Difference between revisions of "Craniotomy for tumor resection"

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{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = Large bore IV
Arterial line
± Central line
| monitors = Standard
5-lead ECG
Core temp
UOP
ABP
± CVP
± Neuromonitoring
| considerations_preoperative = Characterize neurologic deficits
Evaluate for ↑ ICP
| considerations_intraoperative = Manage ICP
| considerations_postoperative = PONV prophylaxis
}}


A '''craniotomy for tumor resection''' is a neurosurgical procedure to remove a brain tumor.
== Overview ==
=== Indications ===
=== Surgical procedure ===
== Preoperative management ==
=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> ===
{| class="wikitable"
|+
!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<!-- 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. --> ===
Type and screen
=== 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. --> ===
=== 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. --> ===
== 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. --> ===
* 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. Positioning depends on tumor location, but may include supine, prone, park bench, or beach chair.
{| class="wikitable"
|+
!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<!-- 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 ==
=== 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. --> ===
=== 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). --> ==
{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}
== References ==
[[Category:Surgical procedures]]
[[Category:Neurosurgery]]
[[Category:Intracranial neurosurgery]]

Latest revision as of 07:23, 24 May 2023

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

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

Type and screen

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.

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

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

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