Difference between revisions of "Craniotomy for extracranial-intracranial revascularization"
Chris Rishel (talk | contribs) m Tag: 2017 source edit |
|||
(10 intermediate revisions by 2 users not shown) | |||
Line 10: | Line 10: | ||
CVP <br/> | CVP <br/> | ||
EEG | EEG | ||
| considerations_preoperative = Smooth induction <br/> | | considerations_preoperative = Characterize neurologic deficits <br/> | ||
Consider anxiolytic <br/> | |||
| considerations_intraoperative = Smooth induction <br/> | |||
Maintain CPP <br/> | Maintain CPP <br/> | ||
Maximize flow to ischemic areas <br/> | |||
| considerations_postoperative = | Decrease CMRO2 <br/> | ||
Decrease intracranial volume <br/> | |||
}} | Smooth extubation | ||
| considerations_postoperative = Careful control of BP <br/> | |||
PONV prophylaxis | |||
}}'''Craniotomy for extracranial-intracranial revascularization''' (also referred to as '''EC-IC bypass''') is a surgical procedure to increase cerebral blood flow. The procedure involves connecting a branch of the external carotid artery (typically the superficial temporal artery) to a branch of the internal carotid artery (typically the middle cerebral artery). The anastomosis can be achieved via a vein graft or a direct connection. | |||
EC-IC bypass is generally indicated for severe stenosis or occlusion of intracranial arteries that is resulting in focal neurological symptoms. In children, this procedure is used to treat Moya-moya disease. | EC-IC bypass is generally indicated for severe stenosis or occlusion of intracranial arteries that is resulting in focal neurological symptoms. In children, this procedure is used to treat Moya-moya disease. | ||
Line 38: | Line 43: | ||
* Patients often on aspirin through day of surgery | * Patients often on aspirin through day of surgery | ||
* Anticoagulants impacting PT/PTT typically discontinued 1 week prior to surgery | * Anticoagulants impacting PT/PTT typically discontinued 1 week prior to surgery | ||
|} | |} | ||
=== Labs and studies === | === Labs and studies === | ||
Line 59: | Line 55: | ||
=== Operating room setup === | === Operating room setup === | ||
* Infusion pumps | |||
* Surface cooling device (i.e. cold-water circulating blanket) | |||
* Warming device | |||
** Patient will need aggressive rewarming post-anastomosis | |||
** Consider bladder irrigation, warm-water circulating blanket, forced warm air blanket | |||
* Consider central heat exchanger, especially if patient has high surface-to-volume ratio | |||
=== Patient preparation and premedication === | === Patient preparation and premedication === | ||
* Consider pre-op acetaminophen 1000mg PO | |||
* Consider pre-op aprepitant if patient has history of severe PONV | |||
* Consider small dose of anxiolytic | |||
* Detailed discussion with patient regarding anesthetic plan | |||
=== 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. --> === | ||
* Avoid scalp blocks, as they may interfere with donor vessel blood flow | |||
== 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. --> === | ||
* Standard ASA monitors | |||
* 5-Lead EKG | |||
* Core temperature | |||
* Urine output | |||
* Arterial blood pressure | |||
* Central venous pressure | |||
* EEG | |||
=== 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. --> === | ||
* Smooth induction is essential | |||
* Goal is to maintain CPP | |||
* Have vasopressors ready to maintain CPP during induction | |||
* Use narcotic to blunt response to laryngoscopy | |||
* Muscle relaxant used to facilitate tracheal intubation | |||
=== 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. --> === | ||
* Supine | |||
* Table typicaly turned 180 | |||
* Mayfield skull fixation | |||
* Shoulder roll | |||
* Have all lines directed towards patient's feet, where anesthesiologist typically positioned | |||
=== 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. --> === | ||
* Remifentanil (2-4mcg/kg) to minimize BP elevations during pinning | |||
* Maintenance of anesthesia can be achieved with combination of remifentanil, propofol, and/or volatile agent | |||
* Keep PaCO2 around 40 mmHg | |||
** Hypocarbia may cause unwanted cerebral vasoconstriction in these patients | |||
* Goal net zero fluid balance / Maintain normovolemia | |||
* Dexamethasone may be used to decrease PONV | |||
** Avoid scopolamine for PONV, as it may confound post-op neurologic exams | |||
* Mild hypothermia (33-34°C) can be used to decrease CMRO2 and increase the brain's tolerance to ischemia | |||
* Confirm pre-incision antibiotics | |||
* Avoid long-acting opioids | |||
* Phenylephrine infusion typically used to maintain CPP during procedure | |||
** Phenylephrine typically preferred because it is not arrhythmogenic | |||
* Continuous neuromuscular blockade typically not needed | |||
* Establish burst suppression (i.e. propofol 1mg/kg) immediately prior to cross clamping of cerebral artery for anastomosis | |||
** A bolus dose of phenylephrine and/or ephedrine typically needed to counterbalance hypotensive effect of propofol. | |||
* Aggressive rewarming should start as soon as revascularization is complete | |||
=== 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. --> === | ||
* As anesthetic is titrated down, patient's BP will generally increase | |||
* Beta-blockers (esmolol, labetalol) and vasodilators (clevideipine, SNP) may be needed to maintain tight BP control during emergence | |||
* Close regulation of blood pressure is essential | |||
* Reverse any residual neuromuscular blockade | |||
* Prophylactic antiemetics should be given before extubation | |||
* Consider IV acetaminophen | |||
* If patient begins to buck or cough on ETT, extubate or suppress cough reflex (IV lidocaine) | |||
* Achieve appropriate core body temperature prior to extubation | |||
== 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. --> === | ||
* ICU (typically monitored overnight in ICU) | |||
* Supplemental O2 | |||
* Head of bed at 20-30° | |||
* Tight BP monitoring and management post-op (typically maintain at baseline levels) | |||
* Regular neuro checks post-op | |||
=== 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. --> === | ||
* Multimodal pain management | |||
* Consider post-op acetaminophen | |||
* Avoid scalp blocks, as they can interfere with donor vessel blood flow | |||
=== 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. --> === | ||
* Seizures | |||
* Stroke | |||
* Hemorrhage at anastomosis | |||
* Brain swelling can be caused by hyperemia in revascularized areas | |||
== References == | == References == | ||
<references /> | <references /> | ||
[[Category:Surgical | [[Category:Surgical procedures]] | ||
[[Category:Neurosurgery]] | |||
[[Category:Intracranial neurosurgery]] |
Revision as of 17:02, 19 July 2021
Anesthesia type |
General |
---|---|
Airway |
ETT |
Lines and access |
PIV x 2 |
Monitors |
Standard ASA |
Primary anesthetic considerations | |
Preoperative |
Characterize neurologic deficits |
Intraoperative |
Smooth induction |
Postoperative |
Careful control of BP |
Article quality | |
Editor rating | |
User likes | 1 |
Craniotomy for extracranial-intracranial revascularization (also referred to as EC-IC bypass) is a surgical procedure to increase cerebral blood flow. The procedure involves connecting a branch of the external carotid artery (typically the superficial temporal artery) to a branch of the internal carotid artery (typically the middle cerebral artery). The anastomosis can be achieved via a vein graft or a direct connection.
EC-IC bypass is generally indicated for severe stenosis or occlusion of intracranial arteries that is resulting in focal neurological symptoms. In children, this procedure is used to treat Moya-moya disease.
Preoperative management
Patient evaluation
System | Considerations |
---|---|
Neurologic |
|
Cardiovascular |
|
Hematologic |
|
Labs and studies
- EKG
- Echo (if concern for cardiovascular disease)
- Coronary angiography (depending on cardiac risk factors)
- Complete blood count
- Chemistry panel
- Coagulation panel
- Cerebral angiography performed to identify cause of neurologic symptoms
Operating room setup
- Infusion pumps
- Surface cooling device (i.e. cold-water circulating blanket)
- Warming device
- Patient will need aggressive rewarming post-anastomosis
- Consider bladder irrigation, warm-water circulating blanket, forced warm air blanket
- Consider central heat exchanger, especially if patient has high surface-to-volume ratio
Patient preparation and premedication
- Consider pre-op acetaminophen 1000mg PO
- Consider pre-op aprepitant if patient has history of severe PONV
- Consider small dose of anxiolytic
- Detailed discussion with patient regarding anesthetic plan
Regional and neuraxial techniques
- Avoid scalp blocks, as they may interfere with donor vessel blood flow
Intraoperative management
Monitoring and access
- Standard ASA monitors
- 5-Lead EKG
- Core temperature
- Urine output
- Arterial blood pressure
- Central venous pressure
- EEG
Induction and airway management
- Smooth induction is essential
- Goal is to maintain CPP
- Have vasopressors ready to maintain CPP during induction
- Use narcotic to blunt response to laryngoscopy
- Muscle relaxant used to facilitate tracheal intubation
Positioning
- Supine
- Table typicaly turned 180
- Mayfield skull fixation
- Shoulder roll
- Have all lines directed towards patient's feet, where anesthesiologist typically positioned
Maintenance and surgical considerations
- Remifentanil (2-4mcg/kg) to minimize BP elevations during pinning
- Maintenance of anesthesia can be achieved with combination of remifentanil, propofol, and/or volatile agent
- Keep PaCO2 around 40 mmHg
- Hypocarbia may cause unwanted cerebral vasoconstriction in these patients
- Goal net zero fluid balance / Maintain normovolemia
- Dexamethasone may be used to decrease PONV
- Avoid scopolamine for PONV, as it may confound post-op neurologic exams
- Mild hypothermia (33-34°C) can be used to decrease CMRO2 and increase the brain's tolerance to ischemia
- Confirm pre-incision antibiotics
- Avoid long-acting opioids
- Phenylephrine infusion typically used to maintain CPP during procedure
- Phenylephrine typically preferred because it is not arrhythmogenic
- Continuous neuromuscular blockade typically not needed
- Establish burst suppression (i.e. propofol 1mg/kg) immediately prior to cross clamping of cerebral artery for anastomosis
- A bolus dose of phenylephrine and/or ephedrine typically needed to counterbalance hypotensive effect of propofol.
- Aggressive rewarming should start as soon as revascularization is complete
Emergence
- As anesthetic is titrated down, patient's BP will generally increase
- Beta-blockers (esmolol, labetalol) and vasodilators (clevideipine, SNP) may be needed to maintain tight BP control during emergence
- Close regulation of blood pressure is essential
- Reverse any residual neuromuscular blockade
- Prophylactic antiemetics should be given before extubation
- Consider IV acetaminophen
- If patient begins to buck or cough on ETT, extubate or suppress cough reflex (IV lidocaine)
- Achieve appropriate core body temperature prior to extubation
Postoperative management
Disposition
- ICU (typically monitored overnight in ICU)
- Supplemental O2
- Head of bed at 20-30°
- Tight BP monitoring and management post-op (typically maintain at baseline levels)
- Regular neuro checks post-op
Pain management
- Multimodal pain management
- Consider post-op acetaminophen
- Avoid scalp blocks, as they can interfere with donor vessel blood flow
Potential complications
- Seizures
- Stroke
- Hemorrhage at anastomosis
- Brain swelling can be caused by hyperemia in revascularized areas
References
Top contributors: Chris Rishel and Barrett Larson