title: ProSeal Laryngeal Mask Airway Attenuates Systemic and Cerebral Hemodynamic Response During Awakening of Neurosurgical Patients: A Randomized Clinical Trial.
abstract: BACKGROUND
  Extubation and emergence from anesthesia may lead to systemic and cerebral hemodynamic changes that endanger neurosurgical patients. We aimed to compare systemic and cerebral hemodynamic variables and cough incidence in neurosurgery patients emerging from general anesthesia with the standard procedure (endotracheal tube [ETT] extubation) or after replacement of the ETT with a laryngeal mask airway (LMA).
  
  
  METHODS
  Forty-two patients undergoing supratentorial craniotomy under general anesthesia were included in a randomized open-label parallel trial. Patients were randomized (sealed envelopes labeled with software-generated randomized numbers) to awaken with the ETT in place or after its replacement with a ProSeal LMA. We recorded mean arterial pressure as the primary endpoint and heart rate, middle cerebral artery flow velocity, regional cerebral oxygen saturation, norepinephrine plasma concentrations, and coughing.
  
  
  RESULTS
  No differences were found between groups at baseline. All hemodynamic variables increased significantly from baseline in both groups during emergence. The ETT group had significantly higher mean arterial pressure (11.9 mm Hg; 95% confidence interval [CI], 2.1-21.8 mm Hg) (P=0.017), heart rate (7.2 beats/min; 95% CI, 0.7-13.7 beats/min) (P=0.03), and rate-pressure product (1045.4; 95% CI, 440.8-1650) (P=0.001). Antihypertensive medication was administered to more ETT-group patients than LMA-group patients (9 [42.9%] vs. 3 [14.3%] patients, respectively; P=0.04). The percent increase in regional cerebral oxygen saturation was greater in the ETT group by 26.1% (95% CI, 9.1%-43.2%) (P=0.002), but no between-group differences were found in MCA flow velocity. Norepinephrine plasma concentrations rose in both groups between baseline and the end of emergence: LMA: from 87.5±7.1 to 125.6±17.3 pg/mL; and ETT: from 118.1±14.1 to 158.1±24.7 pg/mL (P=0.007). The differences between groups were not significant. The incidence of cough was higher in the ETT group (87.5%) than in the LMA group (9.5%) (P<0.001).
  
  
  CONCLUSIONS
  Replacing the ETT with the LMA before neurosurgical patients emerge from anesthesia results in a more favorable hemodynamic profile, less cerebral hyperemia, and a lower incidence of cough.
authors.affiliation: Departments of *Anesthesiology ‡Neurosurgery †Biostatistics and Data Management Platform, IDIBAPS, Hospital Clinic, de Barcelona, University of Barcelona, Barcelona, Spain.
authors.forename: Laura
authors.initials: L
authors.lastname: Perelló-Cerdà
authors.forename: Neus
authors.initials: N
authors.lastname: Fàbregas
authors.forename: Ana M
authors.initials: AM
authors.lastname: López
authors.forename: José
authors.initials: J
authors.lastname: Rios
authors.forename: Javier
authors.initials: J
authors.lastname: Tercero
authors.forename: Enrique
authors.initials: E
authors.lastname: Carrero
authors.forename: Paola
authors.initials: P
authors.lastname: Hurtado
authors.forename: Adriana
authors.initials: A
authors.lastname: Hervías
authors.forename: Isabel
authors.initials: I
authors.lastname: Gracia
authors.forename: Luis
authors.initials: L
authors.lastname: Caral
authors.forename: Nicolás
authors.initials: N
authors.lastname: de Riva
authors.forename: Ricard
authors.initials: R
authors.lastname: Valero
mesh_terms: D000762:Anesthesia Recovery Period; D000768:Anesthesia, General; D001921:Brain / Q000378:metabolism / Q000502:physiology* / Q000601:surgery; D002560:Cerebrovascular Circulation; D003399:Craniotomy; D005260:Female; D006339:Heart Rate; D006439:Hemodynamics; D006801:Humans; D007442:Intubation, Intratracheal; D017214:Laryngeal Masks; D008297:Male; D008875:Middle Aged