1 / 21

Anesthesia for Intracranial Aneurysm Surgery

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.

liuz
Download Presentation

Anesthesia for Intracranial Aneurysm Surgery

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Anesthesia for Intracranial Aneurysm Surgery • Pekka O. Talke, MD

  2. 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

  3. Surgeons • Lawton

  4. 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)

  5. 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

  6. 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)

  7. 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)

  8. 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

  9. 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)

  10. 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)

  11. 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

  12. 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

  13. 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

  14. 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.

  15. 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

  16. Potential Complications • Delayed awakening from anesthesia • Cerebral ischemia (retraction, temporary clips, vasospasm) • Brain swelling • Intraoperative hemorrhage

  17. 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

  18. 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

  19. What’s new? • Retractor pressure • Temp control • Normotension

  20. 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)

  21. Surgical Steps cont. • Burst supression • Temporary clips, permanent clip(s) • Close (60 min) • Dura (water tight) • Bone flap • Scalp and skin • Dressing, remove pins

More Related