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Ve [25,38]. Dexmedetomidine, an alpha-2 adrenoceptor agonist, enables sedation, anxiolytic effects, and

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Ve [25,38]. Dexmedetomidine, an alpha-2 adrenoceptor agonist, enables sedation, anxiolytic effects, and analgesia. It was successfully used for AC since 2001 [64]. Dexmedetomidine was applied in four studies, either combined with remifentanil [34,56], or propofol [50], or with remifentanil and propofol together [53,57]. The use of dexmedetomidine seems to show several advantages in AC. Shen et al. compared the effect of dexmedetomidine- to propofol-based SAS technique [56]. They showed that patients in the dexmedetomidine group had a shorter arousal time after the first asleep phase and a higher degree of surgeon satisfaction. Fast and sufficient recovery after craniotomy is a crucial factor for successful awake cortical mapping within adequate surgery time. A further study, showed reduction of pain induced haemodynamic reactions to pinning and incision, when AC with propofol, dexmedetomidine and local anaesthesia was performed (n = 101), compared to balanced GA (n = 77) [50]. This could partly be explained by the buy TAK-385 analgesic and sympathic blockage effect of dexmedetomidine. Furthermore, the patients needed less intraoperative vasopressors and opioids compared to the GA group. Also postoperative requirement of opioids and antiemetic drugs was P144 site reduced in the AC group. Of note, in contrast to the AC group, a RSNB was not performed in all GA patients, which maybe accompanied by more opioid application and consecutive nausea. Conversely they observed more oxygen desaturations (SaO2 <90 ) in the AC group, despite the absence of respiratory suppression by dexmedetomidine. This might be explained by the propofol saving effect of dexmedetomidine, which bears the risk of over sedation with propofol, especially during the painful beginning of the surgery. Of note, only one AC patient required the placement of a LMA. In contrast two GA patients showed significant postoperative desaturations and one of them required a re-intubation. The airway in the included studies was secured either with a laryngeal mask (LMA) [21,25,26,38,45,46], an endotracheal tube in all [56],respectively one patient [20,44] or an oesophageal naso-pharyngeal catheter [23]. One study, which used a TIVA, did not mention the utilized airway device, they only reported naso-pharyngeal airway [53] and another one reported only an “oral airway” for five patients [51]. Twelve studies [21,23,26,56] used controlled ventilation, the others maintained spontaneous breathing. A nasal cannula with spontaneous breathing was used in one trial [34,50] and Shinoura et al. did not report the ventilation mode [57]. Once the dura was opened and brain exposed, propofol was terminated and remifentanil and dexmedetomidine infusions were reduced or also stopped to allow patient awakening and removal of the airway device. In the study, which used the naso-pharyngeal catheter, the proximal balloon sealing the naso- and oro-pharyngeal cavities was deflated to allow patient vocalisation [23]. Dexmedetomidine was also successfully used after cessation of propofol and fentanyl, during the awake resection phase of the SAS technique [60]. Of note, this study reported the SAS technique for only two patients and concurrently the MAC technique for four patients. The second asleep phase was not described in detail in all included studies, but it consisted of sedative anaesthesia, remaining spontaneous breathing during wound closure up to controlled ventilation with endotracheal intubation like in the study of Dera.Ve [25,38]. Dexmedetomidine, an alpha-2 adrenoceptor agonist, enables sedation, anxiolytic effects, and analgesia. It was successfully used for AC since 2001 [64]. Dexmedetomidine was applied in four studies, either combined with remifentanil [34,56], or propofol [50], or with remifentanil and propofol together [53,57]. The use of dexmedetomidine seems to show several advantages in AC. Shen et al. compared the effect of dexmedetomidine- to propofol-based SAS technique [56]. They showed that patients in the dexmedetomidine group had a shorter arousal time after the first asleep phase and a higher degree of surgeon satisfaction. Fast and sufficient recovery after craniotomy is a crucial factor for successful awake cortical mapping within adequate surgery time. A further study, showed reduction of pain induced haemodynamic reactions to pinning and incision, when AC with propofol, dexmedetomidine and local anaesthesia was performed (n = 101), compared to balanced GA (n = 77) [50]. This could partly be explained by the analgesic and sympathic blockage effect of dexmedetomidine. Furthermore, the patients needed less intraoperative vasopressors and opioids compared to the GA group. Also postoperative requirement of opioids and antiemetic drugs was reduced in the AC group. Of note, in contrast to the AC group, a RSNB was not performed in all GA patients, which maybe accompanied by more opioid application and consecutive nausea. Conversely they observed more oxygen desaturations (SaO2 <90 ) in the AC group, despite the absence of respiratory suppression by dexmedetomidine. This might be explained by the propofol saving effect of dexmedetomidine, which bears the risk of over sedation with propofol, especially during the painful beginning of the surgery. Of note, only one AC patient required the placement of a LMA. In contrast two GA patients showed significant postoperative desaturations and one of them required a re-intubation. The airway in the included studies was secured either with a laryngeal mask (LMA) [21,25,26,38,45,46], an endotracheal tube in all [56],respectively one patient [20,44] or an oesophageal naso-pharyngeal catheter [23]. One study, which used a TIVA, did not mention the utilized airway device, they only reported naso-pharyngeal airway [53] and another one reported only an “oral airway” for five patients [51]. Twelve studies [21,23,26,56] used controlled ventilation, the others maintained spontaneous breathing. A nasal cannula with spontaneous breathing was used in one trial [34,50] and Shinoura et al. did not report the ventilation mode [57]. Once the dura was opened and brain exposed, propofol was terminated and remifentanil and dexmedetomidine infusions were reduced or also stopped to allow patient awakening and removal of the airway device. In the study, which used the naso-pharyngeal catheter, the proximal balloon sealing the naso- and oro-pharyngeal cavities was deflated to allow patient vocalisation [23]. Dexmedetomidine was also successfully used after cessation of propofol and fentanyl, during the awake resection phase of the SAS technique [60]. Of note, this study reported the SAS technique for only two patients and concurrently the MAC technique for four patients. The second asleep phase was not described in detail in all included studies, but it consisted of sedative anaesthesia, remaining spontaneous breathing during wound closure up to controlled ventilation with endotracheal intubation like in the study of Dera.

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