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Neurosurgery overview Flashcards

1
Q

Preoperative considerations for neurosurgery include

A

general assessment- access
normal preoperative evaluation- systems, airway, mobility
neurological assessment- LOC, reflexes, motor/sensory function, evaluate for s/s of increased ICP, document preexisting neurological deficits

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2
Q

Describe preoperative considerations for medications & monitoring.

A

medications- anticonvulsants (frequency & continue), premedications, antibiotics, diuretics, steroids
monitoring- arterial line & intraoperative neuro monitoring

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3
Q

The types of intraoperative neuromonitoring include

A

MEP
SSEP
EMG

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4
Q

Describe MEP

A

used in surgeries where motor tract is at risk
direct & scalp electrodes
more sensitive to ischemia than SSEP by 15 minutes and degree detection
difficult to obtain due to pre-existing conditions or anesthetic conditions

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5
Q

Describe SSEP.

A

most commonly monitored
stimulation of peripheral sensory nerve
mapping in spinal cord and sensory cortex
ischemia detection in cortical tissue
reduce risk of spinal cord/brainstem- mechanical or ischemic insults
-may use paralytic but it does monitor some motor

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6
Q

Describe EMG

A

records muscle electrical activity needle pairs- continuous recording, triggered responses
uses- detect nerve irritation, nerve mapping, assess nerve function, monitoring cranial nerves

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7
Q

Stereotactic neurosurgery applies rules of

A

geometry to radiologic images to allow for precise localization within the brain, providing up to 1 mm accuracy

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8
Q

Stereotactic neurosurgery allows surgeons to

A

perform certain intracranial procedures less invasively

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9
Q

Smaller brain biopsies may be done

A

under local/MAC

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10
Q

_____ needs to be used for larger brain resections

A

GETA

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11
Q

With stereotactic neurosurgery, radiologically small markers are affixed to the scalp and forehead with adhesive and it is important that

A

these fudicials do not move between the time of imaging and entry into the OR
once in the OR the patient’s head is appropriately positioned & the locations of the fudicials are entered into a computer

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12
Q

Medications commonly found in the crani bag include

A

cleviprex, mannitol, keppra, phenylephrine, precedex, epi

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13
Q

Drips commonly used in craniotomies include

A

propofol at 40-100 mcg/kg/min ABW- max 40 mg/kg/min for asleep motor mapping and awake craniotomy
phenylephrine at 0.2 mcg/kg/min
remifentanil @ 0.2 mcg/kg/min IBW- no real max if patient needs it due to low propofol dose

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14
Q

Describe common induction medications for craniotomies.

A

fentanyl, propofol, rocuronium

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15
Q

Antibiotics for craniotomies include

A

vancomycin & cefazolin

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16
Q

Analgesics for craniotomies include

A

tylenol

narcotic (hydromorphone or fentanyl)

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17
Q

Antiepileptics for craniotomies include

A

keppra 1 g & vimpat

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18
Q

Drugs that decrease ICP in the setting of craniotomies include

A

decadron- 10 mg
mannitol- 50-100 mg (actual dose 0.25-0.5 g/kg)
+/- lasix

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19
Q

Specific drugs used for awake cranies include

A

caffeine- adenosine receptor antagonist

physostigmine- anticholinesterase

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20
Q

Types of mass lesions include

A

congenital
neoplastic (benign vs. malignant)
infectious (abscess or cyst)
vascular (hematoma or arteriovenous malformation)

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21
Q

Typical presentation of intracranial mass lesions include

A 
HA (50-60%)
seizures (50-80%)
focal neurological deficits (10-40%)
sensory loss
cognitive dysfunction
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22
Q

Supratentorial masses can be found in

A

frontal: personality changes, increased risk taking, difficulty speaking
parietal: sensory problems
temporal: problems with memory, speech, perception, and language skills
occipital: difficulty recognizing objects, an inability to identify colors, and trouble recognizing words

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23
Q

Infratentorial/Posterior fossa masses can affect

A

cerebellar dysfunction: ataxia/poor balance, nystagmus, dysarthria, cannot perform rapid alternating movements, loss of muscle coordination
brainstem compression: cranial nerve palsy, altered LOC, abnormal respiration
edema, obstructive at 4th ventricle

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24
Q

Primary tumors include

A

glial cells- astrocytoma, oligodendroglioma, glioblastoma
ependymal cells- ependymoma
supporting tissues- meningioma, schwannoma, choroidal papilloma

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25
Major considerations for intracranial mass lesions include
tumor location- determines position, EBL, risk for hemodynamic changes intraoperatively ICP elevated Growth rate & size- slow growing tumors are often asymptomatic
26
Describe anesthetic goals for intracranial mass management
control ICP maintain CPP protect from position-related injuries rapid emergence for neuro assessment
27
Describe monitoring for intracranial mass lesion
standard monitors arterial line (zero based on positioning) foley catheter +/- central line PNS: do not monitor on hemiplegic side b/c you may end up overdosing paralytics +/- ventriculostomy for ICP monitoring (zero at external auditory meatus) possible IONM monitoring
28
Describe positioning needs for intracranial mass lesions
anticipate turning HOB 90-180 degrees ensure ability to access all vital equipment adequate IV line extensions long breathing circuit PNS often on LEs HOB elevated 10-15 degrees pt may be supine, lateral, prone, or sitting anticipate sympathetic response with placement of Mayfield head pins
29
Preoperative considerations for intracranial mass lesions include:
determine presence or absence of increased ICP document LOC & neuro deficits review PMHx and general health status Review medication regime: pay special attention to anticonvulsants, diuretics Review lab findings: glucose levels, anticonvulsant drug levels, electrolyte disturbances, H/H review radiological studies: evidence of edema, midline shift, change in ventricular size premedications: avoid benzodiazepines/narcotics in pt with increased ICP, continue corticosteroids & anticonvulsants
30
Describe maintenance for intraoperative mass lesions
no preferred anesthetic technique hyperventilation (30) avoid excessive PEEP (<10)
31
Describe fluid management for intraoperative mass lesions.
glucose free crystalloids or colloids | replace blood loss with blood/colloids
32
Describe ICP control for intraoperative mass lesions.
EVD/lumbar drain | increases in cerebral blood flow
33
Emergence for intraoperative mass lesions must be
slow & controlled- straining or bucking can cause ICH or worsen cerebral edema aggressive BP management (SBP <140 or <160)- risk for hemorrhage or stroke- clevidipine, labetalol, esmolol surgical team will do neuro exam immediately after extubation; prior to OR departure
34
Postoperative considerations for intracranial mass lesion
``` admit to ICU for observation transport with HOB elevated- 30 degrees manage hypertension O2 for transport minimal pain post craniotomy observe for seizures, neuro deficits, increased ICP ```
35
Describe an awake-awake craniotomy.
no infusions until closing | propofol or remi for pins
36
Describe an asleep-awake craniotomy.
start under GA with LMA/ETT (don't get them back breathing) wake the patient up once tumor is exposed propofol drip 40 mcg/kg/min ABW remifentanil drip 0.2-0.4 mcg/kg/min IBW
37
Describe an asleep craniotomy
TIVA-IONM, asleep motor mapping | GETA: no IONM
38
Awake craniotomies are used for
epilepsy surgery and resection of tumors in frontal lobes & temporal lobes when speech and motor are to be assessed intraoperatively
39
Patient considerations for awake craniotomies include
airway temperature anxiety
40
Additional considerations for awake craniotomies include
asleep with LMA for exposure awake for cortical mapping & tumor resection sedated for iMRI deployment- evaluate resection when tumor resection complete use appropriate anesthetic to keep comfortable
41
Safety hazards for personnel in iMRI include
magnetic field strength cold hazards acoustic noises
42
Monteris medical "LITT" may be used to intervene for
epilepsy glioblastomas recurrent brain metastases radiation necrosis
43
MR thermography uses
phase change to calculate real time temperature data at and around probe thermal dose confirmed in real time using bio-thermodynamic theory
44
Describe what the white line, blue line, and yellow line
white line- vaporized blue line- dead yellow line recoverable
45
The contents of the posterior fossa include
cerebellum- movement and equilibrium brainstem- autonomic nervous system, CV & respiratory centers, RAS, motor/sensory pathways cranial nerves I-XII large venous sinuses
46
Brainstem injuries can be a result of
bradycardia & hypertension-trigeminal nerve stimulation (Cushing's reflex) bradycardia & hypotension- glossopharyngeal or vagus nerve stimulation respiratory centers may be damaged and necessitate mechanical ventilation postoperatively tumors around glossopharyngeal and vagus nerves may impair gag reflex and increase risk of aspiration cranial nerves IX, X, and XI control pharynx and larynx
47
Anesthetic considerations for posterior fossa surgery include
preoperatively- same considerations as those with intracranial lesions positioning- may be sitting, modified lateral, or prone
48
Sitting position advantages include
``` improved surgical exposure- more anatomically "correct" less retraction and tissue damage less bleeding less cranial nerve damage better resection of the lesion access to airway, chest, extremities ```
49
Disadvantages relating to CV compromise as a result of the sitting position include
postural hypotension arrhythmias venous pooling
50
Describe nerve injuries related to the sitting position
ulnar compression-arms across abdomen, pad elbows sciatic nerve stretch- pillow under knees lateral peroneal compression- pad knees brachial plexus stretch- pad under arms to support shoulders
51
Describe pneumocephalus related to the sitting position.
open dura--> CSF leak--> air enters after dural closure, air can act as a mass lesion as CSF reaccumulates usually resolves spontaneously tension pneumocephalus- Burr holes to relieve symptoms include delayed awakening, HA, lethargy, confusion if using N2O, discontinue before dural closure
52
A venous air embolism occurs when
pressure in a vein is subatmospheric level of incision is >5 cm higher than the heart patients with PFO can have air enter arterial circulation
53
The incidence of venous air embolism is
potentially lethal sitting position 25-50% prone, lateral supine: 12%
54
Paradoxical air embolism is when
air enters left side of heart & travels to systemic circulation occurs when right heart pressure is greater than left common in patients with PFO
55
Signs & symptoms of venous air embolism include
``` decreased ETCO2 decreased PaCO2 decreased SaO2 spontaneous ventilation mill-wheel murmur detection of ET nitrogen increased PaCO2 hypotension dysrhythmias ```
56
Monitoring for VAE is through
capnography CVP/PA line precordial doppler ** do not rely on one monitor alone to diagnose VAE. use monitors with different sensitivities to confirm
57
Sensitivity for monitoring of VAE from most sensitive to least
``` TEE (5-10x more sensitive than doppler) precordial doppler ETCO2- decreases with 15-25 mL of air PAP- increased with 20-25 mL of air CVP PaCO2 MAP ```
58
Treatment for venous air embolism includes
100% O2, discontinue N2O notify surgeon to flood field or pack wound call for help aspirate from CVP line (have stopcock close to insertion site, aspirate with 30-60 mL syringe) volume load inotropes/vasopressors jugular vein compression PEEP position patient LLD with slight Trendelenburg CPR if necessary
59
Craniocervical decompression is when
the cerebellum protrudes through foramen magnum- compresses brainstem and cervical spinal cord types I-IV syringomyelia
60
Anesthetic considerations for chiari malformation include
position- prone or sitting EBL- large venous sinuses vital sign instability due to brainstem manipulation postoperative: pain management

Advanced Principles 2 (42 decks)

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