Craniotomy for tumor resection
|Lines and access||
Large bore IV Arterial line ± Central line
Standard 5-lead ECG Core temp UOP ABP ± CVP ± Neuromonitoring
|Primary anesthetic considerations|
Characterize neurologic deficits Evaluate for ↑ ICP
A craniotomy for tumor resection is a neurosurgical procedure to remove a brain tumor.
|Neurologic||Focused neuro exam to identify deficits
Evaluate for ↑ ICP
|Cardiovascular||Evaluate for ↑ ICP
|Pulmonary||Evaluate for neurogenic pulmonary edema|
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
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
Mayfield pins are placed after intubation. Positioning depends on tumor location, but may include supine, prone, park bench, or beach chair.
|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.
Maintain normotensive and avoid bucking, all of which can lead to increased ICP
|Variant 1||Variant 2|