Rigorous anaesthesia management protocol for patients with intracranial arterial stenosis: a prospective controlled-cohort study

Azim N Laiwalla, Yinn Cher Ooi, Barbara Van De Wiele, Keren Ziv, Adam Brown, Raymond Liou, Jeffrey L Saver, Nestor R Gonzalez, Azim N Laiwalla, Yinn Cher Ooi, Barbara Van De Wiele, Keren Ziv, Adam Brown, Raymond Liou, Jeffrey L Saver, Nestor R Gonzalez

Abstract

Objectives: Reducing variability is integral in quality management. As part of the ongoing Encephaloduroarteriosynangiosis Revascularisation for Symptomatic Intracranial Arterial Stenosis (ERSIAS) trial, we developed a strict anaesthesia protocol to minimise fluctuations in patient parameters affecting cerebral perfusion. We hypothesise that this protocol reduces the intraoperative variability of targeted monitored parameters compared to standard management.

Design: Prospective cohort study of patients undergoing encephaloduroarteriosynangiosis surgery versus standard neurovascular interventions. Patients with ERSIAS had strict perioperative management that included normocapnia and intentional hypertension. Control patients received regular anaesthetic standard of care. Minute-by-minute intraoperative vitals were electronically collected. Heterogeneity of variance tests were used to compare variance across groups. Mixed-model regression analysis was performed to establish the effects of treatment group on the monitored parameters.

Setting: Tertiary care centre.

Participants: 24 participants: 12 cases (53.8 years ± 16.7 years; 10 females) and 12 controls (51.3 years ± 15.2 years; 10 females). Adults aged 30-80 years, with transient ischaemic attack or non-disabling stroke (modified Rankin Scale <3) attributed to 70-99% intracranial stenosis of the carotid or middle cerebral artery, were considered for enrolment. Controls were matched according to age, gender and history of neurovascular intervention.

Main outcome measures: Variability of heart rate, mean arterial blood pressure (MAP), systolic blood pressure and end tidal CO2 (ETCO2) throughout surgical duration.

Results: There were significant reductions in the intraoperative MAP SD (4.26 vs 10.23 mm Hg; p=0.007) and ETCO2 SD (0.94 vs 1.26 mm Hg; p=0.05) between the ERSIAS and control groups. Median MAP and ETCO2 in the ERSIAS group were higher (98 mm Hg, IQR 23 vs 75 mm Hg, IQR 15; p<0.001, and 38 mm Hg, IQR 4 vs 32 mm Hg, IQR 3; p<0.001, respectively).

Conclusions: The ERSIAS anaesthesia protocol successfully reduced intraoperative fluctuations of MAP and ETCO2. The protocol also achieved normocarbia and the intended hypertension.

Trial registration number: NCT01819597; Pre-results.

Keywords: NEUROSURGERY; STROKE MEDICINE.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Figures

Figure 1
Figure 1
Flow diagram of patients examined for eligibility and included in the ERSIAS (Encephaloduroarteriosynangiosis Revascularization for Symptomatic Intracranial Arterial Stenosis) group. ICAS, intracranial arterial stenosis.
Figure 2
Figure 2
Box plot of end point vitals per group. Distribution of 3 219 917 data points obtained by minute-to-minute electronic data collection in 24 patients (12 ERSIAS and 12 matched controls). HR, heart rate; ETCO2, end tidal CO2; MAP, mean arterial blood pressure; SBP, systolic blood pressure.

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