Neuro-Anaesthesia Outside the Operating Room

1. Neuro-AnaesthesiaOutside the Operating Room April 2013 Mark Angle, M.D. Kuwait City

2. Outside the Operating Room • Neuro-Interventional Suite : • Coiling of cerebralaneurysm • Obliteration of AVM’s • Balloon occlusion • Vascularstenting • Thrombolysis • Thrombectomy • Speech and memorytesting • MRI

3. Outside the Operating Room • ProceduralSedation vs General Anaesthesia • Quality of the image • Completion of the procedure • Duration of the procedure • Safety of the procedure • Resource consumption • Outcome

4. Outside the Operating Room • Doesgeneralanaesthesiaworsenoutcomeafter stroke intervention ? • Davis et al. (February 2012, Anaesthesiology)

5. Outside the Operating Room • Potentialcontributors to outcome gap: • Neurotoxicity of anaesthetic agents • Lasting dysregulation of cerebral circulation • Selectionbias • Procedural hypotension

6. Outside the Operating Room • Stroke outcome and blood pressure (NINDS) • 18 % increase in deaths per each 10 mmHgbelow 150 mmHg • 4% increase in deaths per each 10 mmHgabove 150 mmHg

7. Outside the Operating Room • Operator’sdesires: • Immobility • Silence • Compliance • Stable but manipulable hemodynamics • Medicalback-up

8. Outside the Operating Room • General Conduct: • Standard team • Standard monitoring • Arterial line optional (rare) • Intubation optional (rare) • Laryngealmask • Paralysisoptional (rare)

9. Outside the Operating Room • Sub-arachnoidhemorrhage : • Principles: • Proceduralsedation (IV, art. line, ng, Foley, EVD, transport) • Heavysedation post-intubation in ICU or ER • Tight BP control

10. Outside the Operating Room • Sub-arachnoidhemorrhage : • MNH Protocol: • Midazolam 4 mg • Propofol 2-4 mg/kg • Esmolol 50-100 mg • LMA • PC Ventilation, EtCO2 28-32 • Isoflurane (low-grade) • Propofol / Remifentanyl(high-grade) • Maintenance BP @ 100-120 sys.

11. Outside the Operating Room • Sub-arachnoidhemorrhage : • Events : • Heparinization • Heparin reversal • Local thrombosis • Vasospasm (catheter-induced) • Rupture

12. Outside the Operating Room • Stroke: • Intra-arterialthrombolysis • Sedation vs anaesthesia • Embolectomy • General anaesthesia (LMA, TIVA) • Issues : • Efficacy (NEJM 2013) • Resource consumption

13. Outside the Operating room • Vasospasm : considerations • Oftenintubated • Usuallywith EVD • Always on pressors / milrinone • Exquisitely BP dependent • Angioplasty Intra-arterialmilrinone 3-8 mg

14. Outside the Operating room • AVM : • Usuallyasleep : LMA / Inhalational • Rarelyawake : Dexmedetomidine, Remifentanyl • Occasionalfunctionaltesting • Supra-selectivecatheterization and IA etomidate • Hypotension or circulatoryarrest for high flow lesions

15. Outside the Operating room • MRI: • Indications : • Claustrophobia • Pain • Physiologicalinstability • Abnormalmovements • Non-compliance • Technique: • Propofol • LMA • Inhalational

16. Outside the Operating room • Etomidate Speech and Memory Test (Neurology 2006) • Evolved from the WADA protocol (bolusmethohexital) • Hemisphericanaesthesiaproduced by intra-carotid injection • Etomidatebolus and infusion

17. Outside the Operating room • Carotidstenting / balloon occlusion • Awake • Minimal sedation (Nabilone, low-dose dexmedetomadine, midazolam, propofol) • Trans-cutaneous pacemaker • Glycopyrrolate

18. Outside the Operating room • Other issues • Contrastallergy • Contrastnephropathy • Protamine reaction • Radiation safety

19. Outside the Operating room • Conclusions : • justneuro-anaesthesia in a less confortable zone … • Communication with the operatorisparamount • Familiaritywith the procedure and itsgoals are essential • Simplicity and the LMA shouldbe the rule