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8361 Exam 4 > Mod IX: Special Considerations for Posterior Fossa Craniotomies, Epilepsy Procedures & Intracranial Hemorrhage > Flashcards

Mod IX: Special Considerations for Posterior Fossa Craniotomies, Epilepsy Procedures & Intracranial Hemorrhage Flashcards

1
Q

Special Considerations for Posterior Fossa Craniotomies

•Position

A

Typically sitting, park bench, or prone

(Positions that allow for the posterior aspect of the head to be accessed)

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2
Q

Special Considerations for Posterior Fossa Craniotomies

Risk associated with the SITTING Position

A

VAE – 25-45%

Mid-cervical quadraplegia

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3
Q

Special Considerations for Posterior Fossa Craniotomies

Contraindications to the SITTING Position

A

Cardiac instability

Cervical spine disease

Others…

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4
Q

Special Considerations for Posterior Fossa Craniotomies

If SITTING Position must be used, Ensure:

A

Proper neck flexion

At least two finger breaths between chin and chest

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5
Q

Special Considerations for Posterior Fossa Craniotomies

PARK BENCH position is Similar to full lateral, but:

A

Down axilla is off the head of the bed

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6
Q

Special Considerations for Posterior Fossa Craniotomies

Describe the Posterior fossa and it’s constituent structures

A

Confined space comprised of the Medulla, Pons, and Cerebellum

This is where Motor & sensory pathways are

This is where Primary respiratory & cardiovascular centers are

Has Lower cranial nerve nuclei

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7
Q

Special Considerations for Posterior Fossa Craniotomies

Function of the Medulla

A

Autonomic control of respiration, BP, HR, reflex arcs and vomiting

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8
Q

Special Considerations for Posterior Fossa Craniotomies

Function of the Pons

A

Relays sensory info between cerebellum & cerebrum

Contains the pneumotaxic center that helps regulate respiration

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9
Q

Special Considerations for Posterior Fossa Craniotomies

Function of the Cerebellum

A

Multiple functions

Mainly to do with movement

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10
Q

Special Considerations for Posterior Fossa Craniotomies

Monitors

A

Standard monitors

2 large bore IVs

A-line positioned at highest point of skull

Multiorifice CVP catheter (b/c of high incidence of VAE)

Doppler (for VAE assessment)

Will probably be doing SSEPs, BAEPs, and MEPs

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11
Q

Special Considerations for Posterior Fossa Craniotomies

Why would doing SSEPs, BAEPs, and MEPs makes your case harder?

A

You cannot use NMBs

You must use low inhalation concentrations

etc.

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12
Q

Special Considerations for Posterior Fossa Craniotomies

Incidence of Venous air embolism of patients in sitting position is:

A

20 to 45%

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13
Q

Special Considerations for Posterior Fossa Craniotomies

What’s the Primary pathophysiologic event of VAE (Hemodynamic effect of VAE)?

A

Vasoconstriction of the pulmonary circulation

V/Q mismatch

Interstitial pulmonary edema

↓cardiac output

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14
Q

Special Considerations for Posterior Fossa Craniotomies

Which cardiac abnormality present in 20 to 30% population Lead to paradoxical air embolism?

A

Patent foramen ovale

Lead to paradoxical air embolism

Air to coronary or cerebral circulation

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15
Q

Special Considerations for Posterior Fossa Craniotomies

Measures to diagnose VAE include:

A

Measures to diagnose VAE

[Know what’s most sensitive and what’s easiest]

TEE is the most sensitive, but is considered to be invasive

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16
Q

Special Considerations for Posterior Fossa Craniotomies

Sensitivity ranking of monitors for detecting VAE

A

TEE>Doppler> PA catheter>Capno>Mass-Spec

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17
Q

Special Considerations for Posterior Fossa Craniotomies

Treatment of a VAE

A

Treatment of a VAE

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18
Q

Special Considerations for Epilepsy Procedures

Induction - Benzos typically withheld because

A

They lower the seizure threshold

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19
Q

Special Considerations for Epilepsy Procedures

You do Not want to provide a “Slack Brain”

A

Grids are placed superficially on brain tissue;

then evaluated once brain is full pool

If you provide a “Slack Brain”, then the grid placement moves

Check with surgeon on these cases prior to administering diuretics

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20
Q

Special Considerations for Epilepsy Procedures

What’s the of the grid system?

A

To map and detect the focal areas causing the seizure,

so that they can go in and remove that area of brain

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21
Q

Special Considerations for Epilepsy Procedures

What do you think may be compromised when the patient returns for the resection of the focal area?

A

…

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22
Q

Special Considerations for Intracranial Hemorrhage

Subarachnoid hemorrhage (SAH) - Incidence:

A

Estimated 27,000 Americans/yr

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23
Q

Special Considerations for Intracranial Hemorrhage

Subarachnoid hemorrhage (SAH) - Mortality & Morbidity rates

A

Morbidity rate 50%

Mortality rate 25%

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24
Q

Special Considerations for Intracranial Hemorrhage

Subarachnoid hemorrhage (SAH) - Age of Peak incidence

A

50 to 60 yrs old

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25
Q

Special Considerations for Intracranial Hemorrhage

Subarachnoid hemorrhage (SAH) - Gender differences

A

Women > men

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26
Q

Special Considerations for Intracranial Hemorrhage

Pathophysiology of Subarachnoid hemorrhage (SAH)

A

Blood in subarachnoid space causes abrupt ↑ICP with is often associated with systemic HTN & dysrhythmias

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27
Q

Special Considerations for Intracranial Hemorrhage

Clinical symptoms of Subarachnoid hemorrhage (SAH)

A

“Worst headache of my life,” stiff neck, photophobia, nausea & vomiting

50% have a warning leak

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28
Q

Special Considerations for Intracranial Hemorrhage

What’s the most common complications of Subarachnoid hemorrhage (SAH) in the 1st 24 hrs, and what’s the tx for it?

A

Rebleeding

Tx: Early aneurysm clipping is recommended in patients that were alert on admission

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29
Q

Special Considerations for Intracranial Hemorrhage

What’s the mechanism of Cerebral vasospasm a/w Subarachnoid hemorrhage (SAH)? when does it occur?

A

Mechanism unknown

Occurs 30% of patients most often 4 to 12 days post bleed

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30
Q

Special Considerations for Intracranial Hemorrhage

How is Cerebral vasospasm a/w Subarachnoid hemorrhage (SAH) treated? What’s a risk of this therapy?

A

Treated with “Triple-H” therapy

Hypervolemia, hypertension, and hemodilution

Can worsen cerebral edema, ↑ICP, & cause hemorrhagic infarction

However, Hypervolemia, hypertension, and hemodilution are needed to help perfuse the brain

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31
Q

Special Considerations for Intracranial Hemorrhage

Which anesthetic technique is used when Cerebral vasospasm a/w Subarachnoid hemorrhage (SAH) is treated w/ Cerebral angioplasty? What risk are a/w Cerebral angioplasty?

A

Usually GETA

Risks include rupture, intimal dissection, ischemia, & infarction

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32
Q

Special Considerations for Intracranial Hemorrhage

Intracranial hypertension is present in most SAH. How is it treated?

A

May not require treatment or may need ventriculostomy

Abrupt lowering can lead to rebleed d/t disruption of tamponading

33
Q

Special Considerations for Intracranial Hemorrhage

How often does Acute hydrocephalus occur w/ SAH? How is it treated?

A

Acute hydrocephalus occurs in 20% of SAH

Treated w/ Ventriculostomy

34
Q

Special Considerations for Intracranial Hemorrhage

Picture showing an aneurysm that has been surgically clipped

A

Picture showing an aneurysm that has been surgically clipped

35
Q

Special Considerations for Intracranial Hemorrhage

Anesthetic management - Goals are to:

A

Avoid rupture

Maintain CPP and transmural pressure, and

Provide a “slack” brain

An ↑in MAP or fall in ICP will cause ↑transmural pressure and risk of rupture

36
Q

Special Considerations for Intracranial Hemorrhage

Anesthetic management - Monitors

A

Standard craniotomy monitors

37
Q

Special Considerations for Intracranial Hemorrhage

Anesthetic management - ICP management

A

Maintain normocarbia if ICP normal

If ↑ICP, decrease PaCO2 to 30-35 mmHg

This will give you a “slack” brain

38
Q

Special Considerations for Intracranial Hemorrhage

Anesthetic management - electrophysiology monitoring

A

May or may not do electrophysiology monitoring

39
Q

Special Considerations for Intracranial Hemorrhage

Anesthetic management - Deliberate hypotension technique

A

May request deliberate hypotension technique

Make sure patient can tolerate

Think about what chronic HTN does to the brain an to autoregulation

40
Q

Special Considerations for Intracranial Hemorrhage

Anesthetic management - Hypothermia

A

May be asked to provide Low grade hypothermia

(32C to 34C) may be requested

41
Q

Special Considerations for Intracranial Hemorrhage

Anesthetic management - Intraoperative cerebral protection

A

Intraoperative cerebral protection with thiopental (or brevital)

Provides burst suppression

42
Q

Special Considerations for Intracranial Hemorrhage

Anesthetic management - Extubation

A

If plan to extubate want a smooth extubation

43
Q

Special Considerations for Intracranial Hemorrhage

Anesthetic management - postop HTN and vasospasm

A

Treat postop HTN and vasospasm (“triple H”)

The combination of induced hypertension, hypervolemia, and hemodilution (triple-H therapy) is often utilized to prevent and treat cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH).

44
Q

Neuro Anesthesia

Tangle of congenitally malformed blood vessels that form an abnormal communication between the arterial and venous system

A

Arteriovenous malformations (AVMs)

Incidence Male > females

Age 10 to 40

45
Q

Arteriovenous malformations (AVMs)

Symptoms of Arteriovenous malformations (AVMs)

A

Parenchymal hemorrhage

SAH

Focal epilepsy

Progressive focal neurologic sensory-motor deficits

46
Q

Arteriovenous malformations (AVMs)

Treatment of Arteriovenous malformations (AVMs) May be done by

A

Craniotomy or Radiologic embolization

47
Q

Arteriovenous malformations (AVMs)

Anesthetic management for Arteriovenous malformations (AVMs)

A

same as for craniotomy for aneurysm

48
Q

Arteriovenous malformations (AVMs)

Breakthrough cerebral edema may occur - why?

A

Blood flow diverted to vessels not accustomed to high blood flow

49
Q

Arteriovenous malformations (AVMs)

Complication from Arteriovenous malformations (AVMs) Embolization include

A

Embolic or ischemic stroke, and hemorrhage

50
Q

Special Considerations for OOR Neuro Cases

For procedures Done out of OR, what would you not have?

A

What you don’t take with you

“Take it with you or you won’t have it”

51
Q

Special Considerations for OOR Neuro Cases

Procedures done in OOR Neuro suites

A

Embolizations,

angiography,

coiling of cerebral aneurysms,

balloon angioplasty of cerebrovascular disease or cerebral vasospasm, and

therapeutic carotid occlusion for giant aneurysms and tumors

52
Q

Special Considerations for OOR Neuro Cases

MAC vs. GETA

A

A few cases under MAC

Need for complete immobilization usually requires GETA with NMBs

Patient moves they may die or worse

make sure they are relaxed!

May have drastic BP swings due to periods of no stimulation and then intense stimulation

have vasoactive gtts in line

Usually requires a-line (BP and ACT testing) and 2 IVs

53
Q

Special Considerations for OOR Neuro Cases

Drugs to take

A

Heparin, protamine,

lots of NMBs,

vasoactive gtts, and

standard drugs for any procedure

54
Q

Neuro Anesthesia

Glue placed inside a Cerebral aneurysm

A

Glue placed inside a Cerebral aneurysm

55
Q

Neuro Anesthesia

Coil placed inside a Cerebral aneurysm

A

Coil placed inside a Cerebral aneurysm

56
Q

Special Considerations for Pituitary Tumors

A&P - Pituitary gland located ? - Divided into?

A

at base of skull in the sella tircica

Divided into anterior (adenohypophysis) and posterior (neurohypophysis) lobes

57
Q

Special Considerations for Pituitary Tumors

Hormones produced by the anterior Pituitary

A

Hormones produced by the anterior Pituitary

58
Q

Special Considerations for Pituitary Tumors

Hormones produced by the posterior Pituitary

A

Hormones produced by the posterior Pituitary

59
Q

Special Considerations for Pituitary Tumors

Two categories of Pituitary tumors

A

Nonfunctioning

Functioning

60
Q

Special Considerations for Pituitary Tumors

Nonfunctioning Pituitary Tumors - When diagnosed?

A

When large & producing mass effect

Growth of tumors causes symptoms

Headache, impaired vision, cranial nerve palsies, ↑ICP, & hypothyroidism

61
Q

Special Considerations for Pituitary Tumors

Nonfunctioning Pituitary Tumors - Sudden enlargement caused by spontaneous hemorrhage or infarction into the tumor produces a symptom complex known as

A

Pituitary apoplexy

This is Life threatening

Associated with Acute neurological deficits & rapid decline in pituitary function

Treat with corticosteroids and emergency decompression

62
Q

Special Considerations for Pituitary Tumors

Functioning Pituitary Tumors - Why “functioning?” - when are they diagnosed?

A

Produce an excess of one or more of the anterior pituitary hormones

Usually diagnosed when tumor is small

63
Q

Special Considerations for Pituitary Tumors

Which condition is a/w ↑corticotropin & cortisol?

A

Cushing’s disease

This ia an adrenocorticotropin secreting tumor (ACTH))

a/w

Diabetes mellitus with insulin resistant hyperglycemia

Hyperaldosteronism with hypokalemia & metabolic alkalosis

HTN, mild CHF, and truncal edema (moon face, fat pads)

64
Q

Special Considerations for Pituitary Tumors

(GH producing tumor)

A

Acromegaly

General overgrowth of skeletal, connective & soft tissues

All major organs increase in size

HTN, glucose intolerance, visual loss if tumor involves chiasm, hoarseness, dyspnea, cardiomyopathy, lumbar stenosis & cervical compression

65
Q

Special Considerations for Pituitary Tumors

Acromegaly (GH producing tumor) - Airway concerns

A

Hypertrophy

Hypertrophy of mandible, nasal turbinates, soft palate, tonsils, epiglottis, arytenoids, tongue, lips, & nose

Narrowing

Glottis may be narrow (smaller tube than anticipated)

Can have vocal cord paralysis

May have difficult mask fit

Be ready for difficult airway

66
Q

Special Considerations for Pituitary Tumors

Results from pressure effects of tumor on the pituitary gland

A

Panhypopituitarism

These pts will be on Hormone replacement prior to surgery

67
Q

Special Considerations for Pituitary Tumors

Anesthetic considerations - All patients for pituitary surgery receive which drugs preop?

A

Glucocorticoids

68
Q

Special Considerations for Pituitary Tumors​

Most common surgical approach

A

Transsphenoidal

Has Lower morbidity & mortality rates

Associated with Less diabetes insipidus

69
Q

Special Considerations for Pituitary Tumors​

Anesthetic considerations - If sitting monitor for

A

VAE

Have a doppler & CVP

70
Q

Special Considerations for Pituitary Tumors​

Anesthetic considerations - access

A

2 IVs and a-line

71
Q

Special Considerations for Pituitary Tumors​

Anesthetic considerations - What should you monitor if asked to administer 4% cocaine & lidocaine with epi

A

Can have HTN, dysrhythmias, & ischemia

Purpose of 4% cocaine & lidocaine with epi is to dry out the nasal passages and keeps blood out of the surgical field

72
Q

Special Considerations for Pituitary Tumors​

Anesthetic considerations - Access limited to patient due to

A

Equipements around them

C-arm, and other x-ray equipments that allow to see exactely where they are in the brain

73
Q

Special Considerations for Pituitary Tumors​

Anesthetic considerations - Do not let patient move - why?

A

Surgery is very close to the carotid and the brain

Nasal packing is placed after surgery

Avoid bucking on emergence

but want patient awake to perform a neuro exam

74
Q

Special Considerations for Pituitary Tumors​

Diabetes insipidus can occur

A

pre, intra, or postop (most common)

Can be temporary or permanent

75
Q

Special Considerations for Pituitary Tumors​

Signs and symptoms of Diabetes insipidus

A

Polyuria (3 to 15 L/day),

polydipsia (drinks large amts),

serum hyperosmolality (.320 mosmol/ml),

dilute urine (sp gr 1.001 to 1.005)

76
Q

Special Considerations for Pituitary Tumors​

Administration of Salt containing solutions with Diabetes insipidus could lead to:

A

Hypernatremia

77
Q

Special Considerations for Pituitary Tumors​

Administration of Glucose containing solutions with Diabetes insipidus could lead to:

A

Hyperglycemia & Osmotic diuresis

78
Q

Special Considerations for Pituitary Tumors​

Drug therapy for Diabetes insipidus:

A

DDAVP

Lysine vasopressin

8361 Exam 4 (16 decks)

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