Anesthesie voor

Deep Brain

Stimulation

Kristof Nijs

Promotor: Dr. De Sloovere

13/05/2016

Deep brain stimulation (DBS)

Wat is DBS?

• Primaire DBS operatie

- Microelectrorecording (MER)

- Macrostimulatie

• Secundaire DBS operatie

http://biomed.brown.edu/Courses/BI108/BI108_2008_Groups/group07/Parkinsons.html

Deep brain stimulation (DBS)

Indicaties:

Venkatraghavan et al. Anesthesia for deep brain stimulation. Curr Opin Anaesthesiol

2011, 24: 495-499.

Hickey M, Stacy M. Deep brain stimulation: A Paradigm Shifting Approach to Treat

Parkinson's Disease. Front. Neurosci 2016,10:173.

Preoperatieve evaluatie

• Standaard preoperatieve evaluatie

→ Met extra aandacht voor:

- BD controle (CAVE ß-blockers)

- Preoperatief stop anticoagulantia

- Preoperatief stop (>12u) PD medicatie

- Geen benzo’s, opioïden preoperatief

- Luchtweg management

Intraoperatieve complicaties van DBS

• Luchtwegcomplicaties

• Neurologische complicaties

• Luchtembolen

Anesthesie tijdens de DBS operatie

• Doelen:

- Patiënt comfort en optimale chirurgische condities

- Intraoperatief faciliteren van monitoring

- Snelle diagnose en interventie bij complicaties

• 3 methoden:

- Locale anesthesie

- Conscious sedation

- Algemene anesthesie

Conscious sedation

• “Asleep – Awake – Asleep” methode

• Interefentie door anesthetica?

- MER

- Macrostimulatie

Rozet I. Anesthesia for functional neurosurgery: the role of dexmedetomidine. Curr

Opin Anaesthiol 2008, 21: 537-543.

Conscious sedation

Propofol

(TCI 50µg/kg/h +/- remifentanyl)

N = 16 !

Raz A, Eimerl D, Zaidel A, Bergman H, Israel Z. Propofol decreases neuronal population spiking activity in the subthalamic nucleus of

Parkinsian patients. Anesth Analg 2010, 111: 1285-1289.

Advantages Disadvantages

Propofol Widely used drug Abolishes tremors

GABA receptor agonist Short acting Attenuation of MER

Predictable emergency profile Different pharmacokinetic model in PD patients

Less neurocognitive effects than other agents Induces dyskinesia

Tendency to cause sneezing

Conscious sedation

Dexmedetomidine ( TCI 0,3-0,6µg/kg/h)

Advantages Disadvantages

Dexmedetomidine Non-GABA mediated action High dose can abolish MER

Alpha-2 agonist Less effect on MER Hypotension, bradycardia

Anxiolyse and analgetic effects Increased risk of agitation at high doses

Sedation - easy arousable High dose can cause AV block

Does not amelliorate clinical signs of PD

Maintains hemodynamic stability

Preserves respiration

Rozet I, et al. Clinical experience with dexmedetomidine for implantation of deep brain stimulators in Parkinson’s disease. Neurosurgical Aneasthesia 2006, 103: 1224-1228.

N=22 !

Rozet I, et al. Clinical experience with dexmedetomidine for implantation of deep brain stimulators in Parkinson’s disease. Neurosurgical Aneasthesia 2006, 103: 1224-1228.

Rozet et al. (2006)

MAAR !

(2008)

Conclusie herzien

Rozet I. Anesthesia for functional neurosurgery: the role of dexmedetomidine. Curr

Opin Anaesthiol 2008, 21: 537-543.

Conscious sedation

Remifentanyl ( TCI 0,05-0,15µg/kg/min) (+ midazolam max 2mg)

Goede sedatie! Snel uitgewerkt!

Goede coöperatie!

Advantages Disadvantages

Remifentanyl Short acting Suppression of tremors

Midazolam Anxiolyse Abolishes MER

Gray H, et al. Parkinson’s disease and anaesthesia. Br J Anaesth 2003, 90: 524-525.

Data ontbreken!

Besluit

• De beste anesthetische techniek is niet gekend

• Grote prospectieve studies zijn nodig!