Difference between revisions of "Craniotomy for tumor resection"

Craniotomy for tumor resection
Anesthesia type	General
Airway	ETT
Lines and access	Large bore IV Arterial line ± Central line
Monitors	Standard 5-lead ECG Core temp UOP ABP ± CVP ± Neuromonitoring
	Primary anesthetic considerations
Preoperative	Characterize neurologic deficits Evaluate for ↑ ICP
Intraoperative	Manage ICP
Postoperative	PONV prophylaxis
	Article quality
Editor rating	In development
User likes	0

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Revision as of 05:58, 24 May 2023

A craniotomy for tumor resection is a neurosurgical procedure to remove a brain tumor.

Overview

Indications

Surgical procedure

Preoperative management

Patient evaluation


System	Considerations
Airway
Neurologic	Focused neuro exam to identify deficits Evaluate for ↑ ICP Headache Nausea/vomiting Visual changes Seizures
Cardiovascular	Evaluate for ↑ ICP HTN Bradycardia Respiratory irregularity
Pulmonary	Evaluate for neurogenic pulmonary edema
Gastrointestinal
Hematologic
Renal
Endocrine
Other

Labs and studies

Operating room setup

Patient preparation and premedication

Generally avoid sedating premedication that may affect neuro exam after extubation

Regional and neuraxial techniques

Intraoperative management

Monitoring and access

At least 2 large bore peripheral IVs
Arterial Line needed if history of patient indicates need for closer hemodynamic monitoring or if there is concern for venous air embolism if surgical site is near the sinus and the position of the head is above the level of heart.

Induction and airway management

Positioning

Mayfield pins are placed after intubation. Positioning depends on tumor location, but may include supine, prone, park bench, or beach chair.

Supine

Generally the easiest to position.

Maintenance and surgical considerations

Maintenance should ensure that the patient does not move once in Mayfield pins and patient will be able to participate in a basic neurological exam upon emergence.

Inhaled anesthetics should be avoided due to dampening of neuromonitoring signals. Reasonable considerations would be TIVA (propofol/remifentanil) or a combination of propofol/sevoflurane.

If MEP, EMG, or BAERs are needed, then patient cannot be fully paralyzed. Generally must maintain 2+ twitches on TOF monitoring. Vecuronium infusions should be considered for smoother signaling monitoring. If SSEPs or EEG, then patient can be fully paralyzed.

As these are painful procedures, consider titrating fentanyl up to 5 mcg/kg.

Emergence

Maintain normotensive and avoid bucking, all of which can lead to increased ICP

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

Top contributors: Chris Rishel, Tony Wang and J T

@@ Line 77: / Line 77: @@
 === Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
+Generally avoid sedating premedication that may affect neuro exam after extubation
 === 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. --> ===
@@ Line 83: / Line 84: @@
 === Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
-At least 2 peripheral IVs.
-Arterial Line needed if history of patient indicates need for closer hemodynamic monitoring or if there is concern for venous air embolism if surgical site is near the sinus and the position of the head is above the level of heart.
+* At least 2 large bore peripheral IVs
+* Arterial Line needed if history of patient indicates need for closer hemodynamic monitoring or if there is concern for venous air embolism if surgical site is near the sinus and the position of the head is above the level of heart.
 === 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. --> ===
-Mayfield pins are placed after intubation.
+Mayfield pins are placed after intubation. Positioning depends on tumor location, but may include supine, prone, park bench, or beach chair.
+==== Supine ====
+Generally the easiest to position.
 === 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 should ensure that the patient does not move once in Mayfield pins and patient will be able to participate in a basic neurological exam upon emergence.
+Inhaled anesthetics should be avoided due to dampening of neuromonitoring signals. Reasonable considerations would be TIVA (propofol/remifentanil) or a combination of propofol/sevoflurane.
+If MEP, EMG, or BAERs are needed, then patient cannot be fully paralyzed. Generally must maintain 2+ twitches on TOF monitoring. Vecuronium infusions should be considered for smoother signaling monitoring. If SSEPs or EEG, then patient can be fully paralyzed.
+As these are painful procedures, consider titrating fentanyl up to 5 mcg/kg.
 === Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
+Maintain normotensive and avoid bucking, all of which can lead to increased ICP
 == Postoperative management ==