gms | German Medical Science

Objective: For over 70 years, awake craniotomies have been part of treatment of gliomas located in so called “eloquent regions”. The patients’ compliance plays an important role in the success of each surgery. Finding the optimal balance between dosage and type of sedative, analgesic and anxiolytic drugs and keeping the patient clinically and neurologically assessable remains challenging. Different techniques are applied in neurooncology centres: “Asleep-awake-asleep” and “awake-awake-awake” are both techniques which have been used at the Department of Neurosurgery, University Hospital of Münster. Since 2013, we performed solely “awake-awake-awake” surgeries using the a2-receptor agonist, dexmedetomidine, as sole anaesthetic drug. The aim of this study was to compare both techniques and evaluate the clinical use of dexmedetomidine in the setting of awake craniotomies for glioma surgery.

Methods: We retrospectively analysed patients that were operated in the Department of Neurosurgery, University Hospital of Muenster either under “asleep-awake-asleep” using propofol-remifentanil sedation, or under “awake-awake-awake” conditions, using dexmedetomidine infusions. In the „asleep-awake-asleep“- group patients were intubated with laryngeal mask and extubated for the assessment period. Patients in the fully awake group were sedated with dexmedetomidine beyond the test phase. A scalp block was used in both conditions. We evaluated the electronical medical record and the digitalized anesthetic protocols from each patient. Adverse events, as well as applied drugs with doses and frequency of usage were recorded. Compliance was evaluated according to the surgeons’ perception.

Results: Two-hundred twenty-four (n=224) awake surgeries were performed in the period from october 2009 till september 2015. One-hundred eighty (n=180) of these were performed for the resection of gliomas and included into the study. In the “awake-awake-awake”- group (n=75) significantly less opiates (p<0.000), less vasoactive (p<0.000) and antihypertensive (p<0.000) drugs were used in comparison to the “asleep-awake-asleep”- group (n=105). In addition, compliance was much higher rated in the “awake-awake-awake”-group. Furthermore, the overall length of stay (p<0.000) and the surgical time (p<0.000) were significantly lower in the “awake-awake-awake” group.

Conclusion: Dexmedetomidine provides excellent setting for fully awake surgeries. Our experience shows that using dexmedetomidine as sole anaesthetic drug during awake craniotomies sedates moderately and acts anxiolytic. Thus, after ceasing infusion it enables quick and reliable clinical neurological assessment of patients. Furthermore, according to our experience, it reduces the length of hospital stay and duration of the whole surgical procedure.