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Anesthesia for Intracranial Aneurysm Surgery

Anesthesia for Intracranial Aneurysm Surgery. Pekka O. Talke, MD. Aneurysms. 2-5 % population 30K SAH/yr 2/3 get to hospital 1/3 in hospital severely disabled or dead Unruptured:1-2%/yr rupture Ruptured: 50% rerupture within 6 mo Urgent, not emergent cases. Surgeons. Lawton.

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Anesthesia for Intracranial Aneurysm Surgery

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  1. Anesthesia for Intracranial Aneurysm Surgery • Pekka O. Talke, MD

  2. Aneurysms • 2-5 % population • 30K SAH/yr • 2/3 get to hospital • 1/3 in hospital severely disabled or dead • Unruptured:1-2%/yr rupture • Ruptured: 50% rerupture within 6 mo • Urgent, not emergent cases

  3. Surgeons • Lawton

  4. Anesthetic Goals • Prevent aneurysm rupture (avoid hypertension) • Decrease ICP (surgical exposure, retraction) • Maintain CPP (>70 mmHg) • Prevent cerebral ischemia from retraction • Good operating conditions (NO movement, brain relaxation for exposure)

  5. Patients, preop • Symptomatic/asymptomatic • Ruptured (SAH grade, myocardial effects), unruptured • Possibly intubated • Location and size of aneurysm • Intracranial mass effect from SAH (increased ICP) • Neurologic deficits and symptoms • Timing, vasospasm

  6. Preop • One IV • Premedicate with up to 2 mg of midazolam if normal mental status. • Remind of potential post op intubation • Adequate fluid loading (5 to 7 ml/kg of LR, angio)

  7. Induction • Routine monitors • Propofol or thiopental • Fentanyl 5 ug/kg in divided doses prior to intubation • Muscle relaxant (roc). • Arterial cannula before intubation • Avoid hypertension (propofol) and hypotension (CPP, vasospasm)

  8. Induction cont. • Ceftriaxone 1 gm, 4-10 mg decadron, 1 gm/kg mannitol. • Tape eyes with tagaderms (prep solution) • Temp probe, foley • Additional IV (limited access, 300 cc to liters of blood loss) • Compression stockings

  9. Positioning • Supine, bump • Long cases, lots of padding (pink and blue foam) • Table turned typically 90 degrees • Head down?, aeroplaning • After draping minimal/no access to face (secure ET well)

  10. Maintenance • Oxygen • Propofol infusion (50-200 ug/kg/min) (SSEPs, EEG) • Inhalation agent (<0.25 MAC Isoflurane). Muscle relaxation (vec, panc) • Moderate hyperventilation (ET CO2 30 mmHg) • Euvolemia to 500 cc more (LR) • Moderate hypothermia (34 oC)

  11. Burst supression • When requested by surgeon • Thiopental 125 mg (5 cc) doses • Till 70-80% EEG burst supression • Redose as needed • Turn fentanyl infusion off • Reduce propofol infusion rate • Support CPP with phenylephrine infusion

  12. Clipping • Temporary clips (golden) • Permanent clips (silver) • Aneurysm manipulation before clipping (bleed) • Record clip on/off times • Maintain CPP during temporary clipping • Start closing, warming and more fluid loading after clipping

  13. Toward the end • First indication of end of surgery when clip aneurysm (60 min) • Normalize CO2 once dura closed or earlier if lots of intracranial space • Reduce propofol if possible, and titrate in labetalol

  14. Toward the end cont. • Turn propofol infusion off about 10 min before wakeup • Reverse relaxation once Mayfied pins have been removed • Attempt to wakeup patient. Unlikely if more than 1 gm of thiopental given.

  15. Recovery • Wake patient up as soon as possible • Extubate if possible • Prevent post op hypertension (bleed). Labetalol • Transport to ICU with monitor and oxygen • Head up position

  16. Potential Complications • Delayed awakening from anesthesia • Cerebral ischemia (retraction, temporary clips, vasospasm) • Brain swelling • Intraoperative hemorrhage

  17. Aneurysm rupture • Reasonably common • Intubation, pinning, skin insicion, surgical manipulation • Maintain intravascular volume (blood in the room, get help) • Maintain CPP • Adequate anesthesia • Thiopental before temporary clipping

  18. Vasospasm • Only if SAH • 5-14 days after SAH • Leading cause of SAH morbidity (infarct) • Maintain CPP at all times (neo infusion, volume) • HHH therapy • Consider CVP measurement

  19. What’s new? • Retractor pressure • Temp control • Normotension

  20. Surgical Steps • Mayfield pins (stimulation), head positioning • Shaving/prepping/local anesthesia • Skin incision (stimulation, blood loss) • Scalp off the bone (most stimulation) • Burr holes, sawing • Removing bone • Open dura • Surgical approach to aneurysm (microscope, minimal stimulation, retraction)

  21. Surgical Steps cont. • Burst supression • Temporary clips, permanent clip(s) • Close (60 min) • Dura (water tight) • Bone flap • Scalp and skin • Dressing, remove pins

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