Difference between revisions of "Awake craniotomy"
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===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. -->=== | |||
*For patients who are used to a morning cup of coffee, consider caffeine 200 mg PO before surgery to reduce the risk of withdrawal headache<ref>{{Cite journal|last=Potters|first=Jan-Willem|last2=Klimek|first2=Markus|date=2015|title=Awake craniotomy: improving the patient's experience|url=https://pubmed.ncbi.nlm.nih.gov/26263121/|journal=Current Opinion in Anaesthesiology|volume=28|issue=5|pages=511–516|doi=10.1097/ACO.0000000000000231|issn=1473-6500|pmid=26263121|via=}}</ref> | |||
===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. -->=== | ||
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===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. -->=== | ||
* Provide sedation and anxiolysis during line placement<ref name=":0" /> | *Provide sedation and anxiolysis during line placement<ref name=":0" /> | ||
** Midazolam 1-10 mg IV (titrated incremental doses) | **Midazolam 1-10 mg IV (titrated incremental doses) | ||
** Dexmedetomidine 0.2-0.7 mcg/kg/hr | ** Dexmedetomidine 0.2-0.7 mcg/kg/hr | ||
* Place lines with field blocks using buffered lidocaine for patient comfort | *Place lines with field blocks using buffered lidocaine for patient comfort | ||
** Arterial line | **Arterial line | ||
** CVC vs PICC | ** CVC vs PICC | ||
* Large bore IV(s) | *Large bore IV(s) | ||
* Microphone for patient to communicate | *Microphone for patient to communicate | ||
* ± Precordial doppler | *± Precordial doppler | ||
===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. -->=== | ||
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===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. -->=== | ||
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Revision as of 17:48, 11 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. Patients are sedated during line placement and cranial opening, and then awakened once the dura is opened. 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
Counsel patient in great detail about the process of an awake craniotomy to set expectations and minimize anxiety intraoperatively
- Lines and foley catheter will be placed under sedation
- May awaken with a feeling of a full bladder
- Head will be unable to move, patient may feel pressure but should not feel pain
- Patient will be asked to perform tasks and/or answer questions during procedure
| 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:
|
| Endocrine |
In patients with a history of diabetes, intraoperative glucose should be closely monitored.
|
Labs and studies
- Complete blood count
- Metabolic panel
- Coagulation panel
- Type and screen
Operating room setup
- Be aware of type of table and head support to be employed to adjust anesthesia technique accordingly
Patient preparation and premedication
- For patients who are used to a morning cup of coffee, consider caffeine 200 mg PO before surgery to reduce the risk of withdrawal headache[3]
Regional and neuraxial techniques
- Scalp blocks are placed using 0.5% bupivacaine with epinephrine
Intraoperative management
Monitoring and access
- Provide sedation and anxiolysis during line placement[2]
- Midazolam 1-10 mg IV (titrated incremental doses)
- Dexmedetomidine 0.2-0.7 mcg/kg/hr
- Place lines with field blocks using buffered lidocaine for patient comfort
- Arterial line
- CVC vs PICC
- Large bore IV(s)
- Microphone for patient to communicate
- ± Precordial doppler
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 Jaffe, Richard A. (2014). Anesthesiologist's Manual of Surgical Procedures. New York: Wolters Kluwer. pp. 31–36. ISBN 978-1-4511-7660-5.
- ↑ Potters, Jan-Willem; Klimek, Markus (2015). "Awake craniotomy: improving the patient's experience". Current Opinion in Anaesthesiology. 28 (5): 511–516. doi:10.1097/ACO.0000000000000231. ISSN 1473-6500. PMID 26263121.