Herrick_Propofol sedation during awake craniotomy

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					Propofol Sedation During Awake Craniotomy for
Seizures: Patient-Controlled Administration Versus
Neurolept Analgesia
Ian A. Herrick, BSC, MD, FRCW, Rosemary A. Craen, MBBS, FANZCA*,
Adrian W. Gelb, MB, ChB, FRCPC*, Laurie A. Miller, PhDt, Cynthia S. Kubu, PhDt,
John P. Girvin, MD, FRCSCS, Andrew G. Parrent, MD, FRCSCS, Michael Eliasziw, PhD§, and
Joyce Kirkby, RNA*
Departments   of *Anaesthesia, tPsychology, SClinical Neurological   Sciences, and §Epidemiology                                    and Biostatistics,         London
Health Sciences Centre, University of Western Ontario, J. I’. Robarts Research Institute, London,                                   Ontario, Canada

        This prospective study evaluated the safety and effi-                             intraoperative    sedation and patient satisfaction were
        cacy of patient-controlled       sedation (PCS) using propo-                      similar between groups. Memory and cognitive func-
        fol during awake seizure surgery performed under bu-                              tion were well preserved in both groups. The incidence
        pivacaine    scalp blocks. Thirty-seven         patients were                     of transient episodes of ventilatory            rate depression
        randomized      to receive either propofol PCS combined                           (~8 bpm) was more frequent among the propofol pa-
        with a basal infusion of propofol (n = 20) or neurolept                           tients (5 vs 0, P = 0.04), particularly     after supplemental
        analgesia using an initial bolus dose of fentanyl and                             doses of opioid. Intraoperative           seizures were more
        droperidol    followed by a fentanyl infusion (n = 17).                           common among the neurolept              patients (7 vs 0, P =
        Both groups received supplemental            fentanyl and di-                     0.002). PCS using propofol represents an effective alter-
        menhydrinate       for intraoperative    pain and nausea, re-                     native to neurolept analgesia during awake seizure sur-
        spectively. Comparisons         were made between groups                          gery performed in a monitored          care environment.
        for sedation, memory, and cognitive function, patient
        satisfaction, and incidence of complications.          Levels of                                            (Anesth Analg        1997;84:1285-91)

        ortical resection    for the management      of refrac-                           a popular technique (1,2). Recently, the use of propo-
        tory seizures or cerebral     lesions located in close                            fol sedation during these procedures has been re-
        proximity    to eloquent   areas of the brain is often                            ported (3,4) and has become popular at our hospital.
performed      with the patient awake. Anesthesia is usu-                                    Patient-controlled sedation (PCS) with propofol, us-
ally provided using a combination of local anesthesia                                     ing patient-controlled   analgesia (PCA) technology,
(local infiltration and regional blockade) and intra-                                     has been reported to be safe, to provide effective se-
venous (IV) medications to provide sedation, anxioly-                                     dation, and to be associated with a high degree of
sis, and supplemental analgesia during these long                                         patient satisfaction and acceptance (5-7). Most of the
procedures.                                                                               available data involving PCS relate to surgical proce-
   The need to minimize interference with intraopera-                                     dures of relatively short duration.
tive electrocorticography (ECoG), when this is used,                                         This prospective, randomized study was designed
limits the repertoire of drugs available for sedation.                                    to evaluate the safety and efficacy of propofol PCS
Traditionally, neurolept analgesia using a combina-                                       during awake craniotomy for seizure surgery. The
tion of opioid (often fentanyl) and droperidol has been                                   impact of propofol sedation on intraoperative ECoG is
                                                                                          addressed in an accompanying article.

   This study was supported           by a grant from           the Physicians’    Ser-
vices Incorporated       (PSI) Foundation.
   Accepted     for publication     March    6, 1997.                                     Methods
   Address    correspondence        to Ian A. Herrick,          MD, Department       of
Anaesthesia,      London      Health Sciences Centre,           University   Campus,      After institutional ethics approval and acquisition of
339 Windermere         Road, London,       Ontario   N6A        5A5, Canada.              written, informed consent, adult patients (aged 18-65

01997 by the International    Anesthesia   Research   Society
0003.2999/97/$5.00                                                                                                         Anesth    Analg   1997;84:1285-91        1285
1286   NEUROSURGICAL     ANESTHESIA         HERRICK   ET AL.                                             ANESTH        ANALG
       PCS PROPOFOL    & SEIZURE    SURGERY                                                                 1997;84:1285-91

yr) scheduled for cortical resection for refractory sei-       preoperatively, intraoperatively (at 1 h after the com-
zures were randomized to receive either propofol PCS           mencement of sedation), postoperatively in the post-
or neurolept analgesia (fentanyl and droperidol).              anesthesia care unit (PACU), and on postoperative
   Sedation for the PCS group consisted of patient-            day (POD) 1. Memory was also evaluated on POD 1
administered propofol using a bolus dose of 0.5 mg/            and 2 by free recall of specific intraoperative events.
kg, a lockout interval of 3 min, and a basal infusion of       Cognitive functioning was assessed preoperatively,
0.5 mg * kg-’ * h-’ via a standard PCA device (Baxter,         intraoperatively at 1 h, in the PACU, and on POD 1
McGaw Park, ILPCAII). Patients were shown how to               using examination questions listed in Appendix 1.
use the device preoperatively and were instructed to              Intraoperative sedation was assessedprior to seda-
administer sedation if they wished to be more                  tion (baseline) and then hourly by the attending anes-
“sleepy” or if they experienced anxiety or discomfort.         thesiologist based on a 5-point scale (Appendix 2). The
Patients were encouraged to use the PCS device early           technical difficulty associated with each surgical pro-
in the operative procedure (to ensure that they under-         cedure was evaluated by the attending surgeon based
stood how to use it and what effect it would have on           on a 5-point scale (technically easy = 1, technically
them) and were reminded that they could use the                difficult = 5).
pump if they requested more sedation or became rest-              Intraoperative    and postoperative     complications
less during the operation. They were also told that            were noted. These included hemodynamic instability
supplemental analgesia was available from their an-            (systolic blood pressure ~85 or >170 mm Hg, heart
esthesiologist if they were uncomfortable and that the         rate ~45 or >llO bpm), decreased ventilatory fre-
anesthesiologist would take over administration of             quency (~8 bpm), pulse oximetric desaturation
sedation if they were unable or unwilling to do so at          (<90%), intraoperative vomiting, and inappropriate
any point in the operation. To avoid potential inter-          seizures (seizures not associated with ECoG recording
ference with ECoG recordings, propofol administra-             or cortical mapping). The ability to perform appropri-
tion (both the PCS boluses and the basal infusion) was         ately during cortical mapping was also noted. Patient
                                                               satisfaction was evaluated using a short questionnaire
suspended 15 min prior to ECoG recording and func-
                                                               completed by each patient in the PACU and on PODS
tional cortical mapping.
                                                               1 and 5 (Appendix 3).
   For the neurolept group, sedation consisted of ini-
                                                                  Nonparametric data (e.g., the incidence of compli-
tial IV boluses of droperidol (0.04 mg / kg) and fenta-
                                                               cations) were analyzed using Fisher’s exact test or 2
nyl (0.7 pg/kg) followed by an anesthesiologist-
                                                               analysis. The unpaired Student’s t-test was used to
controlled      continuous   infusion   of fentanyl    at
                                                               analyze parametric data (e.g., drug dose comparisons
0.7 pg - kg-’ . h-‘. Administration     of supplemental
                                                               between groups). Satisfaction questionnaire and cog-
droperidol was performed at the discretion of the
                                                               nitive function test results were reported in parametric
attending anesthesiologist.                                    terms and analyzed using Students t-test. Identical
   Both groups received supplemental anesthesiologist-         results were obtained using nonparametric methods
administered fentanyl (25-pg boluses) and dimenhydri-           (Mann-Whitney      U-test). Sedation scores were ana-
nate (25-mg boluses) as needed for intraoperative pain         lyzed parametrically using analysis of variance for
and nausea or vomiting, respectively.                          repeated measures and the Student-Newman-Keuls
   Regional blockade of the scalp was performed by             test. To confirm the acceptability of parametric analy-
the surgeon l-2 h preoperatively using bupivacaine             sis methods, the sedation scores were also subjected to
0.5% with epinephrine. Supplemental local anesthetic           nonparametric analysis, which yielded identical re-
solution (bupivacaine 0.33% with epinephrine) was              sults. A level of P 5 0.05 was accepted as statistically
used to infiltrate along the incision lines prior to sur-      significant.
gery. During craniotomy, dura mater was anesthe-
tized using a mixture of lidocaine 1% and 0.25% bu-
pivacaine without epinephrine. Our block technique
for craniotomy under local anesthesia has been previ-          Results
ously described in detail (8).                                 Thirty-seven adult patients scheduled for cortical re-
    All patients received supplemental oxygen via nasal        section for refractory seizures were studied; 20 re-
prongs during surgery. Intraoperative monitoring in-           ceived propofol PCS, and 17 received neurolept anal-
cluded ECG, pulse oximetry, noninvasive automated              gesia. Three additional patients were excluded from
blood pressure measurements, and capnography via               the study because they required general anesthesia.
the nasal prongs.                                              One patient in the propofol group was converted to
    On the day before surgery, patients were visited to        general anesthesia 1.5 h after the commencement of
obtain demographic data and to perform baseline cog-           sedation due to incomplete regional blockade that
nitive function and memory testing. Memory for ob-             could not be remedied during dural opening. Two
jects was evaluated using recall and recognition tests         patients in the neurolept group were converted to
ANESTH         ANALG                                                                                NEUROSURGICAL          ANESTHESIA            HERRICK    ET AL.            1287
1997;84:1285-91                                                                                                        PCS I’ROPOFOL        & SEIZURE    SURGERY

Table       1. Demographic Data and Surgical Variables                                   Table2. Intraoperative Drug Administration Profile and
                                                                                         Complication Rate
                                                        PCS               Fentanyl /
              Characteristic                        propofol              droperidol                                                           PCS             Fentanyl /
                                                                               + 11                   Characteristic                        propofol           Droperidol
   Age W                                              30 -c 8                34
   Sex (M:F)                                            14:6                  12:5        Total dosefentanyl (Fg / kg)                       N/A                6.3     ? 3
   Weight (kg)                                        69 i 13               72 + 12       Supplemental fentanyl                              2.9 ? 2            2.6     ? 2
   Duration anesthesia                              327 2 48               360 -c 62         (/-dk)
     (min)                                                                                Total dose droperidol                                N/A             0.04     2 0.01
   Surgical site (T/F / C)                           141214                  14/l/2          (mgk)
   Surgical difficulty (l-5)                          3 -c 0.7                 3 k 0.8    Total dosepropofol (mg/kg)                        10.2 * 4                  N/A
   Local anesthetic scalp                            20 t 1                  20?    1     Total propofol bolus dose                          7.2 + 4                  N/A
     blocks (bupivacaine                                                                     (mgk)
     0.5% with epinephrine                                                                PCS demand ratio (%)                                  40.3                  N/A
     1/ 200,000)(mL)                                                                         (successful:totaldemands)
   Local anesthetic scalp                            45   +   22             51 ? 23      Total dose dimenhydrinate                          13 t      22        22 ? 26
     infiltration (bupivacaine                                                               (mg)
     0.33% with epinephrine                                                               Number of patients given                               6                     9
     1/ 200,000)(mL)                                                                         intraoperative
    Data are presented       as mean + SD or number   of patients.
    PCS = patient-controlled        sedation, T/F/C = temporal/frontal/central            Intraoperative vomiting                                2                     3
                                                                                          Intraoperative seizures                                0                     7"
                                                                                          Transient respiratory rate                             5                     0%
general anesthesia due to marked anxiety and agita-                                          depression
                                                                                          Intraoperative tachycardia                             2                     6
tion. For one patient, general anesthesia was induced
prior to sedation; for the other patient, anesthesia was                                    Data are presented       as mean 2 SD or number     of patients.
                                                                                            PCS = patient-controlled         sedation, N/A = not applicable
induced approximately 30 min after the commence-                                            * P < 0.05 between       groups.
ment of sedation. In both cases, the patients were
unwilling to continue the procedure awake and re-
quested general anesthesia.                                                              which was prompted by discomfort and fatigue dur-
   Demographic data for the two groups are shown in                                      ing the terminal stages of the cortical resection. In the
Table 1. The duration of anesthesia and surgery aver-                                    neurolept group, the fentanyl infusion was increased
aged 5-6 h. The majority of patients underwent tem-                                      to 0.9-1.8 pg. kg-i . h-l for five patients. In addition
poral lobectomy.                                                                         to an increased fentanyl infusion, one of these patients
   Preoperative anticonvulsant medications were sim-                                     also received incremental doses of propofol (lo- to
ilar between groups. Thirty-five percent and 45% of                                      20-mg boluses, total dose 240 mg over a 1.5-h interval)
the patients in the PCS and neurolept groups, respec-                                    at the discretion of the attending anesthesiologist to
tively, received the usual dose of anticonvulsant                                        manage agitation during the terminal aspects of the
medications on the morning of surgery. The remain-                                       resection and closure. Three patients also received a
der of the patients had anticonvulsant medications                                       single supplemental dose of droperidol ranging from
tapered, partially or completely, during preopera-                                       0.5 to 1.25 mg. Dose adjustments, if needed, typically
tive evaluations and received a reduced dose or no                                       reflected a response to restlessness or discomfort, of-
dose of anticonvulsant       medication on the day of                                    ten compounded by nausea, which may accompany
surgery.                                                                                 resection of the mesial temporal lobe or basal frontal
   All patients received supplemental anesthesiologist-                                  lobe. The predetermined sedation protocol, which in-
administered fentanyl for discomfort during the cor-                                     cluded the suspension of propofol administration dur-
tical resection. The supplemental dose was similar for                                   ing testing, was not altered in either group during the
the two groups (Table 2). The PCS patients received a                                    preresection period (i.e., prior to or during ECoG
mean propofol dose of 690 + 287 mg, of which 494 2                                       recording).
291 mg (72%) was patient-administered.
   Adjustments to predetermined dose regimens (in-                                       Sedation Scores
creases in the rate of the fentanyl infusion or increases
in the bolus dose or basal infusion of propofol) were                                    Compared with baseline, sedation scores increased in
required for five patients in the neurolept group and                                    a similar fashion in both groups except at the 2-h
four patients in the PCS group. Three of the patients in                                 assessment, at which point sedation scores in the
the PCS group had the propofol bolus dose increased                                      propofol group decreased significantly. This assess-
to 0.75-1.0 pg/kg. The fourth PCS patient was con-                                       ment coincided with the period during which propo-
verted to a propofol infusion (2-3 mg * kg-’ * h-i) in                                   fol administration was suspended during intraopera-
response to a request to stop using the PCS device,                                      tive testing (Figure 1).
1288      NEUROSURGICAL        ANESTHESIA         HERRICK          ET AL                                                                                       ANESTH       ANALG
          PCS PROPOFOL       & SEIZURE    SURGERY                                                                                                                1997;84:1285-91


                                       /                       I           I                               PCS      NEUROLEPT     PCS      NEUROLEPT           PCS      NEUROLEPT
              PREOP          1         2         3             4           5                                     I-HOUR                  PACU                        POD1
                            TIME    FROM     PREOP     (Hrs)
                                                                                                 iIfIUUI   = RECALL
Figure 1.   Patient    sedation       scores assessed intraoperatively     by the                =         = RECOGNITION
attending   anesthesiologist.        Scoring based on a 5-point scale (Appen-
dix 1). Scores for propofol        PCS (0) and neurolept      analgesia (a) were    Figure       2. Object recall and recognition              test results at 1 h intraop-
assessed at l-h intervals        intraoperatively.   Error bars represent    SEM.   eratively,      in the postanesthesia         care unit, and on the first postoper-
*P < 0.05 between        groups.                                                    ative      day (PODl).        Prior to sedation,         patients    were shown        three
                                                                                    objects,      and memory           for these objects was tested 1 h after the
                                                                                    commencement             of sedation.     Patients were then shown three addi-
Memory and Cognitive Functioning                                                    tional objects, and memory               was evaluated          for all six objects in the
                                                                                    postanesthesia         care unit and on PODl. The mean number                     of objects
                                                                                    recalled directly        is shown by the height of the vertically             striped area
Based on recall and recognition tests, memory for                                   of each bar. The additional              contribution       of recognition     to the total
objects was not different between the two groups (Fig-                              number        of objects remembered           is depicted      by the open area of each
ure 2). Memory encoding and retrieval were not af-                                  bar.
fected substantially by either type of sedation. Cogni-
tive function test results were similar between the two                             Table        3. Patient Satisfaction Questionnaire Results
groups. Free recall of intraoperative events was not
depressed in either group.                                                                                                          Questionnaire score (l-4)
                                                                                               Satisfaction index                  PACU             POD 1               POD 5
Patient Satisfaction                                                                 General level of comfort
Patient satisfaction was similar between groups with                                   PCS                                       2.7 5 0.8         2.7 t 1.1          2.9 +- 1.1

respect to the general level of comfort and willingness                                NEUROLEPT                                 2.7 +- 0.8        2.5 -c 0.8         2.8 ? 0.9
                                                                                     Willingness to use same
to repeat the procedure using the same sedation tech-                                     technique in future
nique (Table 3). Satisfaction with the option of self-                                 PCS                                       2.9 -c 0.8        3.1 ? 0.9          3.0 ? 1.1
administering sedation (assessed only in the PCS                                       NEUROLEPT                                 2.7 IL 0.9        2.7 +- 0.9         2.6 ? 1.2
group) was high. Satisfaction with PCS was main-                                     Satisfaction with
tained through the fifth postoperative day.                                               patient-administration
                                                                                       PCS only                                  3.3 i     0.7     3.6 -c 0.5         3.6 ? 0.6

Complications                                                                           Data    are presented as mean +- SD
                                                                                        PACU       = postanesthesra care umt,        POD     = postoperatrve          day, PCS =
                                                                                    patm+controlled         sedatmn
Transient decreases in respiratory rate (<8 bpm) after
supplemental doses of fentanyl were more common in
the PCS group (PO.04, Fisher’s exact test) (Table 2).                               neurolept analgesia to manage agitation (as discussed
These episodes were short in duration (<l min) and                                  previously).
did not require intervention. One patient in the neu-                                  Intraoperative inappropriate seizures were mark-
rolept group experienced a brief episode of pulse oxi-                              edly more common in the neurolept group (P = 0.002,
metric desaturation (Spo,89%) associated with the ad-                               Fisher’s exact test). Five patients experienced general-
ministration  of small doses of propofol during                                     ized convulsions, and two experienced focal motor
ANESTH          ANALG                                                  NEUROSURGICAL       ANESTHESIA        HERRICK    ET AL.   1289
1997;84:1285-91                                                                        PCS PROPOFOL     & SEIZURE    SURGERY

seizures. Four of the patients who experienced gener-              Based on our experience, the inclusion of a basal
alized convulsions received IV thiopental (50- to              infusion is advantageous during propofol PCS for
75-mg boluses) to terminate the seizures (mean dose            long procedures during which patients often become
125 mg, range 50-200 mg). Each patient recovered               restless or fatigued as the procedure progresses (15). A
satisfactorily to complete the procedure under neuro-          basal infusion provides a baseline level of sedation
lept analgesia. ECoG recordings were satisfactory in           that patients may augment using PCS demands in
both groups, although a low frequency of ECoG spike            response to clinical circumstances. The PCS demand
activity noted in one of the patients in the neurolept         ratio in this study was 40%. This is consistent with the
group was attributed to the administration of thiopen-         results of other investigators (7,16). Although the tech-
tal to terminate a seizure that occurred during the            nique is associated with a relatively high number of
period preceding ECoG recording. The frequency of              ineffective demands, patients achieved effective levels
ECoG spike activity did not correlate with the type of         of sedation and expressed a high degree of satisfaction
sedation administered, as discussed in detail in the           with PCS. These findings probably reflect a favorable
accompanying article. All patients performed satisfac-         response to the sense of control or participation pro-
torily during functional cortical mapping.                     vided by PCS.
    Two patients in the PCS group and six patients in              Propofol may exert a positive or euphoric effect on
the neurolept group developed tachycardia in excess            mood (17-19), which has been postulated to contribute
of 110 bpm in response to intraoperative discomfort            to the high levels of patient satisfaction reported with
(P = 0.07, Fisher’s exact test) (Table 2). In all cases,this   PCS, particularly when assessmentsare conducted in-
response was satisfactorily attenuated with supple-            traoperatively or during the early postoperative pe-
mental fentanyl. The incidence of intraoperative vom-          riod (6,14). Our results suggest that patient satisfaction
iting and the administration of antiemetic medication          with propofol PCS is independent of these effects, if
were similar between the two groups.                           they exist, since satisfaction is maintained well into the
                                                               postoperative period, up to POD 5.
                                                                   Complications associated with the two sedation
Discussion                                                     techniques were similar. A higher incidence of tran-
Sedation during awake craniotomy has traditionally              sient respiratory rate depression was found in the
been provided using a combination of fentanyl and              propofol group after doses of supplemental fentanyl.
droperidol. Propofol offers several potential advan-            However, the fact that these events were not associ-
tages over traditional techniques: its short duration of        ated with pulse oximetric desaturation emphasizes the
action facilitates titration of sedation, it has a wide         advantage associated with providing supplemental
spectrum of applications (including conversion to               oxygen during these procedures. Patients receiving
general anesthesia if clinical circumstances warrant),          propofol sedation appear to be prone to respiratory
and it has been reported to have both antiemetic and            depression associated with the administration of opi-
amnestic properties at sedative doses (9-12).                   oids. This observation has also been reported by oth-
   Several studies (5,6,13,14) have endorsed the use of         ers (20).
propofol for sedation during procedures of short du-               Patients receiving neurolept analgesia experienced a
ration, both by continuous infusion and via PCA de-             higher incidence of inappropriate intraoperative sei-
livery systems. Although the use of propofol sedation           zures compared with the patients who received
has been reported during epilepsy surgery (3,4), there          propofol. Since the management of anticonvulsant
is no information available regarding the safety or             medications in the preoperative period was similar
efficacy of patient-administered     propofol sedation          between the two groups, these findings suggest that
during these procedures. PCS offers the opportunity             propofol may suppress seizure activity or that neuro-
to combine bolus doses of sedative medication admin-            lept analgesia may either facilitate seizures or at least
istered by the patient with a continuous basal infusion         permit normal convulsions. Although its proconvul-
controlled by the anesthesiologist. This strategy offers        sant and anticonvulsant profile remains controversial,
the patient a sense of control and provides the capac-          propofol has anticonvulsant activity at sedative doses
ity to administer sedation in response to the individ-          (21). In contrast, many neuroleptic drugs, including
ual needs of the patient while enabling the anesthesi-          butyrophenones such as droperidol, have been re-
ologist to determine the background level of sedation.          ported to lower the seizure threshold, and caution has
    Our results demonstrate that patient-administered           been advised when administering these drugs to pa-
propofol is just as effective as anesthesiologist-              tients with untreated epilepsy (22,23). The facilitation
administered neurolept analgesia during these proce-            of seizure activity has not been reported in association
dures. Patients achieved similar levels of sedation and         with the administration of droperidol during anesthe-
were similarly satisfied with both techniques. Patients         sia for intractable epilepsy (21). However, compara-
using PCS were satisfied with the option of controlling         tive studies involving the use of distinctly different
the administration of sedation.                                 sedation techniques during epilepsy surgery have not
1290    NEUROSURGICAL      ANESTHESIA         HERRICK       ET AL                                                                                      ANESTH        ANALG
        PCS PROPOFOL     & SEIZURE    SURGERY                                                                                                             1997;84:1285-91

been reported previously.            Further investigations        are          sedation doses, our findings, consistent with the re-
needed to define the basis for the observed difference                          sults of other investigators,     show that at lower doses,
in the incidence of seizures.                                                   the amnestic       effects    of propofol   are negligible
    ECoG recordings were satisfactory            to proceed with                (10,12,19).
resection in all patients. A comparison              of the ECoG                   The results of this study demonstrate      that propofol
effects of each of the sedation protocols is addressed in                       PCS provides an effective alternative to neurolept an-
the accompanying          article.                                              algesia during craniotomy        performed  under regional
    Propofol reportedly has significant antiemetic prop-                        anesthesia.   Our experience regarding        the effect of
erties (9), but the incidence of intraoperative          vomiting               propofol    sedation on the quality of intraoperative
and the administration           of dimenhydrinate      were simi-              ECoG recordings        is described in the accompanying
lar between       our two groups. This may be because                           article.
droperidol     also possesses antiemetic properties, or be-
cause intraoperative        vomiting was preempted by the
                                                                                The authors gratefully     acknowledge     the assistance of Ms. C. Hawke,
administration      of dimenhydrinate        in response to com-                Ms. L. Szabo (secretarial     assistance),   and Mr. P. Lok (data analysis)
plaints of nausea. An additional possibility may relate                         in the preparation     of this manuscript.
to the fact that many episodes of vomiting                    during
these operations appear to result from discomfort                  as-
sociated with traction on blood vessels or dura at the
base of the cortical resection. Although propofol and
droperidol     are effective antiemetics for drug-induced                       Appendix           1
nausea and vomiting mediated by the area posterema,                             lntraoperative            Sedation Scale
the mechanisms          for intraoperative      vomiting      during
these procedures        may be less responsive        to therapy.                Score                                         Criteria
    Cognitive     function      was well preserved          in both                 1        Fully awake and oriented
groups, as was memory. Patients in both groups per-                                 2        Drowsy,          eyes     open
formed well on formal memory testing involving ob-                                  3        Drowsy, eyes closed, but rousable to command
ject recall and recognition and demonstrated              little am-                4        Drowsy, eyes closed, rousable to mild physical
nesia for intraoperative         events. Although propofol has                                  stimulation
                                                                                    5        Unrousable              to mild   physical       stimulation
been reported to possess amnestic properties at higher

Appendix         2
Mental Status Questionnaire
1. What is your name?                                                                                                                                                        (3)

2. What is the date today?                                                                                                                                                   (3)
                                                    Month                                                     Day                                               Year

3. What is the name of this place?                                                                                                                                           (3)
                                                        Hospital                                       City                                                 Province

4. What is your address?                                                                                                                                                     (3)

5. What is your telephone            number?                                                                                                                                 (1)

6. What is your mother’s            first name?                                                                                                                              (1)

7. Name the next 3 months              in a calendar          year after the month of August.                                                                                (3)

8. Subtract    serial 3’s:                              I                   I                             I                               I                              41)

9. McGill Picture Anomalies Test: Two pictures                      will be shown.        Patient is asked to demonstrate                            what      is funny,
   peculiar, or out of place in each picture.                                                                                                                         (2)

Total score =                                 120
ANESTH         ANALG                                                                                                    NEUROSURGICAL           ANESTHESIA              HERRICK    ET AL.            1291
1997;84:1285-91                                                                                                                             PCS PROI’OFOL          & SEIZURE    SURGERY

Appendix 3
Patient Satisfaction Questionnaire
Please help us evaluate your anesthetic by completing the following questions. We are interested in your honest
opinion, positive or negative. We also welcome your comments and suggestions.
Circle your answer:
1. How satisfied were you with your pain management and overall level of comfort?
           4                         3                         2                         1
     very satisfied            mostly satisfied      mildly satisfied           quite dissatisfied
                                                      or indifferent
2. If you were to have surgery again, would you opt for the same method of management?
              1                         2                        3                     4
     no, definitely not       no, I don’t think so       yes, I think so         yes, definitely
3. Did you like the method of self-administration                                                 of sedative medication?
            4                          3                                                                          2                                                  1
      yes, definitely          yes, I think so                                                          no, I don’t think so                                no, definitely not

                                                                                                           13. Mackenzie         N, Grant IS. Propofol           for intravenous        sedation.      An-
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