Neuroanesthesia Peer-review Journals
Volume control is no longer used for managing elevated ICP, as it is only mildly successful and has the side effects of hypotension, resulting cortical and renal hypoperfusion, and electrolyte and acid-base imbalance. In fact, many neurochirurgical patients are resuscitated to volume. Blood loss should be replaced during
surgery at a 3:1 ratio (3L crystalloid per 1L EBL) with a 25-30 percent hematocrit. Glucose is avoided because it exacerbates
ischemia (increases the production of neuronal lactate) and edema. During surgery, patients are typically held at 15-30 degrees to facilitate venous drainage. Avoid PEEP > 10 cm H2O which affects venous drainage and ICP above. The following devices are indicated for major neurochirurgical procedures-arterial line / ABG, central venous catheter, urine production. Paralyze properly and obtain deep general anesthesia until DL, retain 30-35 mm Hg PaCO2 during operation, stop PEEP if necessary, as it can hinder venous return from the brain. Intracranial Neuroanesthesia to Keep in Mind-CNS elements: minimize opiates and benzos (high pCOs). Avoid alterations to ICP. Sleep at 15-30 degrees makes venous removal from
brain smoother. Often infuse mannitol in excess of 10 minutes – CV: a-line is advised almost always – Pulm: retain pCO2 30-35 mm Hg. The hyperventilation lasts just 4-6 hours. Hold PEEP < 10 – Renal: volume limitation is not advised – FEN: Stop glucose – Anesthesia: suggest a pseudo-cardiac intervention (midazolam + fentanyl) to reduce hypotension. Paralyze profoundly for intubation to prevent disturbed emergence
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