Exam II: Neurosurgical Anesthesia Flashcards
Space-occupying ____ and ↑’d ____ volume
[Challenges of a Craniotomy]
lesions, intracranial
Closed non-expandable___ ___“closed box”
-Brain tissue (___), blood (___) and CSF (___)
[Challenges of a Craniotomy]
cranial vault
80%, 12%, 8%
Altered vasoreactivity and ____
[Challenges of a Craniotomy]
autoregulation
Control of___, ___, CPP, ICP and brain swelling
[Challenges of a Craniotomy]
CBF, CBV
Varying levels of ___stimulation occur
-Scalp, skull, dura elicit ___ noxious stimuli
-___tissue almost free from nocioceptive nerve tissue.
[Challenges of a Craniotomy]
noxious
increased
Brain
Unfamiliar monitoring , HOB away from ___
[Challenges of a Craniotomy]
anesthetist
Access to ___is not readily available
[Challenges of a Craniotomy]
airway
Cushing’s reflex: ___=___=___
*Respect ↑’d ICP ability to damage___
[Challenges of a Craniotomy]
↑ICP =↑ HTN = ↓ HR
brain
Flow & ___ are coupled:
___ also ___ & ___
___can alter this coupling
[Challenges of a Craniotomy]
metabolism
↓CMRO2 also ↓CBF & ICP
Drugs
Blood loss & ___can change rapidly
[Challenges of a Craniotomy]
hemodynamics
___ and vasodilators are usually inline and ready for immediate titration.
[Challenges of a Craniotomy]
Vasoconstrictors
Goal is “___” brain not a “___” brain
[Challenges of a Craniotomy]
relaxed, tight
___soaked gauze utilized
[Challenges of a Craniotomy]
Epinephrine
___ surgery
[Challenges of a Craniotomy]
Tedious
Intense noxious stimulation at___ and ___ with little in the ___
[Challenges of a Craniotomy]
beginning, end, middle
Head ROM is fixed due to ___ ___.
[Challenges of a Craniotomy]
cranial pinning
Glucose is the ___ substrate of metabolism
[Metabolism of the Brain]
primary
____worsens hypoxic injury
[Metabolism of the Brain]
Hypoglycemia
The metabolic rate of the brain is measured in ___ ___
[Metabolism of the Brain]
oxygen consumption
Cerebral metabolic rate of oxygen consumption-___
[Metabolism of the Brain]
CMRO2
Adult human brain = ___-___ gms
[Cerebral Blood Flow]
1300-1400
___-___ ml of blood per minute (___/___)
Around ___of total cardiac output
[Cerebral Blood Flow]
650-700, 700/5000
14%
CNS has a ___-___coupling ensuring a supply and demand match:
Increased brain metabolic activity increases ___&___
[Cerebral Blood Flow]
flow-metabolism
CBF & ICP
The brain can increase flow as much as ___-___% of cardiac output
[Cerebral Blood Flow]
15-20
CBF averages ___mL/___ gm/min but can vary regionally from ___-___ mL/___ gm/min
[Neuro Electrical Activity and CBF]
50 , 100, 30-300, 100
CBF < ___ mL/100 gm/min = slowing of EEG
[Neuro Electrical Activity and CBF]
25
CBF ≈ ___-___ mL/100 gm/min = isoelectric EEG
[Neuro Electrical Activity and CBF]
15-20
CBF___ mL/100 gm/min = irreversible injury
[Neuro Electrical Activity and CBF]
< 10
___ & ___more sensitive to hypoxic brain injury than other parts of the brain
[Neuro Electrical Activity and CBF]
Hippocampus & cerebellum
CPP = ___-___ or ___ which ever is higher
[Cerebral Perfusion Pressure (CPP)]
MAP – ICP or CVP
Since ___/___ is small CPP is essentially = to ___
[Cerebral Perfusion Pressure (CPP)]
ICP/CVP, MAP
CPP ___ torr = EEG changes
[Cerebral Perfusion Pressure (CPP)]
< 50
CPP ___ torr = irreversible damage
[Cerebral Perfusion Pressure (CPP)]
< 25
Autoregulation is diminished below ___torr
[Cerebral Perfusion Pressure (CPP)]
50
CBF is autoregulated at MAP between ___-___ torr
[Cerebral Blood Flow (CBF)]
50-150
___, ___ & CMRO2 are closely linked
[Cerebral Blood Flow (CBF)]
CBF, ICP
___/___metabolism coupling occurs
[Cerebral Blood Flow (CBF)]
Flow/cerebral
When CMRO2 decreases then ___ & ___ decreases
[Cerebral Blood Flow (CBF)]
CBF & ICP
Luxury perfusion: ___ > ___
Do not want ___ brain surgery
[Cerebral Blood Flow (CBF)]
CBF, CMRO2
during
CBF is ____ to PaCO2
[Cerebral Blood Flow (CBF)]
proportional
When Vm doubles CBF ___by half.
[Cerebral Blood Flow (CBF)]
deceases
CBF increases ___-___% for every ___ C° temperature
[Cerebral Blood Flow (CBF)]
5-7, 1
Volatile anesthetic drugs (above ___MAC) cause a CNS flow/metabolism uncoupling:
They ___CRMO2 but unfortunately also cause cerebral ____ so CBF and ICP ___
[Anesthesia Drugs & CMRO2, CBF, ICP Coupling]
1.5
reduce, vasodilation, increase
IV Anesthetic drugs preserve CNS ___/___ coupling:
[Anesthesia Drugs & CMRO2, CBF, ICP Coupling]
flow/metabolism
IV anesthetic drugs ___CMRO2 but do not cerebrally ___
[Anesthesia Drugs & CMRO2, CBF, ICP Coupling]
reduce , vasodilate
___CRMO2, CBF and ICP ___ remains intact
[Anesthesia Drugs & CMRO2, CBF, ICP Coupling]
Decrease, coupling
Different agents & doses have ___ effects
[Volatile Inhalational Agents, CBF & ICP]
different
All volatiles ___ cerebral vascular resistance
Dose dependent impairment of ___
Greater than __-___MAC ___ autoregulation resulting in cerebral vasodilation & ___/___ decoupling
[Volatile Inhalational Agents, CBF & ICP]
↓
autoregulation
1-1.5 , impairs
flow/cerebral metabolism
Increases ___, ___ and ICP
[Volatile Inhalational Agents, CBF & ICP]
CBV, CBF
___CMRO2 and even ___cortical activity
Can be ___ at high doses
[Volatile Inhalational Agents, CBF & ICP]
Decrease, abolish
neuroprotective
___attenuates the increases in ICP
[Volatile Inhalational Agents, CBF & ICP]
Hyperventilation
N2O still used, considered ___ by some
-Expands___gas spaces
-Increases ___, ___ and can actually increase ___
[Nitrous Oxide and Craniotomy]
neurotoxic
closed
CBF, ICP, CMRO2
Avoid N2O when:
Presence of ___ air such as during a recent craniotomy, repeat craniotomy or cranial ___.
[Nitrous Oxide and Craniotomy]
intracranial, trauma
Avoid N2O when:
___potential signal is inadequate
Evidence of___ ICP
___ brain
[Nitrous Oxide and Craniotomy]
Evoked
increased
Tight
Barbiturates: decrease ___, ___, and __, inhibit excitatory neurotransmitter receptors, and causes a ___ of EEG
[IV Agents and CBF & ICP]
CBF, ICP and CMRO2, slowing
Propofol:____ ___ ___CBF, CMRO2 isoelectric EEG at ___ mcg/kg/min
Very good at maintaining ___/___ metabolism coupling
[IV Agents and CBF & ICP]
dose dependent decrease, 500
flow/cerebral
Etomidate: ___CBF, ICP and CMRO2 but can cause seizures in patients with ___ history
[IV Agents and CBF & ICP]
decreases, seizure
Opioids: ___ ____ ___ in CBF, CMRO2, ____metabolite can cause seizures
[IV Agents and CBF & ICP]
dose dependent decreases, Demerol
___: anticonvulsant, decreases CBF, CMRO2, respiratory depression limits their use. Contraindicated in patients with ___ ICP
[IV Agents and CBF & ICP]
Benzodiazepines
↑’d
Ketamine: ___ effects, ↑ ICP (___%), CBF
[IV Agents and CBF & ICP]
dissociative, >80%
Muscle Relaxants:
Depolarizers: ___ ICP, CBF, CMRO2, contraindicated in ___ muscle, CVA, motor neuron lesions.
[IV Agents and CBF & ICP]
Increase, denervated
Nondepolarizers: effects are ___ anticonvulsants such as dilantin cause ___ dosage requirements.
[IV Agents and CBF & ICP]
small, increased
Fluid Management
-Avoid ____containing solutions
[Fluid Management for Craniotomy]
dextrose
-Limit volume of___ and use ___and NS for volume resuscitation
[Fluid Management for Craniotomy]
LR, colloid
-Limit ___ to 1 to 1.5L to avoid coagulopathy
[Fluid Management for Craniotomy]
hetastarch
-Maintain Hct at ___ to ___
[Fluid Management for Craniotomy]
30% to 35%
-Mild volume expansion for ___ ___may help reduce vasospasm
[Fluid Management for Craniotomy]
aneurysm clipping
-Kee patients ___, isotonic, and isooncotic
[Fluid Management for Craniotomy]
isovolemic
Monitoring for Craniotomy
-Electrocardiography
-Direct intraarterial blood pressure monitoring
-End-tidal CO2, pulse ox, ABG analysis
-Peripheral nerve stim
-CVP
-Body temp measurement
-UOP
-Electroencephalography or somatosensory evoked potentials
-Cerebral oxygen monitoring
[Monitoring for Craniotomy]
It’s more important to accomplish a ___ ___ than any particular drug combination
[Goals of Induction ]
smooth induction
Avoid ___ ICP or ___ CBF
[Goals of Induction ]
↑, compromising
Avoid hypertension which ___ CBF and ___ ICP
[Goals of Induction ]
↑, ↑
Avoid hypotension which ___
[Goals of Induction ]
↓ CPP
Maximize ___drainage
Avoid excessive ___ ___
HOB ↑ ___
[Goals of Induction ]
venous
neck flexion
> 15°
Hyperventilation during___time or ___period
[Goals of Induction ]
apnea, preoxygenation
Opioids can ___SNS outflow
[Goals of Induction ]
blunt
Adequate muscle relaxant to prevent___/___
[Goals of Induction ]
bucking/cough
___, ___ and controlled is a must!
[Goals of Emergence ]
Slow, smooth
Neurological fxn intact prior to ___
[Goals of Emergence ]
extubation
Prevent ___, ___ or bucking on ETT
[Goals of Emergence ]
straining, coughing
Various opinions regarding ___emergence.
-Re-establishing spontaneous breathing ___ skin closure and pin removal
-Once pins (noxious stimulation) is removed then return of __ ___may be delayed.
[Goals of Emergence ]
optimal
prior to
spontaneous respirations
HOB returned to ___ and ___
[Goals of Emergence ]
machine and CRNA
Rapid awakening promotes ___assessment
[Goals of Emergence ]
neuro
___genital
Neo___
Benign
Mal___
I___ or ____
Cyst
Abscess
Vascular
Hematoma
AVM
[Types of Intracranial Mass Lesions]
Con—
—plastic
—ignant
-nflammatory or Infectious
___: above the tentorium
(4)
[Resection of Mass Lesions]
Supratentorial
Headache
Seizures
hemiplegia
aphasia
___: below the tentorium
___ ___ (ataxia,nystagmus)
Brain stem compression (___ or ___)
[Resection of Mass Lesions]
Infratentorial
Cerebellar dysfunction
altered mental status or altered respirations
Intracranial mass symptoms are present based on
___ rate:
[Resection of Mass Lesions]
Growth
Slow growing are typically ___
[Resection of Mass Lesions]
asymptomatic
