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Book reading. 報告日期 : 2012-02-23 指導醫師 : 藺瑞安 醫師 指導老師 : 戴溫然 老師 報告者 : 黃淑宜、李如萍. Chapter 30 CENTRAL NERVOUS SYSTEM DISEASE. Neuroanatomy Neurophysiology Intracranial pressure Intracranial pressure-volume relationship Cerebral protection Preoperative assessment Anesthesia for neurosurgery

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book reading

Book reading

報告日期:2012-02-23

指導醫師: 藺瑞安 醫師

指導老師:戴溫然 老師

報告者: 黃淑宜、李如萍

Chapter 30 CENTRAL NERVOUS SYSTEM DISEASE

table of contents
Neuroanatomy

Neurophysiology

Intracranial pressure

Intracranial pressure-volume relationship

Cerebral protection

Preoperative assessment

Anesthesia for neurosurgery

Clinical cases

Table of contents
neuroanatomy1
Neuroanatomy
  • Blood brain barrier disruption
  • Hypertension
  • Trauma
  • Infection
  • Hypoxemia
  • Sever hypercapnia
  • Tumors
  • Seizure
neurophysiology
Neurophysiology
  • Cerebral Blood Flow
  • Effects of CBF
  • Cerebral Metabolic Rate
  • Cerebral Perfusion Pressure

and Autoregulation.

  • Effects of PaCO2 and PaO2 on CBF
  • Effects of anesthetics
cerebral blood flow
Cerebral Blood Flow
  • Cerebral Blood Flow= 15% Cardiac output
  • CBF: 50 ml/100g/min
  • CPP =MAP-ICP (or CVP)
cerebral metabolic rate
Cerebral Metabolic Rate

Body Temperature 37℃

↓ 1℃→ CMRO2↓7 %

cerebral perfusion and autoregulation
Cerebral perfusion and Autoregulation

Autoregulation OK  CPP: 50~150mmHg

Autoregulation(-) Trauma;neurosurgery

Hypertension shifts the auto regulatory curve

 Right

effects of paco 2 and pao 2 on cbf
Effects of PaCO2 and PaO2 on CBF

PaO2

PaCO2

CPP

ICP

Autoregulation

50-150mmHg

effects of cbf
Effects of CBF

CMRO2

CPP=MAP-ICP (or CVP)

PaCO2: 於 PaCO2 :20~80mmHg 範圍內,

↑1mmHg, CBF ↑ 1-2 ml/100g/min

PaO2

effects of anesthetics
Effects of anesthetics

Thiopental & Propofol : CBF ↓ CMRO2 ↓

Ketamine:CMRO2 ↑; CBF & ICP ↑

N2O:CBF ↑ may be CMRO2 ↑

Opioids : CBF ↓ CMRO2 ↓

slide14
IICP

ICP=5-15mmHg

IICP

  • Positionalheadache
  • Nausea +Vomiting
  • Hypertension + Bradycardia
  • Conscious change
  • Altered patterns of breathing
  • Papilledema
methods to decrease icp
1.Cerebrospinal fluid ↓

Ventricular drainage

Lumbar drainage

Lasix

2.Cerebral blood volume↓

IV anesthetic

HyperventilationPaCO2

<30mmHg

Avoid hypotension&

hypertension

3.Increase venous outflow

Elevate head

Avoid constriction at the neck.

Avoid PEEP

Avoid airway pressure↑

4.Cerebral edema ↓

Mannitol ;Craniectomy

Resection space

Occupying lesions

Prevent ischemia

Methods to decrease ICP
effect of anesthetic on icp
Effect of anesthetic on ICP

Intravenous anesthetic: CMRO2↓CBF ↓ICP ↓

Avoid Etomidate (epilepsy history)

Opioids: PaCO2↑

Neuromuscular blocking drugs(-)

Volatile anesthetic :CBF ↑ CBV ↑ ICP↑

Dose-dependent increase

cerebral protection
Cerebral protection

Cerebral protection

  • Barbiturates
  • Hypothermia
intracranial aneurysms
Pre-op

Neurologic evaluation

IICP?

Vasospasm?

EKG

HHH therapy if vasospasm

Calcium channel blockers.

Induction

Avoid ↑SBP.

Maintain CPP

Avoid ischemia

Intracranial Aneurysms

HHH: Hypertension, Hypervolemia, Hemodilution

intracranial aneurysms1
Maintenance

Opioid plus propofol or volatile anesthetic

Mannitol (0.25-1 g/kg IV)

Normal or ↑systemic blood pressure

Postoperative

Normal to ↑ systemic blood pressure.

Early awakening Neurologic assessment

HHH therapy

Intracranial Aneurysms

HHH: Hypertension ,Hypervolemia Hemodilution

slide20

Preoperative Assessment

  • Altered level of consciousness
  • Headaches
  • Motor or sensory deficits
  • IICP?
  • Cranial nerve abnormalities
  • Compression of the optic chiasm focal deficits or

visual impairment

  • Seizures
  • Steroid/Diuretic/Anti-convulsion drug…etc.
  • CT/MRI for mass lesion. Mid-line shift?
slide21

Monitoring

  • Standard monitors,ex:EKG,NIBP,SpO2
  • A-Line, CVP(not routinely used)
  • Capnography, GAS
  • NMT (peripheral nerve stimulator)
  • Foley catheter
  • ICP or EVD monitor
slide22

Positioning-

Supratentorial tumorsIntracranial vascular lesions

→Supine

slide23

Positioning-Sitting (I)Posterior fossa or Infratentorial tumors

  • Posterior cervical spine and the posterior fossa operation.
  • Decreased blood in the operative field.
  • Provider have a superior accesses to the airway and improved ventilation.
slide24

Venous Air Embolism (I)

  • Increased risk for venous air embolism
  • Significant elevation of the head
  • The operative site above the level of the heart
  • The venous sinuses in the cut edge of bone
  • or dura may not collapse when transected.
slide25

Venous Air Embolism (II)

  • ETCO2↓、SpO2↓、PaCO2↑
  • Arterial hypoxemia、Cardiovascular collapse
  • Transesophageal echocardiography
  • Central venous catheter
slide26

Induction of Anesthesia

  • The Goal of induction
  • Avoid Hyper/Hypotension
  • As close as possible to and certainly within
  • 10% of average awake values
  • Avoid Cough
  • Avoid ICP↑or MAP↓→CBF↓
  • Avoid use of PEEP
  • PaCO2:Keep 30 and 35 mmHg
slide27

Common clinical cases

  • Intracranial Aneurysms
  • Intracranial Masses
  • Arteriorvenous Malformation (AVM)
  • Carotid Stenosis
slide28

Intracranial Masses

  • Pre-op
  • IICP? Avoid sedatives and opioids
  • CT/MRI
  • Anxiolytics
  • Monitors
  • Supratentorial masses
  • Standard ASA monitors, A-line, Foley catheter
  • Infratentorial masses
  • depend on positioning
  • Induction+Maintenance
  • Avoid increasing ICP
  • Deep anesthesia
  • Skeletal muscle paralysis
  • Nitrous oxide (X)
  • Mannitol (0.25-1g/kg IV)
slide29

Arteriorvenous Malformation (AVM)

  • Pre-op
  • Is similar to that for aneurysms.
  • Intra-op
  • ↓Blood loss
  • A-line, IV
  • Hyperventilation
  • Mannitol
  • Resection
  • Embolization
  • Stereotactic Radiosurgery
  • (gamma knife).
slide30

Carotid Stenosis-Carotid Endarterectomy (CEA)

  • Pre-op
  • Neurologic examination is indicated to look for preoperative deficits.
  • Screen for associated CAD.
  • Anxiolytics may be useful.
  • Induction+ Maintenance
  • Avoid increases in mean arterial pressure
  • Maintain adequate CPP (baseline to 20% above)
  • during carotid clamping
  • Nitrous oxide.(X)
questions of the day
QUESTIONS OF THE DAY
  • 1. What is cerebral autoregulation? Under what circumstances is it altered?

What is the impact of intravenous (IV) or inhaled anesthetics on cerebral

autoregulation?

  • 2. What are the effects of changes in PaCO 2 or PaO 2 on cerebral blood

flow?

  • 3. What are the effects of IV or inhaled anesthetics on cerebral blood flow?
  • 4. What are the manifestations of venous air embolism

in a patient undergoing craniotomy under general anesthesia? What is

the appropriate management?

  • 5. During craniotomy for tumor resection, the surgeon notes “brain swelling”

in the operative field. What are the initial steps in management?

  • 6. A patient with subarachnoid hemorrhage (SAH) pre-sents for intracranial

aneurysm clipping. What complications of SAH may develop in the

perioperative period?

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