Anesthesia for Intracranial Aneurysm Surgery

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Anesthesia for Intracranial Aneurysm Surgery. Pekka O. Talke, MD. Aneurysms. 2-5 % population 30K SAH/yr 2/3 get to hospital 1/3 in hospital severely disabled or dead Unruptured:1-2%/yr rupture Ruptured: 50% rerupture within 6 mo Urgent, not emergent cases. Surgeons. Lawton.
Transcript
Anesthesia for Intracranial Aneurysm Surgery
  • Pekka O. Talke, MD
  • Aneurysms
  • 2-5 % population
  • 30K SAH/yr
  • 2/3 get to hospital
  • 1/3 in hospital severely disabled or dead
  • Unruptured:1-2%/yr rupture
  • Ruptured: 50% rerupture within 6 mo
  • Urgent, not emergent cases
  • Surgeons
  • Lawton
  • Anesthetic Goals
  • Prevent aneurysm rupture (avoid hypertension)
  • Decrease ICP (surgical exposure, retraction)
  • Maintain CPP (>70 mmHg)
  • Prevent cerebral ischemia from retraction
  • Good operating conditions (NO movement, brain relaxation for exposure)
  • Patients, preop
  • Symptomatic/asymptomatic
  • Ruptured (SAH grade, myocardial effects), unruptured
  • Possibly intubated
  • Location and size of aneurysm
  • Intracranial mass effect from SAH (increased ICP)
  • Neurologic deficits and symptoms
  • Timing, vasospasm
  • Preop
  • One IV
  • Premedicate with up to 2 mg of midazolam if normal mental status.
  • Remind of potential post op intubation
  • Adequate fluid loading (5 to 7 ml/kg of LR, angio)
  • Induction
  • Routine monitors
  • Propofol or thiopental
  • Fentanyl 5 ug/kg in divided doses prior to intubation
  • Muscle relaxant (roc).
  • Arterial cannula before intubation
  • Avoid hypertension (propofol) and hypotension (CPP, vasospasm)
  • Induction cont.
  • Ceftriaxone 1 gm, 4-10 mg decadron, 1 gm/kg mannitol.
  • Tape eyes with tagaderms (prep solution)
  • Temp probe, foley
  • Additional IV (limited access, 300 cc to liters of blood loss)
  • Compression stockings
  • Positioning
  • Supine, bump
  • Long cases, lots of padding (pink and blue foam)
  • Table turned typically 90 degrees
  • Head down?, aeroplaning
  • After draping minimal/no access to face (secure ET well)
  • Maintenance
  • Oxygen
  • Propofol infusion (50-200 ug/kg/min) (SSEPs, EEG)
  • Inhalation agent (<0.25 MAC Isoflurane). Muscle relaxation (vec, panc)
  • Moderate hyperventilation (ET CO2 30 mmHg)
  • Euvolemia to 500 cc more (LR)
  • Moderate hypothermia (34 oC)
  • Burst supression
  • When requested by surgeon
  • Thiopental 125 mg (5 cc) doses
  • Till 70-80% EEG burst supression
  • Redose as needed
  • Turn fentanyl infusion off
  • Reduce propofol infusion rate
  • Support CPP with phenylephrine infusion
  • Clipping
  • Temporary clips (golden)
  • Permanent clips (silver)
  • Aneurysm manipulation before clipping (bleed)
  • Record clip on/off times
  • Maintain CPP during temporary clipping
  • Start closing, warming and more fluid loading after clipping
  • Toward the end
  • First indication of end of surgery when clip aneurysm (60 min)
  • Normalize CO2 once dura closed or earlier if lots of intracranial space
  • Reduce propofol if possible, and titrate in labetalol
  • Toward the end cont.
  • Turn propofol infusion off about 10 min before wakeup
  • Reverse relaxation once Mayfied pins have been removed
  • Attempt to wakeup patient. Unlikely if more than 1 gm of thiopental given.
  • Recovery
  • Wake patient up as soon as possible
  • Extubate if possible
  • Prevent post op hypertension (bleed). Labetalol
  • Transport to ICU with monitor and oxygen
  • Head up position
  • Potential Complications
  • Delayed awakening from anesthesia
  • Cerebral ischemia (retraction, temporary clips, vasospasm)
  • Brain swelling
  • Intraoperative hemorrhage
  • Aneurysm rupture
  • Reasonably common
  • Intubation, pinning, skin insicion, surgical manipulation
  • Maintain intravascular volume (blood in the room, get help)
  • Maintain CPP
  • Adequate anesthesia
  • Thiopental before temporary clipping
  • Vasospasm
  • Only if SAH
  • 5-14 days after SAH
  • Leading cause of SAH morbidity (infarct)
  • Maintain CPP at all times (neo infusion, volume)
  • HHH therapy
  • Consider CVP measurement
  • What’s new?
  • Retractor pressure
  • Temp control
  • Normotension
  • Surgical Steps
  • Mayfield pins (stimulation), head positioning
  • Shaving/prepping/local anesthesia
  • Skin incision (stimulation, blood loss)
  • Scalp off the bone (most stimulation)
  • Burr holes, sawing
  • Removing bone
  • Open dura
  • Surgical approach to aneurysm (microscope, minimal stimulation, retraction)
  • Surgical Steps cont.
  • Burst supression
  • Temporary clips, permanent clip(s)
  • Close (60 min)
  • Dura (water tight)
  • Bone flap
  • Scalp and skin
  • Dressing, remove pins
  • Related Search
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