Perioperative Considerations and Positioning for Neurosurgical Procedures: A Clinical Guide

Perioperative Considerations and Positioning for Neurosurgical Procedures: A Clinical Guide

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There are relationships that exist between neuroanesthesia, neurosurgical procedures, individual patient pathology and the positioning of a patient for said procedure.  A comprehensive examination of these relationships, their association with patient morbidity/mortality and how to approach these issues in an evidence-based manner has yet to become available. Positioning related injuries have been documented as major contributors to neurosurgical/neuroanesthesiology liability.
This text examines these relationships. It provides considerations necessary to the correct positioning of a patient for a neurosurgical procedure for each individual patient and their individual pathology. In other words, this text will demonstrate how to construct the necessary surgical posture for the indicated neurosurgical procedure given the individual constraints of the patient within the environment of anesthesia and conforming to existing evidence-based practice guidelines. Sections will address physiological changes inherent in positioning in relation to anesthesia for neurosurgical procedures, assessment of patient for planned procedure, as well as considerations for managing problems associated with these relationships. Additional sections will examine the relationship between neurosurgical positioning and medical malpractice and the biomechanical science between positioning devices and neurosurgical procedures.
Neurosurgery and its patient population are in a constant state of change. Providing the necessary considerations for the neurosurgical procedure planned under the anesthesia conditions planned in the position planned, often in the absence of multicase study literary support, without incurring additional morbidity is the goal of this text.

Association of Perioperative Statin Use With Mortality and Morbidity After Major Noncardiac Surgery

Metaanalysis indicated that the use of statins decreases the occurrence of cerebral vasospasm, whereas did not support a beneficial effect of statins on the occurrence of delayed ischemic neurological deficit (DIND), death or poor neurological outcomes in patients with aneurysmal SAH 1).

Statins have been shown to decrease aneurysm progression and rupture in two experimental settings: animals with cerebral aneurysm and humans with abdominal aortic aneurysms. AIMS: To investigate statin use and outcomes in humans with unruptured cerebral aneurysms through Medicare administrative data.
Bekelis et al. used a 40% random sample Medicare denominator file and corresponding inpatient, outpatient (2003-2011), and prescription (2006-2011) claims to conduct a retrospective cohort study of patients diagnosed with unruptured cerebral aneurysms, between 2003 and 2011. We used propensity score-adjusted models to investigate the association between statin use and risk of subarachnoid hemorrhage. Secondary analyses repeated the main models stratified on tobacco use status and separately assessed other composite outcomes.
They identified 28 931 patients with unruptured cerebral aneurysms (average age 72·0 years, 72·6% female); mean follow-up was 30·0 months; 41·3% used statins. Overall, 593 patients developed subarachnoid hemorrhage, and 703 underwent treatment before subarachnoid hemorrhage. Current or recent statin use was not associated with a difference in subarachnoid hemorrhage risk (odds ratio, 1·03; 95% conflict of interest 0·86-1·23); models stratified on tobacco use status were nearly identical. No association was observed between statin use and the composite outcome of subarachnoid hemorrhage or aneurysm treatment (odds ratio, 0·94; 95% conflict of interest, 0·84-1·06). The risk of subarachnoid hemorrhage or out-of-hospital death was lower among statin users (odds ratio, 0·69; 95% conflict of interest, 0·64-0·74).
Statin use by patients with unruptured cerebral aneurysms was not associated with subarachnoid hemorrhage risk. Given the prior animal experimental studies demonstrating a protective effect, further prospective studies are needed to investigate the potential relationship 2).

A retrospective, observational cohort analysis included 180 478 veterans undergoing elective or emergent noncardiac surgery (including vascular, general, neurosurgery, orthopedic, thoracic, urologic, and otolaryngologic) who were admitted within 7 days of surgery and sampled by the Veterans Affairs Surgical Quality Improvement Program (VASQIP). Patients were admitted to Department of Veterans Affairs hospitals and underwent 30-day postoperative follow-up. Data were collected from October 1, 2005, to September 30, 2010, and analyzed from November 28, 2013, to October 31, 2016.
Statin use on the day of or the day after surgery.
All-cause 30-day mortality (primary outcome) and standardized 30-day cardiovascular and noncardiovascular outcomes captured by VASQIP. Use of statins and other perioperative cardiovascular medications was ascertained from the Veterans Affairs Pharmacy Benefits Management research database.
A total of 180 478 eligible patients (95.6% men and 4.4% women; mean [SD] age, 63.8 [11.6] years) underwent analysis, and 96 486 were included in the propensity score-matched cohort (96.3% men; 3.7% women; mean [SD] age, 65.9 [10.6] years). At the time of hospital admission, 37.8% of patients had an active outpatient prescription for a statin, of whom 80.8% were prescribed simvastatin and 59.5% used moderate-intensity dosing. Exposure to a statin on the day of or the day after surgery based on an inpatient prescription was noted in 31.5% of the cohort. Among 48 243 propensity score-matched pairs of early perioperative statin-exposed and nonexposed patients, 30-day all-cause mortality was significantly reduced in exposed patients (relative risk, 0.82; 95% CI, 0.75-0.89; P < .001; number needed to treat, 244; 95% CI, 170-432). Of the secondary outcomes, a significant association with reduced risk of any complication was noted (relative risk, 0.82; 95% CI, 0.79-0.86; P < .001; number needed to treat, 67; 95% CI, 55-87); all were significant except for the central nervous system and thrombosis categories, with the greatest risk reduction (relative risk, 0.73; 95% CI, 0.64-0.83) for cardiac complications.
Early perioperative exposure to a statin was associated with a significant reduction in all-cause perioperative mortality and several cardiovascular and noncardiovascular complications. However, the potential for selection biases in these results must be considered 3).

1) Zhu RL, Chen ZJ, Li S, Lu XC, Tang LJ, Huang BS, Yu W, Wang X, Qian TD, Li LX. Statin-treated patients with aneurysmal subarachnoid haemorrhage: a meta-analysis. Eur Rev Med Pharmacol Sci. 2016 May;20(10):2090-8. PubMed PMID: 27249609.
2) Bekelis K, Smith J, Zhou W, MacKenzie TA, Roberts DW, Skinner J, Morden NE. Statins and subarachnoid hemorrhage in Medicare patients with unruptured cerebral aneurysms. Int J Stroke. 2015 Jun 29. doi: 10.1111/ijs.12559. [Epub ahead of print] PubMed PMID: 26120925.
3) London MJ, Schwartz GG, Hur K, Henderson WG. Association of Perioperative Statin Use With Mortality and Morbidity After Major Noncardiac Surgery. JAMA Intern Med. 2016 Dec 19. doi: 10.1001/jamainternmed.2016.8005. [Epub ahead of print] PubMed PMID: 27992624.
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