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S5 - Principles III - Test 2 > Neurosurgery > Flashcards

Neurosurgery Flashcards

1
Q

3 components of the non-expandable cranial vault

A
  • brain tissue (80%)
  • blood (12%)
  • CSF (8%)
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2
Q

Cushing’s reflex

A

Increased ICP= Increased BP and Decreased HR

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3
Q

How are CBF and CMRO2 coupled?

A

In a direct manner. If one decreases, so does the other.

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4
Q

At what point in a craniotomy is there intense stimulation?

A

At the beginning and end of the procedure.

Minimal stimulation in the middle

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5
Q

What is the primary substrate of metabolism

A

glucose

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6
Q

what effect does hypoglycemia have on the brain

A

worsens hypoxic injury

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7
Q

How is the metabolic rate of the brain measured

A

oxygen consumption (CMRO2)

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8
Q

How much does the adult human brain weigh

A

1300-1400 gms

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9
Q

Amount of cerebral blood flow per minute

A

650-700ml

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10
Q

What % of total cardiac output does cerebral blood flow make up?

A

about 14%

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11
Q

The brain can increase flow as much as __ % of cardiac output

A

15-20%

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12
Q

Average CBF

A

50mL/100gm/min

but varies regionally from 30-300mL/100gm/min

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13
Q

What CBF is associated with slowing of EEG

A

<25mL/100gm/min

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14
Q

What CBF is associated with isoelectric EEG

A

~15-20mL/100gm/min

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15
Q

What CBF results in irreversible injury?

A

<10mL/100gm/min

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16
Q

Which 2 parts of the brain are more sensitive to hypoxic brain injury than others

A
  • hippocampus

- cerebellum

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17
Q

CPP is = to ?

A

MAP-ICP or CVP (which ever is higher)

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18
Q

Why is CPP essentially = to MAP?

A

bc ICP/CVP is small

unless they have increased ICP…

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19
Q

CPP associated with EEG changes

A

CPP < 50 torr

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20
Q

CPP that results in irreversible damage

A

CPP < 25 torr

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21
Q

At what CPP is autoregulation diminished

A

below 50 torr

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22
Q

CBF is autoregulated at MAP between ___ torr

A

50-150

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23
Q

When does luxury perfusion occur? DO we want this during brain surgery

A

CBF> CMRO2

nope

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24
Q

What is CBF proportional to?

A

PaCO2

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25
Q

What happens to CBF when minute ventilation is doubled

A

decreases by half

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26
Q

When do volatile anesthetic drugs cause a CNS/metabolism uncoupling?

A

MAC above 1.5

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27
Q

What results from volatile anesthetic CNS uncoupling

A

reduced CMRO2 but also cerebral vasodilation so increased CBF and ICP

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28
Q

What type of anesthetic drugs preserve CNS coupling

A

IV anesthetics

Reduce CMRO2 but do not cerebrally vasodilate

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29
Q

which volatiles decrease cerebral vascular resistance

A

all of them

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30
Q

What effect do volatiles have on CBV, CBF, and ICP

A

increases

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31
Q

volatile effect on CMRO2

A

decreased

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32
Q

volatile effect on cortical activity

A

abolishes it

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33
Q

How does hyperventilation affect the increases in ICP

A

attenuates it (reduces the effect)

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34
Q

Should you use nitrous on a crani

A

no maam

expands closed gas spaces, increases CBF, ICP and can increase CMRO2

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35
Q

4 absolute contraindications to nitrous use

A
  • intracranial air present
  • EP signal is inadequate
  • increased ICP
  • tight brain
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36
Q

What class of drugs decreases CBF, ICP, and CMRO2, inhibits NT receptors, and slows EEG

A

barbiturates

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37
Q

effect of propofol on CBF

A

dose dependent decrease

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38
Q

What propofol dose results in an isoelectric EEG

A

500mcg/kg/min

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39
Q

What IV agent is associated with decrease CBF, ICP and CMRO2 but causes seizures in patients with a seizure history

A

etomidate

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40
Q

metabolite of what drug is associated with seizures

A

demerol

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41
Q

Opioids affect on CBF and CMRO2

A

dose dependent decrease

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42
Q

What limits the usefulness of benzodiazepines in cranial surgery

A

respiratory depression

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43
Q

What contraindicates the use of benzos in a crani

A

increased ICP

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44
Q

Ketamine effect on ICP and CBF

A

increases both.

ICP increased >80%

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45
Q

depolarizing NMB effects on ICP, CBF, CMRO2?

A

Increases all

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46
Q

When are depolarizing NMB contraindicated in neurosurgery

A
  • denervated muscle
  • CVA
  • motor neuron lesions
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47
Q

nondepolarizing NMB effect on ICP, CBF, CMRO2

A

minimal effects

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48
Q

Which type of drug therapy can cause increased dosage requirement of nondepolarizers?

A

anticonvulsant meds like dilantin

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49
Q

Which type of fluids should be avoided in neurosurgery

A

dextrose fluids

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50
Q

What are the 2 preferred fluids for volume resuscitation in NSGY

A
  • normal saline

- colloid

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51
Q

Can LR be used in neurosurgery?

A

yes but volume must be limited. NS is a better choice

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52
Q

Do not exceed __ L of hetastarch in order to avoid coagulopathy

A

1- 1.5L

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53
Q

Hct goal for NSGY pts

A

30-35

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54
Q

What may help reduce vasospasm for aneurysm clipping?

A

mild volume expansion

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55
Q

In general keep neurosurgery patients… ( the 3 I’s)

A
  • isotonic
  • isovolemic
  • isooncotic
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56
Q

common monitors involved in neurosurgery (lots of them srry)

A

-EKG
-artline
-ETCO2, pulse ox, ABG
-peripheral nerve stimulator
-CVP
-temp
-UOP
EEG or SSEP
cerebral oxygen monitoring

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57
Q

What is more important…that a certain drug combo is used, or ensuring a smooth induction??

A

smooth induction :)

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58
Q

To facilitate a smooth induction what 3 things are we trying to avoid?

A

increased ICP
HTN
hypotension

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59
Q

What 2 things are used during induction to maximize venous drainage?

A
  • avoid excessive neck flexion

- HOB >15 degrees

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60
Q

During preoxygenation for a NSGY case do we want to hyperventilate or hypoventilate the patient?

A

hyperventilate :)

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61
Q

What is used during induction to blunt SNS outflow

A

opioids

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62
Q

What is used during induction of NSGY pt to prevent bucking/coughing

A

muscle relaxant

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63
Q

What must be evaluated before extubation

A

intact neurological function

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64
Q

What do we want to avoid when waking up a neuro patient

A

bucking, straining, or coughing on ETT

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65
Q

When should the CRNA re-establish spontaneous breathing in a NSGY case and why?

A

prior to skin closure and pin removal

because once the pins are removed there is little stimulation and return of respirations may be delayed if you wait until after pin removal

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66
Q

What is the benefit of rapid awakening

A

promotes neuro assessment

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67
Q

What are the 4 major types of Intracranial mass lesions

A
  1. Congenital
  2. Neoplastic ( benign or malignant)
  3. Inflammatory/infectious (cyst or abscess)
  4. Vascular (hematoma or AVM)
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68
Q

name of a mass lesion that is located above the tentorium

A

supratentorial

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69
Q

infratentorial mass lesion is located where

A

below the tentorium

cerebellum

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70
Q

4 symptoms seen with Supratentorial mass

A
  • Seizures
  • Hemiplegia
  • Headache
  • Aphagia

(Supratentorial Hurts Head Alot)

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71
Q

What 2 things are associated with Infratentorial mass and what are the symptoms for each

A

Cerebellar dysfunction: ataxia and nystagmus

Brain stem compression: AMS or altered respirations

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72
Q

Infratentorial is what part of the brain

A

cerebellum

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73
Q

supratentorial is what part of the brain?

A

cerebrum

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74
Q

What do the symptoms of intracranial mass depend on

A

growth rate

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75
Q

Are slow-growing masses symptomatic or asymptomatic

A

asymptomatic

76
Q

acute neurologic deficits are associated with what growth rate of intracranial mass

A

fast growing

77
Q

Deficits from mass lesions are specific to what

A

where the mass is located

78
Q

Do intracranial masses affect ICP and if so how?

A

yes, they increase ICP :)

79
Q

What are the common neurologic symptoms seen with intracranial masses (3)

A
  • Reduced cognitive function
  • HA
  • focal neurologic deficits
80
Q

the majority of intracranial mass surgeries are supra or infratentorial?

A

supratentorial

81
Q

are there different anesthetic implications depending on the type of mass?

A

no, all managed the same

82
Q

What may be seen on CT with an intracranial mass

A

edema and midline shift

83
Q

What 3 drugs are patients with intracranial masses often on that can result in electrolyte and glucose imbalance

A
  • steroids
  • anticonvulsants
  • diuretics
84
Q

What preop drugs should be avoided in NSGY pts and why?

A

benzos and opioids to ensure not to effect ability to obtain neuro exam

85
Q

What degree should HOB be for neuro patients

A

15-30 degrees to control ICP

86
Q

Symptoms of increased ICP

A
  • Nausea/Vomiting
  • AMS
  • Focal neuro deficits
  • HA
  • Papilledema

(Neurologists Aim to Fix Head Patients)

87
Q

What are the 7 potentially neuroprotective properties of anesthesia

A
  • decrease CMRO2
  • inhibits protein kinase C
  • decreases the production of free fatty acids
  • scavenging reactive oxygen species
  • inhibiting WBC function
  • inhibiting excitatory NT receptors
88
Q

What allows the brain to tolerate disruption of metabolic substrate delivery when under GA

A

suppression of electrocortical activity

89
Q

Increases of what 3 things are known to contribute to poor outcomes after cerebral ischemic events

A
  • increased blood glucose
  • increased temp
  • increased CPP
90
Q

What is burst suppression and what can cause it?

A

EEG slows to random burst of electrical activity

Caused by volatile agents and acts as a neuroprotective mechanism

91
Q

goal ETCO2 with increased ICP

A

30-35mmHG

92
Q

What diuretics are recommended for increased ICP

A
  • mannitol 0.25-1g/kg

- lasix

93
Q

When ICP is elevated what is the goal for fluid status?

A

want them normovolemic

-dont overhydrate

94
Q

Positioning interventions for increased ICP

A
  • raise HOB

- avoid excessive neck flexion/neck vein compression

95
Q

If ICP is increased and hematoma is present what should be considered

A

decompressive crani

96
Q

What drugs can be administered with increased ICP in order to cause cerebral vasoconstriction

A
  • propofol

- thiopental

97
Q

for increased ICP pt do we want to keep their temp higher or lower?

A

mild hypothermia should be considered

98
Q

For posterior fossa( infratentorial) surgery what is most concerning about the location

A

close proximity to vital brain centers including circulatory and respiration centers, RAS, ANS, and cranial nerves

99
Q

Which type of mass can obstruct CSF at the 4th ventricle and lead to obstructive hydrocephalus

A

Infratentorial

100
Q

What do surgeons use to monitor for respiratory center damage during posterior fossa surgery

A

spontaneous ventilation

101
Q

What position is preferred by the surgeons for posterior fossa surgery

A

sitting position

102
Q

What surgery and position creates the highest risk for VAE

A

sitting crani

103
Q

What increases the risk for VAE

A

open venous system subatomospheric (pulls air in vascular space) with surgery site above the heart

104
Q

Large air bubble can impede pulmonary blood flow which leads to what effect on the heart?

A

increased RV pressure which causes decreased CO

105
Q

What agent enhances VAE

A

nitrous

106
Q

What can indicate VAE during surgery?

A
  • decreased ETCO2
  • decreased O2 sat
  • sudden hypotension
  • circulatory arrest
  • increased ET nitrogen
107
Q

What is the most sensitive non-invasive monitor for detecting VAE

A

Precordial doppler

108
Q

When using precordial doppler and VAE is detected what do you hear

A

mill-wheel roaring sound

109
Q

What is the most sensitive invasive monitor for detecting VAE. What is the smallest volume of air it can detect

A

TEE

detect 0.25ml aire

110
Q

What tool has the least sensitivity for detecting VAE

A

esophageal stethoscope

will hear v faint mill-wheel with VAE

111
Q

Symptoms of small < 0.5ml/kg of air entrainment (5)

A 
Decreased ETCO2
Increased EtN2
Desaturation
AMS
Wheezing
112
Q

Symptoms of 0.5-2ml/kg RV air entrainment

A 
breathlessness, wheezing
hypotension
pulm HTN
R heart strain
ST changes, peaked p
JVD
AMS
cerebral ischemia
pulm vasoconstriction
bronchoconstriction
113
Q

symptoms of large > 2ml/kg of air entrainment (3)

A

chest pain
R heart failure
CV collapse

114
Q

Surgeries considered low risk for VAE (7)

A 
peripheral nerve 
anterior neck
burr hole
vaginal
hepatic
ophthalmic
115
Q

surgeries/procedures with medium risk for VAE (7)

A 
spinal fusion
cervical laminectomy
prostatectomy
gastric endoscopy
contrast radiology
rapid blood transfusion
coronary surgery
116
Q

surgeries/procedures considered high risk for VAE (7)

A 
sitting crani
posterior foss/neck
laprascopic
Total hip
C section
Central line placement
criniosynostosis
117
Q

Advantages of precordial doppler

A

most sensitive noninvasive monitor

earliest detector

118
Q

some disadvantages of precordial doppler

A

nonquantitative
false negative
difficult to place with obese or chest wall deformity
useless during cautery

119
Q

what drug may mimic air when using precordial doppler

A

mannitol

120
Q

Does ETN2 detect air before or after ETCO2

A

before

121
Q

The earliest detector of air

A

precordial doppler

122
Q

most sensitive detector of air

A

TEE

123
Q

If you suspect VAE what should you do first

A

alert surgeon so they can flood the field with saline and wax bone edges

124
Q

Therapy for VAE after alerting the surgeon

A
  1. discontinue N2O, 100% FIO2
  2. Valsalva or compression of jugular veins
  3. aspirate air from the central line
  4. CV support
  5. left lateral decubitus position with 15-degree head down tolt
125
Q

What is paradoxical air embolism and what defects is it seen with

A

air enters systemic circulation

Seen with PFO or atrial/ventricular septal defect

126
Q

What % of the population has a PFO

A

30-35%

127
Q

What is a cerebral aneurysm

A

dilated intracrania arteries

128
Q

complications of aneurysms (3)

A

Subarachnoid hemorrhage (SAH)
re-bleeding
vasospasm

129
Q

What is the leading cause of subarachnoid non-traumatic hemorrhage

A

sacular aneurysm rupture

130
Q

What is the peak rupture age for aneurysms?

A

55-60years

131
Q

what gender are aneurysms more likely to occur

A

female

132
Q

What are the most common cerebral aneurysms

A

internal carotid bifurcation

anterior cerebral artery

133
Q

Subarachnoid bleed usually presents with what 3 symptoms

A

HA
transient LOC
N/V

134
Q

How does HTN affect SA bleed

A

worsens it

135
Q

Why is decreasing BP with a ruptured aneurysm, not a good option

A

bc autoregulation is impaired

136
Q

What EKG changes are seen with ruptured aneurysm/ SA bleed

A

T and ST changes but non-ischemic with no adverse outcome

137
Q

Is it likely for previously ruptured aneurysms to re-bleed?

A

yes, 50% will re-bleed with an 80% mortality rate

138
Q

What is the major cause of mortality and morbidity with a ruptured aneurysm

A

cerebral vasospasm 4 days post rupture

139
Q

When is surgical intervention required for an aneurysm

A

> 7mm requires clipping

140
Q

Where should you place your transducer in order to monitor the circle of Willis CPP

A

external auditory meatus and tragus

141
Q

How will the pressure at the circle of Willis compare to the pressure at the level of the heart? why?

A

lower pressure due to the vertical column and hydrostatic pressure difference

142
Q

What is the formula for calculating the change in pressure to compensate for the distance that the base of the skull is above the heart

A

1mmHg for each 1.25 cm above the heart OR 7.5mmHG for every 10cm that the base of the skull is above the heart

143
Q

Treatment of vasospasm

A 
maintain cerebral perfusion
CV support
inotropes
nicardipine or nimodipine (~but one of the H's for treatment is HTN so sos~)
intravascular volume expansion
relative hemodilution (Hct 32)
correct hyponatremia
transluminal angioplasty
144
Q

blood collects b/t dura and arachnoid layers of the brain

A

subdural hematoma

145
Q

subdural hematoma: venous or arterial bleed?

A

venous

146
Q

which patients are at a greater risk for subdural hematoma

A

anti-coagulated pts

147
Q

With subdural hematoma what symptoms occur and in what order to they occur

A

HA–> drowsiness–> cognitive decline–>obtunded

148
Q

what surgical options are available for subdural hematoma

A

crani

burr holes

149
Q

T/F with subdural hematoma hypocapnia is desired

A

false, normocapnia is preferred

150
Q

For treatment of vasospasm, we want to hemodilute to a goal Hct of ?

A

< 32%

151
Q

what is the “triple H” therapy for vasospasm

A

hemodilution
hypervolemia
HTN

152
Q

What type of hemorrhage is seen with AVM

A

intracerebral

153
Q

When do AVMs typically present and with what?

A

10-30 y/o with bleeding

154
Q

2 symptoms often present with AVM

A

HA

seizures

155
Q

Do AVMs result in more or less bleeding compared to an aneurysm

A

extensively more

156
Q

What two interventions help facilitate surgical resection of AVM

A

mannitol

hyperventilation

157
Q

what % of neoplasms are pituitary in origin

A

10%

158
Q

What % of pituitary neoplasms are non-secretory

A

20-50%

159
Q

Hypersecretory tumors lead to what 2 complications

A

hyperglycemia

acromegaly

160
Q

What anesthesia complication do we worry about with hypersecretory tumors

A
  • difficult intubation d/t enlarged facial features
  • laryngeal hypertrophy
  • enlarged tongue
161
Q

What surgical approaches are common for pituitary mass

A

transsphenoidal or intracranial

162
Q

What are the advantages to the transsphenoidal approach compared to intracranial

A

decreased blood loss

decreased morbidity and mortality

163
Q

What comorbidities could a pt with a pituitary mass present with

A 
Cushings
HTN
DM
osteoporosis
obesity 
friability of skin
164
Q

What complication is seen post-op with pituitary surgery

A

DI

165
Q

For the transsphenoidal approach, what must we consider when making our anesthetic plan

A
  • shared airway
  • surgical entry site is the nare, so ETT should be secured to the chin not the upper lip
  • lubricate eyes with petroleum jelly to prevent fluids from entering eye
166
Q

What side of the mouth should ETT be placed/taped for transsphenoidal approach

A

left side of the mouth and secured to the chin

167
Q

Why should we avoid hyperventilation in pituitary surgery

A

causes pituitary to retract into the sella which hinders resection

raising ETCO2 forces the pituitary into view

168
Q

what vessels lie in close proximity to the pituitary

A

carotid arteries, be prepared for blood loss

169
Q

Stereostatic procedures are performed with what type of anesthesia

A

MAC or light sedation

yikes

170
Q

What is used for stereostatic procedures that prevents DL

A

halo

171
Q

if you have to intubate a pt in a halo what is your best option

A

fiberoptic bronchoscopy

172
Q

for stereostatic procedures why must we be super careful when giving sedation

A

we absolutely do not want to eliminate respirations or compromise the patients ability to protect their airway

173
Q

Malformation where medulla protrudes through the foramen magnum

A

Arnold Chiari malformation

fun fact my sister has this but its v small

174
Q

How does Chiari affect CSF flow

A

obstructs flow and can cause hydrocephalus

175
Q

is chiari more common in males or females

A

females

176
Q

what is the treatment for chiari

A

decompressive pressure relief

177
Q

anesthesia implications for chiari are similar to what other surgery

A

posterior fossa

178
Q

What is an important consideration when doing a head trauma case (v broad)

A

they probably have multiple other injuries that you dont know about

179
Q

all head traumas are assumed to have what other injury

A

c spine

180
Q

all traumas are considered

A

full stomachs

181
Q

can we use nitrous on a head trauma patient

A

nope

182
Q

what do you treat head trauma HYPERtension with

A

increased agent, hyperventilation

be careful to avoid too much hyperventilation as it will result in decreased CBF

183
Q

what do you treat a head trauma with hypotension with

A

alpha adrenergic agonist

184
Q

CPP goal for head trauma

A

70-110mmHg

185
Q

What do you treat enhanced vagal tone with for a head trauma

A

atropine

186
Q

PEEP in head traumas should be avoided until when?

A

after dura is opened bc of increased ICP

187
Q

T/F Head trauma patients are left intubated and paralyzed until increased ICP is resolved

A

true

S5 - Principles III - Test 2 (5 decks)

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