Hemodynamic and Bispectral Changes During Pin Insertion in Craniotomy - Effect of Locally Infiltrated Bupivacaine
Hemodynamic and Bispectral Changes During Pin Insertion in Craniotomy - Effect of Locally Infiltrated Bupivacaine
Hemodynamic and Bispectral Changes During Pin Insertion in Craniotomy - Effect of Locally Infiltrated Bupivacaine
Corresponding author: Vesna Durnev. University Clinic of Traumatology, Orthopedics, Anaesthesia, Reanimation,
Intensive care and Emergency at Medical School, University “St. Cyril and Methodius”, Skopje, R. of Macedonia,
Vodnjanska st. 17, Skopje, R. of Macedonia; Tel: +38972 238506; Е-mail: vesna.durnev@gmail.com
Abstract
Introduction Cranial pins insertion is a method for head stabilization and together with the scalp
incision is one of the biggest noxious stimulus associated with arousal and rapid increase of the
blood pressure leading to pathological increase of the intracranial pressure. The aim of this in-
vestigation is to study the superiority of the locally infiltrated anesthetic bupivacaine just before
the skull pin insertion and the scalp incision in craniotomy under general anesthesia.
Methods In the study thirty patients of both genders aged 24-72 years were included. They were
categorized as ASA 1 and 2 and divided into two group of 15 patients each, group B (bupivacaine)
and group S (saline). We recorded the bispectral (BIS) index, the mean arterial pressure (MAP)
and the pulse rate (PR) in five time intervals:
t 0-2min before pin insertion; t 1-2 min after pin insertion; t 2-5 min after; t 3-10min after and t
4-15 min after.
Results Significant difference p<0.05 was achieved in group S for all three followed parameters:
blood pressure, heart rate and bispectral index. The difference is present in all four time intervals
compared to the initial one before the pin insertion. With further analysis it was demonstrated that
the investigated BIS index participates the most in the overall significance in group F.
Conclusion The scalp infiltration with local anesthetic bupivacaine results with stable hemody-
namic parameters and stable intracranial pressure during the painful procedures as craniotomy.
Key words: cranial pin, local infiltrative anesthesia, hemodynamics, bispectral index, bupivacaine
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116 Vesna Durnev
stress response is detrimental in patients with in- Clinic of Traumatology, Orthopedics, Anesthesia,
tracranial pathology [3]. Reanimation, Intensive care and Emergency and
The insertion of cranial pins for head stabili- the University Clinic of Neurosurgery at Medical
zation is a method for head stabilization in elective School, University “St. Cyril and Methodius”,
craniotomy and together with skin incision is one Skopje, Republic of Macedonia, in a period of six
of the prominent noxious stimuli. They induce in months (January 2016 till June 2016).
insufficiently anesthetized patients significant he- After obtaining the written information consent
modynamic response, increased stress hormones from each patient, we enrolled a total of thirty pa-
and in patients with impaired autoregulation may tients of both genders, aged 20-70 years ASA phys-
lead to increased intracranial pressure [4, 5]. ical status I and II, undergoing elective craniotomy.
The determination of the bispectral index Criteria for exclusion were patients with
(BIS) is a method which has gained popularity uncontrolled hypertension, patients undergoing
because it reflects the hypnotic and anesthetic emergency surgery, intracranial aneurysm surgery,
depth. The BIS index is a measure derived from those having significant cardiac, pulmonary, renal
the processed electroencephalogram (EEG) data or hepatic disease, those having contraindication
[6]. The BIS index has been shown to be superior to beta blockers, or taking treatment that can affect
to the other processed EEG parameters in assess- hemodynamic parameters. Criterion for exclusion
ing the depth of anesthesia and sedation [7,8]. A is the already known hypersensitivity to local an-
BIS value of 40–65 is suitable for anesthesia [9]. esthetic bupivacaine.
The BIS index can be also used as a predictor of All patients were premedicated with diazepam
patient’s response to nociceptive stimulus under 5 mg orally the night before the day of surgery and
anesthesia and it has decreased the incidence of on the morning of surgery. In the operating room,
intraoperative awareness [10, 11]. a BIS sensor (Covidien) was attached to the fore-
These detrimental hemodynamic and aware- head and the monitor was set to generate a value
ness changes can be prevented by infiltration of every 15 s. The routine monitoring consisted of
the scalp with local anesthetic [12] or by skull an electrocardiogram (ECG), end tidal CO2, pulse
block prior to pin placement [13]. oximetry, invasive blood pressure (IBP) and heart
We hypothesized that the values of the BIS rate measurement.
index and hemodynamic parameters would in- The patients were induced with fentanyl 2µ/
crease when skull pins are inserted and skin inci- kg, propofol 1.5-2 mg/kg and rocuronium in dose
sion is performed although the anesthetic depth of 0.6mg/kg. Ventilation was maintained with a
is adequate enough. It would remain unchanged tidal volume of 6–8 ml/kg and respiratory frequen-
when patients received local anesthetic bupiva- cy of 12–15/min. Anesthesia was maintained with
caine infiltration of the scalp, which blocks the continuous remifentanil infusion and isoflurane
strong nociceptive stimuli followed with stable 1%-2% in mixture of 50% air/oxygen. The depth
perioperative patient condition. of the anesthesia was maintained within the BIS
index value of 40–60.
Objective After the normalization of the hemodynamic
effects of the tracheal intubation (approximately
The objective of the study is to examine the 5 min after intubation), the patients were random-
superiority of the locally infiltrated anesthetic bu- ized in two groups. The first group (Group B)
pivacaine at the place of the pin insertion and the of 15 patients received 20ml 0.25% bupivacaine
skin incision in preventing pain stimulation in local anesthetic infiltrated at the place of the pin
patients with craniotomy measured through the insertion and the skin incision. The second group
changes in the bispectral index (BIS) and the he- (Group S) consisted of 15 patients same as the first
modynamic parameters as mean arterial pressure one who received 20 ml saline scalp infiltration
and heart rate. 2 to 5 minutes before the pin insertion and the
skin incision. We followed the changes in the BIS
Materials and Methods index value and the hemodynamic parameters as
the mean arterial pressure and heart rate using
The study was designed as prospective, con- recorded values before the pin insertion and the
trol randomized research. This randomized pro- skin incision in time (t0) and subsequently the
spective trial was conducted at the University regular intervals of 5 min (t1, t2, t3, t4) after the
pin insertion for total time of 20 min.
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HEMODYNAMIC AND BISPECTRAL CHANGES DURING PIN INSERTION IN CRANIOTOMY 117
Table 3. Hemodynamic parameters and BIS index in different time intervals comparing the two groups
MAP HR BIS
time Gr B Gr S Gr B Gr S Gr B Gr S
p p p
бр=15 бр=15 бр=15 бр=15 бр=15 бр=15
t0 61 69.6 70.3 68 44.4 44.6
0.082974 0.672267 0.912244
±7.7 ±16.9 ±14.1 ±15.6 ±4.8 ±4.9
t1 47,9
64.26 96.2 74.3 85.4 52.4
0.000005 0.049579 ±6.3 0.061110
±7.2 ±20.7 ±13.8 ±15.7 ±6.2
t2 64.53 97.6 72.8 87.4 46.9 54
0.000002 0.002810 0.001962
±7.4 ±20.4 ±13 ±11.4 ±5.8 ±5.4
t3 45.4
62.46 97.13 72.3 85.8 52.3
0.000000 0.003751 ±4.4 0.000120
±7.0 ±18.6 ±13.2 ±9.8 ±4.0
t4 61.3 86.5 71.6 79.5 44.9 51.3
0.000006 0.076774 0.000398
±6.1 ±16.3 ±13.1 ±10.1 ±4.6 ±4.0
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118 Vesna Durnev
Table 4. Comparing the values for BIS, MAP and HR (t0/t1; t0/t2; t0/t3;t0/t4)
SS – Eff. df – Eff. MS – Eff. SS – Err. df – Err. MS – Err. F p
BIS т0 Gr S 806.800 4 201.700 1757.87 70 25.1124 8.031895 0.000022
MAP 8593.520 4 2148.380 24531.07 70 350.4438 6.130455 0.000274
HR 3834.587 4 958.647 11537.60 70 164.8229 5.816224 0.000423
BIS т0 Gr B 129.520 4 32.380 1960.00 70 28.0000 1.156429 0.337539
MAP 159.387 4 39.847 3565.73 70 50.9390 0.782242 0.540523
HR 129.813 4 32.453 12765.73 70 182.3676 0.177956 0.949058
{0} - M=44.600 {1} - M=52.400 {2} - M=54.000 {3} - M=52.333 {3} - M=51.333
1 {0} 0.000690 0.000143 0.000766 0.004142
2 {1} 0.000690 0.905400 1.000000 0.977248
3 {2} 0.000143 0.905400 0.891881 0.593297
4 {3} 0.000766 1.000000 0.891881 0.982080
5 {4} 0.004142 0.977248 0.593297 0.982080
Table 7. Group S HR t0
{0} - M=68.000 {1} - M=85.467 {2} - M=87.467 {3} - M=85.800 {4} - M=79.533
1 {0} 0.003594 0.000952 0.002888 0.111841
2 {1} 0.003594 0.993001 0.999995 0.712916
3 {2} 0.000952 0.993001 0.996576 0.445385
4 {3} 0.002888 0.999995 0.996576 0.669483
5 {4} 0.111841 0.712916 0.445385 0.669483
Significant difference p < 0.05000 (Tukey HSD тест)
With post hoc Tukey test in Table 5, 6 and 7 with local anesthetic bupivacaine and the effect
we can see that variable BIS in group S contribute upon hemodynamics is for the first time investi-
the most in total significant difference. gated in the study of Hillman et al from 1987 [17]
which demonstrated the blocking effect of the
Discussion nerve endings for skin, subcutaneous tissue, mus-
cles and periosteum of external part of the scalp.
The scalp is densely innervated with C-fibers Several possible mechanisms are suggested
[14]. A lot of studies with scalp blocks and skin for the analgesic effect of the bupivacaine as local
incision infiltration were done to describe the re- anesthetic. The studies of Pinosky from 1996 [3]
lief from postoperative pain after craniotomy as and Hillman from 1987 [17] describe the mem-
in the study of Bloomfield from 1998 and Biswas brane stabilizing effect occurring on smooth vas-
from 2003 [15, 16]. Subcutaneous infiltration cular musculature or sympathetic nerves.
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HEMODYNAMIC AND BISPECTRAL CHANGES DURING PIN INSERTION IN CRANIOTOMY 119
The prolonged activity of the bupivacaine is before the pin insertion we found significant dif-
due to the decreasing of the absorption and the ference in Group S where patients were locally
increasing of the capillary permeability. Since the infiltrated with saline.
scalp is highly vascularized we did not use vaso- Also, our hypothesis was confirmed by moni-
constrictor as adjunct to the local anesthetic just to toring the depth of the anesthesia (bispectral mon-
disable the possibility for accidental intravascular itoring) following the BIS index which has shown
injection and absorption in circulation leading to big fluctuations using saline. With further analysis
hypertension and tachycardia. it was proven that precisely, the variable BIS in-
The study of Kinna G Shah et al. from 2014 dex contributes the most to the total significance
[18] investigated the changes of the hemodynam- in Group S.
ic parameters in patients with craniotomy who
were divided in three groups depending on the Conclusion
substance which was infiltrated before the pin fix-
ation and the scalp incision: the group with saline, Scalp infiltration with local anesthetic bupiv-
the group with bupivacaine and the group with acaine results with stable hemodynamic condition
tramadol. The results demonstrated significantly and normal intracranial pressure during the painful
higher values of the hemodynamic parameters in procedures in craniotomy as pin insertion and skin
the group of saline. incision. This condition is achieved through main-
Likewise, in the study of Mohammadin from taining continuous appropriate anesthesia depth
2003 [19] it is found that the biggest significant without increasing the nervous cell metabolism
difference p = 0.03 using bupivacaine 0.25% is and without increasing the perfusion in the rigid
achieved through the heart rate changes. The study cranial vault.
of Bloomfield from 1998 [15] reported a lacking
hemodynamic response as result of the skin incision References
with 0.5% bupivacaine adding adrenaline as adjunct.
In the study of Bithal from 2007 [13] 44 pa- 1. Matakas F, Von Waechter R, Knüpling R,
tients with cervical discectomy were followed. In Potolicchio SJ Jr. Increase in cerebral per-
their skull were inserted cranial pins for fixation. fusion pressure by arterial hypertension in
In the group without locally infiltrated anesthetic brain swelling. A mathematical model of the
changes in the hemodynamic parameters it oc- volume‑pressure relationship. J Neurosurg
curred with significant difference compared to 1975;42:282‑9
the other group. He also found that the bispectral
index increased significantly in the group without 2. Palmer JD, Sparrow OC, Iannotti F. Postoper-
local anesthetic. ative hematoma: A 5‑year survey and identifi-
These results correspond to the results in our cation of avoidable risk factors. Neurosurgery
study. We used 0.25 % bupivacaine as anesthetic 1994;35:1061‑4.
and it was locally infiltrated at the place of the 3. Pinosky ML, Fishman RL, Reeves ST, Har-
cranial pin insertion and the skin scalp incision. vey SC, Patel S, Palesch Y, et al. The effect
We selected bupivacaine because of its longer of bupivacaine skull block on the hemody-
activity and safety for vascularized scalp tissue. namic response to craniotomy. Anesth Analg
We investigated the effect upon hemodynamics 1996;83:1256‑61.
and awareness using the value of the bispectral 4. Colley RS, Dunn . Prevention of blood pres-
index as measure of the anesthesia depth. Ana- sure response to skull pin head holder by local
lyzing the results in both groups and comparing anesthesia. Anesth Analg 1979; 58:241–243
them, we found significant difference p<0.05 for 5. Levin R, Hesselvik JF, Kourtopoulos H,
all three parameters: MAP, HR and BIS index. Vavruch L Local anaesthesia prevents hy-
The difference for the mean arterial pressure was pertension following application of the May-
statistically significant in all four time intervals field skull pin head holder. Acta Anaesthesiol
(t1, t2, t3 and t4), for the heart rate the significant Scand 1989; 33:277–279
difference was in time intervals t1, t2 and t3 and
6. Sigl JC, Chamoun NG. An introduction to
for the BIS index the significant difference was
bispectral analysis for the electroencephalo-
in t2, t3 and t4.
gram. J Clin Monit 1994; 10:392–404
Comparing the parameters changes in all four
time intervals related to the initial time t0, 2-5min
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Download Date | 2/28/18 11:23 AM
120 Vesna Durnev
7. Struys M, Versichelen L, Mortier E, Ryckaert skull pin attachment with and without local
D, De Mey JC, De Deyne C, Rolly G. Com- anesthetic infiltration of the scalp. J Anesth
parison of spontaneous frontal EMG, EEG, 2007;21:442‑4
power spectrum, and bispectral index to mon- 14. Bala I, Gupta B, Bhardwajal, Ghai B, and
itor propofol drug effect and emergence. Acta Khosla VK.2006: Effect of scalp block on
Anaesthesiol Scand 1998; 42:628–636 post op pain relief in craniotomy patients.
8. Doi M, Gajraj RJ, Mantzarids H, Kenny Anesth.Intensive Care, 34(2)224-7.
GN. Relationship between calculated blood 15. Bloomfield EL, Schubert A, Secic M, Barnett
concentration of propofol and electrophys- G, Shutway F, Ebrahim ZY. The influence
iological variables during emergence from of scalp infiltration with bupivacaine on hae-
anaesthesia: a comparison of bispectral, spec- modynamic and postoperative pain in adult
tral edge frequency, median frequency, and patients undergoing craniotomy.AnesthAnalg
auditory evoked potential index. Br J Anaesth 1998. Sep; 87(3):579-82
1997; 78:180–184 16. Biswas, Binay K.; Bithal, Parmod K.Preinci-
9. Johansen JW, Sebel PS. Development and sion 0.25% Bupivacaine Scalp Infiltration and
clinical application of electroencephalograph- Post craniotomy Pain. Journal of Neurosurgi-
ic bispectrum monitoring. Anesthesiology cal Anesthesiology 2003;July; 15(3):234-2
2000; 93:1336–1344 17. Hillman DR, Rung G W, Thompson W R,
10. Ekman A, Lindholm ML, Lennmarken C, Davis N J.The effect of Bupivacaine scalp
Sandin R. Reduction in the incidence of infiltration on the haemodynamic response to
awareness using BIS monitoring. Acta An- craniotomy under general anaesthesia. Anaes-
aesthesiol Scand 2004; 48:20–26 thesiology 1987. 67:1001-4
11. Myles PS, Leslie K, McNeil J, Forbes A, Chan 18. Shah G. K, ShahC. B , Prajapati D. Skull
MTV. Bispectral index monitoring to prevent pins and scalp incision infilteration with Bu-
awareness during anaesthesia: the B-aware pivacaine Hydrochloride and Tramadol hy-
randomized controlled trial. Lancet 2004; drochloride -- effects on the haemodynamic
363:1753–1763 response in craniotomy under general an-
12. Mathieu D, Beaudry M, Martin R, McLelland esthesia. International Journal of Advanced
H, Robert B, Kenny B. Effect of local anes- Research 2014; 2(9): 590-597
thetic agent bupivacaine prior to application 19. Mohammadi SS, Shahbazian E, Shoeibi G,
of the skull pin holder for craniotomies. J Almassi F. 2009.Effect of scalp infiltration
Neurosurg 2003; 98:1194–1197 with Bupivacaine on early haemodynamic
13. Bithal PK, Pandia MP, Chouhan RS, Sharma responses during craniotomy under general
D, Bhagat H, Dash HH, et al. Hemodynam- anesthesia .Pak J Biol Sci. Apr 1; 12(7):603-6.
ic and bispectral index changes following
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HEMODYNAMIC AND BISPECTRAL CHANGES DURING PIN INSERTION IN CRANIOTOMY 121
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