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Avoiding Complications in NeuroanesthesiaRen
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Tempelhoff, M.D. St. Louis, Missouri
 
311Page 1Most complications in neuroanesthesia can be categorized in 2 groups:1) Complications that are the direct result of our actions (errors of commission) or inactions (errors of omission) in patient management.2) Complications resulting from the primary neurological ailment and the required surgical/anesthesiologicmanipulations which are more difficult to control.In this RC, I will address only the first category.While complications are inevitably encountered in any type of anesthesia, neurosurgical complicationsusually result in the highest awards in medico-legal compensations.
Airway:
 This is the classic complication for all types of anesthesia. The incidence of airway complications is significantlyincreased in patients undergoing transphenoidal surgery for acromegaly.
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These patients may present with major anatomical facial changes that render the management of the airway extremely hazardous. They may present with anassociation of macroglossia, cartilaginous and redundant soft tissue hypertrophy of the larynx, laryngeal stenosis andcervical rigidity. In the advanced stage of the disease, assisted ventilation by mask is extremely difficult andobtaining a view of the vocal cords with direct laryngoscopy may be impossible. The safest approach is to achievecontrol of the airway while the patient is awake. Under light sedation, after thorough topical anesthesia of the oralcavity and a transtracheal injection of 4% lidocaine, a fiber optic intubation (FOI) or in more difficult cases, aretrograde FOI should allow the safe positioning of an endotracheal tube. ENT surgeons who are usually part of thesurgical team for the transphenoidal approach should be ready for an emergency tracheotomy. Extubation alsorepresents a dangerous time for these patients. Every effort should be made to extubate these patients only whentotally awake, keeping in mind that maintenance of the airway by mask or emergent endotracheal reintubation willoften be impossible. The presence of the surgical team during awakening and extubation can be life saving.Another challenge in Neurosurgery is the unstable cervical spine or compromised cervical cord. While this topic istreated elsewhere as a separate entity, it bears mentioning as it is a recurrent theme in neuranesthesia practice. Theusual recommendation for these patients is “Manual In Line Stabilization” while the tracheal tube is inserted. Thisdoes reduce mobilization of the cervical spine but also increases the difficulty of the intubation under directlaryngoscopy. Other techniques, always with the head in a neutral position, include the use of a fiber optic or Bullard laryngoscope. The physician should use his best clinical judgment in evaluating the patient, and use thetechnique he feels most comfortable with. In difficult situations, when the patient’s airway appears difficult, and thecervical spine may be unstable, a planned tracheotomy under light sedation and local anesthesia represents a better outcome than a quadriplegia. When feasible, a rapid neurological assessment after intubation will allowdocumentation of a new onset or the worsening of any neurological deficits.The same precautions should apply in patients with Down’s syndrome.
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 Patients with Arnold Chiari malformation, characterized by a descent of the cerebellar tonsils into the cervical spinalcanal can as appear to have relatively easy airways. However, during the mobilization of the cervical spineassociated with direct laryngoscopy lower cranial nerves or direct brain stem compression may occur resulting,among other things, in vocal cords paralysis or swallowing difficulties. The patients’ airway management should bedecided upon preoperatively with the neurosurgical team. In case of doubt, a fiberoptic intubation in the neutral position or with a Bullard laryngoscope may avoid a disastrous complication in the post operative period.
Positioning:
A characteristic of neurosurgery is the surgical need to operate in all kind of strange positions: park bench, prone,lateral with one arm in a splint hanging under the table, partially sitting, or sitting.Peripheral nerves injury can occur in any of these positions and pressure points should always be checked and padded properly. All peripheral pulses should be present and this should be recorded. In the prone position with thearms in a surrender position, brachial plexus injury can occur if the arm angle is greater than 90 degrees to the body.Facial trauma and eye compression can also occur in that position. Devices designed to prevent facial trauma or eyecompression are available. An example is a foam facial mask with an opening for the orbits and the ETT with amirror allowing an easy observation of the eyes. Whatever the tool used, repetitive inspection of the face and orbits
 
 311Page 2is necessary to ensure that sliding of the body during surgery does not compromise the facial structures. Ischemicoptic nerve injury is a completely different type of complication and will be treated separately.
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 The sitting position, which was a staple of neurosurgery, has been on the wane for a few years now, with somerecent burst of renewed interest supported by few publications in favor of its use while minimizing the potentialsrisks incurred.
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Venous air embolism (VAE) can happen in any position where the surgical field is located abovethe cardiac cavities. However, it is more frequent during craniotomies, where the venous sinuses of the bone anddura are non collapsible structures. In the sitting position, the incidence of VAE is fairly high, up to 40% in somestudies. Most of them have no clinical significance. However, when they do occur they can be catastrophic. This iscompounded by the fact that most intracranial procedures require a marked degree of hypovolemia that will increasethe likelihood of air entry. The best early detection tool for a VAE is via trans-esophageal echocardiography (TEE).It is becoming more and more available in most centers but it does require specially trained anesthesiologists able tointerpret the pictures with accuracy. It is also especially useful to screen preoperatively for patients with a patentforamen ovale (FO). In these patients a VAE can have dire consequences as the air embolus can migrate to the leftcirculation (paradoxical air embolism) through the opening of the FO. This is facilitated by the acute onset of  pulmonary hypertension and increase pressure in the right heart cavities that accompanies the arrival of air in thelungs. The precordial Doppler, when placed properly,
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is a very sensitive monitoring tool but not as specific as theTEE, while end-tidal CO2 monitoring remains the mainstay for diagnosis of VAE. A sudden decrease in the end-tidal CO2 reflects a sudden increase in dead-space resulting from the embolus. The decrease in end-tidal CO2reflects the impact of the embolus on respiratory gases exchange. A blood gas in this setting confirms a largegradient between the PaCO2 and the end-tidal CO2. Unfortunately, this may be a late sign. For patients at high risk for VAE, a central line may be placed after induction, with its tip approximately one centimeter inside the rightatrium. Catheters with multi aspiration ports at their distal end are most efficient at retrieving air. While mostclinicians have abandoned the use of nitrous oxide during neurosurgery to avoid its possible neurotoxicity, this isespecially true during the sitting position, so as to eliminate the effect of nitrous on the size of the air embolism.When acceptable to the neurosurgical team, it is important to maintain a positive central venous pressure duringsurgery with the head elevated. A CVP equal to the distance from the wound to the right atrium should be the best protection against a VAE. Unfortunately, this defeats to some extent the purpose of the sitting position for drier field, better venous drainage and better surgical exposure. The use of PEEP in an effort to increase the intrathoracic pressure, thereby decreasing the intravenous suction force and the risk of air aspiration, is contraindicated. PEEPincreases right sided pressures and the risk of a paradoxical air embolism through a patent foramen ovale. When proceeding with a surgical position that may lead to a VAE, one may accept the fact, that even with the earlydetection of air by the TEE, once the bolus of air has entered the circulation, there is little that can be done to avoidits consequences that can be either negligible or devastating depending on the rate of air flow entry and itsdestination. The clinician should attempt to prevent further air entry by requesting the surgical field to be flooded,while applying pressure on both jugular veins. The patient position has to be modified rapidly to place the surgicalwound below the level of the right atrium. Simultaneously, the anesthesiologist should attempt to retrieve any air entrapped in the right atrium via the central line and should initiate measures to support adequate perfusion andoxygenation. The consequences of VAE include stroke, myocardial infarction, acute right heart failure and death. Itappears reasonable that prior to any surgery in the sitting or semi-sitting position, preoperative TEE with Vasalvamaneuvers should be performed to eliminate the patients with a patent FO. Most neurosurgeons agree that mostneurosurgical procedures can be done in safer positions. The best way to avoid the complications associated with theVAE is to have a surgical field leveled with the heart. When this is not feasible, the presence of a patent FO should be taken into consideration.
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Positioning of the head during posterior fossa surgery in any position - sitting, prone or supine - can be fairlydangerous if the cervical spine is over flexed. Quadriplegia has been described after prolonged procedures in that position. One should always keep a free space between the chin and the chest of at least 2 fingers breadth.
Hemodynamic:
The brain is a very unforgiving organ without any energetic reserves. Its dependence on oxygen and substrates istotal and any short period of deprivation, up to a few minutes in the best scenario will result in cerebral ischemia.Cerebral perfusion and hemodynamic stability are essential in the maintenance of neuronal homeostasis. The magicformula of brain preservation has not changed: Cerebral perfusion pressure (CPP) =MAP- intracranial pressure(ICP). During intracranial neurosurgery, once the dura is open, ICP can be considered theoretically as nil in healthy
 
 311Page 3 brain. This is not always the case, when the size of the craniotomy does not allow the brain to expand and somedegree of herniation subsists. This is further compounded by the pressures transmitted to the brain by the necessarysurgical brain retraction. CPP is totally dependant upon the MAP. The consensus upon the lowest limit of CPPacceptable is that below 60mmHg, and definitively below 50, the risk of cerebral ischemia is present and more pronounced in the zones of surgical manipulations. The secondary brain injury, resulting from retraction pressure,decreases in collateral flow, loss of cerebral autoregulation around the primary lesion or the intentional temporaryinterruption of flow in some vessels will have worst consequences if a cerebral perfusion pressure (MAP>65mmHg)is not maintained. In previously hypertensive patients, the minimal acceptable MAP threshold is more elevated.Maintenance of an effective CPP is further compromised by the necessity to induce hypovolemia in patientsundergoing intracranial procedures in an effort to decrease the intracranial volume and pressure. This may causearterial hypotension. Most of the times the clinician will need to support the MAP. The choice of pressors in thissituation is an important question not well answered. However, there is some literature favoring norepinephrine over other agents including its precursor dopamine which may increase further the ICP.
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While almost everyone agrees onthe necessity to maintain an increased MAP, there is little conclusive literature on how high we should go. Oneshould always keep in mind the loss of autoregulation around the primary lesion and the possibility of spontaneoushemorrhage in its vicinity. Also, the patient’s co-morbidity such as coronary artery disease or left ventricular failureshould be taken into consideration. The clinician has to use his judgment regarding the upper limit of the MAP.
Seizures:
Seizures are a prominent feature of intracranial surgery. It is fairly obvious that one should avoid a proconvulsantagent as part of the anesthetic regimen in this setting. While most anesthetics are usually biphasic in their action: proconvulsant at lower dosage and anticonvulsant at higher doses,
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sevoflurane has demonstrated a strong proconvulsant activity especially in epileptic children at clinical concentrations.
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This is something to keep in mindwhen dealing with patients with a strong epileptic history to avoid a possible evolution to status epilepticus in the post operative period. Patients with a strong history of seizures on multiple anticonvulsants will also have muchhigher requirements for narcotics and neuro muscular blockade agents.
Electrophysiologic monitoring: requirements and consequences.
The introduction of more efficacious monitoring requires different anesthetic approaches.Total intravenous techniques are usually necessary to record a clean signal during trans-cranial motor evoked potentials (TcMEP). While nitrous oxide can be used without much alteration of the signal recorded, all inhalationsagents significantly reduce it. The signal will also be altered by a significant decrease in MAP. To render thingsmore complex, this monitoring technique does not theoretically allow any neuro muscular blockade. However, insome instances the electro physiologist will accept a minimal use of neuromuscular blockade at 2 twitches responseon the train of four.
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 The combination of a total IV anesthetic without much muscle relaxant in patients placed in a head holder undergoing deep intracranial neurosurgery under a microscope is a recipe for disaster. The risks of suddenawakening, bucking or total awareness are real. The consequences of a patient bucking during an intracranial or intraspinal procedure include the risk of cerebral herniation or the patient’s head slipping off the head holder andcreating a cervical lesion similar to hanging. The only solution is deepening the plane of anesthesia whilemaintaining an adequate MAP. For such procedures, recording the electrical cortical signal via an EEG (%deltawaves) or a BIS monitor (or equivalent) may provide another piece of information, which, in association with theclinical signs, may help the anesthesiologists to recognize a drift towards a lighter plane of anesthesia.
Glucose control:
Intracranial procedures often require high dose steroids. The result may be marked hyperglycemia. Poor glucosecontrol appears to worsen the outcome of patients with brain injury. It also plays an important role in thedevelopment of post operative infections. Tight control is easy to achieve and should be mandatory for anyneurosurgical (or other) procedures.
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