Difference between revisions of "Craniotomy for tumor resection"
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| airway = ETT | | airway = ETT | ||
| lines_access = Large bore IV | | lines_access = Large bore IV | ||
Arterial line | |||
± Central line | |||
| monitors = Standard | | monitors = Standard | ||
5-lead ECG | 5-lead ECG | ||
Core temp | Core temp | ||
UOP | UOP | ||
ABP | ABP | ||
± CVP | |||
± Neuromonitoring | |||
| considerations_preoperative = Characterize neurologic deficits | | considerations_preoperative = Characterize neurologic deficits | ||
Evaluate for ↑ ICP | Evaluate for ↑ ICP | ||
| considerations_intraoperative = Manage ICP | | considerations_intraoperative = Manage ICP | ||
| Line 73: | Line 73: | ||
=== 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. --> === | === 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. --> === | === 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. --> === | === 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. --> === | === 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 85: | ||
=== 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. --> === | ||
* 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. --> === | === 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. --> === | ||
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 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. --> === | === 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 == | == Postoperative management == | ||
| Line 140: | Line 176: | ||
[[Category:Surgical procedures]] | [[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 | |
| 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
|
| Cardiovascular | Evaluate for ↑ ICP
|
| 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