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26. Anesthesia for Neurosurgery

26. Anesthesia for Neurosurgery. 마취통증의학과 R1 이강우. INTRACRANIAL HYPERTENSION (1). 정의 : ICP 가 15mmHg 이상으로 계속 증가된 상태 원인 : ① expanding tissue or fluid mass            ② depressed skull fracture             ③ CSF 의 흡수 장애

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26. Anesthesia for Neurosurgery

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  1. 26. Anesthesia for Neurosurgery 마취통증의학과 R1 이강우

  2. INTRACRANIAL HYPERTENSION (1) 정의 : ICP가 15mmHg이상으로 계속 증가된 상태 원인 : ① expanding tissue or fluid mass            ② depressed skull fracture             ③ CSF의 흡수 장애             ④ brain edema를 일으키는 systemic disturbance 증상 : headache, nausea, vomiting, papilledema, focal neurological deficits, altered consciousness Cushing response : periodic increases in arterial BP with reflex slowing of the HR, abrupt increases in ICP lasting 1~15min. CEREBRAL EDEMA 정의 : brain water content의 증가 원인 : BBB의 파괴(vasogenic edema) 가 m/c 종류 : 1) Vasogenic edema : mechanical trauma, inflammatory lesion,                               brain tumors, hypertension, infarction        2) cytotoxic edema : hypoxemia or ischemia            3) interstitial cerebral edema :obstructive hydrocephalus,                              entry of CSF into brain interstitium

  3. INTRACRANIAL HYPERTENSION (2) TREATMENT   - underlying cause의 치료 - vasogenic edema: corticosteroids ; BBB repair 촉진     - fluid restriction, osmotic agents, loop diuretics     - moderate hyperventilation(PaCO2 30-33mmHg) : CBF감소 & ICP 정상화 1)Mannitol      - dose : 0.25-0.5g/kg      - effect : 빠르게 ICP감소      - disadventage : transient increase intravascular volume 심장, 신장 질환자에게  pul. edema야기 가능 - 금기 : cranium을 열기전에 Aneurysms, AVM, intracranial Hemorrhage 2)Loop diuretics(furosemide)     - 덜 효과적이고 30분 정도 시간이 걸리지만 직접적으로 CSF생성 억제하는 효과 - mannitol과 함께 사용시 synergy effect        but, serum potassium농도를 close monitoring해야 한다.

  4. ANESTHESIA & CRANIOTOMY FOR PATIENTS WITH MASS LESIONS(1) Intracranial mass : ① congenital ② neoplastic ③ infectious ④ vascular 원인에 상관없이 mass는 growth rate, location, ICP 따라 증상, 경과가 달라짐 Common sx : headache, seizures, a general decline in cognitive or specific neurological function , focal neurological deficits PREOPERATIVE MANAGEMENT preanesthetic evaluation : Intracranial HTN 여부 Neurologic assessment : mental status, any existing sensory or motor deficits medication : corticosteroid, diuretic, anticonvulsant therapy laboratory evaluation :  steroid-induced hyperglycemia                              electrolyte disturbance by diuretics or ADH                              anticonvulsant level Premedication normal ICP : benzodiazepine intracranial hypertension이 예상될때 : Avoid premedication (∵ respiratory depression 으로 인한 hypercapnia → ICP ↑) corticosteroid와 anticonvulsant는 수술전까지 복용

  5. ANESTHESIA & CRANIOTOMY FOR PATIENTS WITH MASS LESIONS(2) INTRAOPERATIVE MANAGEMENT Monitoring     1) standard monitoring   2) direct intraarterial pr. monitoring  - arterial blood gas measure : PaCO2, ETCO2     3) bladder catheterization (∵ diuretics사용 ) 4) central venous access & pressure monitoring - vasoactive drug 필요로 할때     5) visual evoked potential -  pituitary tumor resection시 optic n. damage 예방 위해 6) ICP monitoring – intracranial HTN시 perioperatively Induction anesthesia and intubation the trachea - SLOW~~ ICP의 상승과 CBF손상 없이 과도하거나 지속된 HTN-> ICP 증가 ->CPP감소, herniation가능성 증가 BP의 과도한 감소 -> CPP손상  m/c induction technique ① thiopental or propofol together with hyperventilation           ② NMBAs : ventilation용이하게, 몸의 긴장, 기침을 방지           ③ IV opioid : sympathetic response를 무디게 해줌          ④ esmolol : tachycardia 예방

  6. ANESTHESIA & CRANIOTOMY FOR PATIENTS WITH MASS LESIONS(3) Positioning Frontal, temporal, parietooccipital craniotomies : supine position head elevation : 15-30도 (∵ venous drainage and CSF drainage 촉진) Positioning시 Tube disconnection 주의 Maintenance of Anesthesia Nitrous oxide - opioid - NMBA technique 로유지 HTN지속시 : low- dose (1<MAC) 흡입마취제 사용 가능 opioid + low dose inhalation agents  or total IV technique continued hyperventilation : PaCO2 30-35mmHg avoid - PEEP & High mean airway pr (low rate and large tidal vol.) (∵ CVP증가) fluid - glucose-free isotonic crystalloid(ex. N/S) or colloid solution              * hyperglycemia-> ischemic brain damage악화 Colloid solution : restore intravascular vol. deficits Isotonic crystalloid solution : maintenance fluid requirements Emergence  like intubation, emergence또한 SLOW and CONTROLLED  IV lidocaine 1.5mg/kg or small dose propofol(20-30mg) or thiopental(25-50mg)         -extubation전에 cough억제 위해

  7. ANESTHESIA FOR SURGERY IN THE POSTERIOR FOSSA(1) Obstructive Hydrocephalus infratentorially located mass : obstruct flow of CSF& increase ICP ∴ICP를 감소시키기 위해 전신마취전에 국소마취로 ventriculostomy Brain Stem Injury posterior fossa operation : cranial nerve injury circulatory and respiratory brain stem center손상 Damage to respiratory center : circulatory change와 항상 연관됨. ex.) abrupt change in BP, HR, cardiac rhythm → 이런 변화시 surgeon에게 반드시 알려야함 수술종료시 abnormal respiratory pattern or inability to maintain a patent airway following extubation → brain stem injury 의심 Brain stem auditory evoked potentials - useful Positioning Modified lateral, prone, sitting position (preferred) position에 상관없이 head는 항상 심장위쪽에 위치한다 Careful positioning – avoid injuries

  8. ANESTHESIA FOR SURGERY IN THE POSTERIOR FOSSA(2) Pneumocephalus sitting position -pneumocephalus ↑ CSF가 수술중 소실되면서 air가 subarachnoid space로 쉽게 들어감 Dural closeure후 pneumocephalus의 확장 → compress the brain Postoperative pneumocephalus : delayed awakening impairment of neurological function Venous Air Embolism (1) wound가 heart level위에 위치할경우 어느 position에서도 생길 수 있다 sitting craniotomy시 가장 발생률이 높다 (20-40%) Physiological consequences depend on – vol. and rate of air entry , patent foramen ovale ( paradoxical air embolism ) Air bubble → venous sys. → pul. Circulation (diffuse into the alveoli ) Pul. Clearence 가능한 양보다 많은경우 : pul. a. pr.증가 → Rt. ventriclular afterload ↑ → cardiac output ↓ N2O : air 의 volume ↑ (적은 양의 air로도 큰 효과) Sign : hemodynamic change전에 ETCO2와 saturation의 감소 sudden hypotension rapid & large amounts of air – sudden circulatory arrest

  9. ANESTHESIA FOR SURGERY IN THE POSTERIOR FOSSA(3) Venous Air Embolism (2) A. Central Venous Catheterization  : allow aspiration of entrained air        catheter가 정확한 위치에 있는지 확인하는것은 매우 중요 위치 confirm : TEE or intravascular electrocardiography(biphasic P wave) B. Monitoring For Venous Air Embolism  most sensitive intraop. Monitor : TEE and precordial Doppler sonography        ETCO2 와 pul. a. pr. 의 변화 : less sensitive but clinical sign이 나타나기전 진단가능 sx. : sudden decrease in ETCO2 ( pul. Dead space ↑ ) mean pulmonary artery pressure ↑ change in BP, & Heart sound – late manifestation

  10. ANESTHESIA FOR SURGERY IN THE POSTERIOR FOSSA(4) Venous Air Embolism (3) C.Treatment Of Venous Air Embolism  1. surgeon에게 notify : surgical field를 saline으로 잠기게 하거나 skull edge 를 밀봉시키거나 bone wax로 두른다 ( entery site찾기위해)      2. N2O 끄고, 100%O2      3. CVP Cath.를 aspirated      4. volume infusion -> CVP증가 시킨다 5 .vasopressor사용 (hypotension의 치료)      6. Bilateral jugular vein compression (cranial venous pr.증가시켜서) - air 유입속도를 늦추기 위함      7. PEEP(CVP증가 위해)      8. Head down position & wound closed quickly      9. cardiac arrest지속시, advanced cardiac life support algorithms 시행

  11. ANESTHESIA FOR STREOTACTIC SURGERY Indication : invountary movement disorders intractable pain epilepsy diagnosing and treating tumor- located deep within the brain 대부분 local anesthesia상태에서 시행 sedation 과 amnesia 가 필요한경우 propofol을 사용하기도 함 Stereotactic head frame 을 하고 있는 환자에서 가장 안전한 intubation은 awake intubation with a fiberoptic bronchoscope!

  12. ANESTHESIA FOR HEAD TRAUMA(1)  Significance of a head injury 1) Irreversible neuronal damage정도 2) 2차적인 손상들 (1) hypoxemia나 hypercapnia같은 전신적 상태       (2) epidural,subdural,intracerebral hematoma 의 존재여부와 정도 (3) intracranial HTN 의정도 --> surgical & anesthetic management 는 이러한 2차적인 손상을 예방하거나 최소하하는것이 목표 Glasgow Coma Scale (GCS) score : severity of injury and outcome 과 연관 ( ex. GCS score < 8 → 약 35 % mortality )

  13. ANESTHESIA FOR HEAD TRAUMA(1)

  14. ANESTHESIA FOR HEAD TRAUMA(2) PREOPERATIVE MANAGEMENT(1) Patency of the airway, adequacy of ventilation & oxygenation, correction of systemic hypotension → 우선적으로 확보되어야 함 Airway Obx and hypoventilation이 흔히 나타남 Pul. contusion, fat emboli, or neurogenic pul.edema 등의 complication에 의해 70%까지 hypoxemia 가 나타날 수있다. 명백한 hypoventilation, absent gag reflex, or GCS점수가 8점이하인경우 -> Tracheal intubation and hyperventilation Intubation 모든 환자는 full stomach상태로 간주 mask로 충분한 preoxygenation and hyperventilation thiopental or propofol 과 rapid-onset NMBA사용 Hypotensive(sys <100mmHg)일경우 : small dose thiopental or propofol, or etomidate Succinylcholine in closed head injury –금기 ( . ICP ↑, hyperkalemia) If difficult intubation : awake intubation, fiberoptic techniques, or tracheostomy

  15. ANESTHESIA FOR HEAD TRAUMA(3) Hypotension Head trauma 환자에서 hypotension : 항상 다른 injury가 함께 있을 가능성이 높다. spinal cord injury 시 ; spinal shock과 연관된 sympathectomy에 의해 유발됨 Hypotension 교정 - by colloid solution and blood (brain edema방지 위해) - severe한경우에 vasopressor사용 glucose-containing or hypotonic solution을 피한다 Hct >30%유지 invasive monitoring – intraarterial pr. , central venous or pul. a. pr, ICP...

  16. ANESTHESIA FOR HEAD TRAUMA(4) INTRAOPERATIVE MANAGEMENT other mass lesion과 같다 barbiturate-opioid-nitrous oxide-NMBA technique가 흔히 사용된다 PaCO2 <30 의 hyperventilation은 피한다 (CBF의 감소 피하기 위해) HTN with tachycardia 시 : b- blocker가 효과적 Excessive vagal tone - atropine or glycopyrrolate사용 DIC ,ARDS, pulmonary aspiration, neurogenic pul. edema, G-I hemorrhage, Diabetic Insipidus등도 흔히 동반 가능

  17. ANESTHESIA & CRANIOTOMY FOR INTRACRANIAL ANEURYSMS & ARTERIOVENOUS MALFORMATION(1) CEREBRAL ANEURYSMS(1) Preoperative Consideration rupture of a saccular aneurysms: m/c cause of subarachnoid hemorrhage acute mortality following rupture : 10% survivors – 25% subsequently die within 3 months from delayed cx. 생존자의 50% 이상 : left with significant neurological deficits “ prevention of rupture ”  > 7mm :surgical Ix Unruptured Aneurysms m/c sx : Headache m/c sign : 3rd nerve palsy Others : brain stem dysfunction, visual field defects, trigeminal neuralgia, cavernous sinus syndrome, seizure, hypothalamic-pituitary dysfunction Dx : angiography, MRI angiography, helical CT angiography

  18. ANESTHESIA & CRANIOTOMY FOR INTRACRANIAL ANEURYSMS & ARTERIOVENOUS MALFORMATION(2) Ruptured Aneurysms usuallyacute subarachnoid hemorrhage less commonly epidural spaceorbrain hemorrhage Sx. : focal neurological deficits없이 sudden severe headache often associated with nausea, vomiting            transient loss of consciousness ( ∵ 갑작스런 ICP증가와 CPP의 감소) Delayed Cx : cerebral vasospasm (30%) , rerupture, hydrocephalus symptomatic vasospasm Tx : triple H therapy – hypervolemia, hemodilution, HTN neurosurgical management : rebleeding과 vasospasm의 risk로 인해 어렵다. rerupture : 10~30% early surgical obliteration of the aneurysm: recommended for stable patient

  19. ANESTHESIA & CRANIOTOMY FOR INTRACRANIAL ANEURYSMS & ARTERIOVENOUS MALFORMATION(3) PREOPERATIVE MANAGEMENT Preanesthetic evaluation : determine whether rupture has occurred Neurological findings와 coexisting disease여부 controlled hypotension의 relative contraindication      : preexisting HTN and renal, cardiac or ischemic cerebrovascular disease EKG Abn. - commonly seen in subarachnoid hemorrhage(not heart dis.) Persistent elevation in ICP : little or no premedication to avoid hypercapnia INTRAOPERATIVE MANAGEMENT(1) rupture or rebleeding의 가능성 : 수술 시작전에 blood를 준비 anesthetic Mx & focus : preventing rupture or rebleeding cerebral ischemia or vasospasm 일으킬 요소를 피해야함 intubation이나 수술로 인해 혈압이 증가되는것을 막는다 intraarterial and central venous(or pulmonary artery) pressure monitoring BP는 과도한감소 없이 유지 mannitol : dura is opened ( to facilitate surgical exposure & reduce tissue trauma)

  20. ANESTHESIA & CRANIOTOMY FOR INTRACRANIAL ANEURYSMS & ARTERIOVENOUS MALFORMATION(5) INTRAOPERATIVE MANAGEMENT(2) controlled hypotension is useful (1) decrease transmural tension across the aneurysm (2) rupture가능성 낮추고 surgical clipping용이하게 해줌 (3) blood loss감소 (4) bleeding시 수술시야 확보 head-up position 과 volatile anesthesia(Iso.)도 혈압을 낮추는 효과가 있다 thiopental과 mild hypothermia : protect Brain neurological condition에 따라 extubation여부 결정 Rapid awakening: ICU 가기 전 OR에서 neurological evaluation가능하게 해줌

  21. ANESTHESIA FOR SURGERY ON THE SPINE(1) PREOPERATIVE MANAGEMENT Any existing ventilatory impairment and airway평가 anatomic abn. and limited neck movement neurological deficits 기록 Patients with Degenerative dis. : pain ←opioid with premedication 반대로, difficult airways or ventilatory impairment : premedication 자제해야함 INTRAOPERATIVE MANAGEMENT(1) Positioning 대부분 prone position       : corneal abrasion or retinal ischemia  주의   nose, ear, forehead, chin, breast(female) or genitalia(male)등이 눌리는것 주의 arm - comfortable position or extended with elbow flexed    supine position : ant. approach to cervical spine : ass. with injuries to the trachea, esophagus, recurrent laryngeal n. sympathetic chain, carotid a. or jugular vein 드물게 sitting and lateral decubitus position

  22. ANESTHESIA FOR SURGERY ON THE SPINE(2) INTRAOPERATIVE MANAGEMENT(2) Monitoring Intraarterial & possibly central venous pr. Monitoring – positioning or turning전에 시행 ( significant blood loss가 선행되었거나 preexisting cardiac dis. 존재시) Elective hypotension or weak epinephrine infiltration of the wound - intraoperative blood loss ↓ somatosensory evoked potentials and motor evoked potentials 측정 - detect intraoperatively spinal cord injury from excessive distraction

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