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Anesthesiology. 2016 Mar;124(3):598-607. doi: 10.1097/ALN.0000000000000994.

Mild Sedation Exacerbates or Unmasks Focal Neurologic Dysfunction in Neurosurgical Patients with Supratentorial Brain Mass Lesions in a Drug-specific Manner.

Author information

1
From the Department of Anesthesiology (N.L., R.H.) and Department of Critical Care Medicine (J.Z.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California (A.W.G.).

Abstract

BACKGROUND:

Sedation is commonly used in neurosurgical patients but has been reported to produce transient focal neurologic dysfunction. The authors hypothesized that in patients with frontal-parietal-temporal brain tumors, focal neurologic deficits are unmasked or exacerbated by nonspecific sedation independent of the drug used.

METHODS:

This was a prospective, randomized, single-blind, self-controlled design with parallel arms. With institutional approval, patients were randomly assigned to one of the four groups: "propofol," "midazolam," "fentanyl," and "dexmedetomidine." The sedatives were titrated by ladder administration to mild sedation but fully cooperative, equivalent to Observer's Assessment of Alertness and Sedation score = 4. National Institutes of Health Stroke Scale (NIHSS) was used to evaluate the neurologic function before and after sedation. The study's primary outcome was the proportion of NIHSS-positive change in patients after sedation to Observer's Assessment of Alertness and Sedation = 4.

RESULTS:

One hundred twenty-four patients were included. Ninety had no neurologic deficits at baseline. The proportion of NIHSS-positive change was midazolam 72%, propofol 52%, fentanyl 27%, and dexmedetomidine 23% (P less than 0.001 among groups). No statistical difference existed between propofol and midazolam groups (P = 0.108) or between fentanyl and dexmedetomidine groups (P = 0.542). Midazolam and propofol produced more sedative-induced focal neurologic deficits compared with fentanyl and dexmedetomidine. The neurologic function deficits were mainly limb motor weakness and ataxia. Patients with high-grade gliomas were more susceptible to the induced neurologic dysfunction regardless of the sedative.

CONCLUSIONS:

Midazolam and propofol augmented or revealed neurologic dysfunction more frequently than fentanyl and dexmedetomidine at equivalent sedation levels. Patients with high-grade gliomas were more susceptible than those with low-grade gliomas.

PMID:
26756518
DOI:
10.1097/ALN.0000000000000994
[Indexed for MEDLINE]

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