Abstract SNACC-97

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Asleep Awake Asleep Craniotomy: Postoperative Pain Experience

Gabel E, Hudson A, Van de Wiele B
David Geffen School of Medicine University of California Los Angeles, Los Angeles, California, USA

Introduction: A high incidence of severe pain after craniotomy has raised interest in techniques to mitigate it (1). Pain induced hypertension is also implicated as a cause of secondary intracranial hemorrhage (2). Several studies have evaluated the effect of pre and postoperative scalp nerve blocks (SNB) on early postoperative pain. A meta-analysis of 320 patients found a significant reduction of pain at 1 hour postoperatively with effects lasting up to 12 hours (3). We evaluated pain experienced during the first 5 postoperative days (POD) after awake craniotomy with SNB performed prior to incision.
Methods: Our electronic medical record (EMR) system was reviewed to identify all supratentorial craniotomy cases performed in our main operating suite from March 2013 to March 2014. We divided these into two groups: adult patients who underwent supratentorial craniotomy under general anesthesia (GA) without SNB and adult patients who underwent supratentorial craniotomy with awake intraoperative functional mapping and pre-incisional SNB. Using the two cohorts, we queried the EMR for all pain scores (reported on a scale from 0 – 10) for each patient from the post anesthesia care unit (PACU) and from the first 5 post-operative days.
Results: We identified 16 patients (6 Female 10 Male, with an average age of 39.7, age range 21-62) who underwent awake craniotomy and 165 patients who had GA for supratentorial craniotomy. Of these, 9 awake patients and 98 GA patients were treated immediately postoperatively in the PACU. We examined 424 pain scores in awake SNB patients (41 in PACU) and 4856 pain scores in GA patients (461 in PACU).
Our data demonstrate a trend towards lower PACU average pain scores in the awake cohort (1.5 [sd 2.7] for the awake group versus 2.5 [sd 2.7] in the GA group). Additionally, 88% of PACU pain scores were 0/10 for the awake cases versus 64% in GA cases. The average pain scores converge on POD 0 after PACU discharge (2.1 [sd 2.2] for the awake group versus 2.4 [sd 2.3] for the GA group) continuing through POD 5. For analysis we divided PACU pain scores into 4 categories; 0, 1-4, 5-6, and 7-10. The groupings were based on our definition of moderate pain as a score ≥ 5/10 and severe pain as a score ≥ 7/10. Using a one-way analysis of variance (Kruskal-Wallis Test), we demonstrated that awake patients who received SNB reported a significantly lower frequency of moderate and severe pain scores (p= 0.0209). Average PACU length of stay was 207 min for the awake patients versus 155 min for the GA group.
Discussion: The understanding of our institution’s pain scores gives us insight into the local pain experience and a target for improvement. The evidence favoring use of the relatively benign SNB procedure may have advantages for patients immediately following surgery. Ultimately, we were unable to detect a significant decrease in average pain scores following PACU discharge in patients who received SNB likely due to a small cohort of awake patients and overall low average pain scores.
1. De Benedittis G et al. Neurosurgery. 1996; 38:466-70.
2. Basali A et al. Anesthesiology. 2000; 93:48-54.
3. Guilfoyle M et al. Anesth Analg. 2013; 116:1093-102.

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