Awake craniotomy

From WikiAnesthesia
Awake craniotomy
Anesthesia type
Airway
Lines and access
Monitors
Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative


Awake craniotomy is a surgical technique that is sometimes employed for patients undergoing tumor excision or clipping of arteriovenous malformation in regions of the brain that involve speech or motor function. Due to the "unconventional" nature of the surgery, his technique is generally reserved for patients who have undergone careful preoperative selection, with considerations for temperament, overall health status, and adequate education.

Preoperative management

Patient evaluation

System Considerations
Neurologic
  • As with all neurosurgical techniques, a careful preoperative neurological history and exam should be conducted and documented preoperatively to obtain a baseline assessment of function preoperatively. This exam should be particularly focused on eliciting deficits that may exist due to the nature of the lesion that is to be intervened on.
  • Patients may exhibit signs and symptoms of increased ICP, neurological deficits from impingement of motor areas, or intracranial bleeding.
Cardiovascular
  • Assessed for cardiovascular comorbidities prior to the day of surgery
  • Acute intraoperative stress response associated with the procedure (i.e. being under drapes, head clamped in Mayfield pins, listening to the sound of the surgeons working, etc.) may in some instances result in cardiovascular dysfunction.
  • The patient should have demonstrated no significant issues managing situations requiring exertion and psychological responses (e.g. panic episodes) that might result in tachyarrhythmias
Respiratory
  • Any significant respiratory comorbidity (e.g. advanced COPD requiring supplemental oxygen or history of exacerbation, asthma with history of exacerbations requiring rescue inhaler use, etc.) should elicit a preoperative assessment with an physician preoperatively prior to the day of surgery for determination of suitability for this procedure.
Gastrointestinal
  • History of nausea and/or vomiting, especially on the day of surgery, should result in a careful reassessment in terms of proceeding to surgery immediately.
  • History of significant uncontrolled gastrointestinal reflux (GERD), may be a contraindication for this procedure due to periods of the procedure that require extubation if general anesthesia for the beginning of the procedure is selected as anesthetic technique.
Hematologic
  • Any issues with normal coagulation should be assessed to determine if significant blood loss will result, and anesthetic technique including invasive monitoring, preoperative type and screen, and adequate IV access should be obtained prior to start of the procedure.
Renal
  • The patient should be informed that a Foley catheter will be placed at the beginning of the procedure under sedation, and that they will have the sensation of the catheter in their lower urinary tract when awakened during the procedure.
Endocrine
  • In patients with a history of hypoglycemia and hyperglycemia in particular, intraoperative glucose monitoring should be routinely conducted to prevent complications.
  • Patients with a history of other endocrine disorders should also be counseled on possible complications associated with the particular disease process as it relates to anesthesia.
Other

Labs and studies

Operating room setup

Patient preparation and premedication

Regional and neuraxial techniques

Intraoperative management

Monitoring and access

Induction and airway management

Positioning

Maintenance and surgical considerations

Emergence

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