Neuro II Flashcards
Things to ask neurosurgeon about/find out preop (non med related) 3
Hemodynamic and ventilation goals, positioning
Things to ask neurosurgeon about preop (med related) 4
Need for abx, steroids, diuretics, anticonvulsants
Glucose and sodium control in neuro pts
Glucose 90-180 in diabetics. Avoid changes in na >3-4 meq/L per hour (central pontine myelinosis)
Ways to eval ICP without a monitor (5)
Headache, nausea, papilledema, pupil size, respiratory pattern
Main IR neuro goals (4)
May do conscious sed if able, control anesthetic level for prompt neuro eval if needed, keep pt from moving, and manip cerebral hemodynamics as needed
IR neuro: what kind of anticoagulation dose used/how long. ACT goal
24 hours 3000-5000u heparin + gtt to keep act 1.5-2.5x baseline
IR neuro: what two things may need to manipulate as needed, consider p-ox where
End tidal and arterial BP. Bilateral lower extremities
IR neuro: what 4 things may alter anesthetic plan
EEG, evoked potentials, transcranial Doppler, awake pt feedback
Dose of protamine in case vessel knicked while on heparin
1 mg per 1000u heparin given
IR neuro complications: do what if bleeding, do what if occlusive crisis
Bleed: protamine and controlled hypotension. Clot: htn +/- thrombolysis
Types of tumors that may be supratentorial 4 (one of them has two subtypes)
Meningiomas, glioma (oligodendroglioma and astrocytoma), metastatic lesion, and chronic subdural hematoma
Supratentorial tumors: when symptoms show, small changes in ___ lead to big changes in ___ and ___
When compensatory mechanisms exhausted by growing lesion. Small BP changes= big CBF/ICP changes
Supratentorial tumors: lesions are often ___ and have a ___ ___ core or a wide border of brain ___. Increased ___ and inc area of impaired ___.
Vascular, necrotic and hemorrhagic core. Edema. Inc bulk and imp autoreg
Supratentorial tumors: __ risk is low unless lesions encroach on __ __. Subfrontal approach leads to what
VAE, saggital sinus. “Frontal lobey”/sluggish to wake up
Supratentorial tumor sx: what is top priority. Diuretics/doses
ICP control. Mannitol 1-1.5 g/kg or 3% saline 50-100 ml/hr with hourly na checks
Osmolarity of: plasmalyte and normosol, LR, normal saline
Pla/norm= 290. LR= 273. NaCl= 308
Supratentorial IC tumor: ask hx of ___, ___ reg, consider giving what drug/how often/dose except in which pts
Seizures. Decadron 10 mg q6. UNLESS lymphoma is a potential dx.
Supratentorial IC tumors: 3 things that warrant a right atrial line
CVP measurement, if major blood loss concern, or VAE risk
Infratentorial/post fossa tumors common in children (4)
Medulloblastoma, pilocytic astrocytoma, ependymoma, brainstem glioma
Infratentorial/post fossa tumors in adults (4)
Acoustic neuroma, mets, meningioma, hemangioblastoma
In post fossa tumors, look for warning signs of damage to what two things
Adjacent cranial nerves and respiratory centers
CV Signs of damage to cranial nerves/resp centers during sx (4)
Bradycardia+hypotension. Tachycardia+hypertension. Bradycardia+hypertension. Ventricular dysrhythmias.
Post fossa tumor sx: risk dissection on floor of __ ventricle. Can result in loss of 3
4th. Upper airway patency, cranial nerve function, and respiratory drive
Positioning for post fossa tumor 5
Sitting, lateral, prone, park bench, or 3/4 prone
Post fossa tumor positioning risks/complications (5)
Quadriplegia, macroglossia, pneumocephalus, VAE, PAE
Post fossa tumor monitoring: what ecg for __ and __ changes. Watch a line for alt due to __ and __ __
Rate and rhythm. CPP and brain stem.
Nerve/neuro monitoring that may occur in post fossa tumor sx 3
BAEP, SSEP, EMG facial nerve monitoring (need at least 2 twitches)
Infratentorial posterior fossa IC tumor: main induc/maintenance/emergence considerations
CN assessments. May RSI if chronic asp. Prob not versed. Dont do precedex. A line. Check for cv instability. Emergence: back up airway available.
Hormones released by posterior pituitary
Vasopressin (adh) and oxytocin
Nonfunctioning pituitary tumors: 3 ex, dx when
Chromosphere adenoma, craniopharyngioma, meningioma. When large and impinging adjacent structures
Functioning pituitary tumors: ex. Diagnosed when
Prolactinomas followed by GH and ACTH descreting adenomas. Small symptoms r/t produc of excess of 1 or more anterior pituitary hormones
Pituitary tumor endo assessment: what to look for in panhypopituitarism (3)
Correct hypocortisolism, hyponatremia, hypothyroid
Pituitary tumor endo assessment: acromegaly (3)
Airway, cardiac func: arrhythmias, hypertrophic CM
Pituitary tumor endo assessment: cushing’s disease 5
DM, hyperaldosteronism (low K/metab acidosis), HTN, CHF, obesity
Pituitary tumor assessment: which have no mass effect, which lead to SIADH
Microadenoma- no fx. Sellar tumor- SIADH.
Pituitary tumor assessment: which you need to eval for inc ICP. Clear what with surgeon, assess which nerve
Suprasellar. Decadron use (could give false + test postop). If visual exam assess optic nerve
If transphenoidal approach need what two things
Nasal culture and abx
Which drug inhibits ADH at renal tubules
Demeclocycline (tetracycline)
Pituitary: positioning/prec, ____ pack, airway consid
Supine, VAE risk if >15 degrees sx site above heart. Pharyngeal. Rae to lower jaw, opposite dominant side.
Transphenoidal: where incision is made, local used, what he for what
Upper lip through septum. 4% cocaine 2% lido w epi. Dysrhythmias,
Pit sx anes consid: emergence. Airway cleared of what. Test what before extub.
Smooth. Debris/clots. Visual acuity.
Surrounding structures that may be damaged in pituitary surgery 5
CN 3-6, cavernous sinus, internal carotid, hypothalamus, optic nerve/chiasm
DI: when it occurs, 3 main signs
4-12 hrs postop. Polyuria (>2L), serum osmolarity >300, specific gravity <1.005
Tx DI 2
1/2 NSD5W hourly maintenance req + 2/3 prev hour’s urine output. If hourly req >350-400 ml DDAVP 0.5-1 mcg IV/SQ
SAH grading systems/what they look at: fed of neurosurgeons __ and ___, hunt and Hess ___ ___, fisher grade ___ ___
GCS and motor deficit. Clinical symptoms. Radiologic bleeding
SAH symptoms 5
NV, severe headache, stiff neck, photophobia, LOC
What happens when subarachnoid space bleeds acutely: 3
Abrupt ICP increase leading to htn and dysrhythmias
SAH: what is considered small vs giant. What size demands treatment.
Small <10 mm. Giant >24 mm. Large= in between. Tx if over 6 mm
Ecg changes w SAH: main one, 5 others
Canyon t waves (upside down). ST dep/elev, t wave flattening, u waves, prolonged QT, dysrhythmias
IC aneurysm/SAH complic: 4
IC htn, hydrocephalus, rebleed, vasospasm
When IC aneurysms pts can go to OR
Preferable 18-24 hr (<48 hr), if not then delayed 10-14 days to avoid vasospasm risk
Cerebral vasospasm signs: 7
Headache, htn, confusion, lethargy, motor and speech deficits, coma
How to dx cerebral vasospasm. Prophylactic meds (2)
Angio or transcranial Doppler. Nomodipine is standard, statins may help
What is triple H therapy, when its used
Hemodilution, htn, hypervolemia. In IC aneurysm/SAH prevent vasospasm
Intra arterial vasodilators used in vasospasm 4
Verapamil, nicardipine, milrinone, papaverine
SAH/IC aneurysm preop consid: assess for __ ___ and ___ over activity. Assess ___ status (2 ex)
Hypothalamic dysfunc and sympathetic over activity. Fluid. SIADH (vol restrict), cerebral salt wasting syndrome (no vol restrict)
What is max safe clamp time while controlling aneurysm bleed
14 min
When controlled hypotension is contraindicated (6). Max reduction
Cv disease, cerebrovascular disease, intracerebral hematoma, fever, anemia, renal disease. 20-30 mmHg
Adenosine at what dose can be used during clipping
0.3-0.4 mg/kg
Use what for burst suppression. If a rupture occurs lower map to what range
Propofol. 30-50
AVM- abn communication leads to what. S/s
No capillary bed in between leads to shunting blood from surrounding brain- ischemia. Bleed/SAH, focal epilepsy/sz, sensory-motor deficits
AVM main anesthesia points (4), similar to what mgmt
Sim to SAH. ICP control, hypotension to reduce bf, avoid acute htn, manip bp w bleeding
AVM dysautoreg: ___ is best, how to
Prevention. Keep sedated/intubated or aggressive bp control at emergence and have labetolol/hydralazine/nicardipine ready to go
AVM dysautoreg: 5 treatment strategies
High dose barbs, osmotic diuretics, hyperventilation, low-normal map, +/- hypothermia
GCS 3 key points and grading. Which score is severe and requires what
Eye opening (1 never 4 spont), verbal response (1 none 5 oriented) , motor response (1 none 6 obeys commands). 8 or less is severe, requires intubation for airway and ICP control
Head injury main goal
Prevention of secondary injury
Head injury: aggravating factors (7), which one super prominent
Hypotension*, hypoxia, hypercarbia, anemia, hyperglycemia, seizures, infection
Head injury: fracture where would make us avoid nasal ett
Skull base fracture
Which hematoma is the most urgent
Epidural (meningeal artery tear)
Head trauma: BP goal, hypothermia POV
Maintain CPP >60 1st 3 days. No benefit in hypothermia
Head trauma anes: hyperventilation (when its encouraged (4)/discouraged)
Routine use discourage esp first 1-2 days. May use for acute ICP mgmt, herniation prevention, minimize retractor p, and to improve surgical access
Head trauma: fluid goal, prevent what, check what, which products good and not good
Maintain volume. Prevent reduced serum osmolarity. Check labs (preop mannitol/fluid therapy). 0.9% saline, 5% albumin, and blood all better than LR (hypoosmolar)
Head trauma: specific coag abn
Brain thromboplastin release can lead to DIC
Head trauma: ____ circulatory response. 4 signs. Treat with
Hyperdynamic. Tachycardia, htn, inc CO, arrythmia. Labetolol or esmolol
Head trauma: ___ ___ - need ICP reduction. Ways to do it (6)
Cushing’s triad. Diuretics, HOB 30 degrees, barbs, Paco2 30-35, ventricular drainage, mild hypothermia 34-35 c
Spinal cord sx: 4 things that may alt our plan
Wake up test (45 min warning, short acting agents), SSEP (IAs), MEPs (NMR/IAs), pedicle EMG (NMR)
Supine/anterior cervical discectom: risks related to location
Retractor compressing airway and carotid arteries, postop swelling and airway compression/CN dysfunction
Cervical sx: two risks w complete cord injury, ___ intubation if unstable, keep map where for how long after injury
Low bp (spinal shock) and resp insuff. Awake/axial stabiliz. >85 for 7 days
Cervical sx: ____ at ___ mg/kg over 1 hour then ___ mg/kg for 23 hr is a treatment option
Methylprednisolone, 30. 5.4
Vertebral mets: major risk. Positioning. Airway consid
Large blood loss. Prone or anterolateral/retroperitoneal. Double lumen ett for lesions above L1
Spinal cord tumor: have what during contraction, ___ position
High normal MAP, prone
Csf shunting sx: ___ __ is helpful, insert what/why
Muscle relaxant. OGT to prevent distended stomac/gastrostomy inadvertently
VP shunt: catheter into ___ ventricle, reservoir where, drainage limb via tunnel to where
Lateral. Res in sq adjacent to burr hole. Point near epigastrum where inserted into peritoneal space through small laparotomy.
CSF shunt: what isn’t usually required. Positioning of pt and bed.
Invasive monitoring. Supine, bed turned 90
Csf shunt: avoid increases in ___/how. Avoid dramatic ____ drop. BP may do what after ventricular cannulation and consid
ICP, drop paco2 to 25-30. ICP drop (for surgeon visualization). May drop, brief pressor support
Csf shunt: positioning after, prevents what
Nursed flat. Subdural hematoma
Pedi neuro: neuronal development continues through when, SC ends where/when it is at adult level
3rd year of life. L3, adult level when 8
Pedi neuro: CBF of infants and children __ml/100g/min. CMRO2 ___ ml/100g/min. ICP ___-___
- 5-6. 2-4.
Pedi anesthesia: how to monitor ICP
Palpate fontanelle
When posterior fontanelle closes
2-3 months
When anterior fontanelle closes
12-16 months
Cranuisynostosis: what it is, when it occurs, need what, risks
Premature cranial suture fusion, 2-8 months. IVs and a line (blood loss). VAE risk (need precordial Doppler)
Meningomyelocele: assoc w what two things. What allergy. Consider what for induction
Arnold chiari malformation and hydrocephalus. Latex. Prone
Meningomyelocele: do what w fluids, maintain ___, ebl
Account for csf leak/3rd space loss. Temp. 15-50cc, more if big defect
Tethered cord: main thing to avoid, check w surgeon on what, may be positioned how post op
Sux. Check before giving NMB (nerve func monitoring intraop). Prone.
Anes consid for stereotactic sx: restriction of ___ access. Restriction in what else
Airway access due to frame. Sedation/anes depth bc need to assess pt and ep recordings.
Anes for stereotactic sx: need to detect/manage 2 complic intraop
Seizures and IC hematoma
Stereotactic sx: preop eval ___ status and edu pt on what
Coag (ask about meds and herbals/discontinuing). Movement restraints and procedure length
Stereotactic anesthesia: two sedatives that are ok to give. Avoid what
Precedex and remi. Avoid benzos.
Stereotactic sx: control what bc of intracerebral hematoma risk. Prepare for what just in case. Other risk
Htn . Craniotomy in case hematoma occurs. VAE risk r/t spontaneous ventilation
