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Anaesthesia for intracranial SOL, including vascular surgeries

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Presentation on theme: "Anaesthesia for intracranial SOL, including vascular surgeries"— Presentation transcript:

1 Anaesthesia for intracranial SOL, including vascular surgeries
Dr. Megha Aggarwal University College of Medical Sciences & GTB Hospital, Delhi

2 Outline Introduction to SOL Neuroanaesthetic goals
Classification Presentation Management strategies Neuroanaesthetic goals Hemodynamic concerns Conduct of anaesthesia Pre anaesthetic assessment Monitoring Induction, maintenance and emergence Post-operative concerns

3 Classification of SOL CONGENITAL Dermoid, epidermoid, teratoma.
TRAUMATIC Subdural & extradural haematoma INFLAMMATORY Abscess, tuberculoma, syphilitic gumma,fungal granulomas. PARASITIC Cysticercosis, hydratid cyst, amebic abscess, Schistosoma NEOPLASMS  Meningionas, gliomas, choroid pappilomas , metastasis VASCULAR Aneurysms, A-V malformations

4 Neoplasms

5 Common SOLs 1. Meningioma- 90% supratentorial 5-6th decade benign Highly vascular with large feeding vessels 2. Gliomas - most common 1⁰ intracranial tumors slow growing astrocytomas to malignant glioblastomas seizures, focal deficits, ↑ ICP as per tumour type

6 Common SOLs (cont …) 3. Tumors of ventricular system
Choroid plexus papillomas, ependymomas, Obstructive hydrocephalus, midbrain compression 4. Metastatic Most common intracranial tumors Multiple 5. Intracerebral abscess Frontal sinus, middle ear, blood born, foreign body Meningitis , ↑ ICP

Supratentorial (forebrain) Seizures Headache Motor/ sensory deficits Infratentorial (brainstem) (RAS, CN, Cardiac & resp centres) - CN deficit (3-12)- ocular palsy, dysphagia, laryngeal dysfunction (chronic aspiration). - Arrhythmias/ respiratory irregularities Sleep abnormality Infratentorial (cerebellum) Ataxia Tremors Vestibular signs Hydrocephalus Infratentorial (vestibular system) Head tilt Postural deficit Nystagmus

8 Herniation / midline shift
HTN , Tachy/ brady arrythmias, 3 & 6th CN palsy (I/L pupil dilation + no light reflex), C/L hemiplegia/ paresis, Coma , Resp arrest

9 Treatment Chemotherapy Surgical resection Radiotherapy

10 Goals of anaesthesia Preserve both injured & uninjured cerebral territories by global maintenance of cerebral homeostasis. Maintain normocarbia, normotension, normoxia, euthermia, euglycemia. Avoid secondary brain insults Optimizing operative conditions to facilitate resection

11 Anaesthetic implications
Depending on type (vascularity) and location (supra/ infratentorial) of tumor Supratentorial ICP management Monitoring brain function Massive intraoperative hemorrhage Seizures Air embolism (if venous sinuses traversed) Infratentorial Air embolism Care during vital structure handling Positioning Higher mortality

12 Secondary insults INTRACRANIAL SYSTEMIC
Increased intracranial pressure Hypercapnia/hypoxemia Epilepsy Hypo-/hypertension Vasospasm Hypo-/hyperglycemia Herniation: falx, tentorium, foramen magnum, craniotomy Low cardiac output Midline shift: tearing of cerebral vessels Hypo-osmolality Shivering/pyrexia

13 WHY CONTROL BP ? AVM/ aneurysm/ head injuries/ tumors
Disruption of cerebral autoregulation BP fluctuation poorly tolerated ↑BP – Vasogenic edema, ↑ tumor / aneurysm size, aneurysmal rupture ↓ BP – Ischemia/ infarction

14 Stimuli for BP fluctuation Preventive measures
Laryngoscopy Intubation Positioning Suction Skeletal fixation of head Preventive measures Deep plane of anesthesia Additional dose of iv anesthetic agent Adequate muscle relaxation Lignocaine (1.5 mg/kg) Esmolol (0.5 – 1 mg/kg)

15 Preoperative assessment

16 Preoperative assessment
HISTORY Level of consciousness Seizures - ↑ CMRO2 , ↑ ICP ↑ ICP – headache, vomiting, without nausea, blurred vision, ocular palsy (CN 6) Hydration – fluid intake, NPO status, diuretics, SIADH Medications – steroids, antiepileptic drugs, aspirin/ clopidogrel, diuretics, mannitol CN palsies- dysphagia, laryngeal dysfunction Associate systemic illness- Cardiac – HTN (hypotensive anaesthesia) Respiratory Renal – intraoperative mannitol and diuretics, SIADH, DI

17 Preoperative assessment
EXAMINATION Mental status, level of consciousness (GCS) Hydration status Systemic examination a) CNS ↑ICP – papilloedema, cushing response (↑BP, ↓HR), sutural diastasis, bulging fontanels. Focal signs (CN palsies) - Dysphagia, strabismus, focal seizures, speech deficit, motor & sensory examination. Midline shift - I/L Pupillary dilatation and absent light reflex (3rd CN)

18 Preoperative assessment
EXAMINATION b) Respiratory- effect of positioning, resp. pattern, neurogenic pulm. edema c) CVS – Cushing reflex, HTN (resets limits of cerebral autoregulation), BP (cerebral perfusion) d) GI -↑ Aspiration (steroids, ↑ ICP , low GCS, emergency) e) Renal - ↓fluid intake, diuretics, mannitol, SIADH, DI f) Paraneoplastic syndromes

19 Preoperative assessment
INVESTIGATION Complete blood count – Hb, TLC, Platelet count RBS – hyperglycemia – cerebral edema , ↑ischemic brain injury KFT – urea, Na, K Coagulation profile ECG – ischemic changes, arrhythmias CXR

20 Preoperative assessment
INVESTIGATION 7. CT/ MRI – tumor assessment Location – silent/ eloquent area Size – degree of compromise of intracranial dynamics including auto regulation. Ventricular distortion / CSF obstruction Midline shift Perilesional edema - makes tumor functionally bigger Contrast enhancement - degree of BBB disruption Proximity to venous sinuses - blood loss

21 ASA physical status ???? Nature of surgery
High incidence of systemic involvement – CN palsies, motor/ sensory involvement Higher comorbidities Poor surgical outcome

22 Premedication 1. Sedation -Risk assessment, individualised - often avoided 2. Others - Continue anticonvulsants, antihypertensives, steroids till morning of surgery - mannitol, furosemide Sedation - hypoventilation (hypercapnia, hypoxia, airway obst ) Sedation - ↓stress→↓ICP→↓ vasogenic edema

23 Vascular access 1. Intravascular a) 2 large bore i.v cannulas b) CVP -VAE (diagnostic + therapeutic ) - vasoactive drugs 2. Arterial canulation a) NIBP (anticipated blood loss) b) ABG c) Hypotensive anaesthesia

24 Monitoring ECG, HR – myocardial ischemia, arrhythmias SpO2 ETCO2
NIBP/ IBP – at level of operative field NMT – on non hemiplegic limb Temperature CVP Urine output Precordial doppler, TEE, ETN2 ICP – currently rarely used, except in neurotraumatology UMN lesion ↑ Ach receptor density Resistance to NDMR

25 GOALS – Normotension, Normocarbia, Normoxia
Induction GOALS – Normotension, Normocarbia, Normoxia Preoxygenation P/M – opioid (fentanyl 1-2 μg/kg , morphine 0.1 mg/kg) Lignocaine , Esmolol, 2nd dose of i.v induction agent sec earlier I/W – Thiopentone (3-5 mg/kg) Propofol (1.5 – 2.5 mg/kg) Myorelaxation – Sch (transient ↑ ICP) Use intermediate acting relaxants Atracurium – histamine release ( cerebral vasodilatation) Vecuronium, Rocuronium – commonly used Only after adequate muscle relaxation achieved, perform quick + gentle laryngoscopy Intubation – armoured ETT Tape on opposite side of surgery Bandaging may ↓cerebral venous return Controlled ventilation

26 Positioning GOAL- Slow and gentle positioning with ⁰ head up tilt to aid cerebral venous drainage Verify cautiously – 1. All potential pressure points padded 2. Eyes protected & padded 3. Peripheral pulses palpable 4. Nerve compression absent 5. Ventilation adequate ( PEEP, ETT position) ETT – Kinking in post. Oropharynx Advancement / extubation Neck – Extreme rotation / flexion may cause ↑ ICP, quadriparesis, tongue swelling Head pins – Adequate plane of anaesthesia Local infiltration / bolus opioid (fentanyl)

27 Optimization of ICP Dural opening in presence of high ICP –
- sudden decompression & transcalvarial herniation - herniated tissue cannot be interposed back - permanent neural damage ICP to be brought within normal limits before opening the dura. Methods – head elevation, mannitol, furosemide, CSF drainage

28 Optimize ICP (cont…) Mannitol (20%) Hyperosmolar agent
Dose : 0.5 – 2 mg/kg i.v. (0.5-1 mg/kg over 15 min just before opening dura) Action reaches peak at min. Advantages : Draws water from brain (↓ brain bulk) ↓ Hct (↑CBF , O2 delivery) Disadvantages: 1.If given fast, it transiently ↑ blood vol. & may cause CHF , pulmonary edema 2. Hypokalemia 3. Worsen C. edema if BBB disrupted

29 Optimize ICP (cont…) Furosemide
Loop diuretic (Na K 2Cl channel blocker) Dose : 0.5 – 1 mg/kg i.v. use : sole agent to ↓ ICP adjunct to mannitol Mannitol draws fluid out of brain & lasix discards it through kidneys

30 Optimize ICP (cont…) CSF drainage Lumbar subarachnoid drainage system
Ventriculostomy drain (EVD) (connected by tubing to a CSF collection device which can be elevated or lowered) CSF drainage (↑ICP, aneurysm / ENT surgeries) ICP measurement CSF drainage Slow bolus ≤ ml Complications hematoma formation infection if abrupt ↓ICP – aneurysmal rupture

GOAL- Maintain cerebral homeostasis + Aid “slack” brain. TARGET – Anaesthetic agent , Fluid therapy, Neuroprotection strategies. ANAESTHETIC AGENT VOLATILE ANAESTHETIC I.V. ANAESTHETIC PROS Easy, Extensively available Intact CBF – CMRO2 coupling ↓brain bulk Propofol blunts N2O cerebrostimulation CONS CBF – CMRO2 uncoupling ↑ICP 1. Short acting RECOMMENDATION Use in short, uncomplicated surgeries At < 1.5 MAC Avoid combination with N2O 1. Use in cases with high risk of ↑ICP/ brain bulk

32 Maintenance (cont…) FLUID THERAPY
Principle – BBB is selectively permeable Water crosses freely, most ions (Na+) don't. If BBB disrupted (ischemia, head injury, tumors) – hyperosmolar agents may ↑brain water instead of drawing water out.

FLUID LOSS – Do not replace fasting / III space losses BLOOD LOSS – Assessment difficult (drapes + continuous irrigation) SERUM OSMOLARITY – Maintain at mosm/L Give NS (309 mosm/L) Avoid RL (272 mosm/L) Use them alternately Avoid glucose containing solutions (5%D , DNS) Mannitol (0.5 – 2 mg/kg) Furosemide ( mg/kg)

34 Maintenance (cont…) NEUROPROTECTION OTHERS PaO2
PaCO2 BP (sympatholysis, antihypertensives) Glucose ( <170 mg/dL ) Temperature ( controlled hypothermia 32-34⁰C) Analgesia Adequate depth of anaesthesia OTHERS Seizure prophylaxis/ control Steroids Nimodipine (SAH) Barbiturates Magnesium (experimental)

35 Maintenance (cont…) The chemical brain retractor concept
Mild hyperosmolality Adequate head-up positioning Lumbar cerebrospinal fluid drainage Intravenous anesthetic agent (propofol) Avoidance of brain retractors Venous drainage: jugular veins free

36 Emergence Due to pain and shivering, associated with
Most important but often neglected “ A well planned procedure is often rewarded by a fully awake patient who is appropriately responding to verbal commands and neurological examination.” Due to pain and shivering, associated with ↑ catecholamine release ↑ O2 Consumption ( X 5 times) AIMS To maintain intra + extracranial homeostasis (MAP- CPP- CBF- ICP- CMRO2 - PaO2 - PaCO2- temp) Avoid intracranial bleed ( coughing, ventilator fight)

Early neurological examination & reintervention Less ↑BP/ catecholamine burst ↓ cost of postop care Less risk of ↓O2,↑CO2 associated with anaesthesia hangover Better respiratory & hemodynamic control RECOMMENDATION – Early awakening is recommended unless contraindicated.

38 Emergence (cont…) Checklist for early extubation
Good preop GCS (>8) CVS stability + normothermia + normoxia Limited brain surgery, no major brain laceration No extensive post fossa manipulation ( CN 9 – 12) No major AVM removal

39 Emergence (cont…) Indication of late extubation Low GCS
Inadequate airway control Intraop catastrophe Brain edema/ deranged cerebral homeostasis (long duration/ extensive/ repeat surgery) 5. Surgery around vital areas

40 Immediate postoperative concerns
Failure to awaken Nonanaesthetic causes – seizures, cerebral edema, intracranial hematoma, pneumocephalus, vsl occlusion, metabolic/ electrolyte disturbance, herniation. Anaesthesia hangover – opioid, volatile anaesthetic, muscle relaxant.

41 Immediate postoperative concerns (cont….)
2. Post operative care a) Head end elevation (15-30⁰) b) Adequate ventilation & oxygenation c) Monitoring of neurological function d) Check for serum electrolytes and osmolarity (mannitol, frusemide to continue) e) Seizure prophylaxis (phenytoin / fosphenytoin) f) Seizure treatment (thiopentone mg, midazolam 2-4 mg , lorazepam 2 mg)

42 Immediate postoperative concerns (cont….)
g) SIADH Hyponatremia, S. hyposmolarity, high U. osmolarity T/T restrict free water intake h) DI After pituitary surgery Hyponatremia, S. hyposmolarity, low U. osmolarity T/T ↑ water intake, vasopressin , desmopressin i) Tension pneumocephalus Skull X ray / CT T/T opening the dura

43 Concerns for posterior fossa surgery
Presentation Cranial nerve palsies (IX, X) may impair gag reflex- aspiration Hydrocephalus Cerebellar dysfunction Edema in floor of fourth ventricle- damage to resp. centers 2. Cardiovascular instability Bradycardia and hypertension – due to V nerve stimulation (resolve with cessation of stimulus) Bradycardia, asystole/ hypotension- due to IX/X nerve stimulation

44 Concerns for posterior fossa surgery
3. Sitting position Advantages Better surgical exposure Improved venous/CSF drainage Low bleeding Improved access to airway, chest Disadvantages VAE CVS instability

45 Concerns for pituitary surgery
Trans-sphenoidal resection through nasal/ labial incision Endocrine manifestations- normo/hypo/ hyperpituitarism ICP is not a concern due to small size of tumor Uncontrolled bleeding is rare Throat pack to prevent blood from accumulating in stomach / aspiration Nasal breathing obscured by postoperative nasal packs.

46 References Miller’s anaesthesia.Ronald D Miller. 7th ed.
Stoelting's Anesthesia and Co-Existing Disease, 5th ed. Handbook of neuroanaesthesia. James E Cottrell. 4th ed. Clinical anaesthesia procedures of massachusettes general hospital. 7th ed. Morgan’s clinical anaesthesiology.4th ed.


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