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

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

Type and screen

Patient preparation and premedication

Generally avoid sedating premedication that may affect neuro exam after extubation

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.

Positioning

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

Position	Considerations
Supine	Easiest to position
Prone	Ensure extra tape around ETT as cleaning solution can quickly damage tape integrity leading to ETT falling out while prone.
Park bench	Down arm must have good IV to avoid infiltration (decreased drainage leading to worse complications if infiltration occurs). Consider pulse ox on down arm to monitor for ischemia to arm from compression. NIBP should be on up arm to prevent falsely elevated readings

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

Procedure variants

	Variant 1	Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications