Intraoperative aneurysm rupture
1) Take a deep breath
2) Let room know and get blood in room to provide (i.e. anesthesia attdg in room, extra nurse present)
3) Switch to large bore suctions
4) Strict blood pressure control (i.e. MAP over 65, SBP < 120)
5) Adenosine in room (0.3 mg/kg)
6) Notify endovascular team and burst suppress to reduce metabolic rate
7) Suction over bleeding, identify source, get cottonoid over it
8) If proximal control obtained, temporary clip proximal and distal to trap segment
9) If no proximal control, cottonoid over source to control bleeding and then obtain proximal control
10) If still can’t obtain proximal control can go to neck (if prepped) for proximal control
11) Clip aneurysm (if it’s source of bleeding)
12) If can’t clip, crushed temporalis muscle over site of bleeding or Tachosil patch
13) ICG run to evaluate patency of parent vessels
Endonasal carotid artery injury
1) Take a deep breath
2) Let room know and get blood in room to provide (i.e. anesthesia attdg in room, extra nurse present)
3) Switch to large bore suctions
4) Strict blood pressure control (i.e. MAP over 65, SBP < 120)
5) Adenosine in room (0.3 mg/kg)
6) Notify endovascular team and burst suppress to reduce metabolic rate
7) Suction over bleeding, identify source, cottonoid patty over
8) Instruct assistant to go to thigh or abdomen to obtain muscle patch and crush
9) Swap cottonoid with crushed muscle and direct pressure (but not enough to occlude carotid) for 15 mins
10) Quick reconstruction and go to angio suite for possible stenting or further intervention
- Remember to monitor for delayed pseudoaneurysm formation
Intraoperative seizure
1) Assess airway (if awake), hemodynamics, stabilize head/mayfield
2) Initial Lorazepam 2-4mg every 5 mins max of 9mg
3) Ice-cold LR irrigation
4) Load with Keppra (20mg/kg) (or added dose if given at start of case)
5) Increase propofol if patient already asleep
6) Second load with Phenytoin (20mg/kg)
7) Third agent or consider more continuous therapy if still seizing
8) Start closing rapidly
*Simultaneous in all this should be sending labs for anything reversible
Status epilepticus (not intraoperative)
1) ABCs assessment/Lateral decub position
2) Labs: CBC, BMP, Glucose, Lytes
3) Lorazepam 2-4 mg dose every 5 mins to max of 9mg
4) Load with Keppra (20mg/kg)
5) Second agent load with Phenytoin (20mg/kg)
6) Continuous infusion therapy and intubation
6a) Midazolam 0.2mg/kg load, maintenance 0.1-0.4 mg/kg/h, max of 2.0 mg/kg/h
6b) Propofol 1-2mg/kg at 10mg/min, maintenance 2-10mg/kg/h, max 15mg/kg/h
6c) Pentobarbital load 3mg/kg, maintenance 0.3-3mg/kg
7) As seizure being controlled, simultaneously preparing to reverse reversible issues
7a) Obtaining CTH
7b) LP and antibiotics if infected
7c) Narcan if OD suspected
7d) Glucose/Thiamine if alcoholic
Postop ACDF presenting infected (esophageal injury)
- CBC, ESR/CRP, and BCx. Initiate broad spectrum antibiotics
- NPO
- Barium swallow/rigid esophagoscopy
- OR for repair primarily vs SCM flap
- Prolonged NPO period (NG vs PEG vs TPN)
Postoperative neuropathic pain
- Rule out organic causes with necessary imaging
- Gabapentin 300mg TID, titrate up as tolerated
- Spinal cord or peripheral nerve stimulator if all else fails
C5 nerve palsy
- Rule out structural causes with appropriate imaging
- Aggressive PT/OT
-Nerve transfer in severe cases (i.e. spinal accessory to suprascapular or radial to axillary)
Intraoperative brain swelling
- Assess vitals/End-tidal CO2 (i.e. tube kinked/not ventilating)
- Reverse trendelenberg
- Check neck for kinks
- Hyperventilate temporarily
- Mannitol (0.5-1.0 g/kg)
- Burst suppression
- Intraoperative ultrasound (eval for hematoma)
- Intraoperative EVD/CSF release
- Rapid tumor resection (if due to tumor swelling)
- Extend craniotomy (if traumatic herniation)
- Ensure no occlusion of major venous sinuses
- If all else fails, rapid closure
Vasospasm (Post-SAH)
- Evaluate patient
- Imaging (rule-out rebleed, seizure, infection)
- Ensure hydrocephalus not precipitating (i.e. interrogate EVD)
- Triple H therapy (mostly fluid resuscitation for hypervolemia)
- Elevate a SBP floor
- CTA
- Nimodipine 60mg Q4 (or 30mg Q2)
- TCDs
- Endovascular consultation for intra-arterial vasodilators or angioplasty)
What Lindegaard ratios indicate vasospasm?
LR < 3: Normal
LR 3.0-4.5: Mild vasospasm
LR 4.5-6.0: Moderate vasospasm
LR > 6.0: Severe vasospasm
What does the Lindegaard ratio measure?
MCA velocity/ICA velocity
Intraoperative loss of monitoring (spine)
- Stop what I’m doing
- Anesthesia elevate MAP above 85
- Neuromonitoring check leads (technical)
- Check positioning of patient (arm fall, etc)
- Undo last step
- Check for surgical compression due to hematoma, cord kinking/drift, or need for additional laminectomy
- Burst suppression (reduce metabolic rate)
- Dexamethasone 10mg
- Intraoperative ultrasound evaluate for hematoma/cord drift
- Repeat signal check
- X-ray if needed
- Wake up test
Chemical meningitis
- LP
- Oral steroid course
Watery appearing blood during trauma
Concern for DIC
- Blood in room and provide
- Anesthesia send coagulation studies but begin giving cryoprecipitate, FFP, platelets
- Stop manipulating brain/tissue
- Warm irrigation/pressure over areas of concern
- Elevate HOB
- Tack-up sutures
- Closure when feasible
Severe TBI ICP crisis
- Examine patient, Assess vitals/temperature
- Elevate HOB
- Remove cervical collar/Jugular compression
- Check EVD for kinks/discontinuities
- CTH if clinically stable
- Mannitol or hypertonic saline bolus
- Send CBC/BMP, 3% to raise Na+
- Shivering? (give magnesium)
- Add sedative agents (fentanyl, dexmedetomidine, propofol)
- Pentobarb coma
- Rocuronium paralysis
- Goals of care with family
- ## Decompressive craniectomy if indicated
Hardware failure
- Examine patient
- Collar or brace placement if unstable
- Feasibility of revision surgery vs removal vs backing patient up
Define Addison’s disease
Primary adrenal insufficiency aka adrenal glands themselves cannot produce cortisol and aldosterone. Often autoimmune cause but others exist
Diabetes Insipidus
- Examine patient
- Assess volume status
- Evaluate BMP, UOP, urine specific gravity
- Based on severity, IV vs oral desmopressin
- IV desmopressin: 0.5-1.0 mcg IV
- Oral desmopressin: 0.05-0.1mg PO BID
SIADH
- Evaluate patient
- Check BMP, urine lytes, volume status
- Fluid restriction 1.0 L
- Salt tabs
- Controlled 3% (no more than 10mEq rise in 24 hrs)
- Tolvaptan if severe
Complication Avoidance Preparation
Tumor invading/adjacent to a major venous sinus
- Blood in room
- Precordial doppler
- Central line/Aspiration catheter
Complication Avoidance Preparation
Aneurysm
-Blood in room
-Large bore suctions
-Adenosine
-Proximal control (Neck prep?)
-Intraop angio (Groin Prep/Sheath)
-Aneurysm clips
-Microvascular doppler
-ICG
Complication Avoidance Preparation
Awake surgery/Epileptogenic Foci
-Preop loading AEDs x 2
-Extra vial propofol, ativan with anesthesia
-Ice cold saline/LR
-Airway tools close by anesthesiologist
-Neuromonitoring
Cerebral Salt Wasting
IVF resuscitation
Monitor Na
Fludricortisone 0.1mg BID
How can you distinguish between cerebral salt wasting and SIADH on clinical examination?
CSW is a hypovolemic state
SIADH is a euvolemic or hypervolemic state
