Complications Flashcards
You encounter significant cerebral edema intraop - swelling out of craniotomy site
- Elevate HOB
- No severe head turn (venous return)
- Anesthesia to hyperventilate (PaCO2 to 25, adequate oxygenation)
- Hyperosmolar therapy (Mannitol 100)
- Intraop EVD - if EVD in place, drop to 0 and drain out 20 of CSF
- Ultrasound to look for hematoma
- Undermine galeal scoring, temporalis muscle resection
- Close as fast as possible with tension sutures
- Extend craniotomy site; Frontotemporal lobectomy
You encounter uncontrolled bleeding
- Alert anesthesia about bleeding, monitor BP, prepare products
- Identify bleeding source
- Direct pressure with cottonoid to stop the bleeding
- Use bipolar if able to identify source
- Apply floseal and patty; duraseal with gel foam and apply pressure
- If arterial - temporal clipping. If venous - pack with glue
Bleeding – Aneurysm Rupture
While dissecting around the aneurysm, you encounter massive bleeding
- Put suction on where it’s bleeding and find source, hold pressure with patty
- Alert anesthesia – intraoperative rupture potential, watch BP, have adenosine ready (20mg dose)
- Have assistance with 3rd suction ready and temporary clip ready
If proximal identified, temporary clip at the proximal control - Patty to hold pressure where it is bleeding, and slowly remove patty to identify bleeding site
- Give adenosine 20mg dose
Bleeding – AVM hemorrhage
While dissecting around the AVM, you encounter massive bleeding
- Put suction where bleeding
- Alert anesthesia of bleeding, watch BP, transfuse
- Identify source of hemorrhage, have AVM or temporary clips in place
- If arterial, clip arterial supply
- Floseal/patty and duraseal/gel foam
Bleeding – Vertebral Injury
During ACDF or posterior cervical fusion, you encounter massive pulsatile hemorrhage
- Alert anesthesia – potential vertebral artery injury, watch blood pressure, transfuse
- Apply direct pressure using cottonoid to tamponade bleeding and suction to identify source
- Dissect and identify source of bleeder – primary repair if possible; packing
- Call endovascular
Bleeding – Carotid Injury (Open)
- Alert anesthesia – potential vertebral artery injury, watch blood pressure, transfuse
- Apply direct pressure using cottonoid to tamponade bleeding and suction to identify source
- Dissect and identify source of bleeder – primary repair if possible; packing
- Call endovascular
Bleeding – Carotid Injury (Endoscopic)
During pituitary tumor resection, you encounter massive hemorrhage
- Alert anesthesia possible carotid injury, possible transfusion, watch BP
- Patty to apply direct pressure to tamponade
- Call Endovascular
Bleeding – Sinus Injury
During suboccipital crani, you encounter massive dark bleeding
- Alert anesthesia possible sinus injury – monitor for BP, bleeding and venous air embolism
- Apply suction and pressure with cottonoid to identify source
- Primary suture (5-0 prolene) to close defect; pericranial or dural patch to repair
EVD Kocher and Occipital points
Kocher: 3cm lateral to midline, 1cm anterior to coronal suture
Occipital: 2cm superior to inion, 2cm lateral to midline
Loss of neuromonitoring
During spine surgery, you have loss of neuromonitoring
- Stop surgical step, undo the last step
- Confirm neuromonitor loss
- Talk with neuromonitoring team to confirm signal change is not technical
- Check equipments such as disconnection, electrode placements
- Confirm anesthesia changes in anesthetics, oxygenation, change in BP, other changes - Optimize physical condition
- Increase MAP to improve spinal cord perfusion
- Avoid neuromuscular blockade/inhalational anesthetics - Reassess surgical field
- Inspect any mechanical causes – distraction, hardware placement
- Reverse last step
- Wake up test
Air Embolism
During parasagittal meningioma resection, you had sudden tachycardia and hypertension
Sudden drop of EtCO2, hypertension/tachycardia, desaturation (SpO2)
- Immediate notify anesthesia team – possible air embolism
- Flood surgical field with saline
- Place patient head down to reduce air traveling to the brain (left lateral decubitus position to trap air in right atrium)
- Administer 100% O2
- CVC to aspirate air from the right atrium through catheter
Hydrocephalus
Post op day.1 from suboccipital craniectomy for meningioma, patient became drowsy with headache
- Physically go see patient, evaluate exam, full labs (CBC, BMP, INR, PTT)
- Stat head CT for imaging – rule out new infarct, hemorrhage, hydrocephalus
- Emergent EVD placement
Post op Infection - Wound
Post op from MCA clipping aneurysm day 5, patient had fever and headache, and mild drainage from incision site
- Examine patient, evaluate the wound, any particular site, type of drainage – if purulent, send for culture
- Full labs, blood culture
- MRI with and without contrast to rule out infection
- Empiric antibiotics (vanc and cefepime); wound exploration
- ID consult
Post op Meningitis
Post op day 4 from lumbar laminectomy and discectomy, patient had fever and neck stiffness
- Evaluate patient, headache, neck stiffness, photophobia, neck ridigity/Brudzinski sign
- Evaluate the wound
- Labs (CBC, ESR, CRP, blood culture)
- MRI with and without contrast
- Lumbar puncture for CSF and culture
- Start empiric antibiotics (vanc and ceftriaxone) while wait for culture, monitor, ID consulut for antibiotic course
Post op Abscess
Post op day 7 from resection of large glioma, patient had headache and confusion
- Physically examine patient, neurologic exam, inspect wound
- Full labs, vitals, cbc/esr/crp, blood culture
- MRI brain
- Return to OR for abscess evacuation; start antibiotic after obtaining culture (vanc/cefepime); ID consult
Seizure
During surgery, or immediate after, you noticed the patient was not responsive with shaking
- Physical examine patient, assess ABC, neurologic exam
- If seizure, turn patient on the side
Vitals, labs (CBC, BMP, INR, PTT, blood culture, glucose), CXR, AED levels, EKG, LFT - Ativan 4mg IV every 3 min x2 if needed
- Fosphenyl 1500mg x1
- Intubate
- Proposal load (1-2mg/kg)
- Call Neurology
Instrument Failure
Patient returned to significant pain after lumbar fusion
- Examine patient, evaluate type of pain
- CT lumbar spine for construct, and MRI for new herniation/compression
Chemical Meningitis with Epidermoid
After resection of posterior epidermoid cyst, POD2 patient had headache and fever
LP shows clear with moderate pleocytosis, normal glucose and elevated protein
- Physical examine, neurologic exam
- Vitals, labs (CBC, BMP, INR, PTT, blood cultures)
- MRI brain – with residual contrast enhancement
- Lumbar puncture – rule out infection/bacterial meningitis
- Admit to ICU, fever control, hydration. Dex 4q6 for inflammation, q1h neuro check; consult ID, start empiric antibiotics if concerned until confirmed negative
Refractory ICP or Swelling
Post MVA accident initial GCS 14 decompensated in the next few hours
GCS became 8.
EVD placed. ICP was 30.
Next day, increased drowsiness and pupil dilated
- Physically examine the patient, assess ABC – GCS 8, place EVD
- Elevated ICP – elevate head of the bed, increase propofol sedation, mannitol, large bore IV – 23% hypertonic saline
- Next day – repeat stat head CT, refractory ICP
Surgical decompression
CSF Leak (Spine)
POD4 from L4-5 laminectomy, patient had fluid from incision and positional headache
From small site
Persistent leak
After several days
- Examine patient, evaluate the wound, type of fluid/location leakage
- Conservative – oversew area, keep flat 48 hours
- MRI imaging
- Place lumbar drain for CSF diversion, 10cc/hour
- Return to OR for exploration and primary dural closure, inspect, glue with muscle patch
CSF Leak (Head)
Post right frontal convexity meningioma, POD5 patient had clear nasal drainage from throat
- Examine patient, evaluate the wound, type of fluid/location leakage
- MRI with and without contrast
- Bed rest with 30 degree elevtion, lumbar drain 5 days
- Return to OR for exploration and primary dural closure, inspect, glue with muscle patch
Frontal Sinus Injury
During coronal craniotomy, you entered frontal sinus
- Strip the sinus mucosa with diamond burr
- Seal the frontal sinus – with fat graft or pericranium, fibrin glue
- Monitor post op for CSF leak
Tension pneumocephalus
If burr hole – needle aspiration/urgent craniotomy to release the trapped air
100% FiO2 to, keep patient flat
