Correspondence
About Bill Young: A Personal Note To JNA Readers: The intellectual ferment that marked the emergence of Neurosurgical Anesthesia as a defined subspecialty of Anesthesiology in the late 1960s and early 1970s was indeed exhilarating. This enthusiasm became remarkably contagious as the organizational aspects of Neurosurgical Anesthesia progressed in the United States and Canada with the formation of the Society of Neurosurgical Anesthesia (SNA), the forerunner of the present day SNACC.1 Before too long, like the dragons teeth of ancient Green mythology, Neuroanesthesia Fellowship Programs sprung-up seemingly out of nowhere. Another factor enhancing this spiritual brew was the active participation of many young neurosurgeons, a number of whom became leaders in the SNA-SNACC as well as Neurosurgical Departmental Chairs in the future. Our open membership policy encouraged and also allowed for many of our female members to participate in all organizational areas. It was within this intellectual context that Bill Young carried out his Neuroanesthesia Fellowship. I first met Bill when he was a Fellow in Neuroanesthesia at Columbia University and remember a rather shy respectful individual, easy to talk with, as we “schmoozed” during a break at a SNACC meeting. I was trying to find out his interests and to also keep the conversation going and mentioned some of the work I was doing and what I had carried out in the past. In passing, I brought up the scientific activity in the area of the isolation and subsequent transplantation of the mammalian brain and the near decade it took to accomplish the task with my neurosurgical colleague Robert J. White.2 Wow! It was like opening the steeply imbedded floodgates as Bill interjected one knowledgeable question often another, to the point where we continued our conversations intermittently during The authors have no funding or conflicts of interest to disclose.
408 | www.jnsa.com
J Neurosurg Anesthesiol
the next day. During our talks, Bill was not only interested in the physiological rationale and sequence of brain transplantation but he wanted to know about immunologic problems and posed unanswerable questions about levels of consciousness, memory, and basic philosophical teasers about the “soul.” As if this was not enough of a challenge, Bill Young was extraordinarily knowledgeable when I mentioned that some science-fiction writers had written stories about our brain transplantation work. In fact, Bill exploded with enthusiasm, having a very good knowledge of the history of science fiction. So in the wink of an eye, we were both discussing Mary Wollenscraft and the contribution of Galvani’s experiment stimulating the frog’s leg with an electric current to the development of the monster, Frankenstein, Edger Allen Poe, H.G. Wells, Jules Verne, Ray Bradbury, and legions of others. In fact, in 1977, I remember alerting Bill to a story in Analog Science Fiction titled, Ender’s Game, by Orson Scott Card, which was just published in full text in 1991 and which I sent to Bill as a gift. To my mind, I have always believed that an active imagination acts as an incubator of ideas, which Bill never appeared to lack. Along with our discussions concerning medicine, theology, mathematics, philosophy, and SciFi, Bill was of course most appreciative of and knowledgeable about music, and as a lover of the classical composers and opera, I was overwhelmed with the ease that he was able to move from the classics to Jazz. A bond that also connected us was the love we both had for languages, especially, some of the more modern writers in the German and Spanish idiom going back to Thomas Mann, Gunter Grass, Erich Remarque, Jorge Borges, Garcia Lorca, and Pablo Neruda. I don’t want to neglect the area of science, but the moving tribute to the memory of Bill Young by David Warner and William Lanier that appeared in the January 2014 issue of the JNA more than adequately covered this aspect of this extraordinary individual.3 I will, however, recommend that one should take a few moments to read the tongue-in-cheek sardonic, yet prophetic critique of our specialty written in a rhythm that Bill would probably
Volume 26, Number 4, October 2014
call punk-rock with a tinge of Jonathan Swift-Cacophony added, titled “Neuroanesthesia—A Look Into the Future,” that appeared in Anesthesiology Clinics of North America in September, 1992.4 This wonderful evaluation of our subspecialty as well as a peek into the future warrants an evaluation that suborns the purpose of this essay, but I must say that the ease in which Bill Young moves from the philosophy of science to considerations of anesthesia mortality and then leaping from hints of genomics to outcomes evaluation, buttressed by a protean selection of references from classical literature, philosophy, and even including the film director, Woody Allen, all indicate the wonderful uniqueness of Bill Young. My, how this Sci-Fi-Guy wunderkind will be missed! Maurice S. Albin, MD, MSc (Anes)* *Department of Anesthesiology University of Alabama, Birmingham, AL
REFERENCES 1. Albin MS. Celebrating silver: the genesis of a Neuroanesthesiology society NAS-SNANCCSNACC. J Neurosurg Anesthesiol. 1997;9: 296–307. 2. White RJ, Albin MS, Davidson E, et al. Brain transplantation: prolonged survival of brain after carotid-jugular interposition. Science. 1965;150:779–781. 3. Warner DS, Lanier WL. Mr. Piano Man: reflections on the life of a physician, scientist, and humanitarian, William L. Young, MD (1954-2013). J Neurosurg Anesthesiol. 2014;26:1–3. 4. Young WL. Neuroanesthesia: a look into the future. Anesthesiol Clin North America. 1992;10:727–746.
Monitored Anesthesia Care With Dexmedetomidine for Chronic Subdural Hematoma Surgery To JNA Readers: Chronic subdural hematoma (CSH) is one of the most common clinical entities encountered in daily neurosurgical practice. However, local anesthesia for surgical treatment of The authors have no funding or conflicts of interest to disclose. r
2014 Lippincott Williams & Wilkins
J Neurosurg Anesthesiol
Volume 26, Number 4, October 2014
Correspondence
1
2
3
4
5
6
7
Extremely dissatisfied
Dissatisfied
Somewhat dissatisfied
Undecided
Somewhat Satisfied
Satisfied
Extremely satisfied
FIGURE 1. A 7-point Likert-like verbal rating scale for the assessment of patients’ satisfaction with intraoperative analgesia.
CSH is not consistently comfortable for either patient or surgeon. Monitored anesthesia care (MAC) can provide adequate sedation and analgesia, facilitate patient comfort, and surgical competence during the procedure. Its safety and efficacy have been proven by numerous studies. Guzel et al1 first reported 24 surgical treatment of CSH under MAC by combination use of midazolam and fentanyl. However, this combination could cause intraoperative respiratory depression.2 In contrast, dexmedetomidine is a highly selective a2 adrenoceptor agonist with both sedative and analgesic properties, and is devoid of a respiratory depressant effect.3 These properties make dexmedetomidine an attractive agent for sedation during MAC for the CSH surgery. We report a case of a 63-year-old man presenting with deterioration of motor function in his right limbs since 2 weeks; he denied a history of head trauma in the last several weeks/ months. His past medical history included hypertension and COPD. Neurological examination showed right hemiparesis with motor strength grade 3. The computed tomography scans documented a large subdural homogenous mixed with hypodense collection of the left hemisphere. Surgery was performed in a similar manner as Santarius4 under MAC on the second day after admission. No premedication was given on arrival in the operation room, and patient’s heart rate, arterial blood pressure, oxygen saturation, respiratory rate, and ECG were monitored. Oxygen was administered by face masks at 4 L/ min, a loading dose dexmedetomidine 1 mg/kg over 10 minutes followed by a continuous infusion of 0.2 to 0.5 mg/kg/ h using an infusion pump. The target end point was a patient having Ramsay Sedation Score = 3. The patient was stable and smooth during the whole surgery. Intraoperative heart rate and mean arterial pressure were lower than r
2014 Lippincott Williams & Wilkins
baseline values, and respiratory rate and SpO2 were normal. No respiratory depression, significant lower heart rate, and mean arterial pressure were observed. After the completion of surgery, the patient and surgeon were asked to answer the question “How would you rate your experience with the analgesia you have received during surgery?” using a 7-point Likert-like verbal rating scale (Fig. 1); both were satisfied with the anesthetic management, scores were 6 and 7, respectively; neurological status was evaluated as normal at discharge. CSH is predominantly a disease of the elderly, and coexisting systemic disease usually poses a problem for general anesthesia. The advantages claimed for the use of local anesthesia, including increased safety, shorter recovery period, and reduced cost when compared with general anesthesia; the main limitation is patient discomfort related to pain, neck position, and noise in the room. MAC is attractive because it involves less physiological disturbance and allows more rapid recovery than general anesthesia. Currently, MAC is commonly used in various surgical procedures, but airway complications impede the application of MAC in neurosurgical procedures. Dexmedetomidine is unique in that it causes less respiratory depression than other sedatives.5 Dexmedetomidine is a highly selective a2 receptor agonist with properties of analgesia, sympatholysis, and titrating sedation. It reduces opioid requirements and stress response to surgery, ensuring a stable hemodynamic state. Dexmedetomidine is increasingly being used as a sedative for MAC in various clinical fields, such as sedation in the intensive care unit, radiologic examination of pediatric patients, awake intubation, shockwave lithotripsy, and endoscopic examination. Our study suggests that an adequate level of sedation is desirable to make CSH surgery more tolerable to the patient and easier to perform for the surgeon. MAC with dexmedetomidine led to comparable
satisfaction compared with general anesthesia, and its can be safely used. Xiao-Ping Xu, MD Cong Liu, MD Qian Wu, MD Department of Neurosurgery, The First People’s Hospital of Neijiang, Neijiang Sichuan, China
REFERENCES 1. Guzel A, Kaya S, Ozkan U, et al. Surgical treatment of chronic subdural haematoma under monitored anaesthesia care. Swiss Medical Weekly. 2008;138:398–403. 2. American Society of Anesthesiologists Task Force on Sedation and Analgesia by NonAnesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. 2002;96:1004–1017. 3. Ramsay MA, Luterman DL. Dexmedetomidine as a total intravenous anesthetic agent. Anesthesiology. 2004;101:787–790. 4. Santarius T, Kirkpatrick PJ, Ganesan D, et al. Use of drains versus no drains after burr-hole evacuation of chronic subdural haematoma: a randomised controlled trial. Lancet. 2009;374:1067–1073. 5. Martin E, Ramsay G, Mantz J, et al. The role of the alpha2-adrenoceptor agonist dexmedetomidine in postsurgical sedation in the intensive care unit. J Intensive Care Med. 2003;18:29–41.
Anesthesia With Antiamoebic Effects: Can Anesthesia Choice Affect the Clinical Outcome of Granulomatous Amoebic Encephalitis due to Acanthamoeba spp.? To JNA Readers It is distressing that despite advances in antimicrobial chemotherapy, the mortality rate associated with The authors have no funding or conflicts of interest to disclose.
www.jnsa.com |
409
About Bill Young: A Personal Note To JNA Readers: The intellectual ferment that marked the emergence of Neurosurgical Anesthesia as a defined subspecialty of Anesthesiology in the late 1960s and early 1970s was indeed exhilarating. This enthusiasm became remarkably contagious as the organizational aspects of Neurosurgical Anesthesia progressed in the United States and Canada with the formation of the Society of Neurosurgical Anesthesia (SNA), the forerunner of the present day SNACC.1 Before too long, like the dragons teeth of ancient Green mythology, Neuroanesthesia Fellowship Programs sprung-up seemingly out of nowhere. Another factor enhancing this spiritual brew was the active participation of many young neurosurgeons, a number of whom became leaders in the SNA-SNACC as well as Neurosurgical Departmental Chairs in the future. Our open membership policy encouraged and also allowed for many of our female members to participate in all organizational areas. It was within this intellectual context that Bill Young carried out his Neuroanesthesia Fellowship. I first met Bill when he was a Fellow in Neuroanesthesia at Columbia University and remember a rather shy respectful individual, easy to talk with, as we “schmoozed” during a break at a SNACC meeting. I was trying to find out his interests and to also keep the conversation going and mentioned some of the work I was doing and what I had carried out in the past. In passing, I brought up the scientific activity in the area of the isolation and subsequent transplantation of the mammalian brain and the near decade it took to accomplish the task with my neurosurgical colleague Robert J. White.2 Wow! It was like opening the steeply imbedded floodgates as Bill interjected one knowledgeable question often another, to the point where we continued our conversations intermittently during The authors have no funding or conflicts of interest to disclose.
408 | www.jnsa.com
J Neurosurg Anesthesiol
the next day. During our talks, Bill was not only interested in the physiological rationale and sequence of brain transplantation but he wanted to know about immunologic problems and posed unanswerable questions about levels of consciousness, memory, and basic philosophical teasers about the “soul.” As if this was not enough of a challenge, Bill Young was extraordinarily knowledgeable when I mentioned that some science-fiction writers had written stories about our brain transplantation work. In fact, Bill exploded with enthusiasm, having a very good knowledge of the history of science fiction. So in the wink of an eye, we were both discussing Mary Wollenscraft and the contribution of Galvani’s experiment stimulating the frog’s leg with an electric current to the development of the monster, Frankenstein, Edger Allen Poe, H.G. Wells, Jules Verne, Ray Bradbury, and legions of others. In fact, in 1977, I remember alerting Bill to a story in Analog Science Fiction titled, Ender’s Game, by Orson Scott Card, which was just published in full text in 1991 and which I sent to Bill as a gift. To my mind, I have always believed that an active imagination acts as an incubator of ideas, which Bill never appeared to lack. Along with our discussions concerning medicine, theology, mathematics, philosophy, and SciFi, Bill was of course most appreciative of and knowledgeable about music, and as a lover of the classical composers and opera, I was overwhelmed with the ease that he was able to move from the classics to Jazz. A bond that also connected us was the love we both had for languages, especially, some of the more modern writers in the German and Spanish idiom going back to Thomas Mann, Gunter Grass, Erich Remarque, Jorge Borges, Garcia Lorca, and Pablo Neruda. I don’t want to neglect the area of science, but the moving tribute to the memory of Bill Young by David Warner and William Lanier that appeared in the January 2014 issue of the JNA more than adequately covered this aspect of this extraordinary individual.3 I will, however, recommend that one should take a few moments to read the tongue-in-cheek sardonic, yet prophetic critique of our specialty written in a rhythm that Bill would probably
Volume 26, Number 4, October 2014
call punk-rock with a tinge of Jonathan Swift-Cacophony added, titled “Neuroanesthesia—A Look Into the Future,” that appeared in Anesthesiology Clinics of North America in September, 1992.4 This wonderful evaluation of our subspecialty as well as a peek into the future warrants an evaluation that suborns the purpose of this essay, but I must say that the ease in which Bill Young moves from the philosophy of science to considerations of anesthesia mortality and then leaping from hints of genomics to outcomes evaluation, buttressed by a protean selection of references from classical literature, philosophy, and even including the film director, Woody Allen, all indicate the wonderful uniqueness of Bill Young. My, how this Sci-Fi-Guy wunderkind will be missed! Maurice S. Albin, MD, MSc (Anes)* *Department of Anesthesiology University of Alabama, Birmingham, AL
REFERENCES 1. Albin MS. Celebrating silver: the genesis of a Neuroanesthesiology society NAS-SNANCCSNACC. J Neurosurg Anesthesiol. 1997;9: 296–307. 2. White RJ, Albin MS, Davidson E, et al. Brain transplantation: prolonged survival of brain after carotid-jugular interposition. Science. 1965;150:779–781. 3. Warner DS, Lanier WL. Mr. Piano Man: reflections on the life of a physician, scientist, and humanitarian, William L. Young, MD (1954-2013). J Neurosurg Anesthesiol. 2014;26:1–3. 4. Young WL. Neuroanesthesia: a look into the future. Anesthesiol Clin North America. 1992;10:727–746.
Monitored Anesthesia Care With Dexmedetomidine for Chronic Subdural Hematoma Surgery To JNA Readers: Chronic subdural hematoma (CSH) is one of the most common clinical entities encountered in daily neurosurgical practice. However, local anesthesia for surgical treatment of The authors have no funding or conflicts of interest to disclose. r
2014 Lippincott Williams & Wilkins
J Neurosurg Anesthesiol
Volume 26, Number 4, October 2014
Correspondence
1
2
3
4
5
6
7
Extremely dissatisfied
Dissatisfied
Somewhat dissatisfied
Undecided
Somewhat Satisfied
Satisfied
Extremely satisfied
FIGURE 1. A 7-point Likert-like verbal rating scale for the assessment of patients’ satisfaction with intraoperative analgesia.
CSH is not consistently comfortable for either patient or surgeon. Monitored anesthesia care (MAC) can provide adequate sedation and analgesia, facilitate patient comfort, and surgical competence during the procedure. Its safety and efficacy have been proven by numerous studies. Guzel et al1 first reported 24 surgical treatment of CSH under MAC by combination use of midazolam and fentanyl. However, this combination could cause intraoperative respiratory depression.2 In contrast, dexmedetomidine is a highly selective a2 adrenoceptor agonist with both sedative and analgesic properties, and is devoid of a respiratory depressant effect.3 These properties make dexmedetomidine an attractive agent for sedation during MAC for the CSH surgery. We report a case of a 63-year-old man presenting with deterioration of motor function in his right limbs since 2 weeks; he denied a history of head trauma in the last several weeks/ months. His past medical history included hypertension and COPD. Neurological examination showed right hemiparesis with motor strength grade 3. The computed tomography scans documented a large subdural homogenous mixed with hypodense collection of the left hemisphere. Surgery was performed in a similar manner as Santarius4 under MAC on the second day after admission. No premedication was given on arrival in the operation room, and patient’s heart rate, arterial blood pressure, oxygen saturation, respiratory rate, and ECG were monitored. Oxygen was administered by face masks at 4 L/ min, a loading dose dexmedetomidine 1 mg/kg over 10 minutes followed by a continuous infusion of 0.2 to 0.5 mg/kg/ h using an infusion pump. The target end point was a patient having Ramsay Sedation Score = 3. The patient was stable and smooth during the whole surgery. Intraoperative heart rate and mean arterial pressure were lower than r
2014 Lippincott Williams & Wilkins
baseline values, and respiratory rate and SpO2 were normal. No respiratory depression, significant lower heart rate, and mean arterial pressure were observed. After the completion of surgery, the patient and surgeon were asked to answer the question “How would you rate your experience with the analgesia you have received during surgery?” using a 7-point Likert-like verbal rating scale (Fig. 1); both were satisfied with the anesthetic management, scores were 6 and 7, respectively; neurological status was evaluated as normal at discharge. CSH is predominantly a disease of the elderly, and coexisting systemic disease usually poses a problem for general anesthesia. The advantages claimed for the use of local anesthesia, including increased safety, shorter recovery period, and reduced cost when compared with general anesthesia; the main limitation is patient discomfort related to pain, neck position, and noise in the room. MAC is attractive because it involves less physiological disturbance and allows more rapid recovery than general anesthesia. Currently, MAC is commonly used in various surgical procedures, but airway complications impede the application of MAC in neurosurgical procedures. Dexmedetomidine is unique in that it causes less respiratory depression than other sedatives.5 Dexmedetomidine is a highly selective a2 receptor agonist with properties of analgesia, sympatholysis, and titrating sedation. It reduces opioid requirements and stress response to surgery, ensuring a stable hemodynamic state. Dexmedetomidine is increasingly being used as a sedative for MAC in various clinical fields, such as sedation in the intensive care unit, radiologic examination of pediatric patients, awake intubation, shockwave lithotripsy, and endoscopic examination. Our study suggests that an adequate level of sedation is desirable to make CSH surgery more tolerable to the patient and easier to perform for the surgeon. MAC with dexmedetomidine led to comparable
satisfaction compared with general anesthesia, and its can be safely used. Xiao-Ping Xu, MD Cong Liu, MD Qian Wu, MD Department of Neurosurgery, The First People’s Hospital of Neijiang, Neijiang Sichuan, China
REFERENCES 1. Guzel A, Kaya S, Ozkan U, et al. Surgical treatment of chronic subdural haematoma under monitored anaesthesia care. Swiss Medical Weekly. 2008;138:398–403. 2. American Society of Anesthesiologists Task Force on Sedation and Analgesia by NonAnesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. 2002;96:1004–1017. 3. Ramsay MA, Luterman DL. Dexmedetomidine as a total intravenous anesthetic agent. Anesthesiology. 2004;101:787–790. 4. Santarius T, Kirkpatrick PJ, Ganesan D, et al. Use of drains versus no drains after burr-hole evacuation of chronic subdural haematoma: a randomised controlled trial. Lancet. 2009;374:1067–1073. 5. Martin E, Ramsay G, Mantz J, et al. The role of the alpha2-adrenoceptor agonist dexmedetomidine in postsurgical sedation in the intensive care unit. J Intensive Care Med. 2003;18:29–41.
Anesthesia With Antiamoebic Effects: Can Anesthesia Choice Affect the Clinical Outcome of Granulomatous Amoebic Encephalitis due to Acanthamoeba spp.? To JNA Readers It is distressing that despite advances in antimicrobial chemotherapy, the mortality rate associated with The authors have no funding or conflicts of interest to disclose.
www.jnsa.com |
409
