Practical tips

Question 1

Transsphenoidal surgery

Answer 1

consider pituitary function pre-operatively (mass effects & hormone hyper or hypo secretion)
art line

head ring, slight head up for OT

SHARED AIRWAY:
either reinforced (if not going through MRI) or south-facing rae
manually check all connections before drape

remifentanil: consider starting (65yo) Ce 2, increase (hypotensive, bradycardia goals) with propofol TCI (eg. at 5 initially) with metaraminol running
Titrate remifentanil for most stimulating points: fracture nasal septum, breaching the dura
monitor urine: consider diabetes insidious (differential= cerebral salt wasting)

Surgical complications:

• bleeding in enclosed space: damage control principles of: permissive hypotension (SBP 90mmHg), consider temporarily suspending cardiac output eg. with adenosine, damage control surgery, damage control resuscitation (normothermia, avoid acidaemia & coagulopathy)
• cranial nerve palsy
• meningitis (ABx prophylaxis)

Transferring to MRI:
MRI safety checklist
change ecg dots to MRI-compatible
remove temp probe
all lines run downwards

endoscopic surgery

CORONER’S CLOT risk (good suction @ end, lift head)

Question 2

Andrew’s tips for lung isolation?

Answer 2

prior to isolating, recruit both lungs (trach cuff inflated, bronchial deflated) with:
Pinsp & PEEP 10
PEEP 15
then PEEP 20 & Pinsp 20 (so no >40cmH2O overall); watch the volumes plateau.
Then able to isolate; keep FiO2 ?80%?, 5mL/kg TVs goal, use PCV