Neuroanesthesia Checklists Contents: 1. Surgical resection of Arteriovenous Malformation (AVM) 2. Deep Brain Stimulation (DBS) 3. Flexible Endoscopic Intubation 4. Checklist: Prone Positioning Lumbar Spine Surgery 5. Moyamoya / Extra- Intracranial Bypass 6. Lidocaine Infusions for Trigeminal Nerve Neurolysis in Neuroradiology Suite 7. Checklist for Stroke – Endovascular Therapy 8. Craniotomy for Resection of Supratentorial Tumor 9. SNACC Neuroanesthetic Emergencies Critical Event Treatment Guides Surgical resection of Arteriovenous Malformation (AVM) Surgical characteristics Duration of surgery Variable. Between 6 to 12 hours. Expected blood loss Variable. Potential high blood loss during the procedure. Blood group confirmation is mandatory. Positioning Depending on the location of AVM Antibiotic therapy As per surgical protocol. Anesthesia Pre-Anesthesia Optimize pre-existing medical conditions. Review the size, location and characteristics of AVM. Was endovascular embolization performed prior to surgery? Mode of Anesthesia Usually general anesthesia. Consider TIVA (Propofol). Airway Standard management / avoid sympathetic response to laryngoscopy. Ventilation Normoventilation. Mild hyperventilation (paCO2 28-33 mmHg) may be indicated in selected cases. Target MAP Initially maintain normotension. Discuss BP management with surgeon, often deliberate hypotension needed. Blood Gases Perform frequently – and as needed to control pCO2. Temperature Maintain normothermia. Use Bear Hugger blankets. Avoid hyperthermia. Transfer Consider ICU for postoperative BP control Special Potential major blood loss during procedure. considerations Be prepared to provide deliberate hypotension. Consider e.g. Esmolol (1 mg/kg, 0.5 mg/kg/min infusion), Labetalol, Nitroglycerin infusion. Often intraoperative angiogram. Indocyanine green dye sometimes used. Patient monitoring and vascular access Patient monitoring Standard CAS monitoring. Peripheral IV access Minimal 2 peripheral IV lines, one suitable for rapid infusion. Connect Hotline to large bore IV. Central venous line Consider placement for BP control peri-operative. Order chest x-ray post- op. Arterial line Mandatory. Can be placed after induction of anesthesia. Foley catheter Post induction. Keep euvolemia. Urine output 0.5 - 1 mL/kg/hour. Pain therapy Acute pain service Not necessary in most cases. Post-op pain therapy Scalp block is indicated for postoperative pain control. Use opioids and acetaminophen as per protocol. Material / Devices needed in room Arterial line set up Connected to monitor, cannula for catherization. Central line set up Double lumen central line usually sufficient. Ultrasound machine Mandatory for central line placement. Helpful for arterial line placement. Hotline Ready and connected to large bore IV. Blood-giving-set, extension and hotline tubing. 3 syringe pumps For Remifentanil, Propofol, Antihypertensives / Vasopressors 1 Baxter pump For Propofol TIVA Created: R. Noppens Verified: Neuroanesthesia Group Revision planed: July 2020 Deep Brain Stimulation (DBS) Surgical characteristics Duration of surgery Variable. Be prepared for longer duration for Stage I (bilateral DBS insertion): between 4 to 7 hours. Stage II (stimulator): usually 1 hour. Expected blood loss Usually minimal. Verify blood group confirmation. Positioning Stage I: Semi-sitting / beach chair position, head fixed in stereotactic frame. Stage II: Supine. Antibiotic therapy As per surgical protocol. Anesthesia Pre-Anesthesia Optimize pre-existing medical conditions. Intensive discussion with patient re: process for awake surgery. Know individual clinical manifestations of underlying disease (Parkinson, Epilepsy). Consider ranitidine pre-op to reduce aspiration risk. Neurosurgery positions stereotactic frame on skull pre-operatively in radiology. Patients with parkinsons discontinue anti-parkinson’s medications pre- operatively. Continue anti-epilectic medications. Mode of Anesthesia Stage I: Sedation. Consider use of Dexmedetomidine (400mg; needs to be ordered one day before surgery, delivery to OR desk at 7:00 AM on the day of surgery). Propofol and Remifentanil syringe pumps in the room. Stage II: General anesthesia Airway Stage I: Oxygen delivery via Nasal prongs / Mask. Airway backup available at bedside: consider LMA ProSeal. Intubation endoscope in the room “ready to go” in expected difficult airway situations. Stage II: Endotracheal intubation or LMA Ventilation Stage I: Measure respiratory rate with capnometry. Stage II: Normoventilation. Blood Gases Perform as needed. Target MAP Normotension. Avoid hypertension and hypotension. Temperature Maintain normothermia. Use Bear Hugger blankets. Avoid hyperthermia. Ask about patient comfort frequently. Post-op Disposition PACU Special Patient in stereotactic frame. Avoid interference of anesthetics during considerations microelectrode recordings and macrostimulation. Patient monitoring and vascular access Patient monitoring Standard CAS basic monitoring Peripheral IV access 2 peripheral IV lines, one suitable for rapid infusion. Arterial line Always used. Central venous line Only special circumstances. Foley catheter Commonly used. Consider sedation for placement (e.g. Propofol). May cause agitation especially in male patients. Consider use of condom catheter. Pain therapy Acute pain service Not necessary in most cases. Post-op pain therapy Scalp block always used Material / Devices need in room Arterial line set up Connected to monitor, cannula for catherization. Ultrasound machine Optional. Helpful for arterial line placement. Hotline Ready, but usually not needed. Have blood-giving-set, extension and hotline tubing available. 3 syringe pumps For Dexmedetomidine, Remifentanil, Propofol, Antihypertensives Created: R. Noppens Verified: Neuroanesthesia Group Revision planed: July 2020 Flexible EndosCopiC Intubation (non-anesthetized patient) Indication ExpeCted diffiCulties in masK ventilation and/or intubation • History of diffiCult intubation • ENT tumors • Limited CerviCal spine mobility, neck injuries, high Mallampati grade or Patil test Patient preparation • Venous acCess • TopiCal anesthesia (max. total dose lidocaine: 7 mg/Kg bw) o Nasal intubation: application of nasal drops (lidocaine + phenylephrine, consider use of MAD deviCe) o Oral intubation: on arrival in the OR: spray oropharynx with lidocaine pump spray (attn: 12 mg / spray). Spray laryngopharynx with e.g. lidocaine 2% / 4% (MAD device, ask for deep inhalation, attn: accidental overdoses reported with lidocaine 4%). • ConneCtion of monitoring (minimum: ECG, SaO2, NiBP) Preparation of flexible intubation endosCope • TechniCal funCtion test of endoscope (adults: usually 5 mm OD), light source and monitor • Attach selected endotracheal tube to the insertion part of the endoscope (tape, rubber band); consider use of armored tube • Prepare the topiCal anesthetiC (2-3 ml lidoCaine 2% in a 10 ml syringe with 7-8 ml air), connect to worKing Channel port • Apply anti-fogging agent to the lens, clean lens Nasal endoscopiC intubation of non-anesthetized patient • EndosCopiC cheCK of both nostrils for biggest space to pass endosCope / tube • AppliCation of 3 l O2/min via nasal Cannula / prongs • Titration of opioid (e.g. i.v. Sufentanil (< 60 Kg: 5 ug, 60-90 kg: 10 ug, > 90 kg: 15 ug), repeat in 5 ug doses if required; Remifentanil syringe pump (e.g. 0.1 - 0.35 μg/kg/min); Fentanyl (e.g. 50 ug boli)) • Advancing the endosCope via larger nasal passage • After reaching the vocal Cords: appliCation of the first topiCal anesthetiC dose (e.g. 2-3 ml lidoCaine 2%), the patient is asked to take a deep breath • After the onset of action (wait Ca. 2 min.) pass the vocal Cords, apply seCond local anesthetiC dose (2-3 ml lidoCaine 2%) into the trachea, ask patient to take a deep breath • Consider retraCting the tip of the endoscope in front of the voCal Cord plane • After 2 minutes: pass vocal Cords, advance into the trachea until bifurCation beComes visible • Nasal tube passage: no obstructive tumors of the respiratory tract and/or no critical airway: mild sedation (no hypnosis) with e.g. 0.5 -1 mg/kg bw Propofol iv • Advancing the endotracheal tube (lubriCate the nasal passage with e.g. lidocaine gel) • If the endotracheal position of the tube is confirmed, remove endoscope • Connect to ventilator (etCO2). Consider cuff inflation after induction of anesthesia (avoid coughing) • Induce anesthesia Created: Dr. R. Noppens; July 4th, 2019 Revision planed: June 2020 1 • Start ventilator, initiate maintenance of anesthesia Oral endoscopiC intubation of non-anesthetized patient • Oral: insert a bite guard • AppliCation of 3 l O2/min via nasal Cannula / prongs • Titration of opioid (e.g. i.v. Sufentanil (< 60 Kg: 5 ug, 60-90 kg: 10 ug, > 90 kg: 15 ug), repeat in 5 ug doses if required; Remifentanil syringe pump (e.g. 0.1 - 0.35 μg/kg/min); Fentanyl (e.g. 50 ug boli)) • Advancing the endosCope through the mouth (bite guard!) • After reaching the vocal Cords: appliCation of the first topiCal anesthetiC dose (e.g. 2-3 ml lidoCaine 2%), the patient is asked to take a deep breath • After the onset of action (wait Ca. 2 min.) pass the vocal Cords, apply seCond local anesthetiC dose (2-3 ml lidoCaine 2%) into the trachea, ask patient to take a deep breath • Consider retraCting the tip of the endoscope in front of the voCal Cord plane • After 2 minutes: pass vocal cords, advance into the trachea until bifurcation becomes visible • Advance endotraCheal tube, rotation maneuver is often helpful to pass larynx • If