Awake Cranies

[ProRealDoc]

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How are you doing yours? Share your technique.

 

[Bertelman]

Nasal cannula
2 midaz, 50-100 mcg fent, hit of prop until unarousable
(continue with add'l fent and prop hits to keep down)
scalp block, pins, prop infusion until wakey-wakey
somnolent but able to follow commands during mapping
more propofol for closing

I've done a couple, and I must say I'm not satisfied. Invariably, I walk a VERY fine line between pt. moving and chin lift for obstruction. Granted, both have been 40-something obese males just waiting to obstruct. I have inserted lidocaine-slathered nasal trumpets, which worked on the first, but likely led to a coughing spell in the second, and ultimately removal of said device d/t pt. complaint once awake.

Unfortunately, our surgeon thus far has dictated the drill. I'm interested in either remi or dex for these, but it will take some convincing. I'd like to hear specifics like doses, etc. from someone using these techniques.

 

[Gimlet]

Unfortunately, our surgeon thus far has dictated the drill. I'm interested in either remi or dex for these, but it will take some convincing. I'd like to hear specifics like doses, etc. from someone using these techniques.

They were using dex for these when I was doing a neurosurgery sub-I this time last year, with good results as far as I could tell (the A**hole neurosurgeon didn't complain, at least). Can't comment on any specifics of dosing, unfortunately.

 

[Bertelman]

They were using dex for these when I was doing a neurosurgery sub-I this time last year, with good results as far as I could tell (the A**hole neurosurgeon didn't complain, at least). Can't comment on any specifics of dosing, unfortunately.

Fortunately half of ours are cool, the other half are tolerable.

 

[Gimlet]

Fortunately half of ours are cool, the other half are tolerable.

I actually got along well with almost all of our neurosurgeons...some of them are super awesome. The guy who does the DBS stuff here was just kind of a bear to deal with in the OR.

 

[SleepIsGood]

what are you guys doing this for?

deep brain stim?

 

[ProRealDoc]

Dex at 1mcg/kg/min for x 1omin and then .001mcg/kig/min along with propofol infusion plus boluses of fentanyl PRN. Nasal cannula but throw in nasal airway as needed. Agressive local by surgeons is key though. Works pretty well for us.

Would like to try with LMA sometime.

 

[Bertelman]

Tumors approaching critical cortical areas. The last one I did had a szr hx, as many as a dozen per day. He had a 4 cm mass.

 

[proman]

Our DBS implants are done completely 100% awake, awake, awake, often with the patient flailing about. The closest thing they get to an anesthetic is what they can absorb through the scalp (plus they are off their meds too). I do not enjoy them one bit.

 

[cchoukal]

A surgeon who's good with local is key to this procedure. I've done 2 of these as a resident, and we used dex 0.5 mcg/kg/HOUR for the duration, with bumps of propofol for the a-line, local, and pins, and the occasional midaz/fent intraop for discomfort. Pts did well.

 

[Hockeyguy]

Awake cranis: Propofol gtt scalp block (basically general at this point), then sufenta gtt, dex titrate to effect. You can substitue prop for dex but I find dex is superior in these cases. We do quite a few I used to hate them but once you get them down these are cool cases. The key IMO is to get all gtts ready in the AM, one well orgaized infusion set-up going through one PIV. 2nd 16 G PIV for volume etc. In these cases putting in an extra 20-30 mins in the AM to program pumps etc, having everything clean and super organized is this difference in looking like a bad ass or a dip s hit.

 

[xjohns1]

our anesthestic of course depends on the indication for the awake crani. for seizure focus excision we give no drugs that suppress seizure activity (no benzos, no propofol). the pt is normally not in pins. we run a dex (0.75 mcg/kg bolus over 10 min then 0.75 mcg/kg/h infusion) and remifentanil (0.05 mcg/kg/min and higher infusion) based anesthetic, titrated to sedation and rr. we use no lma. during closeure, we will add propofol or midazolam, if needed. propofol is in-line for control of locally uncontrollable seizure activity and of course provisions are made for emergency airway access and appropriate blow-by oxygenation. these can be very challenging anesthetics but also very rewarding both in terms of patient outcome (he moves himself over to the gurney after craniotomy and lobectomy, talking and without pain) and in developing an elegant, truly conscious sedation.