Total intravenous anaesthesia versus inhaled anaesthetics in neurosurgery
Keywords:
Anesthesia, Intravenous, Evoked potentials, Neurosurgery, Spine
Abstract
Introduction: The way neurosurgery has evolved has led to increased emphasis on anaesthetic techniques aimed at improving patient well-being. In the United States alone, the number of neurosurgeries has increased significantly, with growth reflected in approximately 12,000 spine procedures per year and another 2700 different neurosurgical procedures per year. For anaesthetists, this means that they are faced more frequently with the need to select the most adequate neuroanaesthesia technique for each patient.
Objectives: The purpose of this review is to analyze the role of inhaled and intravenous anaesthetics in neurosurgical procedures.
Methodology: A search was conducted in PubMed using the terms TIVA, inhaled anaesthetics, neurosurgery and spine surgery.
Results: The articles included in the review show that the adequate anaesthetic technique, besides ensuring a rapid onset of action, contributes to ease of titration with minimum effect on systemic and cerebral haemodynamics; it must enable intraoperative neurophysiological monitoring and rapid emergence, in order to allow early assessment of the patient’s neurological function and improved outcome.
Conclusions: In recent years, the question regarding the use of inhaled vs. intravenous anaesthetics in neurosurgery has given rise to several research studies. Although TIVA is the technique used most frequently, inhaled anaesthetics have also been shown to be safe, titratable, and to provide for adequate intraoperative monitoring and cerebral haemodynamic stability. In patients with normal intracranial compliance, inhaled agents (IA) are a good alternative to TIVA, especially in places where hospital resources are limited.
References
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3. Dagal A, Lam AM, Cerebral autoregulation and anesthesia. Curr Opin Anaesthesiol. 2009;22:547-52.
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6. Petersen KD, Landsfeldt U, Cold GE, Petersen CB, Mau S, Hauerberg J, et al. Intracranial pressure and cerebral hemodynamic in patients with cerebral tumors: a randomized prospective study of patients subjected to craniotomy in propofol-fentanyl, isoflurane-fentanyl, or sevoflurane-fentanyl anesthesia. Anesthesiology. 2003;98:329-36.
7. Hans P, Bonhomme V. Why we still use intravenous drugs as the basic regimen for neurosurgical anaesthesia. Curr Opin Anaesthesiol. 2006;19:498-503.
8. Deiner S. Highlights of anesthetic considerations for intraoperative neuromonitoring. Semin Cardiothorac Vasc Anesth. 2010;14:51-3.
9. Matchett GA, Allard MW, Martin RD, Zhang JH. Neuroprotective effect of volatile anesthetic agents: molecular mechanisms. Neurol Res. 2009;31:128-34.
10. Schlünzen L, Cold GE, Rasmussen M, Vafaee MS. Effects of dose-dependent levels of isoflurane on cerebral blood flow in healthy subjects studied using positron emission tomography. Acta Anaesthesiol Scand. 2006;50:306-12.
11. Grathwohl KW, Black IH, Spinella PC, Sweeney J, Robalino J, Helminiak J, et al. Total intravenous anesthesia including ketamine versus volatile gas anesthesia for combat-related operative traumatic brain injury. Anesthesiology. 2008;109:44-53.
12. Todd MM1, Warner DS, Sokoll MD, Maktabi MA, Hindman BJ, Scamman FL, et al. Prospective, comparative trial of three anesthetics for elective supratentorial craniotomy. Propofol/fentanyl, isoflurane/nitrous oxide, and fentanyl/nitrous oxide. Anesthesiology. 1993;78:1005-20.
13. Petersen KD, Landsfeldt U, Cold GE, Pedersen CB, Mau S, Hauerberg J, et al. ICP is lower during propofol anaesthesia compared to isoflurane ans sevoflurane. Acta Neurochir Suppl. 2002;81:89-91.
14. Petersen KD, Landsfeldt U, Cold GE, Pedersen CB, Mau S, Hauerberg J, et al. Intracranial pressure and cerebral hemodynamic in patients with cerebral tumors: a randomized prospective study of patients subjected to craniotomy in propofol-fentanyl, isoflurane-fentanyl, or sevoflurane-fentanyl anesthesia. Anesthesiology. 2003;98:329-36.
15. Magni G, Rosa IL, Melillo G, Savio A, Rosa G. A comparison between sevoflurane and desflurane anesthesia in patients undergoing craniotomy for supratentorial intracranial surgery. Anesth Analg. 2009;109:567-71.
16. Kaye A, Kucera IJ, Heavner J, Gelb A, Anwar M, Duban M, et al. The comparative effects of desflurane and isoflurane on lumbar cerebrospinal fluid pressure in patients undergoing craniotomy for supratentorial tumors. Anesth Analg. 2004;98:1127-32, table of contents.
17. Bilotta F, Doronzio A, Cuzzone V, Caramia R, Rosa G, PINOCCHIO Study Group. Early postoperative cognitive recovery and gas exchange patterns after balanced anesthesia with sevoflurane or desflurane in overweight and obese patients undergoing craniotomy: a prospective randomized trial. J Neurosurg Anesthesiol. 2009;21:207-13.
18. Bhagat H, Dash HH, Bithal PK, Chouhan RS, Pandia MP. Planning for early emergence in neurosurgical patients: a randomized prospective trial of low-dose anesthetics. Anesth Analg. 2008;107:1348-55.
19. Engelhard K, Werner C. Inhalational or intravenous anesthetics for craniotomies? Pro inhalational. Curr Opin Anaesthesiol. 2006;19:504-8.
20. Magni G, Baisi F, La Rosa I, Imperiale C, Fabbrini V, Pennacchiotti ML, et al. No difference in emergence time and early cognitive function between sevoflurane-fentanyl and propofol-remifentanil in patients undergoing craniotomy for supratentorial intracranial surgery. J Neurosurg Anesthesiol. 2005;17:134-8.
21. Gupta A, Stierer T, Zuckerman R. Comparison of recovery profile after ambulatory anesthesia with propofol, isoflurane, sevoflurane and desflurane: a systematic review. Anesth Analg. 2004;98:632-41.
22. Chui J, Mariappan R, Mehta J, Manninen P, Venkatraghavan L. Comparison of propofol and volatile agents for maintenance of anesthesia during elective craniotomy procedures: systematic review and meta-analysis. Can J Anaesth. 2014.
23. Avila EK, Elder JB, Singh P, Chen X, Bilsky MH. Intraoperative neurophysiologic monitoring and neurologic outcomes in patients with epidural spine tumors. Clin Neurol Neurosurg. 2013;115:2147-52.
24. Pastorelli F, Di Silvestre M, Plasmati R, Michelucci R, Greggi T, Morigi A, et al. The prevention of neural complications in the surgical treatment of scoliosis: the role of the neurophysiological intraoperative monitoring. Eur Spine J. 2011;20 Suppl. 1:S105-14.
25. Sutter M, Deletis V, Dvorak J, Eggspuehler A, Grob D, Macdonald D, et al. Current opinions and recommendations on multimodal intraoperative monitoring during spine surgeries. Eur Spine J. 2007;16 Suppl. 2:S232-7.
26. Malhotra NR, Shaffrey CI. Intraoperative electrophysiological monitoring in spine surgery. Spine (Phila Pa 1976). 2010;35:2167-79.
27. Fehlings MG, Brodke DS, Norvell DC, Dettori JR. The evidence for intraoperative neurophysiological monitoring in spine surgery: does it make a difference? Spine (Phila Pa 1976). 2010;35 9 Suppl.:S37-46.
28. Sala F, Krzan MJ, Deletis V. Intraoperative neurophysiological monitoring in pediatric neurosurgery: why, when, how? Childs Nerv Syst. 2002;18(6-7):264-87.
29. Schwartz DM, Auerbach JD, Dormans JP, Flynn J, Drummond DS, Bowe JA, et al. Neurophysiological detection of impending spinal cord injury during scoliosis surgery. J Bone Joint Surg Am. 2007;89:2440-9.
30. Sloan TB, Heyer EJ. Anesthesia for intraoperative neurophysiologic monitoring of the spinal cord. J Clin Neurophysiol. 2002;19:430-43.
31. Sloan TB, Janik D, Jameson L. Multimodality monitoring of the central nervous system using motor-evoked potentials. Curr Opin Anaesthesiol. 2008;21:560-4.
32. Adhikary SD, Thiruvenkatarajan V, Babu KS, Tharyan P. The effects of anaesthetic agents on cortical mapping during neurosurgical procedures involving eloquent areas of the brain. Cochrane Database Syst Rev. 2011:CD006679.
33. Wang AC, Than KD, Etame AB, La Marca F, Park P. Impact of anesthesia on transcranial electric motor evoked potential monitoring during spine surgery: a review of the literature. Neurosurg Focus. 2009;27:E7.
34. Lo YL, Dan YF, Tan YE, Nurjannah S, Tan SB, Tan CT, et al. Intraoperative motor-evoked potential monitoring in scoliosis surgery: comparison of desflurane/nitrous oxide with propofol total intravenous anesthetic regimens. J Neurosurg Anesthesiol. 2006;18:211-4.
35. Sloan TB, Toleikis JR, Toleikis SC, Koht A. Intraoperative neurophysiological monitoring during spine surgery with total intravenous anesthesia or balanced anesthesia with 3% desflurane. J Clin Monit Comput. 2014.
36. Clapcich AJ, Emerson RG, Roye DP Jr, Xie H, Gallo EJ, Dowling KC, et al. The effects of propofol, small-dose isoflurane, and nitrous oxide on cortical somatosensory evoked potential and bispectral index monitoring in adolescents undergoing spinal fusion. Anesth Analg. 2004;99:1334-40, table of contents.
37. Tamkus AA, Rice KS, Kim HL. Differential rates of false-positive findings in transcranial electric motor evoked potential monitoring when using inhalational anesthesia versus total intravenous anesthesia during spine surgeries. Spine J. 2013.
38. Mahmoud M, Sadhasivam S, Salisbury S, Nick TG, Schnell B, Sestokas AK, et al. Susceptibility of transcranial electric motor-evoked potentials to varying targeted blood levels of dexmedetomidine during spine surgery. Anesthesiology. 2010;112:1364-73.
39. Bala E, Sessler DI, Nair DR, McLain R, Dalton JE, Farag E. Motor and somatosensory evoked potentials are well maintained in patients given dexmedetomidine during spine surgery. Anesthesiology. 2008;109:417-25.
40. Bekker A, Sturaitis MK. Dexmedetomidine for neurological surgery. Neurosurgery. 2005;57 1 Suppl.:1-10, discussion 1-10.
41. Rozet I. Anesthesia for functional neurosurgery: the role of dexmedetomidine. Curr Opin Anaesthesiol. 2008;21:537-43.
42. Zaarour C, Engelhardt T, Strantzas S, Pehora C, Lewis S, Crawford MW. Effect of low-dose ketamine on voltage requirement for transcranial electrical motor evoked potentials in children. Spine (Phila Pa 1976). 2007;32:E627-30.
43. Mishra L, Pradhan S, Pradhan C. Comparison of propofol based anaesthesia to conventional inhalational general anaesthesia for spine surgery. J Anaesthesiol Clin Pharmacol. 2011;27:59-61.
44. Beaussier M, Paugam C, Deriaz H, Mestari M, Chandon M, Sautet A, et al. Haemodynamic stability during moderate hypotensive anaesthesia for spinal surgery. A comparison between desflurane and isoflurane. Acta Anaesthesiol Scand. 2000;44:1154-9.
45. Albertin A, La Colla L, Gandolfi A, Colnaghi E, Mandelli D, Gioia G, et al. Greater peripheral blood flow but less bleeding with propofol versus sevoflurane during spine surgery: a possible physiologic model? Spine (Phila Pa 1976). 2008;33:2017-22.
46. Konstantopoulos K, Makris A, Moustaka A, Karmaniolou I, Konstantopoulos G, Mela A. Sevoflurane versus propofol anesthesia in patients undergoing lumbar spondylodesis: a randomized trial. J Surg Res. 2013;179:72-7.
47. Hans P, Marechal H, Bonhomme V. Effect of propofol and sevoflurane on coughing in smokers and non-smokers awakening from general anaesthesia at the end of a cervical spine surgery. Br J Anaesth. 2008;101:731-7.
48. Guzmán F. Fisiopatología del trauma craneoencefálico. Colomb Med. 2008;39 Suppl. 3:78-84. http://www.scielo.org.co/scielo.php?script=sciarttext&pid=S1657-95342008000700011&lng=en&nrm=iso.
49. Guzmán F, Moreno M, Montoya A. Traumatic brain injury patients at Hospital Universitario del Valle: a 12 months study. North America: Colombia Médica; 2009 http://colombiamedica.univalle.edu.co/index.php/comedica/article/view/602/880.
2. Paulson OB, Strandgaard S, Edvinsson L. Cerebral autoregulation. Cerebrovasc Brain Metab Rev. 1990;2:161-92.
3. Dagal A, Lam AM, Cerebral autoregulation and anesthesia. Curr Opin Anaesthesiol. 2009;22:547-52.
4. Schifilliti D, Grasso G, Conti A, Fodale V. Anaesthetic-related neuroprotection: intravenous or inhalational agents? CNS Drugs. 2010;24:893-907.
5. Cole CD, Gottfried ON, Gupta DK, Couldwell WT. Total intravenous anesthesia: advantages for intracranial surgery. Neurosurgery. 2007;61 5 Suppl. 2:369-77, discussion 377-8.
6. Petersen KD, Landsfeldt U, Cold GE, Petersen CB, Mau S, Hauerberg J, et al. Intracranial pressure and cerebral hemodynamic in patients with cerebral tumors: a randomized prospective study of patients subjected to craniotomy in propofol-fentanyl, isoflurane-fentanyl, or sevoflurane-fentanyl anesthesia. Anesthesiology. 2003;98:329-36.
7. Hans P, Bonhomme V. Why we still use intravenous drugs as the basic regimen for neurosurgical anaesthesia. Curr Opin Anaesthesiol. 2006;19:498-503.
8. Deiner S. Highlights of anesthetic considerations for intraoperative neuromonitoring. Semin Cardiothorac Vasc Anesth. 2010;14:51-3.
9. Matchett GA, Allard MW, Martin RD, Zhang JH. Neuroprotective effect of volatile anesthetic agents: molecular mechanisms. Neurol Res. 2009;31:128-34.
10. Schlünzen L, Cold GE, Rasmussen M, Vafaee MS. Effects of dose-dependent levels of isoflurane on cerebral blood flow in healthy subjects studied using positron emission tomography. Acta Anaesthesiol Scand. 2006;50:306-12.
11. Grathwohl KW, Black IH, Spinella PC, Sweeney J, Robalino J, Helminiak J, et al. Total intravenous anesthesia including ketamine versus volatile gas anesthesia for combat-related operative traumatic brain injury. Anesthesiology. 2008;109:44-53.
12. Todd MM1, Warner DS, Sokoll MD, Maktabi MA, Hindman BJ, Scamman FL, et al. Prospective, comparative trial of three anesthetics for elective supratentorial craniotomy. Propofol/fentanyl, isoflurane/nitrous oxide, and fentanyl/nitrous oxide. Anesthesiology. 1993;78:1005-20.
13. Petersen KD, Landsfeldt U, Cold GE, Pedersen CB, Mau S, Hauerberg J, et al. ICP is lower during propofol anaesthesia compared to isoflurane ans sevoflurane. Acta Neurochir Suppl. 2002;81:89-91.
14. Petersen KD, Landsfeldt U, Cold GE, Pedersen CB, Mau S, Hauerberg J, et al. Intracranial pressure and cerebral hemodynamic in patients with cerebral tumors: a randomized prospective study of patients subjected to craniotomy in propofol-fentanyl, isoflurane-fentanyl, or sevoflurane-fentanyl anesthesia. Anesthesiology. 2003;98:329-36.
15. Magni G, Rosa IL, Melillo G, Savio A, Rosa G. A comparison between sevoflurane and desflurane anesthesia in patients undergoing craniotomy for supratentorial intracranial surgery. Anesth Analg. 2009;109:567-71.
16. Kaye A, Kucera IJ, Heavner J, Gelb A, Anwar M, Duban M, et al. The comparative effects of desflurane and isoflurane on lumbar cerebrospinal fluid pressure in patients undergoing craniotomy for supratentorial tumors. Anesth Analg. 2004;98:1127-32, table of contents.
17. Bilotta F, Doronzio A, Cuzzone V, Caramia R, Rosa G, PINOCCHIO Study Group. Early postoperative cognitive recovery and gas exchange patterns after balanced anesthesia with sevoflurane or desflurane in overweight and obese patients undergoing craniotomy: a prospective randomized trial. J Neurosurg Anesthesiol. 2009;21:207-13.
18. Bhagat H, Dash HH, Bithal PK, Chouhan RS, Pandia MP. Planning for early emergence in neurosurgical patients: a randomized prospective trial of low-dose anesthetics. Anesth Analg. 2008;107:1348-55.
19. Engelhard K, Werner C. Inhalational or intravenous anesthetics for craniotomies? Pro inhalational. Curr Opin Anaesthesiol. 2006;19:504-8.
20. Magni G, Baisi F, La Rosa I, Imperiale C, Fabbrini V, Pennacchiotti ML, et al. No difference in emergence time and early cognitive function between sevoflurane-fentanyl and propofol-remifentanil in patients undergoing craniotomy for supratentorial intracranial surgery. J Neurosurg Anesthesiol. 2005;17:134-8.
21. Gupta A, Stierer T, Zuckerman R. Comparison of recovery profile after ambulatory anesthesia with propofol, isoflurane, sevoflurane and desflurane: a systematic review. Anesth Analg. 2004;98:632-41.
22. Chui J, Mariappan R, Mehta J, Manninen P, Venkatraghavan L. Comparison of propofol and volatile agents for maintenance of anesthesia during elective craniotomy procedures: systematic review and meta-analysis. Can J Anaesth. 2014.
23. Avila EK, Elder JB, Singh P, Chen X, Bilsky MH. Intraoperative neurophysiologic monitoring and neurologic outcomes in patients with epidural spine tumors. Clin Neurol Neurosurg. 2013;115:2147-52.
24. Pastorelli F, Di Silvestre M, Plasmati R, Michelucci R, Greggi T, Morigi A, et al. The prevention of neural complications in the surgical treatment of scoliosis: the role of the neurophysiological intraoperative monitoring. Eur Spine J. 2011;20 Suppl. 1:S105-14.
25. Sutter M, Deletis V, Dvorak J, Eggspuehler A, Grob D, Macdonald D, et al. Current opinions and recommendations on multimodal intraoperative monitoring during spine surgeries. Eur Spine J. 2007;16 Suppl. 2:S232-7.
26. Malhotra NR, Shaffrey CI. Intraoperative electrophysiological monitoring in spine surgery. Spine (Phila Pa 1976). 2010;35:2167-79.
27. Fehlings MG, Brodke DS, Norvell DC, Dettori JR. The evidence for intraoperative neurophysiological monitoring in spine surgery: does it make a difference? Spine (Phila Pa 1976). 2010;35 9 Suppl.:S37-46.
28. Sala F, Krzan MJ, Deletis V. Intraoperative neurophysiological monitoring in pediatric neurosurgery: why, when, how? Childs Nerv Syst. 2002;18(6-7):264-87.
29. Schwartz DM, Auerbach JD, Dormans JP, Flynn J, Drummond DS, Bowe JA, et al. Neurophysiological detection of impending spinal cord injury during scoliosis surgery. J Bone Joint Surg Am. 2007;89:2440-9.
30. Sloan TB, Heyer EJ. Anesthesia for intraoperative neurophysiologic monitoring of the spinal cord. J Clin Neurophysiol. 2002;19:430-43.
31. Sloan TB, Janik D, Jameson L. Multimodality monitoring of the central nervous system using motor-evoked potentials. Curr Opin Anaesthesiol. 2008;21:560-4.
32. Adhikary SD, Thiruvenkatarajan V, Babu KS, Tharyan P. The effects of anaesthetic agents on cortical mapping during neurosurgical procedures involving eloquent areas of the brain. Cochrane Database Syst Rev. 2011:CD006679.
33. Wang AC, Than KD, Etame AB, La Marca F, Park P. Impact of anesthesia on transcranial electric motor evoked potential monitoring during spine surgery: a review of the literature. Neurosurg Focus. 2009;27:E7.
34. Lo YL, Dan YF, Tan YE, Nurjannah S, Tan SB, Tan CT, et al. Intraoperative motor-evoked potential monitoring in scoliosis surgery: comparison of desflurane/nitrous oxide with propofol total intravenous anesthetic regimens. J Neurosurg Anesthesiol. 2006;18:211-4.
35. Sloan TB, Toleikis JR, Toleikis SC, Koht A. Intraoperative neurophysiological monitoring during spine surgery with total intravenous anesthesia or balanced anesthesia with 3% desflurane. J Clin Monit Comput. 2014.
36. Clapcich AJ, Emerson RG, Roye DP Jr, Xie H, Gallo EJ, Dowling KC, et al. The effects of propofol, small-dose isoflurane, and nitrous oxide on cortical somatosensory evoked potential and bispectral index monitoring in adolescents undergoing spinal fusion. Anesth Analg. 2004;99:1334-40, table of contents.
37. Tamkus AA, Rice KS, Kim HL. Differential rates of false-positive findings in transcranial electric motor evoked potential monitoring when using inhalational anesthesia versus total intravenous anesthesia during spine surgeries. Spine J. 2013.
38. Mahmoud M, Sadhasivam S, Salisbury S, Nick TG, Schnell B, Sestokas AK, et al. Susceptibility of transcranial electric motor-evoked potentials to varying targeted blood levels of dexmedetomidine during spine surgery. Anesthesiology. 2010;112:1364-73.
39. Bala E, Sessler DI, Nair DR, McLain R, Dalton JE, Farag E. Motor and somatosensory evoked potentials are well maintained in patients given dexmedetomidine during spine surgery. Anesthesiology. 2008;109:417-25.
40. Bekker A, Sturaitis MK. Dexmedetomidine for neurological surgery. Neurosurgery. 2005;57 1 Suppl.:1-10, discussion 1-10.
41. Rozet I. Anesthesia for functional neurosurgery: the role of dexmedetomidine. Curr Opin Anaesthesiol. 2008;21:537-43.
42. Zaarour C, Engelhardt T, Strantzas S, Pehora C, Lewis S, Crawford MW. Effect of low-dose ketamine on voltage requirement for transcranial electrical motor evoked potentials in children. Spine (Phila Pa 1976). 2007;32:E627-30.
43. Mishra L, Pradhan S, Pradhan C. Comparison of propofol based anaesthesia to conventional inhalational general anaesthesia for spine surgery. J Anaesthesiol Clin Pharmacol. 2011;27:59-61.
44. Beaussier M, Paugam C, Deriaz H, Mestari M, Chandon M, Sautet A, et al. Haemodynamic stability during moderate hypotensive anaesthesia for spinal surgery. A comparison between desflurane and isoflurane. Acta Anaesthesiol Scand. 2000;44:1154-9.
45. Albertin A, La Colla L, Gandolfi A, Colnaghi E, Mandelli D, Gioia G, et al. Greater peripheral blood flow but less bleeding with propofol versus sevoflurane during spine surgery: a possible physiologic model? Spine (Phila Pa 1976). 2008;33:2017-22.
46. Konstantopoulos K, Makris A, Moustaka A, Karmaniolou I, Konstantopoulos G, Mela A. Sevoflurane versus propofol anesthesia in patients undergoing lumbar spondylodesis: a randomized trial. J Surg Res. 2013;179:72-7.
47. Hans P, Marechal H, Bonhomme V. Effect of propofol and sevoflurane on coughing in smokers and non-smokers awakening from general anaesthesia at the end of a cervical spine surgery. Br J Anaesth. 2008;101:731-7.
48. Guzmán F. Fisiopatología del trauma craneoencefálico. Colomb Med. 2008;39 Suppl. 3:78-84. http://www.scielo.org.co/scielo.php?script=sciarttext&pid=S1657-95342008000700011&lng=en&nrm=iso.
49. Guzmán F, Moreno M, Montoya A. Traumatic brain injury patients at Hospital Universitario del Valle: a 12 months study. North America: Colombia Médica; 2009 http://colombiamedica.univalle.edu.co/index.php/comedica/article/view/602/880.
How to Cite
1.
Zuleta-Alarcón A, Castellón-Larios K, Niño-de Mejía MC, Bergese SD. Total intravenous anaesthesia versus inhaled anaesthetics in neurosurgery. Colomb. J. Anesthesiol. [Internet]. 2015 Jul. 1 [cited 2024 Apr. 19];43(Supplement):9-14. Available from: https://www.revcolanest.com.co/index.php/rca/article/view/709
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2015-07-01
How to Cite
1.
Zuleta-Alarcón A, Castellón-Larios K, Niño-de Mejía MC, Bergese SD. Total intravenous anaesthesia versus inhaled anaesthetics in neurosurgery. Colomb. J. Anesthesiol. [Internet]. 2015 Jul. 1 [cited 2024 Apr. 19];43(Supplement):9-14. Available from: https://www.revcolanest.com.co/index.php/rca/article/view/709
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Narrative review
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