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Using
Mayfield’s scalp clamp became mandatory in most craniotomies but it leads to
potentially hazardous hemodynamic pressor effects. Many interventions like
infiltration of local anesthetics at insertion sites or injecting ketamine,
dexmedetomidine, clonidine and magnesium sulphate (MgSO4) had been studied to
attenuate these effects. This mini review aims to highlight the efficacy of
these interventions through the previously published researches.
Conclusion:
These undesired pressor effects can be attenuated or even abolished using
either one modality or combination of two or more.
Keywords:
Mayfield’s Clamp-Press or Response-Craniotomies
INTRODUCTION
In 1973, Frank Mayfield and George Kees
invented Mayfield skull clamp as a head holder during intracranial operations
using three sterile pins deep to the periosteum at two opposite sides of the
head [1]. Nevertheless, this technique resulted in many complications which
were summarized by Beuriat et al. [2] in their review. Air embolism, broken
clamp, dural laceration, skull fractures, epidural hematomas, traumatic
aneurysm of the superficial, traumatic middle meningeal arteriovenous fistula,
temporal artery and sinus fracture with cerebrospinal fluid leak were among
these complications which are potentially serious and life threatening but
fortunately rare.
During our practice, the most frequent
complication is the sudden sharp noxious stimulus resulting from skull clamp
insertion leading to sudden rise in blood pressure and pulse rate which is
hazardous for patients with co-morbidities [3,4].
Through the last decade, researchers tried to
find out a suitable strategy to attenuate or abolish this undesired reflex. Use
of locally infiltrated anesthetic drugs at pins’ insertion sites, injection of
bolus dose of opioids, administration of α2-adrenoceptor agonists
(clonidine) and deepening level of anesthesia are among these strategies. All
these techniques were proved to be effective in attenuating this pressor effect
but, unfortunately, some side effects may arise specially in hemodynamically
unstable patients [5-9]. Recently, Elkafrawy [10] introduced a new technique
using single dose of MgSO4 which has been proved to cause
significant attenuation of the pressor effect without any undesired side
effects. After all these efforts of research; one question should be asked: Is Mayfield's scalp clamp
can be used without any harmful pressor effects?
Or this is still
a nightmare?!
When using Mayfield skull clamp to fix head
during craniotomies, scalp layers must be penetrated by pointed pins deeply to
periosteum and locked at a pressure of 30 lbs. Obviously; this sharp painful
stimulus elicits sympathetic and
neuroendocrine responses resulting in high blood pressure and pulse rate which
may – in turn-
be injurious for patients with coexisting cardiac disorder, intracranial
vascular disease, increased intracranial pressure (ICP) or disturbed
auto-regulatory mechanism.
To attenuate this pressor effect many strategies had been studied and proved to be effective. The first described strategy was the infiltration of pins’ sites before insertion with local anesthetic, Schaffranietz et al. [11] compared the effect of 1% lidocaine and 0.5% bupivacaine when injected locally at pins sites before insertion. Their study concluded the efficacy of both drugs without difference. Addition of vasoconstrictors as adrenaline to local anesthetic to prolong its duration of action was studied by Arshad et al. [12] who concluded that pressor effects can be effectively prevented by prior lidocaine with adrenaline infiltration of the pin insertion sites. But practically the insertion of scalp pins is usually done by junior neurosurgeons trying more than one insertion before final one which is frequently outside the range of local infiltration.
Osborn and Sebeo [13] described thoroughly
the ‘‘scalp block’’ technique to alleviate pain during craniotomy and they
concluded that scalp block is safe even in pediatric and effective in
maintaining hemodynamic stability for intraoperative and postoperative periods.
During practice, we noticed most of anesthetists refrain to block scalp for
being time consuming and need for good experience.
Ketamine as a NMDA blocker was used widely as
an analgesic, Agarwal et al. [14] studied subanesthetic dose of intravenous
(IV) ketamine (0.5 mg/kg) and/or lidocaine infiltration (1%) prior to the pins’
insertion but they found that mean blood pressure response in the ketamine
group was similar to the placebo group. This was explained by the direct effect
of ketamine despite of its analgesic properties, but significant attenuation of
MBP and HR was observed in the lidocaine and ketamine-lidocaine groups which
they dedicated to lidocaine. Injection of bolus dose of opioids as an
alternative was suggested to be helpful, Karamehemet et al. [15] and Ozkose et
al. [16] compared the effects of intravenous fentanyl and intravenous fentanyl
combined with bupivacaine infiltration on the hemodynamic response to skull pin
insertion. Both methods attenuate the hemodynamic response to skull pin
insertion. They stated that; an additional dose (1 µg/kg) of fentanyl just
before skull pin insertion is recommended as a simple and effective option that
requires no extra time.
Dexmedetomidine, α2 adrenoreceptor agonist,
proved to have sympatholytic and antinociceptive properties that may improve
hemodynamic stability during neurosurgical procedures. Paul et al. [17]
compared dexmedetomidine (received as 1 μg/kg over 10 min starting at induction
of anaesthesia) or/with lignocaine (received 3 ml of 2% lignocaine infiltration
at pin application sites before pin application). They concluded that IV
dexmedetomidine was comparable to local infiltration of 2% lignocaine at pin
application sites to attenuate the haemodynamic response associated with skull
pin application. Kondavagilu et al. [18] evaluated the efficacy of intravenous
(IV) dexmedetomidine on attenuation of hemodynamic responses to skull pin head
holder application and compared the effectiveness of two doses of IV
dexmedetomidine (1 μg/kg infusion over 10 min and 0.5 μg/kg bolus).
Dexmedetomidine 0.5 μg/kg was proved to be more effective in attenuating the HR
and MAP response to skull pin insertion as compared to a dose of 1 μg/kg. But
the use of dexmedetomidine was limited be some neuroanaesthetists because of
its higher incidence of hypotension and bradycardia.
Clonidine as a selective alpha 2 receptor
agonist widely used as a centrally acting antihypertensive drug was studied by
Nanjundaswamy et al. [19]. They compared the effectiveness of IV clonidine
infusion and IV lignocaine infusion in suppressing the hemodynamic response to
skull pin head holder insertion. Lignocaine at a dose of 1.5 mg/kg as an
infusion and IV clonidine 2 µg/kg are effective in attenuating laryngoscopy,
intubation and pin insertion in craniotomies. They concluded that IV clonidine
at the dose of 2 µg/kg is a better than IV lignocaine in attenuating these
hemodynamic responses.
MgSO4 as a non-competitive
N-Methyl-D-Aspartate (NMDA) receptor antagonist and a calcium channel blocker
has an analgesic effect either by blocking central nociceptive sensitization or
reduction of catecholamine release peripherally. ElKafrawy [10] evaluated the
effect of MgSO4 on attenuation of hemodynamic pressor activity after
scalp clamp application during craniotomies. When given as an infusion of 50
mg/kg MgSO4 in 100 ml 0.9% sodium chloride over 15 min prior to
anesthesia induction, it attenuated significantly this pressor activity without
any undesired effects.
CONCLUSION
According to this mini review, we can
conclude that no more nightmares. Many strategies were proved to attenuate the
pressor effect following scalp clamp application during craniotomies. For every
patient, each choice must be tailored to his/her preoperative status and anesthetist’s
previous experience. More than one modality can be used; not only to attenuate
but even to abolish this effect safely.
1. Tew JM (1991) Frank H.
Mayfield, MD; 1908-1991. J Neurosurg 75: 347-348.
2. Beuriat PA, Jacquesson T,
Jouanneau E, Berhouma M (2016) Headholders’ - complications in neurosurgery: A
review of the literature and recommendations for its use. Neurochirurgie 62.
3. Arshad A, Shamim MS, Waqas M,
Enam H, Enam SA (2013) How effective is the local anesthetic infiltration of
pin sites prior to application of head clamps: A prospective observational
cohort study of hemodynamic response in patients undergoing elective
craniotomy. Surg Neurol Int 4: 93.
4. Paul A, Krishna HM (2015)
Comparison between intravenous dexmedetomidine and local lignocaine
infiltration to attenuate the haemodynamic response to skull pin head holder
application during craniotomy. Indian J Anaesth 59: 785-788.
5. Irene O, Joseph S (2010)
‘‘Scalp Block’’ during craniotomy: A classic technique revisited. J Neurosurg
Anesthesiol 22: 187-194.
6. Misra S, Koshy T, Unnikrishnan
KP, Suneel PR, Chatterjee N (2011) Gabapentin premedication decreases the
hemodynamic response to skull pin insertion in patients undergoing craniotomy.
J Neurosurg Anesthesiol 23: 110-117.
7. Uyar AS, Yagmurdur H, Fidan Y,
Topkaya C, Basar H (2008) Dexmedetomidine attenuates the hemodynamic and
neuroendocrine responses to skull-pin head-holder application during
craniotomy. J Neurosurg Anesthesiol 20: 174-179.
8. Agarwal A, Sinha PK, Pandey CM,
Gaur A, Pandey CK et al. (2001) Effect of a subanesthetic dose of intravenous
ketamine and/or local anesthetic infiltration on hemodynamic responses to
skull-pin placement: A prospective, placebo-controlled, randomized,
double-blind study. J Neurosurg Anesthesiol 13: 189-194.
9. Vinit K, Abhishek M, Sanjay A,
Sanjay K, Sunil S (2016) Comparative evaluation of dexmedetomidine and
magnesium sulphate on propofol consumption, hemodynamics and postoperative recovery
in spine surgery: A prospective, randomized, placebo controlled, double-blind
study. Adv Pharm Bull 6: 75-81.
10. ElKafrawy SA (2019) The effect
of intravenous single dose of magnesium sulphate on attenuation of hemodynamic
pressor response after Mayfield’s clamp application during craniotomies. Indian
J Clin Anaesth 6: 614-619.
11. Schaffranietz L, Rüffert H,
Trantakis C, Seifert V (1999) Der Einfluss von Lokalanästhetika auf
hämodynamische Effekte beim Anlegen der Mayfield-Klammer in der Neurochirurgie
unter totaler intravenöser Anästhesie [Effect of local anesthetics on
hemodynamic effects during Mayfield skull clamp fixation in neurosurgery using
total intravenous anesthesia]. Anaesthesiol Reanim 24: 51-54.
12. Arshad A, Shamim MS, Waqas M,
Enam H, Enam SA (2013) How effective is the local anesthetic infiltration of
pin sites prior to application of head clamps: A prospective observational
cohort study of hemodynamic response in patients undergoing elective
craniotomy. Surg Neurol Int 4: 93.
13. Osborn I, Sebeo J (2010)
‘‘Scalp Block’’ during craniotomy: A classic technique revisited. J Neurosurg
Anesthesiol 22: 187-194.
14. Agarwal A, Sinha PK, Pandey CM,
Gaur A, Pandey CK, et al. (2001) Effect of a subanesthetic dose of intravenous
ketamine and/or local anesthetic infiltration on hemodynamic responses to
skull-pin placement: A prospective, placebo-controlled, randomized,
double-blind study. J Neurosurg Anesthesiol 13: 189-194.
15. Yildiz K, Madenoglu H, Dogru K,
Kotanoglu MS, Akin A, et al. (2005) The effects of intravenous fentanyl and
intravenous fentanyl combined with bupivacaine infiltration on the hemodynamic
response to skull pin insertion. J Neurosurg Anesthesiol 17: 9-12.
16. Ozköse Z, Yardim S, Yurtlu S,
Dogulu F, Kaymaz M, et al. (2000) The effects of intravenous fentanyl and
lidocane infitration on the haemodynamic response to skull placement. Neurosurg
Rev 23: 218-220.
17. Paul A, Krishna HM (2015)
Comparison between intravenous dexmedetomidine and local lignocaine
infiltration to attenuate the haemodynamic response to skull pin head holder
application during craniotomy. Indian J Anaesth 59: 785-788.
18. Kondavagilu SR, Pujari VS,
Bevinguddaiah Y (2017) Low dose dexmedetomidine attenuates hemodynamic response
to skull pin holder application. Anesth Essays Res 11: 57-61.
19. Nanjundaswamy NH,
Marulasiddappa V (2017) Attenuation of hemodynamic response to skull pin head
holder insertion: Intravenous clonidine versus intravenous lignocaine infusion.
Anesth Essays Res 11: 129-133.
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