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Anesthesia for prolonged surgery aiming to minimise the risk of aneurism rupture through tight hemodynamic control through the several episodes of surgical stimulation, adequate preparation to manage aneurism rupture, and rapid emergence to assess postoperative neurological function.

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Ensure no distractions at the time the surgeon is at the aneurism to minimise inadvertant instrumental rupture. Change over infusions likely to alarm.

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In the event of aneurism rupture the surgeon may place a temporary clip over the parent vessel. Maintain an adequate blood pressure to encourage collateral flow to downstream brain tissue. #ref

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Mar 26, 2012
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Assess and document preexisting neurological deficit to allow for comparison at extubation.

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Ask the surgeon if they will be administering postoperative nifedipine to reduce the risk of cerebral vasospasm. If so, consider inserting a central line (some surgeons may be concerned about encroachment on surgical area or obstruction of cerebral venous outflow and ask you to avoid internal jugular).

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Arterial line preinduction to monitor for hemodynamic changes associated with induction, laryngoscopy, placement of cranial fixation pins, craniotomy, dural opening and closing, and extubation.

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Consider placing BIS/ENTROPY monitoring, if surgical field is amenable, to facilitate pharmacological burst suppression in the event of temporary clipping of the parent artery #ref

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Sep 15, 2011
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Ensure patient is adequately muscle relaxed at the time the aneurism is exposed to avoid coughing and aneurism rupture which is associated with significant morbidity/mortality.

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Muscle relaxant infusion may provide more
reliable relaxation than intermittent dosing which requires additional vigilance

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Perform arterial blood gas early in the case to compare the ETCO2 with pCO2. Adjust ventilation accordingly to desired arterial pCO2. #improve

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Sep 29, 2012
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Position will generally be supine

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Surgeons may request a head up position to improve cerebral venous drainage, minimise cerebral volume, and improve surgical exposure. This, however, increases the risk of venous air embolism. Ensure the arterial line transducer is relevelled after repositioning. #safety

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Jan 09, 2012
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Head pins will likely be used. Ensure adequate analgesia on board to minimise hypertensive response and minimse risk of aneurism rupture.

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0.5-1mcg/kg Remifentanil 30 seconds before pins
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Switching from propofol infusion to Desflurane 1hr before the end of the case will assist in achieving rapid emergence.

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Ensure blood is cross-matched and available in the event of aneurism rupture

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