Tight Brain Checklist
Posted by Clark Venable on 2/11/2006
The anesthetist can have a significant impact on the operating conditions a neurosurgeon has to work with. One example is a situation where the surgeon (or anesthetist) notices the brain no longer appears relaxed but begins to get 'tight' within the craniotomy window. Rather that a knee-jerk response of further hyperventilating the patient and/or giving Mannitol, it is prudent to first consider possible causes as follows:
- Are the pressures controlled?
- Is the metabolic rate controlled?
- Are vasodilators in use?
- Are there any unexpected mass lesions?
Are the pressures controlled?
- Arterial Pressure
- pCO2
- pO2 (remember that hypoxemia is a potent stimulus for cerebral vasodilation
- Intrathoracic pressure
- Airway pressure
- Jugular venous pressure (includes external venous compression by C-spine collar or twill used to secure endotracheal tube)
Is the metabolic rate controlled?
- Pain
- Light anesthesia
- Awareness
- Seizures
Are vasodilators in use?
- Potent agents (Isoflurane, Desflurane, Sevoflurane, Enflurane)
- Nitroprusside
- Nitroglycerine
Are there any unexpected mass lesions?
- Pre-existing pneumocephalus exacerbated by nitrous oxide
- Cerebral hemorrhage remote to the site of surgery
As taught to me by John Drummond, M.D. at UCSD
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