Podcast
Questions and Answers
What is the primary goal of 'Triple H' therapy in the treatment of ischemic neurologic deficits caused by cerebral vasospasm?
What is the primary goal of 'Triple H' therapy in the treatment of ischemic neurologic deficits caused by cerebral vasospasm?
What is the definition of 'Luxury perfusion'?
What is the definition of 'Luxury perfusion'?
What is the effect of hypothermia on CMR?
What is the effect of hypothermia on CMR?
What is the function of the artery of Adamkiewicz?
What is the function of the artery of Adamkiewicz?
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What is the Trigeminal cardiac reflex?
What is the Trigeminal cardiac reflex?
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What is the result of increased ICP?
What is the result of increased ICP?
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What is the definition of the 'Circulatory Steal' phenomenon?
What is the definition of the 'Circulatory Steal' phenomenon?
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What is the 'Robin Hood Effect'?
What is the 'Robin Hood Effect'?
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What is the main consequence of an increase in MAP or decrease in ICP?
What is the main consequence of an increase in MAP or decrease in ICP?
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Which component of the cranial vault plays a key role in emotion, appetite, and response to pain/stressors?
Which component of the cranial vault plays a key role in emotion, appetite, and response to pain/stressors?
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What is the primary function of the blood-brain barrier?
What is the primary function of the blood-brain barrier?
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What is the main function of the cerebellum?
What is the main function of the cerebellum?
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Which neurotransmitter is the major excitatory neurotransmitter in the brain?
Which neurotransmitter is the major excitatory neurotransmitter in the brain?
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What is the gold standard among cerebral protective techniques?
What is the gold standard among cerebral protective techniques?
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What is the primary function of the Monro-Kellie doctrine?
What is the primary function of the Monro-Kellie doctrine?
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What is the major role of the diencephalon?
What is the major role of the diencephalon?
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What is the primary function of the blood-CSF barrier?
What is the primary function of the blood-CSF barrier?
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What is the main function of the hypothalamus?
What is the main function of the hypothalamus?
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Which artery arises from the subclavian artery and feeds the posterior fossa/cerebellum?
Which artery arises from the subclavian artery and feeds the posterior fossa/cerebellum?
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What is the primary reason for the importance of the Circle of Willis?
What is the primary reason for the importance of the Circle of Willis?
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What is a consideration for anesthetic management in patients with Alzheimer's disease?
What is a consideration for anesthetic management in patients with Alzheimer's disease?
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What is a consideration for patients with Parkinson's disease undergoing anesthesia?
What is a consideration for patients with Parkinson's disease undergoing anesthesia?
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What is a characteristic of patients with Eaton-Lambert syndrome?
What is a characteristic of patients with Eaton-Lambert syndrome?
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What is a risk associated with regional anesthesia in patients with rheumatoid arthritis?
What is a risk associated with regional anesthesia in patients with rheumatoid arthritis?
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Which of the following EEG waveforms is typically associated with deep sleep and anesthesia?
Which of the following EEG waveforms is typically associated with deep sleep and anesthesia?
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What is the primary function of consciousness?
What is the primary function of consciousness?
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What happens to a pacemaker when a magnet is placed on it?
What happens to a pacemaker when a magnet is placed on it?
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Which of the following anesthetics is characterized by increased Beta and Gamma oscillations?
Which of the following anesthetics is characterized by increased Beta and Gamma oscillations?
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What is the management strategy for electromagnetic interference with lithotripsy?
What is the management strategy for electromagnetic interference with lithotripsy?
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What is the order of sensitivity of neuromonitoring as affected by anesthesia?
What is the order of sensitivity of neuromonitoring as affected by anesthesia?
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What is the preferred agent for skin prep in invasive procedures?
What is the preferred agent for skin prep in invasive procedures?
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Which of the following medications is an exception to the rule of decreasing cortical amplitudes in evoked potentials?
Which of the following medications is an exception to the rule of decreasing cortical amplitudes in evoked potentials?
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What is the purpose of a bite block in MEP monitoring?
What is the purpose of a bite block in MEP monitoring?
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What is the goal of SCIP guidelines?
What is the goal of SCIP guidelines?
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What is the classification of surgical instruments according to the Spaulding scheme?
What is the classification of surgical instruments according to the Spaulding scheme?
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Which of the following is NOT a factor that affects neuromonitoring?
Which of the following is NOT a factor that affects neuromonitoring?
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What is the function of position 2 in pacemaker programming?
What is the function of position 2 in pacemaker programming?
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What is the effect of desflurane on the environment?
What is the effect of desflurane on the environment?
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What is the response to surgical stress according to the ERAS protocol?
What is the response to surgical stress according to the ERAS protocol?
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What is the purpose of rate modulation in pacemakers?
What is the purpose of rate modulation in pacemakers?
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Which of the following is a characteristic of burst suppression?
Which of the following is a characteristic of burst suppression?
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What is the goal of preoperative optimization in an ERAS protocol?
What is the goal of preoperative optimization in an ERAS protocol?
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What is the component of an ERAS protocol that involves education and referrals?
What is the component of an ERAS protocol that involves education and referrals?
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What is the consequence of RV pacing alone or VOO?
What is the consequence of RV pacing alone or VOO?
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What is the characteristic of meningiomas that distinguishes them from gliomas?
What is the characteristic of meningiomas that distinguishes them from gliomas?
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What is the only medication that reduces brain parenchyma?
What is the only medication that reduces brain parenchyma?
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What is the relationship between wall stress and aneurysm radius according to the Law of Laplace?
What is the relationship between wall stress and aneurysm radius according to the Law of Laplace?
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What is the goal of blood pressure management during thrombectomy?
What is the goal of blood pressure management during thrombectomy?
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What is the characteristic of Mapleson A (Magill) circuit?
What is the characteristic of Mapleson A (Magill) circuit?
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What is the characteristic of Mapleson E circuit?
What is the characteristic of Mapleson E circuit?
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What is the EEG waveform seen in an awake patient with eyes closed?
What is the EEG waveform seen in an awake patient with eyes closed?
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What is the goal of CPP management in TBI?
What is the goal of CPP management in TBI?
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What is the characteristic of AV malformations?
What is the characteristic of AV malformations?
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What is the anesthetic plan for percutaneous rhizotomy?
What is the anesthetic plan for percutaneous rhizotomy?
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Study Notes
Neuroanesthesia
- Circulatory Steal Phenomena: Increase in cerebral blood flow (CBF) in normal tissue rather than ischemic tissue, seen with vasodilators (VA's).
- Luxury Perfusion: CBF exceeds cerebral metabolic rate of oxygen (CMRO2), also seen with VA's.
- Robin Hood Effect: "Reverse steal" phenomenon, where blood flow is redistributed from "rich" areas to ischemic areas, seen with barbiturates.
- "Triple H" Therapy: Primary treatment for ischemic neurologic deficits caused by cerebral vasospasm, consisting of hypertension, hypervolemia, and hemodilution.
- Trigeminal Cardiac Reflex: Massive parasympathetic outflow (bradycardia) seen with opening and closing of dura.
- Artery of Adamkiewicz: Largest segmental medullary artery, supplies anterior and posterior portions of the spinal cord (lower 2/3, lumbosacral region, T11-L2).
- Neurovascular Coupling: Cerebral metabolic rate (CMR) changes affect proportional change in CBF.
- Intracranial Hypertension: Intracranial pressure (ICP) increases, resulting in reduced cerebral perfusion pressure (CPP) and oxygen delivery, leading to cerebral ischemia.
- Monro-Kellie Doctrine: Increases in volume of one intracranial component are compensated by decreases in another component.
Blood-Brain Barrier (BBB) and Blood-CSF Barrier
- BBB: Consists of tight junctions in endothelium, lipid bilayer, and astrocytes, which aid in maintenance.
- CSF: Cushions and buoys the brain, and serves as an excretory pathway.
- Blood-CSF Barrier: Free movement of water and lipophilic substances, but selective transport of ions, glucose, and amino acids.
Cerebral Protection
- Aims: Limiting or reducing ischemic injury via physiologic and pharmacologic techniques.
- Hypothermia: Gold standard among protective techniques, with a 5% change in CMR for every 1°C change in temperature.
- Glucose: Normalization of glucose recommended during cerebral ischemia, as excessive glucose availability can be detrimental.
Blood Distribution to Cerebral Cortex
- Venous Drainage: All venous blood ultimately drains via the internal jugular (IJ) vein.
- Arterial Supply: Anterior and posterior supply, which converge at the circle of Willis.
Anesthetic Considerations
- Alzheimer's: Avoid succinylcholine, avoid anticholinergics, and avoid GETA, as it tends to exacerbate symptoms.
- Parkinson's: Continue Parkinson's medications, avoid butyrophenones and dopamine antagonists, and ensure adequate reversal of neuromuscular blockade.
- Eaton-Lambert: Patients are sensitive to both succinylcholine and non-depolarizing neuromuscular blockers, and require increased dosages of reversal agents.
Miscellaneous Equipment
- Mapleson Systems: Breathing tubing, fresh gas inlet, adjustable pressure-limiting valves (APL)/expiratory valve, and reservoir bag.
- Neuromonitoring: EEG, SSEP, MEP, and BAEP.
Neuromonitoring Pharmacology
- Volatile Anesthetics (VA's): Produce progressive slowing of EEG until burst suppression.
- Intravenous Anesthetics: Ketamine, dexmedetomidine, and opioids affect EEG differently.
Cardiac Implantable Electronic Devices (CIEDs)
- Pacemaker Coding: Position 1-4, which indicate the chamber paced, sensed, response to sensing, and rate modulation, respectively.
- Rate Modulation: Increases supply based on patient demand/activity.
- Magnets: Affect pacemaker and ICD function.
Infection Control
- Transmission-Based Precautions: Contact, droplet, and airborne precautions, with corresponding personal protective equipment (PPE).
- Chlorhexidine vs Povidone-Iodine: Chlorhexidine is preferred for skin preparation in invasive procedures, while povidone-iodine is preferred for neuraxial procedures.
Enhanced Recovery After Surgery (ERAS)
- Surgical Stress Response: Neuroendocrine-metabolic, inflammatory-immune, and catabolic responses to surgical trauma.
- Components of ERAS Protocol: Preoperative, intraoperative, and postoperative components, including education, optimization, medication management, and multimodal analgesia.
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Description
Review anesthetic considerations for neurosurgery, identifying and detailing treatments for anesthetic and surgical emergencies. Focus on definitions, anatomy, and circulatory concepts.
