Posterior fossa tumour excision. Craniotomy : Colligative - Practical Wisdom in Anesthesia, Surgery, and Medicine.

Mar 16, 2012

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Description, Principles

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Goal of anesthesia is to produce a "slack" brain to allow adequate surgical exposure and minimise the need for retraction which can cause further injury refl.in/5b

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Sep 20, 2011

Indications, Relevant Conditions

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Complications, Contraindications

If the patient is in the sitting position, put tape over the table's controls to minimise the risk of the table moving whilst patient's head is independently clamped.

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Mar 16, 2012

Preoperative Optimisation

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Assessment, Workup

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Consent, Discussion

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Coordinating

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Medication management, Premed

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Equipment, Preparation

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Duration

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Anatomy

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IV access

If surgeon thinks patient at high risk of venous air embolism (VAE) consider CVC with tip positioned at junction of IVC & RA for attempted aspiration of air

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Sep 18, 2011

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Monitoring

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Intra-arterial blood pressure monitoring will be required. There is the potential for significant haemodynamic instability from blood loss and stimulation of the brainstem structures. Tight control of blood pressure will also be required to maintain adequate cerebral perfusion pressure in the context of raised intracranial pressure.

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Dec 08, 2011

If the patient is in the sitting position, ensure the arterial line transducer is positioned at the level of the head to reflect cerebral artery pressure

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Mar 16, 2012

Slowing down the end tidal CO2 waveform speed may increase the likelihood of picking up drop in cardiac output from VAE

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Sep 18, 2011

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Special drugs

Avoid N20 as it may exacerbate air embolism, exacerbate postop pneumocephalus, & increase cerebral metabolic rate, blood flow & ICP

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May 18, 2011

Consider avoiding tramadol as this may lower the seizure threshold and increase the risk of perioperative seizure #ref

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Sep 18, 2011

Do not administer dexamethasone (or other steroids) until the surgeon is sure it is not a lymphoma as it may precipitate tumour lysis.

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Dec 08, 2011

Ensure mannitol is available as it may be required to reduce brain volume and improve surgical access

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Dec 08, 2011

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Airway, Ventilation

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Reinforced oral endotracheal tube may help reduce the risk of tube kinking and obstructing.

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(1 comment)

Mar 16, 2012

Keep in mind that reinforced ETTs have no murphy's eye, and have been known to obstruct when lumen is abutting mucosa. In the event of difficult ventilation consider withdrawing the ETT a little to see if it helps.

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Maintain a pCO2 28-30mmHg until dura is reached, then maintain at 32mmHg for duration of case refl.in/5b

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Mar 16, 2012

Perform arterial blood gas at beginning of case to determine pCO2. This should be compared to measure ETCO2 and ventilation adjusted appropriatley to achieve desired pCO2.

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Sep 18, 2011

Positioning, Surgical access

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Positioning may be semi-lateral, prone, or sitting.

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Sep 18, 2011

Reduce venous pooling and drop in blood pressure with leg compression bandages and volume loading.

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May 18, 2011

Anesthesia, Analgesia, Antiemesis

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Procedure technique

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Neurosurgical pins will be used. Ensure analgesia is present at the time of their placement to prevent hypertensive sympathetic response.

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Dec 08, 2011

Cardiovascular, Renal, Fluids

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Aims at induction: Maintain cerebral perfusion pressure and minimise elevation in intracerebral pressure

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Nov 07, 2011

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Surgical stimulation of cardio respiratory centers may cause significant heart rate and blood pressure changes refl.in/ih

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Sep 18, 2011

At risk (especially sitting position) of venous air embolism. Signs include fall in BP, "millwheel" murmur, fall in cardiac output & ETCO2

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May 18, 2011