Anesthesia for awake craniotomy

Purpose of review The current review reports on current trends in the anesthetic management of awake craniotomy, including preoperative preparation, sedation schemes, pain management, and prevention of intraoperative complications. Recent findings Both approaches for anesthesia for awake craniotomy, asleep–awake–asleep and monitored anesthesia care (MAC), have shown equal efficacy for performing intraoperative brain mapping. Choice of the appropriate scheme is currently based mainly on the preferences of the particular anesthesiologist. Dexmedetomidine has demonstrated high efficacy and safety in MAC for awake craniotomy and has become a rational alternative to propofol. Despite the high efficacy of scalp block and opioids, pain remains a common compliant in awake craniotomy. Appropriate surgical tactics can reduce pain and even prevent postoperative neurological complications. Although the efficacy of prophylaxis of intraoperative seizures with anticonvulsants remains doubtful, levetiracetam can be superior to other drugs for this purpose. Summary Following a great deal of progress in anesthetic management, awake craniotomy, which had been a relatively rare approach, is now a commonly performed procedure for neurosurgical intervention. Modern anesthesia techniques can provide for successful brain mapping in almost any patient. Management of awake craniotomy in high-risk patients is a central task for future research. Correspondence to Alexander Kulikov, MD, PhD, Department of Anesthesiology, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia. Tel: +7 903 963 73 64; e-mail: akulikov@nsi.ru Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Opioid-free anesthesia: a different regard to anesthesia practice

Purpose of review In the past two decades, opioids have been prescribed increasingly for the treatment of various chronic pain conditions and during the perioperative period. Perioperative opioid administration is associated with well known adverse effects and recently to long-term use and poor surgical outcomes. In this context, the anesthesiologists have to face their responsibilities. The review discusses the neurophysiological basis of opioid-free anesthesia (OFA), the rational supporting its use in perioperative medicine as well as barriers and future challenges in the field. Recent findings OFA has gained in popularity as a way to enhance early recovery and to spare opioids for the postoperative period. Whether it is possible to deliver safe and stable anesthesia without intraoperative opioids to many patients undergoing various surgical procedures, OFA still raises questions. Accurate monitoring to measure intraoperative nociception and guide the use of adjuvants are not available. There is a need for the development of procedure-specific strategies as well as indications and contraindications to the technique. Finally, objective assessment of OFA use on patient outcomes should be recorded in large multicenter studies. Summary OFA stands as a new paradigm, which questions anesthesiology practice and might help to rationalize perioperative opioids use. Correspondence to Patricia Lavand'homme, MD, PhD, Department of Anesthesiology, Cliniques Universitaires St Luc - University Catholic of Louvain, Av Hippocrate 10, B-1200 Brussels, Belgium. Tel: +32 2 764 18 21; fax: +32 2 764 36 99; e-mail: patricia.lavandhomme@uclouvain.be Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Genetics and genomics in postoperative pain and analgesia

Purpose of review The review describes recent advances in genetics and genomics of postoperative pain, the association between genetic variants and the efficacy of analgesics, and the role of pharmacogenomics in the selection of appropriate analgesic treatments for postoperative pain. Recent findings Recent genetic studies have reported associations of genetic variants in catechol-O-methyltransferase (COMT), brain-derived neurotrophic factor (BDNF), voltage-gated channel alpha subunit 11 (SCN11A) and μ-opioid receptor (OPRM1) genes with postoperative pain. The recent pharmacogenetics studies revealed an association of the organic cation transporter 1 (OCT1) and ATP-binding cassette C3 (ABCC3) polymorphisms with morphine-related adverse effects, an effect of polymorphisms in cytochrome P450 gene CYP2D6 on the analgesic efficacy of tramadol and no effect of CYP2C8 and CYP2C9 variants on efficacy of piroxicam. Summary Genetic variants associate with inter-individual variability in drug responses and they can affect pain sensitivity and intensity of postoperative pain. Despite the recent progress in genetics and genomics of postoperative pain, it is still not possible to precisely predict the patients who are genetically predisposed to have severe postoperative pain or who develop chronic postoperative pain. Correspondence to Eija Kalso, MD, PhD, Pain Clinic, PB 140, 00029 HUS, Finland. Tel: +358 9 47175885; e-mail: eija.kalso@helsinki.fi Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Is epidural analgesia still a viable option for enhanced recovery after abdominal surgery

Purpose of review Although thoracic epidural analgesia (TEA) is considered often as gold standard in multimodal analgesia with regard to major abdominal surgery, there is an ongoing debate if it is still a viable option for enhanced recovery because of its potential severe complications. Recent findings In addition to the unsurpassed analgesic quality, a TEA offers several advantages. Studies have shown that a TEA does have a positive effect on perioperative morbidity and mortality, bowel function, the occurrence of ileus and patient mobility. Furthermore, TEA can reduce opioid-induced side effects, cardiac arrhythmias and pneumonia. When it is embedded into a multimodal fast-track program, it also shortens intensive care and hospital stay. Summary TEA provides superior pain control with a handful of important advantages if used sensibly and with caution. Because of associated risks for severe neurological complications, clear contraindications should be ruled out. Special attention needs be paid to potential hypotension in the setting of epidural analgesia. If these key points are considered, a TEA still represents a viable option for enhanced recovery after major abdominal surgery. Correspondence to Raphael Weiss, MD, University Hospital Münster, Departement of Anesthesiology and Intensive Care Medicine, Albert-Schweitzer-Campus 1, 48149 Münster, NRW, Germany. Tel: +49 251 83 47266; fax: +49 251 83 47257; e-mail: r_weiss@anit.uni-muenster.de Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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The road to accreditation for fellowship training in regional anesthesiology and acute pain medicine

Purpose of review The purpose of this review is to provide the background and rationale for pursuing accreditation of regional anesthesiology and acute pain medicine (RAAPM) fellowships, explain specific steps and challenges in the process, and forecast the future of fellowship training. Recent findings In 2016, the first fellowship program in RAAPM was able to apply for accreditation from the Accreditation Council for Graduate Medical Education (ACGME). The establishment of this newly accredited subspecialty fellowship and the announcement of the first accredited programs represented a tremendous achievement in anesthesiology training and medical education in general and was the culmination of nearly 4 years of dedicated effort. Summary Programs with initial ACGME accreditation are on a 2-year term and will be reviewed to evaluate adherence to the program requirements and the quality of fellowship training. Deficiencies identified will need to be resolved or face loss of accreditation. However, a program's maintenance of accreditation represents a commitment to its fellows to provide a training experience that can be held as a benchmark for all programs. Correspondence to Edward R. Mariano, MD, MAS, Anesthesiology and Perioperative Care Service; VA Palo Alto Health care System; 3801 Miranda Avenue (112A), Palo Alto, CA 94304, USA. Tel: +650 849 0254; fax: +650 852 3423; e-mail: emariano@stanford.edu Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Anesthesia for electroconvulsive therapy

Purpose of review Electroconvulsive therapy (ECT) is a well established and effective therapy in treatment-resistant depression. It is performed under general anesthesia, but no consensus exists regarding the optimal anesthetic drugs. A growing interest in optimizing adjunctive medication regimes in ECT anesthesia has emerged in recent years. Moreover different methods of seizure induction have been evaluated. Recent findings Pretreatment with dexmedetomidine eased the propofol injection pain and reduced the hyperdynamic response to ECT, but prolonged recovery. Remifentanil exhibited no proconvulsive effect and had no effect on seizure quality. Ketamine showed an antidepressive effect but was associated with cardiovascular side effects and an increased recovery time. A bispectral index-guided anesthesia or a time delay between anesthesia and seizure induction resulted in a better seizure quality presumably by avoiding high concentrations of (anticonvulsive) hypnotics. Seizure induction by magnetism seems to be an alternative to ECT, as the former is associated with less cognitive side effects but comparable antidepressive efficacy. Summary The current practice of anesthesia for ECT should not be modified, as the evidence of studies is either too low or the results are inconsistent. Some approaches are promising but require validation in further studies with a higher number of participants. Correspondence to Prof Dr Martin Soehle, Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, D-53127 Bonn, Germany. Tel: +49 228 28714127; e-mail: martin.soehle@ukbonn.de Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Recent developments in ultrasound imaging for neuraxial blockade

Purpose of review Recent research has shed further light on the place of ultrasound imaging in neuraxial blockade in routine clinical practice, its use in thoracic epidurals, and real-time ultrasound-guided techniques. Recent findings Compared with the conventional technique of surface landmark palpation, preprocedural ultrasound imaging minimizes technical difficulty associated with lumbar neuraxial blockade in patients with poor-quality surface landmarks. Novice practitioners are able to learn to employ the technique effectively. Safety benefits include a reduction in postprocedural back pain associated with fewer needle passes and a lower risk of procedure-associated bleeding. The advantage of ultrasound is minimal however in patients with easily discernible surface landmarks, especially if the practitioner is highly experienced. Recent trials show that preprocedural ultrasound scanning for thoracic epidural insertion reduces needle punctures and increases early analgesic efficacy compared with the palpation technique. Real-time ultrasound-guided techniques, while feasible, remain challenging and may not offer significant benefit over preprocedural imaging in lumbar neuraxial blockade. Their role in thoracic epidural insertion requires further investigation. Summary Ultrasound imaging of the spine is a valuable technique that, while not indicated for routine use, should be part of the skillset of any practitioner that regularly performs lumbar and thoracic neuraxial blockade. Correspondence to Ki Jinn Chin, MBBS, MMed, FRCPC, Department of Anesthesia, Toronto Western Hospital, 399 Bathurst St, McL 2–405, Toronto, Ontario M5T 2S8, Canada. Tel: +1 416 603 5118; fax: +1 416 603 6494; e-mail: gasgenie@gmail.com Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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