Anaesthesia for awake craniotomy--evolution of a technique that facilitates awake neurological testing.
BACKGROUND
There is an increasing trend towards performing craniotomy awake. The challenge for the anaesthetist is to provide adequate analgesia and sedation, haemodynamic stability, and a safe airway, with an awake, cooperative patient for neurological testing.


METHODS
The records of all patients who had awake craniotomy at our institution were reviewed. Patients were divided into three groups according to anaesthetic technique. Patients in Group 1 were sedated throughout the procedure. Patients in Groups 2 and 3 had an asleep-awake-asleep technique. Those in Group 2 were anaesthetized with a propofol infusion and fentanyl, and breathed spontaneously through a laryngeal mask airway (LMA). Patients in Group 3 had total i.v. anaesthesia with propofol and remifentanil, and ventilation was controlled using an LMA. We noted the incidence of complications in each group.


RESULTS
There were 99 procedures carried out between 1989 and 2002. Group 3 had the fewest complications. No patients in Group 3 developed hypercapnia (E'(CO(2)) >6 kPa), compared with all of the patients in Group 2. Patients in Group 1 had no E'(CO(2)) monitoring, but 7% developed airway obstruction. No patients in Group 3 required additional analgesia for pain, compared with 70% of patients in Group 2.


CONCLUSIONS
We have developed a technique for craniotomy, which facilitates awake neurological testing, is safe, and has good patient satisfaction.
Sarang
A
A
Department of Anaesthesia, Atkinson Morley's Hospital, Copse Hill, Wimbledon, London SW20 0NE, UK.
Dinsmore
J
J
D000293:Adolescent; D000328:Adult; D000368:Aged; D000701:Analgesics, Opioid; D000758:Anesthesia / Q000379:methods*; D019162:Anesthetics, Combined; D016292:Procedural Sedation / Q000379:methods*; D003399:Craniotomy / Q000379:methods*; D005260:Female; D005283:Fentanyl; D006439:Hemodynamics / Q000187:drug effects; D006801:Humans; D006935:Hypercapnia / Q000209:etiology; D006993:Hypnotics and Sedatives; D007431:Intraoperative Complications / Q000209:etiology; D017214:Laryngeal Masks; D008297:Male; D008875:Middle Aged; D010880:Piperidines; D015742:Propofol; D000077208:Remifentanil
D000701:Analgesics, Opioid; D019162:Anesthetics, Combined; D006993:Hypnotics and Sedatives; D010880:Piperidines; D000077208:Remifentanil; D005283:Fentanyl; D015742:Propofol