Craniotomy
Clinical Procedure
 
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Aim for anesthesia is to avoid secondary brain injury. This is achieved by maintaining oxygen delivery vs demand in the brain tissue, and avoiding inadvertant intracerebral hemorrhage.
Oxygen delivery is maintained by ensuring adequate saturated hemoglobin (avoid hypoxia or significant anemia) and adequate cerebral perfusion (avoid hypotension, hypercarbia, acidosis, and cerebral venous outflow obstruction).
Oxygen demand is minimised by avoiding hyperthermia, seizures, and hyperglycemia.
Risk of intracerebral hemorrhage is minimised by avoiding sudden rises in transmural pressure (maintain stable MAP by minimising pain or coughing).

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Keep the patient anesthetised until their head has been removed from the pins to avoid injury related to coughing or moving. #safety

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Jan 05, 2012
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Infiltration of local anesthetic with adrenaline may result
in hypotension. This may be partially explained by an unmasking of peripheral beta 2 agonist activity of adrenaline by remifentanil. refl.in/lw

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Nov 16, 2011
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If surgeon considers this patient at high risk of venous air embolism, consider insertion of central venous line with tip positioned at junction of IVC and RA for attempted aspiration of air. #ref

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Jun 12, 2011
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Place intra-arterial blood pressure line transducer at the height of the head so that it better reflects cerebral artery pressure.

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Sep 07, 2011
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Consider a CVC in patients at risk of significant blood loss to monitor central venous pressures. (discuss with surgeon, eg tumours near large veins) or those patients at high risk for venous air embolism (eg sitting position)

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Feb 06, 2012
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Avoid nitrous oxide N20 as it may exacerbate air embolism and any postoperative pneumocephalus

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Jun 25, 2011
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Consider avoiding tramadol as this may lower the seizure threshold and increase the risk of seizure #ref

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Sep 07, 2011
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If hypertensive, consider managing with non-cerebrovasodilating agents. These include analgesics, alpha-2-agonists ( clonidine/ dexmedtomidine), propofol.

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Dec 19, 2012
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If surgeon requests, commence phenytoin loading to reduce risk of seizures and secondary brain injury.

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Dec 19, 2012
15mg/kg. Max rate 50mg/min if young, 20mg/min if old. #ref Some surgeons only ask for phenytoin load if parenchymal trauma (eg contusions) CX MMC
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If urgent medical reduction in ICP is required, mannitol 0.25-0.5mg/kg over 15-30 min. Onset of action 30min refl.in/mannitol Duration of action 2-3hrs (Shubert, Clinical Neuroanaesthesia 1997)

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Dec 28, 2013
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Patients that smoke may start coughing on the endotracheal tube when muscle relaxant wears off. Consider using a muscle relaxant infusion rather than intermittent boluses. #safety #smoker

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Feb 25, 2012
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Surgeon may ask for Dexamethasone to reduce cerebral oedema. Monitor blood glucose carefully in the perioperative period to avoid hyperglycemia

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Dec 28, 2013
Dose to reduce brain swelling will be 8-16mg in adults as per surgeon.
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Avoid hypercapnia. This will result in cerebral vasodilation, raised intracranial pressure, and possibly, secondary brain damage.

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Aug 19, 2011
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Avoid hypoxemia as this may result in both cerebral ischemia and raised ICP from the resultant cerebral vasodilation.

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Aug 19, 2011
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Local anesthetic spray to trachea/cords at intubation may help reduce coughing on the tube when muscle relaxant wears off.

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Aug 19, 2011
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Tape the ETT rather than use a tie. This prevents inadvertant obstruction of neck veins and elevation of the patient's ICP. #safety

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Feb 25, 2012
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In the even of "tight" brain, consider hyperventilating to pCO2 of 25mmHg as a temporary measure until others are implemented.

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Sep 17, 2011
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In the event of a "tight" brain, reduce PEEP to improve cerebral venous return.

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Sep 17, 2011
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If tight pCO2 control is important, perform an arterial blood gas early in the case to compare pCO2 with ETCO2 and modify ventilation parameters accordingly.

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Sep 07, 2011
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Patient will need to be awake after extubation for neurological assessment. Avoid agents that will sedate patient on emergence.

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Sep 09, 2011
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Propofol TIVA/TCI plus Remifentanil infusion for patients will aid rapid wakening for those patients that will be be neurologically assessed at end of case.

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Aug 19, 2011
4-6mcg/ml propofol effect site target and 3ng/ml remifentanil effect site target. Remifentanil without TCI is 0.1-0.2mcg/kg/min #ref
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Closing will be more stimulating as dura & muscle involved. If not relaxed, increase analgesia/anaesthesia at end of case to prevent coughing

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Jun 12, 2011
Eg increase by 20%
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Ensure adequate anesthesia to avoid elevated cerebral metabolic rate, blood flow, brain volume, and hence, intracerebral pressure.

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Feb 06, 2012
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At risk of venous air embolism. Signs include fall in end tidal CO2, hypotension, tachycardia, "millwheel" murmur, and hypoxia.

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Sep 06, 2011
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Avoid hypotension where possible. Primary neurologic injury is exacerbated by even mild systemic hypotension. Chestnut et al 1993. refl.in/al

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Jul 26, 2011
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Pediatric age specific CPP thresholds

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Sep 13, 2019
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Avoid hyperglycemia as it has been associated with poorer long term outcomes in patients undergoing cerebral aneurism surgery. refl.in/am

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Adult. Midazolam 1.5mg (unless elderly). Propofol infusion ~8mg/kg/hr and remifentanil 0.15-0.3mcg/kg/min running at induction (0.5mcg/kg/hr too frequently results in hypotension).
Induction with small topup bolus of propofol and muscle relaxant. Local anesthetic to cords. 3 sprays above, 3 below cords.
Bolus remifentanil 1mcg/kg 30secs before pins. Atracurium infusion 0.25mg/kg/hr. 0.05mg/kg morphine 30mins before end, or 0.25-0.5mcg/kg fentanil 10-15min before end.
Gross neurological assessment before extubating.

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Dec 28, 2013
CM #MMC
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To blunt the hypertensive response to placement of neurosurgical pins, use 0.5-1mcg/kg bolus of remifentanil plus propofol boluses titrated to effect whilst watching the heart rate.

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Nov 15, 2011
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