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Despite theoretical benefits of intravenous agents, volatile agents remain popular. In a study comparing desflurane, isoflurane, and sevoflurane in a porcine model of intracranial hypertension, at equipotent doses and normocapnia, cerebral blood flow (CBF) and intra-cranial pressure (ICP) were least with sevoflurane.
Propofol is the most commonly used intravenous anesthetic. It has many theoretical advantages by reducing cerebral blood volume (CBV) and ICP and preserving both autoregulation and vascular reactivity. Neurosurgical patients anaesthetized with propofol were found to have lower ICP and higher CPP than those anaesthetized with isoflurane or sevoflurane.
The well known pharmacodynamic advantages of intravenous anesthetics may give this group of drugs superior cerebral effects when compared with inhalation anesthetics.
The aim of this study is to evaluate the cerebral haemodaynamics and global cerebral oxygenation as well as the systemic haemodaynamic changes using dexmedetomidine, propofol and fentanyl as total intravenous anaesthestics (TIVA) in comparison with sevoflurane - fentanyl anesthesia in brain tumor resection.
Indicators of global cerebral oxygenation and haemodynamics will be calculated using jugular bulb and peripheral arterial blood sampling.
Central venous catheter: A suitable central venous catheter will be inserted into Rt subclavian vein under complete aseptic technique, its correct position will be confirmed with chest X-Ray.
Jugular bulb catheterization: Under strict sterile technique the right internal jugular vein will be cannulated in a retrograde technique with confirmation of the catheter tip position using X-Ray (C- arm). Puncture site will be at the level of cricoid cartilage behind the anterior border of the sternocleido-mastoid muscle.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Propofol-Dexmedetomidine group | Placebo Comparator | this group is planned to receive intravenous anaesthesia only |
|
| Sevoflurane group | Active Comparator | this group is planned to receive sevoflurane/fentanyl anaesthesia |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Propofol-Dexmedetomidine group | Drug | Porofol (1.5-2 mg/kg/h) infusion, Dexmedetomidine (0.2-1µg/kg/h) infusion and Fentanyl in repeated doses (50µ) when needed (heart rate or mean arterial blood pressure increase more than 20% of the basal value). Maintenance infusions will start immediately after induction. |
| Measure | Description | Time Frame |
|---|---|---|
| Arterio-Jugular oxygen content difference | immediately after cannulation (arterial and jugular), every 30 min during surgery and after complete closure of the scalp | |
| Estimated cerebral metabolic rate for O2 (eCMRO2) | eCMRO2=Ca- jO2 x(PaCO2 ∕ 100) Where Ca jO2 is arterio-jugular O2 content difference. PaCO2 is arterial CO2 tension | immediately after cannulation (arterial and jugular), every 30 min during surgery and after complete closure of the scalp |
| Cerebral Extraction Rate of O2 (CEO2) | Calculated as the differences between arterial and jugular bulb O2 saturations, CEO2 = SaO2 - SjvO2 | immediately after cannulation (arterial and jugular), every 30 min during surgery and after complete closure of the scalp. |
| Cerebral Blood Flow equivalent (CBFe) | Which is an index of flow metabolism relationship, calculated as a reciprocal of arterio-jugular O2 content difference. CBFe = 1 ∕CaO2-CjvO. | immediately after cannulation (arterial and jugular), every 30 min during surgery and after complete closure of the scalp |
| Measure | Description | Time Frame |
|---|---|---|
| Heart rate | will be monitored continiously and recorded immediately after intubation, every 30 min during surgery and immediately after closure of the scalp | |
| Blood pressure | will be monitored continiously and recorded immediately after intubation, every 30 min during surgery and immediately after closure of the scalp |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Ahmed A. Daif, MD | Anaesthesia and Intensive Care Department, College of Medicine, Mansoura University | Principal Investigator |
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| ID | Term |
|---|---|
| D001932 | Brain Neoplasms |
| ID | Term |
|---|---|
| D016543 | Central Nervous System Neoplasms |
| D009423 | Nervous System Neoplasms |
| D009371 | Neoplasms by Site |
| D009369 | Neoplasms |
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|
| Sevoflurane group | Drug | Sevoflurane at a concentration of 2-2.5%., Fentanyl in repeated doses (50µ) when needed (heart rate or mean arterial blood pressure increase more than 20% of the basal value). |
|
| End-tidal carbon dioxide tension | will be monitored continiously and recorded immediately after intubation, every 30 min during surgery and immediately after closure of the scalp |
| Central venous pressure | will be monitored continiously and recorded immediately after intubation, every 30 min during surgery and immediately after closure of the scalp |
| Postoperative level of sedation | all patients will be evaluated using Ramsay sedation scale | every 5 min for 60 min, after extubation |
| Time for first analgesic request from extubation | for 6 hours after surgery |
| Total analgesics received | for 24 hours after surgery |
| Intensive care unit stay | for 10 days after surgery |
| D001927 |
| Brain Diseases |
| D002493 | Central Nervous System Diseases |
| D009422 | Nervous System Diseases |