factors. Future studies should focus on improving IONM technology and optimizing sensitivity and specificity for detecting any impending neural damage. Correspondence to Shaun E. Gruenbaum, MD, PhD, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL 32224, USA. Tel: +1 904 956 3398; e-mail: gruenbaum.shaun@mayo.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Awake craniotomy: anesthetic considerations based on outcome evidence Purpose of review This review highlights anaesthesia management options for awake craniotomy and discusses the advantages and disadvantages of different approaches, intraoperative complications and future directions. Recent findings For lesions located within or adjacent to eloquent regions of the brain, awake craniotomy allows maximal tumour resection with minimal consequences on neurological function. Various techniques have been described to provide anaesthesia or sedation and analgesia during the initial craniotomy, and rapid return to consciousness for intraoperative testing and tumour resection; there is no evidence that one approach is superior to another. Although very safe, awake craniotomy is associated with some well recognized complications; most are minor and self-limiting or easily reversed. In experienced hands, failure of awake craniotomy occurs in fewer than 2% of cases, irrespective of anaesthesia technique. Although brain tumour surgery remains the most common indication for awake craniotomy, the technique is finding utility in other neurosurgical procedures. Summary Several anaesthetic approaches are available for the management of patients during awake craniotomy. The choice of technique should be based on individual patient factors, location and duration of surgery, and anaesthesiologist expertise and experience. Appropriate patient selection and excellent multidisciplinary team working is associated with high levels of procedural success and patient satisfaction. Correspondence to Martin Smith, MBBS, FRCA, FFICM, Department of Neuroanaesthesia and Neurocritical Care Unit, The National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London WC1N 3BG, UK;. E-mail: martin.smith@ucl.ac.uk Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Anesthesia and airway management for gastrointestinal endoscopic procedures outside the operating room Purpose of review To review the anesthestic and airway management for gastrointestinal procedures outside of the operating room. Recent findings The number of gastrointestinal endoscopic procedures performed is steadily increasing worldwide. As complexity, duration and invasiveness of procedures increase, there is ever greater requirement for deeper sedation or general anesthesia. A close relationship between anesthetic practitioners and endoscopists is required to ensure safe and successful outcomes. The American Society of Gastrointestinal endoscopy and the British Society of Gastroenterology have recently released guidelines for sedation and general anesthesia in gastrointestinal endoscopy, highlighting the need for careful monitoring for all cases, and anesthetic expertise in complex cases. The recent advances in high-flow nasal oxygenation in sedation may provide alternative options for oxygenation during gastrointestinal sedation, especially in deep sedation and this may reduce the need for general anesthesia. Summary The advances in gastrointestinal endoscopic intervention have increased the requirement for deep sedation and anesthetic involvement outside of the operating room. Careful titration of anesthetic intervention and close monitoring are required to ensure patient safety. Correspondence to Jaideep J. Pandit, St John's College, Oxford OX1 3JP, UK. Tel: +44 1865 221590; e-mail: jaideep.pandit@dpag.ox.ac.uk Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Anesthesia practice for endovascular therapy of acute ischemic stroke in Europe Purpose of review Anesthetic assistance is often required during endovascular therapy (EVT) of large vessel occlusion in patients with acute ischemic stroke. It is currently debated whether EVT should be performed under general anesthesia or conscious sedation. This review will summarize the recent literature with emphasis on the influence of anesthesia method on neurological outcome. Recent findings Recent randomized trials have reported no difference in outcome after EVT performed under either conscious sedation or general anesthesia. This is in contrast to a substantial number of retrospective studies, which found that EVT performed under general anesthesia was associated with a worse neurologic outcome compared with conscious sedation. Anesthetic drugs affect vessel tone and the level of blood pressure may influence outcome. The most favorable choice of anesthetic agents and ventilatory strategy is still debated. Summary The optimal anesthetic practice for EVT remains to be identified. Currently, conscious sedation is often an easy first-line strategy, but general anesthesia can be considered an equal and safe alternative to conscious sedation when there is a carefully administered anesthetic that maintains strict hemodynamic control. Attention to ventilation is advocated. The presence of a specialized neuroanesthesiologist or otherwise dedicated anesthesia personnel is highly recommended. Correspondence to Mads Rasmussen, Section of Neuroanesthesia, Department of Anesthesia, Aarhus University Hospital, Nørrebrogade 44, 8000 Aarhus C, Denmark. Tel: +45 30566977; e-mail: mads.rasmussen@vest.rm.dk Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Nonoperating room anesthesia education: preparing our residents for the future Purpose of review Nonoperating room anesthesia (NORA) is the fastest growing segment of anesthetic practice. This review provides an overview of knowledge and trends that will need to be introduced to residents as part of their education. Recent findings Topics for the future include, but are not limited to, new medications, artificial intelligence and big data, monitoring depth of hypnosis, translational innovation and collaboration, demographic changes, financial driving forces, destination hubs, medical tourism, and new approaches to education training and self-management. Summary Implementing new medical technologies for anesthesia outside the operating room will help to successfully master this ever evolving subspecialty. Anesthesiologists require specific preparation for the diverse settings that they will encounter during their training. In this rapidly changing field, cognitive fitness must be factored into teaching and evaluation of residents. We describe the most important topics to consider when educating anesthesiology residents, and highlight research that addresses upcoming challenges. Correspondence to Steven D. Boggs, MD, MBA, Department of Anesthesiology, The University of Tennessee School of Health Sciences Memphis, Chandler Building, Suite 600, 877 Jefferson Avenue, Memphis, TN 38103, USA. Tel: +1 901 448 5988; e-mail: sboggs6@uthsc.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Anesthesia-administered sedation for endoscopic retrograde cholangiopancreatography: monitored anesthesia care or general endotracheal anesthesia? Purpose of review The decision to undertake monitored anesthesia care (MAC) or general endotracheal anesthesia (GEA) for patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) is influenced by many factors. These include locoregional practice preferences, procedure complexity, patient position, and comorbidities. We aim to review the data regarding anesthesia-administered sedation for ERCP and identify the impact of airway management on procedure success, adverse event rates and endoscopy unit efficiency. Recent findings Several studies have consistently identified patients at high risk for sedation-related adverse events during ERCP. This group includes those with higher American Society of Anesthesiologists class and (BMI). ERCP is commonly performed in the prone position, which can make the placement of an emergent advanced airway challenging. Although this may be alleviated by performing ERCP in the supine position, this technique is more technically cumbersome for the endoscopist. Data regarding the impact of routine GEA on endoscopy unit efficiency remain controversial. Summary Pursuing MAC or GEA for patients undergoing ERCP is best-approached on an individual basis. Patients at high risk for sedation-related adverse events likely benefit from GEA. Larger, multicenter randomized controlled trials will aid significantly in better delineating which sedation approach is best for an individual patient. Correspondence to Zachary L. Smith, DO, University Hospitals Digestive Health Institute, 11100 Euclid Ave, Wearn 2nd Floor, Cleveland, OH 44106, USA. Tel: +1 216 844 6172; fax: +1 216 844 7480; e-mail: zachary.smith2@uhhospitals.org Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Alexandros Sfakianakis
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