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N934 Adv Principles Fa 21 > Neuro Cases and Considerations > Flashcards

Neuro Cases and Considerations Flashcards

1
Q

do you give benzos preop for Neuro cases

A

no, when they wake up postop the surgeon will want to do a neuro exam. if they cant, its aNeStHeSiAs fAuLt

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2
Q

in general, anesthetic drugs do what to CMR?

A

depress CMR

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3
Q

anesthetic drugs that do not depress CMR

A

ketamine and nitrous oxide

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4
Q

preop considerations

A

general assessment including IV access
normal postop eval
neuro assessment
med assessment (anticonvulsants)

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5
Q

medications used intraop

A 
continue antiseizure
usually ancef and vanc as abx
diuretics
mannitol
steroids (usually a big dose up front)
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6
Q

preop considerations: head positioning with mayfield pins

A

premedicate before stimulation with 2cc remi or prop bolus

-these pins are sharp, patient will bleed

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7
Q

MEP neuromonitoring (motor evoked potentials)

A

used in surgeries where motor tract is at risk
direct and scalp electrodes
more sensitive to ischemia than SSEP by 15 minutes and degree detection
pt bleeds when these are taken out-theyre like screws

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8
Q

SSEP neuromonitoring (somatosensory)

A

most commonly monitored
stimulation of peripheral sensory nerve
mapping in spinal cord and sensory cortex
ischemia detection in cortical tissues
reduce risk of spinal cord/brainstem
mechanical or ischemic insults
-can use paralytic if needed
-does have motor monitoring, not as specific.
-does not measure deficits
-hypothermia can increase latency and decrease amplitude

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9
Q

EMG neuromonitoring (electromyography)

A

records muscle electrical activity using needle pairs
continuous recording
triggered responses
uses: detect nerve irritation, nerve mapping, assess nerve function, monitoring cranial nerves.
good for spinals to detect if screws are misplaced

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10
Q

which two drugs increase neuromonitoring wave amplitude

A

ketamine and etomidate

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11
Q

what is stereotactic neurosurgery

A 
applies the rules of geometry to radiologic images to allow for precise localization within the brain, providing up to 1mm accuracy. less invasive approach to certain intracranial procedures.
small markers (fudicials) are affixed to scalp and forehead with adhesive. important that these fudicials do not move between time of imaging and entry into OR
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12
Q

anesthesia for stereotactic neurosurgery

A

smaller brain biopsies may be done under local/mac

GETA for larger resections

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13
Q

craniotomy meds to decrease ICP

A

decadron 10mg
mannitol 50-100g (.25-.5g/kg)
lasix (+/-)

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14
Q

craniotomy induction meds

A

fentanyl, prop, rocuronium

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15
Q

craniotomy maintenance meds

A

TIVA with prop at max 40mcg/kg/min ABW for asleep motor mapping and awake crane
remifentanil .2mcg/kg/min IBW(why doe?)
neo gtt strung up
-increase remi before increasing prop if patient is light

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16
Q

for what types of surgeries can you consider redosing rocuronium

A

aneurysms, pituitary tumors

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17
Q

craniotomy meds: antiepileptics

A

keppra 1g, vimpat

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18
Q

craniotomy meds: abx

A

usually vanc and ancef

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19
Q

craniotomy meds: analgesics

A

tylenol 30m before close

hydromorphone or fentanyl

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20
Q

drugs specifically for awake crani

A

caffeine 60mg/3mL (adenosine receptor antagonist)

physostigmine (anti cholinesterase) .5-1mg q2m

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21
Q

why are cranies usually a delayed wake up (not anesthesia related)

A

CT reveals air that will absorb, delays wake up

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22
Q

types of intracranial mass lesions

A

congenital
neoplastic (benign versus malignant)
infectious (abcess or cyst)
vascular (hematoma or av malformation)

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23
Q

typical presentation of intracranial mass in order from most reported to least reported sx

A

HA, seizures, focal neurological deficits, sensory loss, cognitive dysfunction

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24
Q

supratentorial intracranial mass lesions sx (general)

A

seizures, hemiplegia, aphasia

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25
Q

supratentorial intracranial mass lesions sx: frontal

A

personality changes, increased risk taking, difficulty speaking (damage to brocas area)

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26
Q

supratentorial intracranial mass lesions sx: parietal

A

sensory problems

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27
Q

supratentorial intracranial mass lesions sx: temporal

A

problems with memory, speech, perception, and language skills

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28
Q

supratentorial intracranial mass lesions sx: occipital

A

difficulty recognizing objects, an inability to ID colors, trouble recognizing words

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29
Q

infratentorial/posterior fossa intracranial mass lesions sx: cerebellar dysfunction

A

ataxia, poor balance, nystagmus, dysarthria, cannot perform rapid alternating movements, loss of muscle coordination

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30
Q

infratentorial/posterior fossa intracranial mass lesions sx: brainstem compression

A

cranial nerve palsy, altered LOC, abnormal respiration, edema, obstructive hydrocephalus at 4th ventricle

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31
Q

intracranial mass lesions: primary tumor types

A

glial cells (most common), ependymal cells, supporting tissues

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32
Q

intracranial mass lesion: management major considerations

A

tumor location-determines patient positioning, EBL, risk for hemodynamic changes intraoperatively
growth rate and size: slow growing tumors are often asymptomatic
ICP elevation

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33
Q

intracranial mass lesion: anesthetic goals

A 
control ICP
maintain CPP
protect from position related injuries
rapid emergence for neuro assessment (remi wake up)
SBP <160 is postop goal so keep in mind
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34
Q

intracranial mass lesion: positioning

A

supine with bump under shoulder for tilt. tape ETT on opposite side.
anticipate HOB 90-180
adequate IV line extensions
long breathing circuit
PNS often on LE’s
HOB often elevated 10-15 degrees
supine, lateral, or prone. sitting out of favor
anticipate sympathetic response with mayfield pin positioning if applicable (prop or remi bolus)

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35
Q

intracranial mass lesion: intraoperative monitoring

A

standard monitors
aline
foley
central line (+/-)
PNS (do not monitor on hemiplegic side because you may end up overdosing paralytics)
ventriculostomy (zero at auditory meatus) (+/-)
IONM possible

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36
Q

if you do a CVC, where would you insert it

A

subclavian because theoretically IJ can decrease drainage for maintenance of ICP

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37
Q

intracranial mass lesion: preoperative considerations

A

determine presence of absence of increased ICP
document LOC and neuro deficits
review PMH/general health status
review meds (anticonvulsant schedule, diuretics)
review lab findings (glucose, anticonvulsant drug levels, electrolyte disturbances, H/H)
review radiological studies
premedication (avoid benzos/narcs in patient with increased ICP, continue corticosteroids and anticonvulsants)

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38
Q

incracranial mass lesions and intraoperative ventilation, fluid, ICP control

A

hyperventilation (near 30), avoid excessive PEEP (<10), glucose free crystalloids or colloids, replace blood loss with blood or colloids, EVD/lumbar drain, watch for increases in CBF

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39
Q

intracranial mass lesions: emergence

A

must be slow and controlled because straining or bucking can cause ICH or worsen cerebral edema
aggressive BP management for SBP <140 or <160 r/t risk for hemorrhage or stroke. (clevidipkne, labetalol, esmolol)
surgical team will do neuro exam right after extubation before leaving OR

40
Q

intracranial mass lesion: postoperative considerations

A 
will be admitted to ICU for observation
transport with HOB 30 degrees
manage HTN
O2 for transport
minimal pain post craniotomy (HA)
observe for seizures, neuro deficits, increased ICP
41
Q

awake-awake craniotomy considerations

A

no infusions until closing, only prop bolus for mayfield pins.

42
Q

asleep-awake craniotomy considerations

A

start under GA with LMA/ETT
wake patient up once tumor is exposed for cortical mapping and tumor resection
prop gtt 40mcg/kg/min ABW
remi .2-.4mcg/kg/min IBW
-if LMA is in, control ventilation and do not get them back breathing
sedated for iMRI (not always a thing during these)
sedate once tumor is removed/complete and they are closing

43
Q

asleep craniotomy considerations

A

TIVA, IONM, asleep motor mapping OR

GETA if no IONM, can still do a remi gtt so no paralytic is needed

44
Q

when are awake craniotomies considered

A

used for epilepsy surgery and resection of tumors in frontal and temporal lobes when speech and motor need to be assessed intraop

45
Q

safety hazards of iMRI for medical personnel includes

A

magnetic field strength, cold hazards, acoustic noises

46
Q

in which cases/with what technology is the iMRI employed

A 
awake tumor resection
laser ablation (monteris)
cytokine delivery (medicenna)
ROSA (zimmer biomet) 
clearpoint
47
Q

which interventions is the monterrris medical LITT used for

A

epilepsy
glioblastomas (that a regular craniotomy cannot get)
recurrent brain mets
radiation necrosis

48
Q

MR thermography use

A

uses phase change to calculate real time temperature data at and around probe. thermal dose confirmed in real time using bio thermodynamic theory.
blue line-dead
white-vaporized
yellow-recoverable
“scan, move probe, scan, move probe, scan, move probe”
3-6h case

49
Q

contents in posterior fossa include

A

brainstem (ANS, CV/resp center, motor/sensory pathways)
cerebellum (movement/equilibrium)
CN’s 1-12
large venous sinuses

50
Q

posterior fossa lesions: brainstem injuries sx

A

bradycardia and HTN (trigeminal nerve stimulation-cushings)
bradycardia and HoTN (glossopharyngeal and vagus nerve stimulation)
resp centers may be damaged-may need postop mechanical ventilation
tumors around glossopharyngeal and vagus nerves may impair gag reflex and increase risk of aspiration

51
Q

which cranial nerves, located in posterior fossa, control pharynx and larynx

A

CN IX, X, XI

52
Q

advantages of sitting position

A 
improved surgical exposure (more anatomically correct)
less retraction and tissue damage
less bledding
less CN damage
better resection of lesion
access to airway, chest, extremities
53
Q

disadvantages of sitting position

A 
postural HoTN
arrhythmias
venous pooling
pneumocephalus (tension=burr holes)
if using N2O, d/c before dural closure
nerve injuries (ulnar compression, sciatic nerve stretch, lateral peroneal compression, brachial plexus stretch
54
Q

VAE: when it occurs

A

level of incision >5cm higher than heart

55
Q

what rules out sitting position r/t VAE risk

A

PFO. creates opportunity for paradoxical air embolism where air gets to left heart and out to systemic circulation

56
Q

VAE s/sx

A 
decreased EtCO2 (r/t increased dead space), decreased PaO2, SaO2
mil wheel murmur, detection of ET nitrogen, increased PaCO2, HoTN, dysrhythmias
57
Q

ways to monitor for VAE:

A

capnography (EtCO2 decreases with 15-25mL of air)
CVP/PA line (PAP increases with 20-25mL of air)
precordial doppler
TEE (5-10x more sensitive than doppler)
MAP

58
Q

what constitutes a “large” VAE

A

> 2mL/kg

59
Q

VAE tx

A

100% O2, d/c N2O
notify surgeon to flood field or pack wound
call for help
aspirate from CVP with stopcock and 30-60mL syringe
volume load
inotropes/vasopressors
jugular vein compression
PEEP
position patient LLD with slight trendelenburg
CPR if necessary
valsalva increases venopressure, slows entrainment, helps surgeon ID leak
main goal is get the head down!

60
Q

craniocervical depression (chiari malformation)

A

cerebellum protrudes through foramen magnum. compresses brainstem and cervical spinal cord. types 1-4, syringomyelia
type 3: tonsils herniated through foramen magnum

61
Q

chiari malformation anesthetic considerations (positioning, EBL, postop)

A

positioning is prone or supone
EBL is large r/t venous sinuses
VS instability d/t brainstem manipulation anticipated
postoperatively, pain management is biggest consideration

62
Q

head injury: linear skull fracture sx

A

subdural or epidural hematomas

63
Q

head injury: basilar skull fracture sx

A

CSF, rinorrhea, pneumocephalus, cranial nerve palsies, battle sign, raccoon/panda eyes

64
Q

head injury: depressed fracture

A

creates a brain contusion

65
Q

head injury classification: primary

A

biomechanics effect of forces on brain at time of insult. includes contusion, concussion, laceration, hematoma

66
Q

head injury classification: secondary

A

represents complicating processes r/t primary injury. minutes, hours, days after primary injury.
intracranial: hematoma, increased ICP, seizures, edema, vasospasm

67
Q

prehospital head injury management

A

C-A-B (idk)
stabilize prior to transport
GCS <9, level 1 trauma center
ex)intracranial hematoma

68
Q

ED head injury management (based on severity)

A

mild: recovery rate high
moderate: emergency CT, admission, observation
severe: stabilization, CT, surgery

69
Q

head injury: airway considerations

A

assume c spine injury until otherwise proven radiographically
in line stabilization
intubate early
full stomach precautions
awake FOI if difficulty aw is anticipated
blind nasal intubation contraindicated in basilar skull fractures

70
Q

head injury: anesthetic considerations

A

HoTN, bradycardia, maintain Hct >30%, seizure prophylaxis, DIC may be seen with severe head injuries, pituitary dysfunction possible (DI, SIADH), patient remains intubated

71
Q

non secretory nonfunctioning pituitary tumors

A

arise from growth of transformed cells of anterior pituitary. generally well tolerated until 90% of gland is nonfunctional

72
Q

secretory functioning pituitary tumors

A

cushings disease (ACTH), acromegaly (GH), prolactinomas (prolactin), TSH adenomas (TSH)

73
Q

pituitary: intraoperative considerations

A

transphenoidal approach necessitates HOB raised 10-20 degrees
oral RAE or reinforced ETT
avoid hyperventilation-reductions in ICP result in retraction of pituitary into sella tursica, making surgical access difficult
potential for mass hemorrhage as carotid arteries lie adjacent to suprasellar area
mouth and throat pack: placed to absorb glottic blood and minimize PONV
OGT
avoid positive airway pressure upon extubation

74
Q

pituitary: preop evaluation

A 
visual field evaluation
s/sx increased ICP
endocrine labs
lytes
steroids"
75
Q

pruitary: postop managment

A

DI is common after surgery and usually self limiting (7-10 days). tx with vasopressin or DDAVP
SIADH

76
Q

cerebral aneurysm

A

leading cause of non traumatic intracranial hemorrhage, commonly located in anterior circle of willis

77
Q

unruptured cerebral aneurysm sx

A

HA, unsteady gait, visual disturbances, facial numbness, pupil dilation, drooping eyelid, pain above or behind eye

78
Q

ruptured cerebral aneurysm sx

A

sudden, extremely severe HA

n/v, LOC decreased, focal neuro deficits, hydrocephalus, seizure, s/sx of increased ICP

79
Q

which hess and hunt grading scale grades require intervention within 24-48h for chance of survival

A

1-2

80
Q

ruptured cerebral aneurysm: vasospasms

A

causes ischemia or infarction, exact mechanism unknown

digital subtraction angiography is gold standard for dx (not detectable until 72h post SAH), use CCB’s

81
Q

ruptured SAH and rebleeds

A

peaks seven days post incident, major threat during delayed surgery. antifibrinolytic tx

82
Q

tx for ruptured cerebral aneurysm and vasospasms

A

HTN (SBP 160-200 MAP 80-100)
hemodilution 33% HCT
hypervolemia CVP >10 or PCWP 12-20
-also prophylactic CCB regiment

83
Q

end-vascular coiling in IR: anesthetic plan and considerations intraop

A

GETA with complete muscle paralysis
control CPP via BP, usually lower during vcase
aline preferred
minimal to no blood loss
heparin for ACT 200-250
same postop concerns and with clipping
careful with volume because they use over 1L to clip and flush

84
Q

advantages fo end-vascular aneurysm coiling

A

shorter stay, less anesthetic requirements, uncomplicated positioning, minimally invasive

85
Q

complications of end-vascular aneurysm coiling

A

rupture/SAH (lower BP and go to OR, hyperventilate and keep sedated)
vasospasm
CVA
incomplete coiling

86
Q

cerebral aneurysm in OR

A

most commonly tx by microsurgical flip ligation
crani approach: parent vessel giving rise to aneurysm ID’s
clip placed across aneurysm neck excluding it from circulation
deep circulatory arrest may be necessary with giant aneurysms (prop bolus or adenosine)

87
Q

cerebral aneurysm goals of anesthesia intraop

A

maintain CPP, decrease CPP rapidly if rupture occurs during clipping
maintain transmural pressure (MAP-ICP)
decrease intracranial volume and provide slack in brain
minimize CMRO2

88
Q

cerebral aneurysm: preinduction anesthetic managment

A

limit sedation (hypercapnia), aline, 2 large bore PIV’s, type and cross with 2-4U PRBC, remember HOB turned 90-180

89
Q

cerebral aneurysm: induction anesthetic managment

A

smooth induction, aggressive BP and HR control with narcotics, BB, deep anesthetic

90
Q

cerebral aneurysm: maintenance anesthetic managment

A

TIVA or gas with paralytic (doesnt matter but usually gas), temporary occlusion of cerebral artery, maintain BP 15-20% below baseline to precent vasospasm, decrease EBL, and allow for best exposure. reduce ICP and employ cerebral protection methods.

91
Q

cerebral aneurysm: fluid management

A

keep euvolemic, expand blood volume with colloids, have PRBC’s avail, no glucose containing solutions

92
Q

cerebral aneurysm: control BP

A

surgeon may ask for BP 20-30% above baseline for collateral flow if feeder vessel is clamped for clipping
post clipping, keep map 80-100

93
Q

likely times of intraop aneurysm rupture

A

dural incision, excessive brain retraction, aneurysm dissection, during clipping or releasing of clip

94
Q

tx of intraop aneurysm rupture

A

immediate aggressive resuscitation and replacement of blood
prop bolus for brain to decrease MAP and blood loss
surgeon may apply temp clip on parent vessel to control bleeding, restore BP after clipping to improve collateral flow

95
Q

AVM

A

tx includes intravascular embolization, surgical excision, radiation. preop considerations same as with aneurysm, potential for significant blood loss is much higher

96
Q

cranial nerve decompression

A

treats disorders of cranial nerves (trigeminal neuralgia, hemifacial spasm, glossopharyngeal neuralgia)
unilateral
usually caused by compression of vascular structure like a blood vessel

97
Q

CN decompression considerations and anesthetic approach

A

positioning lateral with bump, supine, or prone
monitor facial nerves, BAER (brainstem activity evoked responses), EMG
TIVA and brain relaxation during maintenance
multimodal PONV approach

N934 Adv Principles Fa 21 (23 decks)

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