PAH M&M – 6.20.13. Attending/CRNA: Parmet /Lamb Operation: Pituitary Adenoma Resection (via transpterygoid middle fossa skull base approach) Surgeons: Lee/Newman Complication: Internal carotid artery bleeding. Endoscopic Transpterygoid Approach. History.
Operation: Pituitary Adenoma Resection (via transpterygoid middle fossa skull base approach)
Complication: Internal carotid artery bleeding
Na 139, K 4.0, BUN 11, Creat 0.70, Glucose 152
Hgb 10.2, Hct 30, Platelets 185
Incident: “Brisk internal carotid artery bleeding”
Patient Safety: A-line, IV access in place, Pt was T&C by anesthesia with 4units PRBC in room
Communication: Bleeding verbalized by surgeon, confirmed by anesthesia witnessing severe hypotension, Anesthesia STAT called for additional support
Health Care System: Transport to HUP via EmSTAR for IR
Luxury Perfusion thought to be reduced by hypocapnia – now concept of luxury perfusion is largely discredited – Why?
CBF and CMRO2 have been found to be decreased after brain injury
Regional CBF is markedly decreased particularly in 1st 24hrs
Early hypocapnia may be harmful
Only 30% of CBV located in arteries (only arteries respond to change in PaCO2)
Decreasing CBF by 30% only translates to decrease of 7% in CBV
Arterioles most sensitive to PaCO2 change, larger arteries least sensitive (ie: ICA)
“Capacity for hypocapnia to decrease CBV is limited and achieved at a disproportionate cost to arterial CBF” (Curley, 2010, p. 1349)
Results in increased CMRO2 and prolongs seizure activity
Increases lactate/O2 demand
Causes regional cerebral ischemia
Produces ischemic changes visualized on MRI
PaCO2 <35mmHg does not improve outcome
RCT compared PaCO2 of 25 v.s 35
Prolonged hyperventilation (>20min) worsens outcome
Hypocapnia increases overall level AND variability of ICP
Hypocapnia lasts 4hrs at most
Rebound intracranial HTN occurs when normocapnia is restored – could potentially result in brainstem herniation
Hypocapnia is ineffective/counterproductive in controlling ICP over time
Beheiry, H.E. (2012). Protecting the brain during neurosurgical procedures: strategies that can work. Current Opinion in Anesthesiology, 25, 548-555.
Bilotta, F., & Rosa, G. (2010). Glucose management in the neurosurgical patient: are we yet any closer? Current Opinion in Anesthesiology, 23, 539-543.
Curley, G., Kavanaugh, B.P., & Laffey, J.G. (2010). Hypocapnia and the injured brain: More harm than benefit. Critical Care Medicine, 38, 1348-1359.
Milani, W.R., Antibas, P.L., & Gilmar, F.P. (2012). Cooling for cerebral protection during brain surgery. The Cochrane Collaboration, 7, 1-39.
Pasternak, J.J., & Lanier, W.L. (2013). Neuroanesthesiology Update. Journal of Neurosurgical Anesthesiology, 25, 98-134.