LETTERSTOTHEEDITOR 375
Reply
Réplica
DearEditor,
WeappreciatethecommentsofProfessorDanielVolquind1 and his interest in our work.2 We would like to clarify the doubts raised. The technique used was spontaneous ventilation,maintainedduringtheprocedure,withoxygen delivered by face mask and modulation of sedation. For patientswhoareappropriatecandidates,spontaneous ven-tilationcombinedsedationwithpropofol,remifentanil,and a scalp blockade is an attractive option.3---7 This protocol hasbeenusedinourhospitaluneventfullyandhasseveral reportsinthemedicalliterature.4---7
Finally, the patient’s physical characteristics (young, ASA-I) allowed the use of doses proposed in our report without ventilatory impairment.When thereis an indica-tion for surgery, the neurosurgical team is faced with a dilemma: wide excision of the lesion, but also increased risk of functional impairment, which mayseverely impair thepatient’s qualityoflife. When motorregionsare con-cerned, cortical area mapping is of interest to define the surgical approach.3.8 In ourpatient, corticalmapping was done using electrical stimulation. Mapping and the patient’s‘‘active’’participationallowedustoobserve pos-siblemotor andverbalchangesanddelineatethesurgical excision.
WeagreewithProfessorVolquindthatanestheticdrugs interfere significantly in certain monitoring. However, to our knowledge, there is no optimum drug for anesthe-sia duringawake surgery. Ramsaysedation scale iswidely usedand easy toapply.9 It is basedon six stages and on stage2,thepatientiscooperative,oriented,andtranquil; on stage 3, the patient is sleepy, but responds to com-mands. We maintained the patient on stage 3 when the headwassecuredwithMayfieldfastenerandduringthescalp approach.
Wewouldliketoemphasizethatthetechniquedescribed inourcasereportisfeasibleandsafe,butitdependsonthe skilloftheanesthesiologistindrugtitration,aswellason hispsycho-emotionalsensitivity tomaintainclose contact withthepatientthroughoutthesurgery.
References
1.Volquind D. Comentário a: Anestesia para craniotomia em paciente acordado: relato de caso. Rev Bras Anestesiol. 2014;64:374.
2.BolzaniND, JunqueiraDOP, Ferrari PAF, et al. Anestesiapara craniotomia em pacienteacordado: relato de caso. Rev Bras Anestesiol.2013;63:500---3.
3.AmorimRL,AlmeidaAN,AguiarPH,etal.Corticalstimulation of languagefields under localanesthesia: optimizing removal ofbrainlesionsadjacentto speechareas.ArqNeuropsiquiatr. 2008;66:534---8.
4.HansP,BonhommeV,BornJD,etal.Target-controlledinfusionof propofolandremifentanilcombinedwithbispectralindex moni-toringforawakecraniotomy.Anaesthesia.2000;55:255---9.
5.Johnson KB,Egan TD. Remifentanil and propofol combination for awakecraniotomy:casereportwithpharmacokinetic sim-ulations.JNeurosurgAnesthesiol.1998;10:25---9.
6.SungB,KimHS,ParkJW,etal.Anestheticmanagementwithscalp nerve block and propofol/remifentanil infusion during awake craniotomy inanadolescent patient----acasereport.KoreanJ Anesthesiol.2010;59:S179---82.
7.Wolff DL, Naruse R, GoldM. Nonopioidanesthesia for awake craniotomy:acasereport.AANAJ.2010;78:29---32.
8.MaertensDN,BornJD,HansP,etal.Intraoperativelocalizationof theprimarymotorcortexusingsingleelectricalstimuli.JNeurol NeurosurgPsychiatry.1996;60:442---4.
9.RamsayMA,SavegeTM,SimpsonBR,etal.Controlledsedation withalphaxalone-alphadolone.BrMedJ.1974;22:656---9.
EdmundoPereiradeSouzaNeto
HôpitalNeurologiquePierreWertheimer,Lyon,France E-mail:edmundo.pereiradesouza@hotmail.fr
Availableonline3July2014
