Carotids and awake crani's

[deleted697535]

How do you do yours? For regional not ga
Esp carotids. USS vs landmark? What sedation, when and how much. When do you turn it off? How do you test?

Ever had to convert to ga in a ****show? Stories please?

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[deleted171991]

Haven't done awake carotids since residency.

Superficial cervical plexus block: ask patient to turn the head, feel the SCM, inject about 10-20 cc of local at the middle of the muscle, under it, coming from lateral/posterior, 360 degrees fanning technique. You literally grab the muscle and lift it, while injecting right under it. We would also inject some local along the lower margin of the lower jaw (field block, to cover the area for the retractor), and maybe also along the ramus (in front of the tragus, not sure, for another branch of the trigeminal) and, finally, a few cc's in the anterior tonsillar pillars in the mouth, to block the glossopharyngeal. The surgeon would also infiltrate the deeper tissues with local during dissec

Sedation was minimal, if any, because the entire purpose of keeping them awake was to judge mental status (by asking them questions, or to follow commands). Preop we would have them tell us about their families in detail. so we could ask them intraop (e.g. How many children do you have? How many boys? What are their names? Etc.).

I only did one or two, and so did most of my colleagues, because only one of the surgeons was doing them awake. Occasionally, a patient would become seriously confused on the table and would need emergent intubation. Not fun with an open neck.

Nowadays I do all of them asleep and with a btO2 monitor. Much easier.

I think you could do the superficial cervical plexus block with an ultrasound-guided technique, if you wanted to be anal about it. The landmark-based field block works well, too.

For example:

Ultrasound-Guided Cervical Plexus Nerve Block - NYSORA

Both US-guided superficial and deep cervical plexus blocks have been well described. The deep cervical plexus block is an advanced block with a risk of potentially serious complications, such as intrathecal injection or injection into the vertebral artery. For this reason, we will focus...

www.nysora.com

 

[Arch Guillotti]

a glossopharyngeal block? Whoa!

 

[kmurp]

We have done all of them awake for many years. In former years it was landmark based superficial and deep. Now it’s landmark or ultrasound superficial. A bit of fentanyl/versed for the block then a variable amount of propofol for the case. Test with hand squeeze (we have a squeeze toy that squeaks ), and verbal response. On occasion they freak out and so an LMA goes in.

 

[Lecithin5]

I’ve done several awake carotids. I like ultrasound superficial cervical plexus block (sometimes you can actually see little hyperechoic dots!), but landmark is obviously acceptable. Heck, site infiltration by surgeon works too. Regarding sedation, I never give anything more than precedex drip and some fentanyl pushes- no propofol, no versed. Again, surely you can use those agents, but I want my patient virtually wide awake. Which is why they have to be well selected and motivated. Don’t want to risk disinhibition and movement. And I want them to be able to crisply follow the surgeon’s (and my) commands and questions.

With awake cranis, I like low dose propofol sedation and some prn fentanyl pushes. Again, more on awake side. My partners will usually do any combo of propofol, precedex, and remi. The key is being able to shut off your sedation and having it wear off within a short period of time. Most of the case is obviously not painful, just a few select portions.

Awake means (mostly) awake. That’s it.

 

[shepardsun]

The ability of a surgeon to perform a good circumferential scalp block seems to be key in the awake cranis I've done. I have also had good success with propofol and remi infusions with small (10-20mcg) remi pushes for the pinning and initial craniotomy. High flow nasal cannula on patients that you would be concerned about potential obstruction with even mild sedation has worked well in my small N set. You just need to turn down the flow when it is time to fully awaken as it's hard for them to be heard speaking with the higher flows going.

 

[AdmiralChz]

Long post alert! I've found myself doing several awake cranis out in PP (not my fave, but the surgeon often requests me... yuck). Most important is having a cooperative and motivated patient, and of course the heavier they are (+ OSA) makes it more challenging. I've found surgeons know this and do a reasonable job at screening beforehand who is a good candidate.

Doing it as an "all awake" approach (MAC-Awake) technique is common but I never had much success with it, personally. My preferred technique I learned in training is "Asleep-Awake-Asleep" or just MAC after the awake portion if preferred. No premedication other than 0.1-0.2 mg Glyco as an antisialogogue (you want them to wake up somewhat quickly) and start with scalp blocks - I do them myself in my practice but you'll need to find a "control" syringe so you can aspirate. You can't inject too much volume under skin so I do a 10 mL mixture of 1/2 Mepivacaine (2 or 3%) and 1/2 ropivacaine (0.5%). Here's the technique and landmarks in this paper: https://pdfs.semanticscholar.org/3be4/3a2edb665bba2024e99de375f4fb6d6cb238.pdf

After that I'll induce (propofol only) and place an LMA and pre-hook up a NC with ETCO2 capability and run 0.5 MAC Sevo (nearly the only time I run it for a neuro case) and run 0.1 mcg/kg/min Remi (more if a chronic narcotic user). An alternative is substituting Precedex (0.5-0.75 mcg/kg/hr with no bolus, but start it early) +/- propofol for inhalation agent and keep it TIVA, this also works well. The stimulating portions are head pinning and craniotomy - with good scalp blocks there shouldn't be a tremendous amount of hemodynamic change. Once the dura is opened the surgeon usually lets me know he'll want the patient awake soon - I'll cut off the gas and turn back the Remi to 0.05. Or you can turn off the propofol and turn back the Precedex to 0.25-0.5, this also works well. I have found that patients do require a very mild plane of sedation to stay calm during surgery. My partners like to turn it all off and there have been some incidents in the past. Usually these patients emerge with a "Remi" wakeup - awaken to voice and I slip out the LMA and turn on 2-4L O2 via NC. I'll keep the patient the calm, explain what is happening, and call over the neuropsych team.

I'll see how the patient handles the awake portion and if it goes super smoothly and is tolerated well I'll just double the infusions after the resection is complete (Precedex is great here). If the patient requests or I am uncomfortable I'll bolus propofol and slip the LMA back in.

Pitfalls: Giving significant amounts of versed and fentanyl will delay your wakeup and provide a very poorly-cooperative patient during that process. Avoid them and lean more on Remi if you need narcotic.
- Incomplete anesthesia of the scalp - discuss craniotomy and pin locations with surgeon ahead of time.
- Obesity/OSA - these are the most difficult awake cases, lean more on Precedex here and less on narcotic.

For those of us in ACT practices and have an anesthetist in the room - you need someone comfortable and facile with this sort of plan and able to adjust sedation quickly and that you can trust to keep you in the loop. I spend a LOT of time in these rooms, probably among my most hands-on. Go over the plan ahead of time, hopefully the day before if you can. These cases are not where you want brand new hires, a CA-1 still working out the basics of anesthesia, or a locums anesthetist who's been doing simple general surgery for 10+ years. I always choose my anesthetist ahead of time personally and the cases have gone well for me so far in my short career.

Hope this has been helpful to folks out there! Just like any other surgery there are many ways to do the anesthesia for this case, what I described works great for my personal practice and experience but I am constantly tweaking things (reading up more on scalp anatomy, incorporating Precedex as it becomes much more readily available).