Anaesthetic considerations in posterior fossa surgery
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Anaesthetic considerations in posterior fossa surgery . Dr. S. Parthasarathy MD., DA., DNB, MD ( Acu ), Dip. Diab . DCA, Dip. Software statistics PhD ( physio ) Mahatma Gandhi medical college and research institute , puducherry – India . What is it ??. Boundaries :.

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Anaesthetic considerations in posterior fossa surgery

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Anaesthetic considerations in posterior fossa surgery

Anaesthetic considerations in posterior fossa surgery

Dr. S. Parthasarathy

MD., DA., DNB, MD (Acu),

Dip. Diab. DCA, Dip. Software statistics

PhD (physio)Mahatma Gandhi medical college and research institute , puducherry – India


Anaesthetic considerations in posterior fossa surgery

What is it ??


Boundaries

Boundaries :

  • Anteriorly : clivus, petrous part of temporal bone

  • Posteriorly: occipital bone

  • Laterally : squamous and mastoid part of the temporal bone

  • Superiorly : tentoriumcerebelli

  • Inferiorly : Foramen magnum


Why do we specially care about this

Why do we specially care about this ??

  • brainstem,

  • The cerebellum

  • fourth ventricle.

  • What is in brainstem??


Anaesthetic considerations in posterior fossa surgery

  • The Respiratory center;

  • The Cardiovascular center;

  • The Swallowing center;

  • The Center of vomiting, coughing,

  • and/or hiccups;

  • The Chewing center;

  • The Salivary centers.

  • The Brainstem Reticular Substance


The cerebellum

The cerebellum

  • coordination,

    controlling voluntary and involuntary

    motor activity like balance and locomotion

    alcoholic ??

    cranial nerve nuclei

    Flow of CSF


Tumours

Tumours

  • Young – primary tumours and aneurysms

  • Medulloblastomas, ependymomas, gliomaastrocytomasglomusjugulare tumors

  • ( Pneumonic - MEGA – GA )

  • Old age -- ?? Secondary lesions


Presentation

Presentation

  • ICH - herniation , ischemia

  • Movement disorders

  • Cerebellum

  • Autonomic disturbance

  • Cranial nerve disorders


Preanaesthetic concerns

Preanaesthetic concerns

  • Routine

  • + + + +

  • Cardiovascular status – is he/she fit for sitting position ??

  • Altered sensorium

  • Cranial nerve palsies, aspiration pulmonary infection

  • Debilitation and nutrition

  • Diuretics and electrolytes


Preanaesthetic concerns1

Preanaesthetic concerns

  • Discussion with surgeon for invasive monitors

  • Preoperative audiometry is useful in predicting hearing preservation after acoustic shwannoma surgery

  • Residual motor, sensory deficits, speech deficits recorded


Preop evaluation

Preop evaluation

  • Obtain the results of any recent intracranial or diagnostic procedure and consider possibility of residual pneumocephalus . prev. surgeries

  • Drug history

  • Steroid, mannitol, antihypertensive, tricyclic antidepressants ,L –dopa, benzodiazepines, phenothiazines ,


In short other than routine

In short – other than routine


Anaesthetic considerations

Anaesthetic considerations

  • Premed

  • Benzodiaepines

  • Antisialogogues

  • May avoid narcotics


Transfer

Transfer

  • Given the value of a head-up posture for controlling ICP, it is recommended that patients with mass lesions be transported with the head of the bed elevated 15–30°.


Goals in anaesthesia

Goals in anaesthesia

  • to facilitate surgical access,

  • minimize nervous tissue trauma and maintain respiratory and cardiovascular stability,(cranial nerves ) VAE prevention and identification

  • CPP , ICP, CMRo2 – comes next in posterior fossa surgery


Anaesthetic considerations in posterior fossa surgery

POSITIONS


Prone position

Prone position

nipple

genital

Minimal neck

flexion

anterior flexion, abducted and

externally rotated

No pressure in

axilla

Abdomen

free

Face in

soft headring

with

no

pressure

on eyes

and nose

Elbow

padded


Sitting

SITTING


Sitting1

Sitting

  • Not frequently used

  • Craniotomy

  • Good surgical access, CSF drainage, easy airway access

  • Venous return decrease and cardiac output decrease

  • HR no change

  • Venous air embolism


Contraindications for sitting position

Contraindications for sitting position

  • Intracardiac defects

  • Unstable hemodynamics

  • Cachexia

  • Severe hydrocephalus

  • extremes of age

  • Degenerative diseases of cervical spine

  • Significant CVD.


Lateral or park bench position

Lateral Or Park Bench Position

  • Can be used for access to the post parietal & occipital lobes & lat. post fossa, including tumors at the cerebellopntine angle & aneurysms of the vertebral & basilar arteries.


Monitoring

Monitoring

  • The goals of monitoring are to ensure adequate CNS perfusion maintain cardiovascular stability and detect and treat VAE ( venous air embolism )

  • Five lead ECG, Pulse oximetry, NIBP, IBP

  • EtCO2 monitoring

  • Temperature

  • Central venous catheter

  • Precordialdoppler probe FOR VAE

  • Esophageal stethoscope

  • TEE


What is special

What is special

  • diuresis, blood glucose, hematocrit.

  • Electromyography

  • ICP -- ???

  • SSEP,

  • MEP ( cranial nerves especially 7 )


Special

Special

  • Facial nerve - CP angle tumours – muscle relaxant use to be restricted

  • SSEP – integrity of neural tracts , tension pneumocephalus , spinal cord ischemia

  • Evoked potential – agents

  • BERA – less sensitive to agents – glomusjugulare


Anaesthetic technique

Anaesthetic technique

  • Induction of anesthesia is a critical time

  • Hypotension, hypertension bradycardia, cough

  • Templehoff's scale – choice of agent and technique


Templehoff s scale

Templehoff's scale

  • Easy use;

  • • Rapid induction and awakening;

  • • Maintenance of perfusion and self-regulation;

  • • Prevention of ICP rise

  • • Maintenance of vascular reactivity to CO2;

  • • Lack of systemic toxicity;

  • • Possibility of electrophysiological monitoring;

  • • Low cost.


Painful times

Painful times

  • Laryngoscopy, tracheal intubation;

  • • Fixing the head in the headrest;

  • • Skin, periosteum, and dura matter

  • incision

  • • Suture of dura matter and scalp.


Anaesthetic considerations in posterior fossa surgery

TIVA

  • Explanation

  • Fentanyl - 1 – 2 mic / Kg

  • Midazolam 1 mg IV

  • Propofol - 1.5 – 2 mg / kg ( 0.1 mg /kg/hour)

  • TCI of 3 – 4.4 mic gm / ml

  • With or without relaxants ,

  • Local infiltration

  • ANY WAY – INTUBATE


Pros and cons tiva

Pros and cons – TIVA

  • Monitoring !!

  • CBF reduced

  • Recovery

  • Awareness

  • Increased complications


Balanced ga technique

Balanced GA technique

1) Preoxygenation and self hyperventilation

2.) Thiopentone 3-4 mg/kg IV.

3.) Vecuronium 0.1 mg/kg IV and mask hyperventilation with oxygen and N2O (50:50) until neuromuscular blockade achieved. ISO CAN BE ADDED

4.) Lidocaine 1.5 mg/kg IV and additional thiopentone 2 mg/kg IV just before ET Intubation.


Others

Others

  • Rapid sequence is an alternative

  • Maintenance :

  • 1. Fentanyl 5 mic /kg with 0.5 % iso

  • 2.Fentanyl 1.5 mic /kg with 1.5 % iso

  • Isoflurane – mild cerebral vasodilation and less effect on autoregulation


Relaxants

RELAXANTS

  • Muscle relaxation is also important during neurosurgery relaxation prevent patient movement at inappropriate time

  • it may decrease ICP by relaxing the chest wall with decrease intra thoracic pressure and encourage venous drainage.

  • Vecuronium – no effect on brain – BUT phenytoin


Fluids

FLUIDS

Dry but stable patient is optimum for tumor surgery.

  • Preferably no dextrose

  • Tube fixation – extra care

  • Spontaneous breathing –respiratory structures


Emergence

Emergence

  • It should be smooth and gentle.

  • Lidocaine 1.5 mg/kg IV decrease cough and strain.

  • If surgery is superficial and performed without much traction on the brain stem,-- may extubate.

  • If lesion is deep seated with frequent traction on the brain stem there may be danger of apnea or decrease sensorium with diminish airway reflexes,- keep ventilating - awaken slowly


Points to ponder before extubation

Points to ponder before extubation

  • Level of consciousness

  • Airway and gag reflex

  • Face and tongue edema

  • Airway edema

  • Regular respiratory pattern

  • Stable vital parameters


Complications

COMPLICATIONS


Intraoperative

Intraoperative

  • Arrhythmias

  • Ventricular and supraventricular arrhythmias can occur from brain stem stimulation.


Cvs side effects

CVS side effects

  • Hypertension results from stimulation of V th CN, periventricular gray area, reticular formation, or nucleus of tractussolitarius.

  • Bradycardia and escape rhythms results from vagus N stimulation,

  • Hypotension can results from pontine or medullary compression.


Venous air embolism

Venous Air Embolism

  • 25 – 50 % in sitting position

  • That dose not mean it cant happen in other positions


Causes

Causes

open veins & non collapsible venous channels

gravitational effects of low CVP

neg. I.v. pressure relative to atm. Pressure

poor surgical technique


Treatment

Treatment

  • Notify the surgeon to flood the surgical site

  • Lower the operative site

  • Stop N2O administration

  • Give 100% O2

  • Perform aspiration through a central venous line

  • Consider compression of the jugular veins

  • Provide cardiopulmonary support (fluids, pressors, inotropes)


Pneumocephalus

Pneumocephalus


Pneumocephalus1

Pneumocephalus

  • Air into the epidural or dural space sufficient to exert a mass effect.

  • Incidence- 3%

  • Sometimes life threatening brain herniation.


Causes1

CAUSES:

  • Diminution of brain volume

    mannitol, hyperventilation, removal of SOL

  • contraction of intravascular blood vol. associated with acute hemorrhage

  • Gravitational effect of sitting position

  • Intraop drainage of CSF

  • “Inverted Pop Bottle Analogy” as CSF pours out, air bubbles to the top of the container(cranium)


Clinical features

Clinical features

  • Confusion

  • Headache

  • Convulsions

  • Neurological deficits

  • Failure to regain conciousness


Diagnosis and treatment

Diagnosis and treatment

CT scan confirms the diagnosis and localisation of intracranial air, if untreated Brain herniation and death.

Treatment

  • IMMEDIATE twist drill aspiration of air through burr holes on either side of the vertex.

  • Nitrous ??


Hydrocephalus

Hydrocephalus

  • Hydrocephalus – CSF obstruction at the level of fourth ventricle


Macroglossia

MACROGLOSSIA

  • Extreme flexion of head with chin resting on the chest

  • Prolong presence of an oral airway

    Obstruction of its venous and lymphatic drainage

    Airway obstruction

    postop hypoxemia, hypercapnia


Tube kinking

Tube kinking


Quadriplegia

Quadriplegia

  • Flexion of head on the neck causes streching of the spinal cord at C5 level, regional cord perfusion may be compromised if MAP is decreased.


Postop hypertension

Postop hypertension

  • Post operative hypertensive response following posterior fossa surgery need not be treated aggressively, as this response could be a reactionary response to brain edema


Summary

Summary

  • Anatomy

  • Tumors

  • Preop

  • Premed

  • Anesthesia – technique , positions, monitors

  • Complications


Thank you all

Thank you all


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