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ANESTHESIA FOR NEUROSURGERY Dr Sonam Norbu Dr Jyoti Pathania.

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Presentation on theme: "ANESTHESIA FOR NEUROSURGERY Dr Sonam Norbu Dr Jyoti Pathania."— Presentation transcript:

1 ANESTHESIA FOR NEUROSURGERY Dr Sonam Norbu Dr Jyoti Pathania

2 Goals of Neuroanesthesia Deep anesthetic level with adequate muscle relaxation and blunting response to intubation, pins and craniotomy No increase ICP, CBV, BP and No decrease in CPP, CBF, BP No hypoxia No coughing

3 The Adult Brain: Blood Flow CBF= ml/100gm/min 750 ml/min(20%co) CSF=150 ml, entire volume replaced 3-4 times/day

4 Intracranial components Brain tissue- 80% Blood- 12% CSF- 8%

5 INTRACRANIAL PRESSURE ICP is determined by the raltionship of the volume of intracranial contents(brain+blood+CSF= cm3) and the volume of the cranial vault (fixed by rigid dura and skull bone). ELASTANCE is the relationship of pressure and volume (dP/dV). In normal condition a small increase in intracranial volume will not result in ↑ ICP. COMPLIANCE is the relationship of volume and pressure (dV/dP) i.e. inverse of Elastance. Initially, as intracranial volume increases, no change in ICP occurs (point A, well compensated) until point B where any further increase will cause dramatic increase in ICP (point C).

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7 ASA TASK FORCE IN POSITIONING 2000 LIMIT ARM ABDUCTION TO 90 AND CAREFUL PADDING OF VULNERABLE PRESSURE POINTS CAREFFULL PAD AND ASSESS AREAS SENSITIVE TO PRESSURE NECROSIS e.g. EYES, EARS, NOSE, GENITALIA AND BREASTS. FEMALE BREASTS DISPLACED MEDIAL AND INFERIOR IN RELATION TO CHEST SUPPORTS PATIENTS WHO HAVE POSITION-DEPENDENT NEUROLOGIC SYMPTOMS OR EXTREMELY OBESE BENEFIT FROM AWAKE INTUBATION FOLLOWED BY AWAKE POSITIONING

8 PROBLEMS RELATED TO PRONE POSITION BRACHIAL PLEXUS INJURY AIR EMBOLI AND CV COLLAPSE BLINDNESS OBSTRUCTION OF FEMORAL VEINS AND IVC →↓ VR →↓ CVP AND ↓ COP ENGORGEMENT OF PERIVERTEBRAL VENOUS PLEXUSES → DIFFICULT SURGICAL EXPOSURE AND ↑ BLOOD LOSS ABDOMEN HANG FREE → NEGATIVE PRESSURE WITHIN IVC → PERIVERTEBRAL VENOUS PLEXUSES- → AIR EMBOLIZATION FROM SUPINE TO PRONE →↑ PVR AND ↑ SVR.

9 PROBLEMS RELATED TO PRONE POSITION ABDOMINAL PRESSURE → DISPLACE DIAPHRAGM → REDUCE LUNG COMPLIANCE → POSITIVE PRESSURE VENTILATION → BAROTRAUMA. POSITIVE INSPIRATORY EFFECT ON DIAPHRAGM- → INCREASE FRC AND DESRIABLE EFFECT ON GAS EXCHANGE VISUAL LOSS 1:100 SPINE SURGERIES DUE TO ISCHEMIC OPTIC NEUROPATHY ( ↑ BLOOD LOSS, ↑ IOP, ↓ PERFUSION PRESSURE) FACIAL EDEMA

10 INTRACRANIAL HYPERTENSION (1) ICP> 15mmHg ICP> 15mmHg ① expanding tissue or fluid mass ① expanding tissue or fluid mass ② depressed skull fracture ② depressed skull fracture ③ CSF absorption interference ③ CSF absorption interference ④ brain edema: systemic disturbance,inc CBF ④ brain edema: systemic disturbance,inc CBF Headache, nausea, vomiting, papilledema, focal neurological deficits,altered consciousness Headache, nausea, vomiting, papilledema, focal neurological deficits,altered consciousness Cushing response : periodic increases in arterial BP with reflex slowing of the HR, abrupt increases in ICP lasting 1~15min Cushing response : periodic increases in arterial BP with reflex slowing of the HR, abrupt increases in ICP lasting 1~15min

11 CEREBRAL EDEMA ↑Brain water content ↑Brain water content BBB:(vasogenic edema) m/c BBB:(vasogenic edema) m/c 1) Vasogenic edema : mechanical trauma, inflammatory lesion,brain tumors, hypertension, infarction 1) Vasogenic edema : mechanical trauma, inflammatory lesion,brain tumors, hypertension, infarction 2) cytotoxic edema : hypoxemia or ischemia 2) cytotoxic edema : hypoxemia or ischemia 3) interstitial cerebral edema :obstructive hydrocephalus, entry of CSF into brain interstitium 3) interstitial cerebral edema :obstructive hydrocephalus, entry of CSF into brain interstitium

12 INTRACRANIAL HYPERTENSION (2) TREATMENT TREATMENT - underlying cause - underlying cause - vasogenic edema : corticosteroids → BBB repair - vasogenic edema : corticosteroids → BBB repair - fluid restriction, osmotic agents, loop diuretics - fluid restriction, osmotic agents, loop diuretics - moderate hyperventilation(PaCO mmHg) :↓ CBF & ↔ ICP - moderate hyperventilation(PaCO mmHg) :↓ CBF & ↔ ICP 1)Mannitol 1)Mannitol - dose : g/kg - dose : g/kg - disadventage : transient increase intravascular volume - disadventage : transient increase intravascular volume ↔ pul. edema ↔ pul. edema : contra: intra cranium Aneurysms, AVM, intracranial Hemorrhage : contra: intra cranium Aneurysms, AVM, intracranial Hemorrhage 2)Loop diuretics(furosemide) 2)Loop diuretics(furosemide) - less effective requiring up to30 min, ↓CSF formation. - less effective requiring up to30 min, ↓CSF formation. - mannitol synergistic effect - mannitol synergistic effect but, serum potassium close monitoring. but, serum potassium close monitoring.

13 ANESTHESIA & CRANIOTOMY FOR PATIENTS WITH MASS LESIONS Intracranial mass : ① congenital ② neoplastic ③ infectious ④ vascular Intracranial mass : ① congenital ② neoplastic ③ infectious ④ vascular Common sx : headache, seizures, a general decline in cognitive or specific Common sx : headache, seizures, a general decline in cognitive or specific neurological function, focal neurological deficits neurological function, focal neurological deficits PREOPERATIVE MANAGEMENT preanesthetic evaluation : Intracranial HTN (CT,MRI) preanesthetic evaluation : Intracranial HTN (CT,MRI) Neurologic assessment : mental status, any existing sensory or motor deficits Neurologic assessment : mental status, any existing sensory or motor deficits Medication reviwed : corticosteroid, diuretic, anticonvulsant therapy Medication reviwed : corticosteroid, diuretic, anticonvulsant therapy laboratory evaluation : steroid-induced hyperglycemia laboratory evaluation : steroid-induced hyperglycemia electrolyte disturbance by diuretics or ADH electrolyte disturbance by diuretics or ADH anticonvulsant level should be measured. anticonvulsant level should be measured. Premedication Premedication normal ICP : benzodiazepine normal ICP : benzodiazepine intracranial hypertension : Avoid premedication intracranial hypertension : Avoid premedication ( ∵ respiratory depression : hypercapnia → ICP ↑ ) ( ∵ respiratory depression : hypercapnia → ICP ↑ ) Corticosteroid and anticonvulsant: cont until surgery. Corticosteroid and anticonvulsant: cont until surgery.

14 ANESTHESIA & CRANIOTOMY FOR PATIENTS WITH MASS LESIONS INTRAOPERATIVE MANAGEMENT Monitoring Monitoring 1) standard monitoring 1) standard monitoring 2) direct intraarterial pr. monitoring - arterial blood gas measure : PaCO2, ETCO2 2) direct intraarterial pr. monitoring - arterial blood gas measure : PaCO2, ETCO2 3) bladder catheterization ( ∵ diuretics ) 3) bladder catheterization ( ∵ diuretics ) 4) central venous access & pressure monitoring - vasoactive drug 4) central venous access & pressure monitoring - vasoactive drug 5) visual evoked potential - pituitary tumor resection →optic n. damage 5) visual evoked potential - pituitary tumor resection →optic n. damage Induction Induction anesthesia and tracheal intubation – SLOW without inc ICP and CBF. anesthesia and tracheal intubation – SLOW without inc ICP and CBF. m/c induction technique ① thiopental or propofol together with hyperventilation m/c induction technique ① thiopental or propofol together with hyperventilation ② NMBAs : facilitate ventilation and prevent straining or coughing →↑ICP ② NMBAs : facilitate ventilation and prevent straining or coughing →↑ICP ③ IV opioid : sympathetic response blunts ③ IV opioid : sympathetic response blunts ④ esmolol : preventing tachycardia. ④ esmolol : preventing tachycardia.

15 ANESTHESIA & CRANIOTOMY FOR PATIENTS WITH MASS LESIONS Positioning Positioning Frontal, temporal, parietooccipital craniotomies : supine position Frontal, temporal, parietooccipital craniotomies : supine position head elevation : ( ∵ venous drainage and CSF drainage ) head elevation : ( ∵ venous drainage and CSF drainage ) Positioning: Tube disconnection. Positioning: Tube disconnection. Maintenance of Anesthesia Maintenance of Anesthesia Nitrous oxide - opioid - NMBA technique Nitrous oxide - opioid - NMBA technique HTN : low- dose (1 ischemic brain damage, * hyperglycemia-> ischemic brain damage, Colloid solution : restore intravascular vol. deficits Colloid solution : restore intravascular vol. deficits Isotonic crystalloid solution : maintenance fluid requirements Isotonic crystalloid solution : maintenance fluid requirements Emergence Emergence like intubation, emergence SLOW and CONTROLLED like intubation, emergence SLOW and CONTROLLED IV lidocaine 1.5mg/kg or small dose propofol(20-30mg) or thiopental(25- 50mg) before suctioning. IV lidocaine 1.5mg/kg or small dose propofol(20-30mg) or thiopental(25- 50mg) before suctioning.

16 ANESTHESIA FOR SURGERY IN THE POSTERIOR FOSSA(1) Obstructive Hydrocephalus infratentorially located mass : obstruct flow of CSF & increase ICP infratentorially located mass : obstruct flow of CSF & increase ICP ∴ ↓ ICP prior to induction GA → ventriculostomy (↓LA) ∴ ↓ ICP prior to induction GA → ventriculostomy (↓LA) Brain Stem Injury posterior fossa operation : cranial nerve injury posterior fossa operation : cranial nerve injury circulatory and respiratory brain stem center circulatory and respiratory brain stem center Damage to respiratory center : circulatory change, Damage to respiratory center : circulatory change, abrupt change in BP, HR, cardiac rhythm abrupt change in BP, HR, cardiac rhythm abnormal respiratory pattern or inability to maintain a patent airway following extubation → brain stem injury abnormal respiratory pattern or inability to maintain a patent airway following extubation → brain stem injury Brain stem auditory evoked potentials – useful(8 th N). Brain stem auditory evoked potentials – useful(8 th N).Positioning Modified lateral, prone, sitting position (preferred) Modified lateral, prone, sitting position (preferred) Position head is always above heart. Position head is always above heart. Careful positioning – avoid injuries Careful positioning – avoid injuries

17 ANESTHESIA FOR SURGERY IN THE POSTERIOR FOSSA(2) Pneumocephalus Pneumocephalus sitting position - pneumocephalus ↑ sitting position - pneumocephalus ↑ CSF is lost → air enters subarachnoid space CSF is lost → air enters subarachnoid space Dural closeure →pneumocephalus → compress the brain Dural closeure →pneumocephalus → compress the brain Postoperative pneumocephalus : delayed awakening and impairment of neurological function Postoperative pneumocephalus : delayed awakening and impairment of neurological function Venous Air Embolism (1) Wound is above heart level Wound is above heart level sitting craniotomy (20-40%) sitting craniotomy (20-40%) Physiological consequences depend on Physiological consequences depend on – vol. and rate of air entry, patent foramen ovale ( paradoxical air embolism ) – vol. and rate of air entry, patent foramen ovale ( paradoxical air embolism ) Air bubble → venous sys. → pul. Circulation (diffuse into the alveoli ) Air bubble → venous sys. → pul. Circulation (diffuse into the alveoli ) Sign : ↓ ETCO2 and o2 saturation Sign : ↓ ETCO2 and o2 saturation sudden hypotension sudden hypotension rapid & large amounts of air – sudden circulatory arrest rapid & large amounts of air – sudden circulatory arrest

18 ANESTHESIA FOR SURGERY IN THE POSTERIOR FOSSA(3 ) Venous Air Embolism (2) Venous Air Embolism (2) A. Central Venous Catheterization : allow aspiration of entrained air : allow aspiration of entrained air catheter confirm : TEE or intravascular electrocardiography(biphasic P wave) catheter confirm : TEE or intravascular electrocardiography(biphasic P wave) B. Monitoring For Venous Air Embolism B. Monitoring For Venous Air Embolism most sensitive intraop. Monitor : TEE and precordial Doppler sonography most sensitive intraop. Monitor : TEE and precordial Doppler sonography changes ETCO2 and pul. a. pr. : less sensitive but can detect venous air embolism before clinical signs are present changes ETCO2 and pul. a. pr. : less sensitive but can detect venous air embolism before clinical signs are present sx. : sudden decrease in ETCO2 ( pul. Dead space ↑ ) sx. : sudden decrease in ETCO2 ( pul. Dead space ↑ ) mean pulmonary artery pressure ↑ mean pulmonary artery pressure ↑ change in BP, & Heart sound – late manifestation change in BP, & Heart sound – late manifestation

19 ANESTHESIA FOR SURGERY IN THE POSTERIOR FOSSA(4) Venous Air Embolism (3) C.Treatment Of Venous Air Embolism C.Treatment Of Venous Air Embolism 1. surgeon notify : surgical field can be flooded with saline or packed and bone wax( entery site identified) 1. surgeon notify : surgical field can be flooded with saline or packed and bone wax( entery site identified) 2. N2O stopped, 100%O2 2. N2O stopped, 100%O2 3. CVP Cath. aspirated 3. CVP Cath. aspirated 4. volume infusion -> CVP 4. volume infusion -> CVP 5.vasopressor:( to treat hypotension) 5.vasopressor:( to treat hypotension) 6. Bilateral jugular vein compression ( ↑cranial venous pr.) 6. Bilateral jugular vein compression ( ↑cranial venous pr.) 7. PEEP( ↑CVP) 7. PEEP( ↑CVP) 8. Head down position & wound closed quickly 8. Head down position & wound closed quickly

20 ANESTHESIA FOR STREOTACTIC SURGERY Indication : invountary movement disorders Indication : invountary movement disorders intractable pain intractable pain epilepsy epilepsy diagnosing and treating tumor- located deep within the brain diagnosing and treating tumor- located deep within the brain local anesthesia local anesthesia sedation and amnesia : propofol sedation and amnesia : propofol Stereotactic head frame : awake intubation with a fiberoptic bronchoscope! Stereotactic head frame : awake intubation with a fiberoptic bronchoscope!

21 ANESTHESIA FOR HEAD TRAUMA(1) Significance of a head injury Significance of a head injury 1) Irreversible neuronal damage 1) Irreversible neuronal damage 2) 2 insults 2) 2 insults (1) hypoxemia, hypercapnia or hypotension (1) hypoxemia, hypercapnia or hypotension (2) epidural,subdural,intracerebral hematoma (2) epidural,subdural,intracerebral hematoma (3) intracranial HTN (3) intracranial HTN --> surgical & anesthetic management directed at preventing these 2 insults. --> surgical & anesthetic management directed at preventing these 2 insults. Glasgow Coma Scale (GCS) score Glasgow Coma Scale (GCS) score : severity of injury and outcome : severity of injury and outcome ( ex. GCS score < 8 → 35 % mortality ) ( ex. GCS score < 8 → 35 % mortality )

22 ANESTHESIA FOR HEAD TRAUMA(2) PREOPERATIVE MANAGEMENT(1) Patency of the airway, adequacy of ventilation & oxygenation, correction of systemic hypotension Patency of the airway, adequacy of ventilation & oxygenation, correction of systemic hypotension Airway Obx and hypoventilation are common. Airway Obx and hypoventilation are common. Pul. contusion, fat emboli, or neurogenic pul.edema : complication Pul. contusion, fat emboli, or neurogenic pul.edema : complication 70% hypoxemia 70% hypoxemia Pt with hypoventilation, absent gag reflex, or GCS< 8 Pt with hypoventilation, absent gag reflex, or GCS< 8 -> Tracheal intubation and hyperventilation -> Tracheal intubation and hyperventilation Intubation Intubation full stomach, in-line axial stabilization. full stomach, in-line axial stabilization. Following preoxygenation and hyperventilation Following preoxygenation and hyperventilation thiopental or propofol and rapid-onset NMBA: biunt intubation response. thiopental or propofol and rapid-onset NMBA: biunt intubation response. Hypotensive(sys <100mmHg) Hypotensive(sys <100mmHg) : small dose thiopental or propofol, or etomidate : small dose thiopental or propofol, or etomidate Succinylcholine in closed head injury – controversial ( ICP ↑, hyperkalemia) Succinylcholine in closed head injury – controversial ( ICP ↑, hyperkalemia) If difficult intubation : awake intubation, fiberoptic techniques, or tracheostomy If difficult intubation : awake intubation, fiberoptic techniques, or tracheostomy

23 ANESTHESIA FOR HEAD TRAUMA(3) Hypotension Hypotension Head trauma: hypotension : related to other associated injury (intra- abdominal) Head trauma: hypotension : related to other associated injury (intra- abdominal) spinal cord injury ; sympathectomy associated with spinal shock spinal cord injury ; sympathectomy associated with spinal shock Hypotension : Hypotension : - by colloid solution and blood (preventing brain edema) - by colloid solution and blood (preventing brain edema) - severe hypotension: vasopressor - severe hypotension: vasopressor glucose-containing or hypotonic solution should not be used glucose-containing or hypotonic solution should not be used Hct >30% Hct >30% invasive monitoring – intraarterial pr., central venous or pul. a. pr, ICP... invasive monitoring – intraarterial pr., central venous or pul. a. pr, ICP...

24 ANESTHESIA FOR HEAD TRAUMA(4) INTRAOPERATIVE MANAGEMENT INTRAOPERATIVE MANAGEMENT Similar to other mass lesion asso with intracranial HTN Similar to other mass lesion asso with intracranial HTN barbiturate-opioid-nitrous oxide-NMBA technique. barbiturate-opioid-nitrous oxide-NMBA technique. PaCO2 <30 avoided as hyperventilation (↓CBF) PaCO2 <30 avoided as hyperventilation (↓CBF) HTN with tachycardia : b- blocker HTN with tachycardia : b- blocker Excessive vagal tone – treated atropine or glyco. Excessive vagal tone – treated atropine or glyco. DIC,ARDS, pulmonary aspiration, neurogenic pul. edema, G-I hemorrhage, Diabetic Insipidus DIC,ARDS, pulmonary aspiration, neurogenic pul. edema, G-I hemorrhage, Diabetic Insipidus

25 ANESTHESIA & CRANIOTOMY FOR INTRACRANIAL ANEURYSMS & ARTERIOVENOUS MALFORMATION(1) CEREBRAL ANEURYSMS(1) Preoperative Consideration rupture of a saccular aneurysms: m/c cause of subarachnoid hemorrhage rupture of a saccular aneurysms: m/c cause of subarachnoid hemorrhage acute mortality following rupture : 10% acute mortality following rupture : 10% survivors – 25% subsequently die within 3 months from delayed cx. survivors – 25% subsequently die within 3 months from delayed cx. 50% survivors : left with significant neurological deficits 50% survivors : left with significant neurological deficits “ prevention of rupture ” “ prevention of rupture ” > 7mm :surgical Ix > 7mm :surgical Ix Unruptured Aneurysms m/c sx : Headache m/c sx : Headache m/c sign : 3rd nerve palsy m/c sign : 3rd nerve palsy Others : brain stem dysfunction, visual field defects, trigeminal neuralgia, Others : brain stem dysfunction, visual field defects, trigeminal neuralgia, cavernous sinus syndrome, seizure, hypothalamic-pituitary dysfunction cavernous sinus syndrome, seizure, hypothalamic-pituitary dysfunction Dx : angiography, MRI angiography, helical CT angiography Dx : angiography, MRI angiography, helical CT angiography

26 ANESTHESIA & CRANIOTOMY FOR INTRACRANIAL ANEURYSMS & ARTERIOVENOUS MALFORMATION(2) Ruptured Aneurysms Ruptured Aneurysms Usually present: acute subarachnoid hemorrhage Usually present: acute subarachnoid hemorrhage less commonly epidural space or brain hemorrhage less commonly epidural space or brain hemorrhage Sx. : sudden severe headache often associated with nausea, vomiting, transient loss of consciousness ( ∵ ↑ ICP and ↓ CPP) Sx. : sudden severe headache often associated with nausea, vomiting, transient loss of consciousness ( ∵ ↑ ICP and ↓ CPP) Delayed Cx : cerebral vasospasm (30%), rerupture, hydrocephalus Delayed Cx : cerebral vasospasm (30%), rerupture, hydrocephalus symptomatic vasospasm Tx : triple H therapy – hypervolemia, hemodilution, HTN symptomatic vasospasm Tx : triple H therapy – hypervolemia, hemodilution, HTN neurosurgical management : complicated by risk of rebleeding, vasospasm. neurosurgical management : complicated by risk of rebleeding, vasospasm. rerupture : 10~30% rerupture : 10~30% early surgical obliteration of the aneurysm : recommended for stable patient early surgical obliteration of the aneurysm : recommended for stable patient

27 ANESTHESIA & CRANIOTOMY FOR INTRACRANIAL ANEURYSMS & ARTERIOVENOUS MALFORMATION(3) PREOPERATIVE MANAGEMENT Preanesthetic evaluation : determine whether rupture has occurred Preanesthetic evaluation : determine whether rupture has occurred Neurological findings, coexisting disease. Neurological findings, coexisting disease. controlled hypotension :relative contraindication to controlled hypotension :relative contraindication to : preexisting HTN and renal, cardiac or ischemic cerebrovascular disease : preexisting HTN and renal, cardiac or ischemic cerebrovascular disease ECG Abn. - commonly seen in subarachnoid hemorrhage (not heart dis.) ECG Abn. - commonly seen in subarachnoid hemorrhage (not heart dis.) Pt with Persistent elevation in ICP : little or no premedication to avoid hypercapnia Pt with Persistent elevation in ICP : little or no premedication to avoid hypercapnia INTRAOPERATIVE MANAGEMENT(1) Surgery can result in rupture or rebleeding :blood should be available Surgery can result in rupture or rebleeding :blood should be available anesthetic Mx focus : preventing rupture or rebleeding anesthetic Mx focus : preventing rupture or rebleeding intraarterial and central venous(or pulmonary artery) pressure monitoring intraarterial and central venous(or pulmonary artery) pressure monitoring mannitol : dura is opened ( to facilitate surgical exposure & reduce tissue trauma) mannitol : dura is opened ( to facilitate surgical exposure & reduce tissue trauma)

28 ANESTHESIA & CRANIOTOMY FOR INTRACRANIAL ANEURYSMS & ARTERIOVENOUS MALFORMATION(5) INTRAOPERATIVE MANAGEMENT(2) controlled hypotension is useful controlled hypotension is useful (1) decrease transmural tension across the aneurysm (1) decrease transmural tension across the aneurysm (2) rupture less likely and facilitates surgical clipping (2) rupture less likely and facilitates surgical clipping (3) ↓blood loss (3) ↓blood loss head-up position with volatile anesthesia(Iso.) enhance the effect of hypotensive agent. head-up position with volatile anesthesia(Iso.) enhance the effect of hypotensive agent. Thiopental and mild hypothermia : protect Brain during prolonged or excessive hypotension. Thiopental and mild hypothermia : protect Brain during prolonged or excessive hypotension. Depending upon neurological condition:most pt extubated at the end of surgery Depending upon neurological condition:most pt extubated at the end of surgery Rapid awakening : allow neurological evaluation before transfer to ICU. Rapid awakening : allow neurological evaluation before transfer to ICU.

29 ANESTHESIA FOR SURGERY ON THE SPINE(1) PREOPERATIVE MANAGEMENT Any existing ventilatory impairment and airway Any existing ventilatory impairment and airway anatomic abn. and limited neck movement complicate airway management. anatomic abn. and limited neck movement complicate airway management. neurological deficits (DOCUMENTED) neurological deficits (DOCUMENTED) Patients with Degenerative dis. : pain ← opioid with premedication Patients with Degenerative dis. : pain ← opioid with premedication INTRAOPERATIVE MANAGEMENT(1) Positioning Positioning prone position prone position : corneal abrasion or retinal ischemia, pressure necrosis of : corneal abrasion or retinal ischemia, pressure necrosis of nose, ear, forehead, chin, breast(female) or genitalia(male) nose, ear, forehead, chin, breast(female) or genitalia(male) arm - comfortable position or extended with elbow flexed arm - comfortable position or extended with elbow flexed supine position : ant. approach to cervical spine supine position : ant. approach to cervical spine : ass. with injuries to the trachea, esophagus, recurrent laryngeal n., sympathetic chain, carotid a. or jugular vein : ass. with injuries to the trachea, esophagus, recurrent laryngeal n., sympathetic chain, carotid a. or jugular vein sitting and lateral decubitus position may used occasionally. sitting and lateral decubitus position may used occasionally.

30 ANESTHESIA FOR SURGERY ON THE SPINE(1) INTRAOPERATIVE MANAGEMENT(2) Monitoring Monitoring Intraarterial & possibly central venous pr. Monitoring – before positioning or turning (when significant blood loss is anticipated and pt preexisting cardiac dis. ) Intraarterial & possibly central venous pr. Monitoring – before positioning or turning (when significant blood loss is anticipated and pt preexisting cardiac dis. ) Elective hypotension or weak epinephrine infiltration of the wound - intraoperative blood loss ↓ Elective hypotension or weak epinephrine infiltration of the wound - intraoperative blood loss ↓ Monitoring somatosensory evoked potentials and motor evoked potentials - detect intraoperatively spinal cord injury from excessive distraction Monitoring somatosensory evoked potentials and motor evoked potentials - detect intraoperatively spinal cord injury from excessive distraction

31 THANK YOU…….


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