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Co-Exisiting Disease 2 > Neurosurgery > Flashcards

Neurosurgery Flashcards

1
Q

Percent of brain volume?

A

80%

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2
Q

Percent of blood volume in head?

A

12%

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3
Q

Percent of CSF?

A

8%

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4
Q

Normal ICP:

A

15mmHg or less

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5
Q

Adult brain weighs how much?

A

1400g

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6
Q

Adult brain is how much of total body weight?

A

2%

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7
Q

What is the oxygen consumption of the brain?

A

3.3ml/100g/min

50ml/min total

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8
Q

Oxygen consumption is how much of the total body consumption?

A

20%

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9
Q

Normal cerebral BF and what percent of CO?

A

50ml/100g/min

15%

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10
Q

Cerebral perfusion pressure is dependent on what?

A

Pressure gradient between arteries and veins (difference between MAP and the mean cerebral venous pressure)

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11
Q

Normal CPP and equation?

A

~80mmHg

MAP-(ICP or CVP, whichever is GREATER)

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12
Q

7 things that cerebral BF depend on?

A
  1. Those affecting cerebral perfusion pressure
  2. Those affecting the radius of cerebral blood vessels
  3. PaCO2
  4. PaO2
  5. Anesthetic agents
  6. Temp
  7. Cerebral metabolic rate for O2 (CMRO2)
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13
Q

CBF is proportional to what?

A

CMRO2

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14
Q

CBF and CMRO relationship is unaffected and affected by what?

A

Unaffected: IV agents
Affected: uncoupled by inhalation agents

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15
Q

Cerebral steal (luxury perfusion): nonischemic and ischemic brain BF and vessel diameter

A

Nonischemic brain: increase BF and vessel diameter

Ischemic brain: decrease and no change to vessel diameter

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16
Q

Inverse steal (Robin Hood, reverse steal): nonischemic and ischemic brain BF and vessel diameter

A

Nonischemic brain: decrease BF and vessel diameter

Ischemic brain: increase BF and no change in vessel diameter

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17
Q

1mmHg change in PaCO2 produces what change in CBF and time frame?

A

1ml/100g/min

6-8hrs

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18
Q

PaCO2 from 40 to 35 reduces CBF by what?

A

5ml/100g/min or 70ml/min

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19
Q

For normal ICP, CBF maintain low; what should PaCO2 be?

A

30-35mmHg

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20
Q

How to lower PaCO2?

A

Hyperventilate

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21
Q

CBF decreased by how much if PaCO2 is 20mmHg?

A

50%

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22
Q

PaO2 of what causes significant increase in BF?

A

<50mmHg

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23
Q

Changes in CBF and metabolism tend to what?

A

Follow each other

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24
Q

Local/global increases in metabolic demand are met rapid by what in CBF and substrate delivery?

A

Increase

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25
Q

7 vasoactive metabolic mediators thought to control:

A
  1. Hydrogen ions
  2. Potassium
  3. CO2
  4. Adenosine
  5. Glycolytic intermediates
  6. Phospholipid metabolites
  7. Nitric oxide (NO)
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26
Q

Cerebral metabolism can be decreased by (2)

A
  1. Hypopyrexia

2. Some anesthetic agents

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27
Q

Cerebral metabolism can be increased by (2)

A
  1. Hyperpyrexia

2. Seizures

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28
Q

CBF changes how much per 1 degree change?

A

5-7%

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29
Q

Hypothermia does what (2)

A

Decreases CMR and CBF

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30
Q

At 27 degrees C, CBF is approximately what?

A

50% of normal

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31
Q

At 20 degrees C, CBF is about what?

A

10% of normal

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32
Q

Auto regulation keeps CBF relatively constant as long as CPP is between what?

A

50-150mmHg

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33
Q

Lower limit of auto regulation causes (3)

A
  1. Cerebral vasodilation is maxed
  2. Below this level the vessels collapse
  3. CBF falls passively with falls in MAP
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34
Q

Upper limit of auto regulation causes (4)

A
  1. Vasoconstriction is maxed
  2. Elevated intraluminal pressure force vessels to dilate
  3. Elevated intraluminal pressure leading to increase in CBF
  4. Elevated intraluminal pressure DAMAGE blood-brain-barrier
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35
Q

Auto regulation impaired by (6)

A
  1. Brain tumor
  2. Subarachnoid hemorrhage
  3. Stroke
  4. Head injury
  5. Damage of control system (cerebral vessels)
  6. Damage to the feedback mechanism involved in brain’s hemodynamic control (impaired CBF become pressure dependent)
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36
Q

Does inhalation anesthetics impair auto regulation?

A

NO

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37
Q

Increased radius (vasodilation) causes (4)

A
  1. Increase in cerebral BF
  2. Increase ICP
  3. Reduce CPP
  4. Balance must be reached
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38
Q

Balance is maintained by 4 primary factors:

A
  1. Cerebral metabolism
  2. CO2
  3. O2
  4. Auto regulation
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39
Q

Sympathetic nerves to radius of cerebral blood vessels:

A

Vasoconstriction protects the brain by shifting the auto regulation curve to the right in HTN

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40
Q

Parasympathetic nerves to radius of cerebral blood vessels:

A

Contribute to vasodilation and may play a part in hypotension and reperfusion injury

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41
Q

7 signs of increased ICP:

A
  1. N/V
  2. Personality change
  3. Altered level of consciousness
  4. Altered pattern of breathing
  5. Papilledema
  6. Seizures, abductees nerve or Abdul ent
  7. Cushing’s triad
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42
Q

What is cushing’s triad?

A
  1. Increased systolic BP
  2. Widened pulse pressure
  3. Bradycardia
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43
Q

Breathing is rapid for a period and then absent for a period

A

Kussmaul, Cheyne-stokes/biot’s respiration

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44
Q

Patients with normal BP retain normal alertness with ICP of what? (Unless tissue shifts at the same time)

A

25-40 mmHg

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45
Q

Only when ICP exceeds to what do CPP and cerebral perfusion decrease to a level that results in loss of consciousness and further elevations will lead to brain infraction and brain death?

A

40-50 mmHg

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46
Q

What part of infants heads bulge when ICP gets too high?

A

Fontanels (soft spot)

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47
Q

What predominantly affects obese women of childbearing age and has an unknown etiology?

A

Idiopathic intracranial HTN (IIH)

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48
Q

What deals with most important neurological manifestation is papilledema and may lead to secondary progressive optic atrophy, visual loss, and possible blindness?

A

Idiopathic intracranial HTN (IIH)

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49
Q

3 consequences of raised ICP?

A
  1. Cerebral ischemia due to reduction of cerebral perfusion pressure
  2. Brain shifts
  3. Brain herniation
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50
Q

Diplopia (double vision) with increased ICP and papilledema is usually what and rarely what?

A 
Usually horizontal (due to nonlocalizing 6th nerve palsy)
Rarely vertical
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51
Q

Lowering ICP first tier treatment steps (8)

A
  1. General physiologic homeostasis
  2. Head of bed elevation 30 degrees
  3. Analgesia and sedation
  4. NMB
  5. CSF drainage
  6. Hyperventilate
  7. Osmotic diuretics
  8. Steroids (dexamethasone)
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52
Q

What 3 drugs are used for sedation?

A
  1. Propofol
  2. Etomidate
  3. Midazolam
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53
Q

What 2 drugs are used for analgesia and antitussive effect?

A
  1. Morphine

2. Alfentanil

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54
Q

Hyperventilate historically to what but new update says what?

A

Used to: 25-30

New to: no lower than 35

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55
Q

What happens if you hyperventilate to <20mmHg?

A

Vasoconstriction and risk of cerebral ischemia

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56
Q

PaCO2 form 40 to 15… CBF reduced by what?

A

25ml/100g/min or 50% reduction

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57
Q

Osmotic diuretics drug to lower ICP?

A

Mannitol blouses at .25-1g/kg or continuous infusion

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58
Q

How does steroid lower ICP?

A

Decreases the amount and duration of plateau waves

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59
Q

Lowering ICP 2nd tier treatment steps (3)

A
  1. Barbiturate coma
  2. Hypothermia
  3. Decompressive craniectomy
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60
Q

What 3 drugs can be used for barbiturate coma?

A
  1. Pentobarbital
  2. Pentothal
  3. Propofol
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61
Q

Barbiturate coma infusion dose rate of barbiturates is increased under monitoring by electroencephalograph until what?

A

Burst suppression or cortical electrical silence (isoelectric “flatline”) is attained

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62
Q

Cooling to what can be effective in lowering refractory intracranial HTN but is associated with a relatively high rate of complications including pulmonary, infectious, coagulation, and electrolyte problems?

A

34 degrees Celsius

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63
Q

When performing a barbiturate coma, what monitor should be used and what should it read?

A

BIS and 40-50

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64
Q

12 goals for ideal neuro anesthetic agents:

A
  1. Rapid onset and rapid offset
  2. Maintains hemodynamic stability
  3. Does not increase CBF
  4. Does not alter CSF production or reabsorption
  5. Decrease ICP
  6. Maintains CO2 reactivity
  7. Maintains cerebral auto regulation
  8. Allows EEG/EP monitoring
  9. Does not increase cerebral metabolic rate
  10. Anticonvulsant
  11. Decrease edema
  12. “Protects” the brain
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65
Q

4 best agents for neuroanesthetic?

A
  1. Propofol
  2. Des
  3. Sevo
  4. Remifentanil
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66
Q

What is special about remifentanil?

A

Reduces MAC by up to 50%

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67
Q

All IV drugs except what decreases CBF and CMRO2?

A

Ketamine

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68
Q
  • decreases CMRO2, CBF, and ICP, MAP, CPP
  • cerebral autoregulation and vascular response to CO2 remain unaltered
  • prevention of large increases in BG
  • anti-oxidative effects
A

Propofol

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69
Q
  • decrease CMRO2, CBF, ICP

- increase EEF activity

A

Etomidate

70
Q
  • increases CMRO2 and CBF

- anti-oxidative effects

A

Ketamine

71
Q

How does opioids affect the brain?

A

Increase PaCO2=increase CBF and ICP

-depress LoC

72
Q

What does lidocaine do to brain?

A

Decrease CBF

73
Q
  • potent cerebral vasoconstrictor
  • decreases CMRO2, CBF, ICP
  • produce reverse steal or Robin Hood syndrome
  • facilitate absorption of CSF
A

Thiopental

74
Q

What kind of correlation is there between CBF and CMRO2 when using propofol?

A

Strong linear

75
Q

What does N2O do to CBF and CMRO2?

A

Increase

76
Q

Cerebral vasodilation can be countered by what?

A

Hyperventilation

77
Q
  • 40-60 years of age
  • s/s reflecting increasing ICP
  • adult onset seizure disorder
  • confirmed with CT or MRI
A

Intracranial tumors

78
Q

Positioning for suprtentorial tumor?

A

Supine

79
Q

Positioning for infratentorial tumor?

A

Prone or sitting

80
Q

Why should you beware with sitting position for brain tumors?

A

Increases risk of venous air embolism

81
Q

Tissue is benign

A

Grade 1

82
Q

Tissue is malignant

A

Grade 2

83
Q

Anaplastic-malignant cells are actively growing

A

Grade 3

84
Q

Malignant cells look most abnormal, tend to grow quickly

A

Grade 4

85
Q

Tumor arises from star-shaped glial cells called astrocytes. Can be any grade. In adults, most often arises in the cerebrum/

A

Astrocytoma

86
Q

Tumor arises in meninges. Can be grade 1,2 or 3. Usually benign (grade 1) and grows slowly.

A

Meningioma

87
Q

Tumor arises from cells that make the fatty substance that covers and protects nerves. Usually occurs in the cerebrum. Most common in middle-aged adults. Can be grade 2 or 3.

A

Oligodendroglioma

88
Q

Usually arises in cerebellum. Sometimes called primitive neuroectodermal tumor. Grade 4.

A

Medulloblastoma

89
Q

Low-grade tumor occurs anywhere in brain.

A

Grade 1 or 2 astrocytoma

90
Q

Most common astrocytoma among children is what?

A

Juvenile pilocytic astrocytoma (grade 1)

91
Q

Arises from cells that line the ventricles or the central canal of the spinal cord. Most commonly found in children and young adults. Can be grade 1, 2 or 3.

A

Ependymoma

92
Q

Occurs in the lowest part of the brain. Can be low grade or high grade.

A

Brainstem glioma

93
Q

4 diagnostic studies for raised ICP:

A
  1. Skull radiography- beaten silver or lacunar skull
  2. Angiography- slowing circulation
  3. CT scan-edema
  4. ICP monitoring
94
Q

Maintenance of what IV fluid for fluid and electrolyte balance?

A

Mild hyperosmolality (NS or LR)

95
Q

No glucose for how long when considering fluid and electrolyte balance?

A

First 4 hrs

96
Q

Do you ignore 3rd space and NPO for neurosurgery?

A

YES

97
Q

Adults and peds maintain how much deficit?

A

Adults: maintain 500-1000cc
Peds: 0

98
Q

What is the most common hypertonic solution used to provide relaxed brain at surgery?

A

Mannitol

99
Q

How does mannitol relax the brain?

A

By cerebral dehydration and decreasing the ICP

100
Q

What are the 3 adverse effects of mannitol?

A
  1. Adverse dehydration, hyponatremia, hypokalemia, renal failure
  2. Transient increase in ICP before diuresis
  3. Exaggeration of brain shifts with unilateral lesions
101
Q

What is the dosage of mannitol?

A

.25-2g/kg bolus and administer bolus over 15-20 min before opening the dura

102
Q

What are the 4 goals for cerebral tumors?

A
  1. Reducing the brain bulk
  2. Providing easy access to the surgical lesion
  3. Monitor urine output, serum osmolality and electrolytes
  4. Carefully monitor IV volume
103
Q

Sitting position has what 2 most common threatening complications?

A
  1. Venous air-embolism

2. Severe hypotension

104
Q

Acute flex ion of the neck may cause (3)

A
  1. Airway obstruction
  2. Obstruction to cerebral venous outflow
  3. Intraop brain swelling
105
Q

Elevation of the head above the heart risk what 2 things?

A
  1. Cerebral venous drainage

2. Venous air embolism from open veins

106
Q

What are the 4 premed risk:

A
  1. Depression of consciousness
  2. Airway obstruction
  3. Hypoxia and hypercapnia
  4. Increased ICP
107
Q

Pts without evidence of raised ICP may be given what to allay anxiety?

A

Small doses of benzodiazepines

108
Q

4 things to limit stimulation during induction and intubation:

A
  1. Liberal doses of thiopental or propofol combined with narcotics
  2. Mild to moderate hyperventilation with mask before intubation
  3. IV lidocaine bolus
  4. To help prevent dangerous increases in ICP, AVOID nitrous oxide and inhalational anesthetics
109
Q

Does TIVA provide bette operating conditions than inhalational anesthesia?

A

Maybe

110
Q

5 definitive measures used for decreasing brain bulk:

A
  1. Hyperventilation
  2. Mannitol
  3. Continuous infusion of IV anesthetic agents
  4. CSF diversion through ventriculostomy catheter
  5. Moderate hypothermia (extreme cases only)
111
Q

What 3 things increase the chances of postop hematoma and edema?

A

HTN, coughing, and asynchrony

112
Q

Does the pt need to be fully awake at the time of extubation?

A

Yes so the neurological exam can be performed

113
Q

Benefits of delayed extubation (3):

A
  1. Reduced risk of hypoxemia
  2. Better respiratory and hemodynamic control
  3. Lower incidence of postop hematoma formation
114
Q

4 things that warrant delaying extubation:

A
  1. Obtunded consciousness and inadequate airway
  2. Intraop brain swelling
  3. Hemostasis problems during surgery
  4. Major postop hemostatic disturbances
115
Q

Blood flow to ischemic region of brain is dependent upon what?

A

CPP

116
Q

Bleed between the arachnoid membrane and pia mater

A

Subarachnoid hemorrhage

117
Q

Subarachnoid hemorrhage is most caused by what?

A

Ruptured aneurysm then trauma, hemorrhagic tumors

118
Q

HHH stands for?

A

Hypervolemia, HTN, and hemodilution

119
Q

2 things that come with HHH?

A
  1. Reduce HCT and lower viscosity (HCT 27-30)

2. Increases CPP

120
Q

CPP goal for intracranial aneurysm?

A

> 70 mmHg

121
Q

5 additional monitors for intracranial aneurysm:

A
  1. 2 large bore IV catheters
  2. A line
  3. ICP monitor
  4. Foley
  5. CVP catheter
122
Q

Induction of anesthesia for intracranial aneurysms (5)

A
  1. Propofol or etomidate
  2. Muscle relaxant (avoid sux becuase raises ICP)
  3. More Propofol, opioids &/or lidocaine 1-2 min prior to DL
  4. Ventilate to PaCO2 25-30
  5. NO PEEP bc increase ICP
123
Q

What do you avoid in patients with elevated ICP before the dura is opened?

A

Vasodilators (nitroprusside, nitroglycerine)

124
Q

4 ways to handle cerebral swelling:

A
  1. Mannitol (.25-1g/kg)
  2. Furosemide (.5-1mg/kg)
  3. Propofol/thiopental
  4. Head up position (30degrees)
125
Q

What to do for aneurysm clipping:

A

Facilitate exposure (shrink brain) and reduce transmural pressure in the aneurysm prior to clipping

126
Q

Temporary clipping of the feeding vessel will require what?

A

Normal to increase BP to maintain collateral flow

127
Q

IV fluids for intracranial aneurysm (4)

A
  1. Restrict 1-3ml/kg/hr
  2. Glucose NOT recommended (may increase cerebral edema and hyperglycemia worsens cellular ischemic injury)
  3. Isotonic crystalloids
  4. Colloids are controversial
128
Q

Avoid N2O during emergence why?

A

May cause tension pneumocephalus

129
Q

If delayed return to consciousness or neurological deterioration then what test should be completed?

A

CT or MRI

130
Q

2 cautions to get venous air embolism:

A
  1. Head >5cm above heart

2. Transecting veins in cut edge of bone or dura and may not collapse

131
Q

8 detections for venous air embolism (VAE):

A
  1. Per ordinal Doppler near R upper sternal
  2. Trans-esophageal
  3. Increase in ET nitrogen
  4. Sudden decrease in EtCO2
  5. PaCO2 decrease
  6. CVP
  7. ECG/esophageal stethoscope
  8. Gasping, hypotension, dysrhythmias, cyanosis, chest pain (awake)
132
Q

8 treatment options for venous air embolism:

A
  1. Irrigate operative site with fluid
  2. Apply occlusive material to bone edges
  3. Gently compress internal jugular veins
  4. Head down position
  5. Aspirate air through RA catheter
  6. Discontinue N2O
  7. Inotropes may be needed
  8. CPR
133
Q

Depression is what?

A

TCA’s (tricyclic antidepressants)

134
Q

Depression has exaggerated response to what?

A

Stimulation and indirect acting vasopressors

135
Q

What 4 things to avoid in pts with depression:

A
  1. Pancuronium
  2. Demerol (meperidine)
  3. Ketamine
  4. Epinephrine
136
Q
  • results in temporary loss or depression of all or most spinal reflex activity below the level of injury
  • hypotension due to loss of sympathetic tone
A

Spinal shock

137
Q

Spinal cord reflex arcs immediately where?

A

Above the level or injury may be severely depressed

138
Q

Phase 1
0-1day
Areflexia/hyporeflexia

A

Loss of descending facilitation

139
Q

Phase 2
1-3days
Initial reflex return

A

Denervation supersensitivity

140
Q

Phase 3
1-4weeks
Hyperreflexia (initial)

A

Axon-supported synapse growth

141
Q

Phase 4
1-12months
Hyperreflexia, spasticity

A

Soma-supported synapse growth

142
Q

Cercival lesions have total loss of what and resolve in what time frame?

A 
Sympathetic innervation (Vasovagal hypertension and Brady)
3-6 weeks
143
Q

What happens if acute spinal injury above T6?

A

Autonomic dysreflexia may occur and parasympathetic is preserved
-synergy between sympathetic and parasympathetic system is LOST

144
Q

What happens below T6 or T7 acute spine injury?

A

Sacral parasympathetic loss

145
Q

Innveration to the heart

A

T1-4

146
Q

How long can spinal shock last?

A

1-3 weeks or longer

147
Q

If vasopressors don’t work for acute c-spine injuries, what should be used?

A

High dose corticosteroids

148
Q

Inability to regulate core body temp (cold blooded)

A

Poikilothermic

149
Q

Can pts sweat below level or injury with complete spinal cord injuries?

A

NO

150
Q

For chronic spine injury, what does suctioning causes?

A

Bradycardia

151
Q

What is permanent for chronic spine injury?

A

Autonomic dysreflexia; occurs form phase 4 and onwards

Remember cyto’s

152
Q

What puts chronic spine injury pts at greater risk (2)?

A
  1. Duration of surgery

2. Operations greater than 4 cervical levels or involving C2

153
Q

Pts with neurogenic bladder dysfunction as a result of spinal cord injury can lead to what bladder functions (5)?

A
  1. UTI
  2. Stone disease
  3. Bladder cancer
  4. Autonomic dysreflexia
  5. Renal dysfunction
154
Q

Is a standard x-ray reliable for an acute c spine injury?

A

NO

155
Q

Airway control with sux:

A

NO sux for 24hrs - 6months and risk of hyperkalemia

156
Q

Autonomic hyperreflexia may include (5):

A
  1. Change in HR (bradycardia)
  2. Excessive sweating
  3. HTN
  4. Muscle spasms
  5. Skin color changes (pale, red, blue-gray)
157
Q

Pts with lesions above where have AH?

A

T6

158
Q

AH is confused with what 4 other things?

A

Thyroid storm, carcinoid syndrome, serotonin syndrome, MH

159
Q

2 prevention of AH?

A

Spinal anesthesia MOST EFFECTIVE (epidural not as good)

Deep general

160
Q

2 treatments for AH?

A
  1. Arterial vasodilators (nitroprusside)

2. Vasodilators (hydralazine)

161
Q

Other 2 considerations for AH?

A
  1. AVOID sux 24 hours after injury until 6months

2. Temp monitoring with lesion above T1

162
Q

Flexed prone positions causes what 6 things:

A
  1. Excessive compression to IVC (decrease preload)
  2. Restriction of diaphragm (increase PIP)
  3. Brachial plexus may be stretched
  4. Ulnar nerve not properly padded
  5. Eye damage from pressure
  6. Nose pressure
163
Q

What table is used for prone position, maintains flexed position, and intrabdominal pressure may be increased if supporting pads are not properly placed?

A

Wilson frame

164
Q

Table for prone position, frame based table, allows abdomen and chest to hang freely, and may allow 180degree rotation?

A

Jackson table

165
Q

POVL (postop visual loss) related to spine surgery in what position?

A

Prone

166
Q

6 postop vision loss risk factors:

A
  1. Atherosclerotic disease
  2. Hypotension
  3. Anemia
  4. Excessive blood loss (>1000ml)
  5. Long duration of surgery (>6hrs)
  6. Head dependent positioning
167
Q

What does venous air embolus respond to normally if not massive?

A

Fluid therapy

168
Q

Up to how much air can stop lungs?

A

1cc/kg

169
Q

How much air in the cerebral circulation can be fetal?

A

2ml

170
Q

How much air into a coronary artery can cause cardiac arrest?

A

.5ml

Co-Exisiting Disease 2 (11 decks)

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