Difference between revisions of "Awake craniotomy"
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}} | }}An '''awake craniotomy''' is a surgical procedure that is sometimes employed for patients undergoing tumor excision or clipping of arteriovenous malformation in regions of the brain that involve speech or motor function. Due to the unconventional nature of the surgery, this technique is generally reserved for patients who have undergone careful preoperative selection, with considerations for temperament, overall health status, and adequate education. | ||
==Preoperative management== | |||
===Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. -->=== | |||
=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> === | |||
{| class="wikitable" | {| class="wikitable" | ||
|+ | |+ | ||
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|Neurologic | |Neurologic | ||
| | | | ||
Neuro exam to establish baseline function and deficits. Consider signs and symptoms of:<ref>{{Cite journal|last=Buckner|first=JC|date=2007|title=Central nervous system tumors|url=|journal=Mayo Clin Proc|volume=82(10)|pages=1271-86|via=}}</ref> | |||
*Increased ICP | |||
*Impingement of motor areas | |||
*Intracranial bleeding. | |||
|- | |- | ||
|Cardiovascular | |Cardiovascular | ||
| | | | ||
Evaluate for comorbidities which may be exacerbated by intraoperative stress during the procedure (i.e. being under drapes, head clamped in Mayfield pins, surgical sounds, etc.) | |||
Increased ICP may result in [[Cushing's triad]] of HTN, bradycardia, and irregular respiratory pattern.<ref name=":0">{{Cite book|last=Jaffe|first=Richard A.|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Wolters Kluwer|year=2014|isbn=978-1-4511-7660-5|location=New York|pages=31-36}}</ref> | |||
|- | |- | ||
|Respiratory | |Respiratory | ||
| | | | ||
Significant comorbidities (e.g. advanced COPD requiring supplemental oxygen or history of exacerbation, asthma with history of exacerbations requiring rescue inhaler use, etc.) should be assessed in advance to determine suitability for this procedure. | |||
|- | |- | ||
|Gastrointestinal | |Gastrointestinal | ||
| | | | ||
* History of nausea | Due to the lack of a protected airway and risk of aspiration, relative contraindications to this procedure include | ||
* History of | *History of nausea or vomiting (especially if present on the day of surgery) | ||
*History of uncontrolled [[GERD]] | |||
**If in Mayfield pins, active GERD may trigger coughing, resulting in potential for injury to head and neck | |||
|- | |- | ||
|Hematologic | |Hematologic | ||
| | | | ||
Coagulation panel | |||
|- | |- | ||
|Renal | |Renal | ||
| | | | ||
Inform patient that a Foley catheter will be inserted under sedation and that when awakened, they will have the sensation of the catheter in their lower urinary tract and may feel as if their bladder is full | |||
|- | |- | ||
|Endocrine | |Endocrine | ||
| | | | ||
In patients with a history of diabetes, intraoperative glucose should be closely monitored. | |||
*Hypoglycemia and extreme hyperglycemia may result in altered mental status that could interfere with neurological monitoring, disinhibition, and airway compromise. | |||
|} | |} | ||
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | ===Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. -->=== | ||
* Verify normal coagulation studies | *Verify normal coagulation studies | ||
* Obtain CBC, and electrolyte panel prior to surgery | *Obtain CBC, and electrolyte panel prior to surgery | ||
=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | ===Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. -->=== | ||
* Be aware of type of table and head support to be employed to adjust anesthesia technique accordingly. | *Be aware of type of table and head support to be employed to adjust anesthesia technique accordingly. | ||
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | ===Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. -->=== | ||
* The patient should counseled extensively on the process of awake craniotomy in great detail to avoid surprises that may result in untoward anxiety intraoperatively. | * The patient should counseled extensively on the process of awake craniotomy in great detail to avoid surprises that may result in untoward anxiety intraoperatively. | ||
* premedication with a short-acting benzodiazepines such as midazolam (in an incremental titrated dose administration to 1-10 mg IV)<ref name=":0" /> | *premedication with a short-acting benzodiazepines such as midazolam (in an incremental titrated dose administration to 1-10 mg IV)<ref name=":0" /> | ||
* dexmedetomidine (0.2-0.7 mcg/kg/hr) may be helpful for preoperative line placement<ref name=":0" /> | *dexmedetomidine (0.2-0.7 mcg/kg/hr) may be helpful for preoperative line placement<ref name=":0" /> | ||
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | ===Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. -->=== | ||
* scalp blocks are placed using 0.5% bupivacaine with epinephrine: [https://www.youtube.com/watch?v=5mTEa7ZdM_g Scalp blocks (by user: Regional Anesthesiology and Pain Medicine @youtube.com)]<ref>{{Citation|title=Scalp Blocks|url=https://www.youtube.com/watch?v=5mTEa7ZdM_g|language=en|access-date=2021-05-10}}</ref> | *scalp blocks are placed using 0.5% bupivacaine with epinephrine: [https://www.youtube.com/watch?v=5mTEa7ZdM_g Scalp blocks (by user: Regional Anesthesiology and Pain Medicine @youtube.com)]<ref>{{Citation|title=Scalp Blocks|url=https://www.youtube.com/watch?v=5mTEa7ZdM_g|language=en|access-date=2021-05-10}}</ref> | ||
== Intraoperative management == | ==Intraoperative management== | ||
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> === | ===Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. -->=== | ||
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | ===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->=== | ||
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | ===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->=== | ||
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | ===Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->=== | ||
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | ===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->=== | ||
== Postoperative management == | ==Postoperative management== | ||
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | ===Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. -->=== | ||
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | ===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->=== | ||
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | ===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->=== | ||
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> == | ==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->== | ||
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|Pain management | | Pain management | ||
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== References == | ==References== | ||
<references /> | <references /> | ||
[[Category:Surgical procedures]] | [[Category:Surgical procedures]] | ||
Revision as of 02:14, 9 July 2021
Awake craniotomy
| Anesthesia type | |
|---|---|
| Airway | |
| Lines and access | |
| Monitors | |
| Primary anesthetic considerations | |
| Preoperative | |
| Intraoperative | |
| Postoperative | |
| Article quality | |
| Editor rating | |
| User likes | 0 |
An awake craniotomy is a surgical procedure that is sometimes employed for patients undergoing tumor excision or clipping of arteriovenous malformation in regions of the brain that involve speech or motor function. Due to the unconventional nature of the surgery, this technique is generally reserved for patients who have undergone careful preoperative selection, with considerations for temperament, overall health status, and adequate education.
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Neurologic |
Neuro exam to establish baseline function and deficits. Consider signs and symptoms of:[1]
|
| Cardiovascular |
Evaluate for comorbidities which may be exacerbated by intraoperative stress during the procedure (i.e. being under drapes, head clamped in Mayfield pins, surgical sounds, etc.) Increased ICP may result in Cushing's triad of HTN, bradycardia, and irregular respiratory pattern.[2] |
| Respiratory |
Significant comorbidities (e.g. advanced COPD requiring supplemental oxygen or history of exacerbation, asthma with history of exacerbations requiring rescue inhaler use, etc.) should be assessed in advance to determine suitability for this procedure. |
| Gastrointestinal |
Due to the lack of a protected airway and risk of aspiration, relative contraindications to this procedure include
|
| Hematologic |
Coagulation panel |
| Renal |
Inform patient that a Foley catheter will be inserted under sedation and that when awakened, they will have the sensation of the catheter in their lower urinary tract and may feel as if their bladder is full |
| Endocrine |
In patients with a history of diabetes, intraoperative glucose should be closely monitored.
|
Labs and studies
- Verify normal coagulation studies
- Obtain CBC, and electrolyte panel prior to surgery
Operating room setup
- Be aware of type of table and head support to be employed to adjust anesthesia technique accordingly.
Patient preparation and premedication
- The patient should counseled extensively on the process of awake craniotomy in great detail to avoid surprises that may result in untoward anxiety intraoperatively.
- premedication with a short-acting benzodiazepines such as midazolam (in an incremental titrated dose administration to 1-10 mg IV)[2]
- dexmedetomidine (0.2-0.7 mcg/kg/hr) may be helpful for preoperative line placement[2]
Regional and neuraxial techniques
- scalp blocks are placed using 0.5% bupivacaine with epinephrine: Scalp blocks (by user: Regional Anesthesiology and Pain Medicine @youtube.com)[3]
Intraoperative management
Monitoring and access
Induction and airway management
Positioning
Maintenance and surgical considerations
Emergence
Postoperative management
Disposition
Pain management
Potential complications
Procedure variants
| Variant 1 | Variant 2 | |
|---|---|---|
| Unique considerations | ||
| Position | ||
| Surgical time | ||
| EBL | ||
| Postoperative disposition | ||
| Pain management | ||
| Potential complications |
References
- ↑ Buckner, JC (2007). "Central nervous system tumors". Mayo Clin Proc. 82(10): 1271–86.
- ↑ 2.0 2.1 2.2 Jaffe, Richard A. (2014). Anesthesiologist's Manual of Surgical Procedures. New York: Wolters Kluwer. pp. 31–36. ISBN 978-1-4511-7660-5.
- ↑ Scalp Blocks, retrieved 2021-05-10