gms | German Medical Science

Objective: The asleep-awake-technique generally used for awake craniotomy involves narcotics that carry the risk of hemodynamic instabilities, respiratory depression, and airway obstruction. Agitation or disorientation may occur, and alertness, co-operation and test performance can be impaired. We questioned the actual need for sedation, when analgesia is guaranteed by cranial nerve blocks, and adequate attendance and therapeutic communication is provided.

Methods: Deep confidence and therapeutic relation were established preoperatively. Scalp blocks were performed with 30 ml of 0.75% ropivacaine (+1/200000 epinephrine). Unconfined presence and attention were affirmed by continuous physical contact, e.g. hand-in-hand. The therapeutic communication was based on utilization of the patient's natural trance state, avoidance of negative suggestions, dissociation to a personal "safe place", utilization of patient`s responses, reframing of noises and sensations, enhancement of individual coping strategies, activation of inner resources, and verbal and nonverbal positive suggestions. Propofol and remifentanil were held in stand-by, but used following the principle to give only as much as needed by the patient.

Results: 50 awake craniotomies were performed on patients at the age of 14 to 75 years following the awake-awake protocol, without drop-outs, signs of stress or complications. No sedatives, and no (12 / 50) or only small amounts (mean total of 124 μg) of remifentanil were used. All patients showed permanent full alertness, so tests could be performed at any time without delay. Only 1 out of 8 patients with intraoperative seizures had to be continued in general anaesthesia. A vasovagal reaction occurred in one patient with realization of the real surgical environment that was reversed by re-orientation to the "safe place". All patients reported lack of stress or discomfort, and would agree in repetition of that procedure if necessary.

Conclusions: With adequate guidance and communication it turned out that patients did not need any sedation and only minimal analgesics in addition to scalp blocks. Therefore, this new and unique protocol has proven to be feasible, and can be named "awake-awake-technique". Avoidance of sedatives offers a unique chance to study the reaction of the brain to surgical trauma aside pharmacological effects. Further studies must clarify, if the achieved high intraoperative alertness and test performance lead to better surgical results and neurological outcomes.