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Correspondence J Neurosurg Anesthesiol  Volume 29, Number 3, July 2017

case 2, occlusion of the P1 segment by a has practice implications (up to 90% studies were included nally.6,7 The 144
temporary clip in the operation room or prevalence in strabismus surgeries; inu- patients included were divided into 2
balloon occlusion in the radiology suite ence on the functional outcome4). Latest groups: 1 with deeper anesthesia (CSI/
may cause ischemia in the midbrain and research implies a strong correlation be- BIS <50) (n = 88) and 1 with light
the thalamus, especially in the cortico- tween the depth of anesthesia and TCR,5 anesthesia (CSI/BIS > 50) (n = 56)
spinal bers, the occulomotor nerve nu- underlining treatment with deeper nar- (Tables 1 and 2). Anesthesia was
cleus. Both MEP and VEP monitoring cosis instead of anticholinergic drugs.2 maintained by volatile narcotics only
will be very useful in detecting ischemia The aim of this study was to evaluate (sevourane/desurane). As in some
resulting from the P1 segment. Patients and review the standard treatment of clinics, it is still common to pretreat
with PCA infarcts usually have hemi- TCR, with special reference to the depth patients with anticholinergic drugs to
anopia, hemiparesis, and sensory dis- of anesthesia. lower their vagal potential and thereby
turbances.4 As literature does not exist A systematic literature review the prevalence of TCR; 84 patients
on this subject, we believe that in pa- was performed from January 1995 to were premedicated with atropine i.m.
tients undergoing PCA aneurysm endo- October 2015, using the terms 0.01 mg/kg.
vascular coiling or surgical clipping, the trigemino-cardiac reex, trigeminal There was a signicantly lower
intraoperative evoked potential mon- cardiac reex, and oculocardiac re- prevalence of TCR in the CSI/BIS r50
itoring modality must take into con- ex in PubMed (MEDLINE) and group (22.7%) than in the CSI/BIS >
sideration the location of the temporary EMABASE (OvidSP) databases. TCR 50 group (67.9%) (w2 [1, N = 144] =
clip/balloon occlusion; monitoring with was dened as a >10% decrease in heart 28.976, P = 7.3289E 8), demonstrat-
both MEP and VEP was more eective rate or induced arrhythmia; inclusion ing a 2.21 times higher risk for TCR
in detecting ischemia. criteria were the fulllment of 2 major under light anesthesia (Tables 1 and
criteria (plausibility and reversibility)3 2). The same signicant dierence was
Nilima R. Muthachen, DM
and availability of the exact cerebral state seen in patients with atropine pre-
index (CSI)/bi-spectral index score (BIS) treatment; the prevalence in the CSI/
Manikandan Sethuraman,
values and exact values of hemodynamic BIS r50 group was 21.4% and in
MD, PDCC, (Neuroanesthesia)
Department of Anesthesiology, Division changes. Data extraction were made by 2 the CSI/BIS > 50 group 71.4% (w2
of Neuroanesthesiology, Sree Chitra independent reviewers (k > 0.8). [1, N = 84] = 19.788, P = 9.0E 6).
Tirunal Institute for Medical Sciences and Three of the 4 articles included In this analysis, we highlight
Technology, Trivandrum, Kerala, India reported a clinical prevalence of TCR light anesthesia as an independent risk
during strabismus and neurosurgery.58 factor for a higher prevalence of pe-
REFERENCES Because of strong dierences (TCR- ripheral TCR and a signicantly lower
1. Hamada J, Morioka M, Yano S, et al. Clinical type, age, procedure, anesthesia), only 2 use of atropine as the treatment for
features of aneurysms of the posterior cerebral
artery: a 15-year experience with 21 cases.
Neurosurgery. 2005;56:662670.
2. Wang H, Du R, Stary J, et al. Dissecting TABLE 1. Analysis of All Patients6,7
aneurysms of the posterior cerebral artery: current
endovascular/surgical evaluation and treatment CSI/BISr50 All CSI/BIS > 50 All
strategies. Neurosurgery. 2012;70:15811588. Patients Patients RR NNT v2
3. Goehre F, Jahromi BR, Hernesniemi J, et al. Patients (n) 88 56
Characteristics of posterior cerebral artery TCR (n) 20 38 0.334 2.21 P = 7.3289E8
aneurysms: an angiographic analysis of 93 Non-TCR (n) 68 18
aneurysms in 81 patients. Neurosurgery. Atropine as treatment 1 (1.4) 4 (2.9)
2014;75:134144. (n [%])
4. Kumral E, BayulkemG, Akyol A, et al.
Mesencephalic and associated posterior cir- Signicance of bold value is provided by the w2-test.
culation infarcts. Stroke. 2002;33:22242231. BSI indicates bi-spectral index score; CSI, cerebral state index; NNT, number needed to treat; RR, relative
risk; TCR, trigemino-cardiac reex.

The Trigemino-cardiac
Reflex: Is Treatment With TABLE 2. Analysis of Patients With Atropine Pretreatment6,7
Atropine Still Justified? CSI/BISr50 CSI/BIS > 50
Pretreated Patients Pretreated Patients RR NNT v2
To JNA Readers: Patients (n) 56 28
Trigemino-cardiac reex (TCR) is TCR (n) 12 20 0.299 2 P = 9.0E6
Non-TCR (n) 44 8
a well-established brainstem reex13 that Atropine as 0 0
treatment (n)
The authors have no funding or conicts of BSI indicates bi-spectral index score; CSI, cerebral state index; NA, not available; NNT, number needed to
interest to disclose. treat; RR, relative risk; TCR, Trigemino-cardiac reex.
DOI: 10.1097/ANA.0000000000000324

372 | Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.

Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.

J Neurosurg Anesthesiol  Volume 29, Number 3, July 2017 Correspondence

bradycardia in deep anesthesia. We, 8. Etezadi F, Orandi AA, Orandi AH, et al. each) of water orally to placate them
therefore, recommend adequate depth Trigeminocardiac reflex in neurosurgical and allow the completion of surgery.
practice: An observational prospective
of anesthesia to prevent the occur- study. Surg Neurol Int. 2013;4:116.
Various factors make these pa-
rence of TCR in high-risk procedures. tients prone to intraoperative dehy-
We also recommend the following dration. Mandatory fasting before
standard treatment of TCR: 1. im- surgery is one of the main reasons
mediately cease surgical manipulation; causing dryness of the mouth and the
2. reassess the depth of anesthesia; 3. Intense Intraoperative throat. The American Society of Anes-
administer anticholinergic drugs only thesiologists recommends fasting from
in case of persistent asystole or repet- Thirst: A Neglected the intake of clear liquids for at least 2
itive TCR. hours before elective procedures re-
Concern during Awake quiring general/regional anesthesia or
Craniotomy Surgeries sedation/analgesia (ie, monitored anes-
Cyrill Meuwly, MMed* thesia care).3 Avoiding unnecessary
Tumul Chowdhury, MD, DM, prolongation of the fasting period and
To JNA Readers: allowing clear uids till the stipulated
FRCPCw The advantages of optimal re-
Ricardo Gelpi, MD, PhDz period ensures adequate hydration per-
section over the eloquent cortex, con- ioperatively. Diuretics (mannitol) used
Paul Erne, MD* stant communication with patients,
Bernhard Schaller, MD, PhD, DSCy to reduce the brain volume can poten-
reduced hospital stay, less resource uti- tiate dehydration. High ambient tem-
*Department of Research, University
Hospital Basel, Basel, Switzerland
lization, and higher patient satisfaction1,2 peratures and low humidity caused by
wDepartment of Anaesthesiology and have enhanced the popularity of the overhead lights in operation theaters
Perioperative Medicine, University of awake craniotomy technique for tumor enhance insensible losses from mucosal
Manitoba, Winnipeg, Canada excision, epilepsy, and deep-brain stim- surfaces. Thus, stringent regulation of
zDepartment of Pathology, University of ulation surgeries. Commonly, these cases operation theaters temperatures and
Buenos Aires, Buenos Aires, Argentina are conducted under scalp block (with humidity should be ensured, especially
yDepartment of Research, University of local anesthetics) along with conscious in tropical climates, to provide opti-
Southampton, Southampton, UK sedation using drugs such as opioids mum comfort and prevent moisture
(fentanyl, remifentanil), midazolam, loss. Oxygen supplementation through
propofol, or dexmedetomidine. The ap- a face mask or nasal prongs should
plication of these unconventional tech- utilize adequately humidied oxygen to
REFERENCES niques has led to the emergence of newer prevent drying of the oral mucosa.
1. Schaller B, Probst R, Strebel S, et al. clinical dilemmas, which hitherto were Anticholinergic drugs such as glyco-
Trigeminocardiac reflex during surgery in not observed under general anesthesia as pyrrolate have antisialogogue eects
the cerebellopontine angle. J Neurosurg. consciously sedated patients are able to
1999;90:215220. and can cause appreciable dry mouth.
2. Chowdhury T, Ahuja N, Schaller B. Severe
verbalize. Unless absolutely indicated, they should
bradycardia during neurosurgical procedure: We wish to report our experi- be avoided during awake surgeries.
depth of anesthesia matters and leads to a ences with 2 patients who were un- Dexmedetomidine, which is extensively
new surrogate model of the trigeminocardiac dergoing awake craniotomies under used during conscious sedation, in-
reflex: a case report. Medicine (Baltimore). bilateral scalp blocks and intravenous
2015;94:e2118. cludes dry mouth in its side-eect pro-
3. Meuwly C, Golanov E, Chowdhury T, et al. dexmedetomidine sedation. Midway le.4Although uncommon, fentanyl
Trigeminal cardiac reflex: new thinking model through the surgery, both the patients administration may cause xerostomia.5
about the definition based on a literature started complaining of severe dryness The success of awake craniotomy
review. Medicine (Baltimore). 201594:e484. of mouth and demanded drinking
4. Hahnenkamp K, Honemann CW, Fischer LG, largely depends on patients cooperation.
et al. Effect of different anaesthetic regimes on
water. Severe thirst caused signicant Preventing distress and ensuring opti-
the oculocardiac reflex during paediatric stra- restlessness and anxiety in these pa- mum intraoperative comfort contributes
bismus surgery. Paediatr Anaesth. 2000;10: tients. Repeated verbal explanations immensely to the smooth conduct of this
601608. and assurances failed to pacify these novel technique. With the widespread
5. Meuwly C, Chowdhury T, Sandu N, et al. patients and the surgery had to be
Anesthetic influence on occurrence and use of conscious sedation for awake
treatment of the trigemino-cardiac reflex: a interrupted repeatedly. The distress craniotomies, underrated problems such
systematic literature review. Medicine (Bal- made the patients agitated and raised as intraoperative thirst are surfacing.
timore). 2015;94:e807. apprehensions of them hurting them- These scenarios should be anticipated
6. Karaman T, Demir S, Dogru S, et al. The selves, as their heads were xed with
effect of anesthesia depth on the oculocar- beforehand and should be explained
diac reflex in strabismus surgery. J Clin
pins over frames. Ultimately, we had sympathetically during preoperative
Monit Comput. 2015. to administer 2 small aliquots (10 mL counseling. The above-mentioned fac-
7. Yi C, Jee D. Influence of the anaesthetic tors, which can aggravate intraoperative
depth on the inhibition of the oculocardiac
reflex during sevoflurane anaesthesia for The authors have no funding or conicts of thirst and dryness, should be modied
paediatric strabismus surgery. Br J Anaesth. interest to disclose. suitably according to the existing local
2008;101:234238. DOI: 10.1097/ANA.0000000000000327 practices. In addition, as continuous

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Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.