Case discussion

[Noyac]

i don’t do cerebral aneurysm clippings currently but a case came to my attention that called for something I either didn’t know or forgot.

Hypothetical case:
52yo female for middle cerebral artery clipping. Just before the surgeon is able to clip the proximal section of the artery, it ruptures.
What’s your immediate response?

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[agammaglobulin]

Bolus Propofol to lower BP (help surgeon get control of bleeding) and decrease CMR. Call for blood. Make sure you have good access and pressors available. Hope surgeon places temporary clip upstream to help get control if they can't get a clip on aneurysm. Talk to surgeon, if total **** show may need Adenosine to stop flow so they can stop the hemorrhage in pulseless environment. Only thing else I could think of to slow bleeding is try to manual occlusion of carotid on side of aneurysm? Probably a bad idea though and wouldn't work.

 

[anbuitachi]

i don’t do cerebral aneurysm clippings currently but a case came to my attention that called for something I either didn’t know or forgot.

Hypothetical case:
52yo female for middle cerebral artery clipping. Just before the surgeon is able to clip the proximal section of the artery, it ruptures.
What’s your immediate response?

I would Bolus some esmolol. Assume already have good access since it's a clipping case. Call for blood. Adenosine if needed. Call for defibrillator

 

[BLADEMDA]

Adenosine can cause myocardial ischaemia in patients with coronary artery disease; it vasodilates healthy coronary arteries but not diseased ones, because they are already maximally dilated. This can cause a coronary steal phenomenon shunting blood away from diseased, underperfused areas to non-ischaemic areas. This principle underlies adenosine usage in cardiac stress testing. Multiple authors caution its use in patients with a preoperative history of myocardial infarction (MI) and recommend avoiding it in patients with severe left main coronary artery stenosis (80%) or severe multivessel coronary artery disease (three vessels or grafts with 80% stenosis).3 4 12 14 15 23

 

[Robotic Wis-Hipple]

A huge dose of adenosine was always required to be in the room for these in training. But I think real world a propofol bolus does about the same thing while providing cerebral protection and you’d likely have it drawn and ready.

 

[BLADEMDA]

Adenosine to facilitate the clipping of cerebral aneurysms: literature review

Great board case. Adenosine has a lot of possible side effects the oral examiners can grill you on and the patient may end up with permanent AV block (rare)

 

[deleted162650]

You DO NOT want to drop BP in this setting. The rupture compromises flow to a significant chunk of the brain. You want to enhance collateral circulation. Dropping the BP will only serve to enlarge the ischemic area. Very short term maneuvers to decrease CO (like esmolol or adenosine) can be employed, but as a late resort, and only in close coordination with the surgeon.

Also remember that the brain receives a ton of blood flow. If an aneurysm pops, you need to start thinking about volume maintenance as well.

 

[Urzuz]

Adenosine can cause myocardial ischaemia in patients with coronary artery disease; it vasodilates healthy coronary arteries but not diseased ones, because they are already maximally dilated. This can cause a coronary steal phenomenon shunting blood away from diseased, underperfused areas to non-ischaemic areas. This principle underlies adenosine usage in cardiac stress testing. Multiple authors caution its use in patients with a preoperative history of myocardial infarction (MI) and recommend avoiding it in patients with severe left main coronary artery stenosis (80%) or severe multivessel coronary artery disease (three vessels or grafts with 80% stenosis).3 4 12 14 15 23

I would be more worried about the myocardial ischemia caused by the MCA pumping the patient's blood volume onto the surgical field. If the surgeon can't see the vessel to put a clamp on it, give the adenosine without hesitation.

 

[deleted162650]

Only thing else I could think of to slow bleeding is try to manual occlusion of carotid on side of aneurysm? Probably a bad idea though and wouldn't work.

I know of a few cases where the aneurysm was in a location that made proximal control difficult. The surgeon actually accessed the carotid in the neck just in case.

 

[nimbus]

Surgical control of hemorrhage is paramount. Do whatever you can to facilitate without simultaneously killing the patient.

 

[agammaglobulin]

You DO NOT want to drop BP in this setting. The rupture compromises flow to a significant chunk of the brain. You want to enhance collateral circulation. Dropping the BP will only serve to enlarge the ischemic area. Very short term maneuvers to decrease CO (like esmolol or adenosine) can be employed, but as a late resort, and only in close coordination with the surgeon.

Also remember that the brain receives a ton of blood flow. If an aneurysm pops, you need to start thinking about volume maintenance as well.

I think we're saying the same thing. Short-term decrease in BP to lesson bleeding and help surgeon get control, followed by normal/high BP for collateral circulation once stabilized. I don't think while the aneurysm is rupturing you want to INCREASE BP to help collateral circulation, this would just make matters worse. Besides, there's no blood getting to collaterals as it's all pouring out...

 

[deleted162650]

I think we're saying the same thing. Short-term decrease in BP to lesson bleeding and help surgeon get control, followed by normal/high BP for collateral circulation once stabilized. I don't think while the aneurysm is rupturing you want to INCREASE BP to help collateral circulation, this would just make matters worse. Besides, there's no blood getting to collaterals as it's all pouring out...

We are not saying the same thing. You do not want to lower BP unless specifically asked to do so by the surgeon. Our neurosurgeons did and do in fact want BP maintained or increased in the event of rupture. This is supported by the neuro anesthesia faculty back at my residency program who happen to be the guys that wrote the neuro chapters in Big Miller (and are actually rockstar clinicians in addition to academic powerhouses).

 

[PainDrain]

You want to do two things: allow for surgical control while also providing neuroprotection. Adenosine will drop CO for a brief period and allow a good surgeon the two or three seconds it takes to place a clip. Neuroprotection can be provided by a quick slug of propofol if you aren’t already doing TIVA but as pointed out you don’t want to drop CPP for a prolonged period of time.

 

[agammaglobulin]

We are not saying the same thing. You do not want to lower BP unless specifically asked to do so by the surgeon. Our neurosurgeons did and do in fact want BP maintained or increased in the event of rupture. This is supported by the neuro anesthesia faculty back at my residency program who happen to be the guys that wrote the neuro chapters in Big Miller (and are actually rockstar clinicians in addition to academic powerhouses).

BMJ Article. States temporary clip upstream first line followed by Adenosine in management of acute aneurysm bleed intraop. Pretty sure hypertension is incorrect during rupture. Adenosine seems to be the better choice vs Propofol.
Adenosine to facilitate the clipping of cerebral aneurysms: literature review

 

[deleted59964]

1st communicate with surgeon, I agree with adenosine but have never needed to actually give it - and would only give it after (brief) discussion with surgeon.

So ... what if it ruptures during a coiling?

 

[Robotic Wis-Hipple]

Outcome is significantly impacted...

 

[Arch Guillotti]

So ... what if it ruptures during a coiling?

OR

 

[anbuitachi]

OR

What meds would you use if it ruptures and in that 1 hour period between rupture and transport to OR + Open skull?

 

[IlDestriero]

When this happened in the adult world a decade or two ago we used to give a slug of Pentothal and then some Neo to put the brain into isoelectric state then correct the pressure after the clip was applied. The proximal clip will take out a lot of healthy brain and it may take a bit of time to control the rupture and then release the clamp. You want to decrease oxygen consumption to try to preserve what you can. Sometimes they get a clip on quickly, sometimes it’s not quite so easy. The Hail Mary was adenosine. Yes it may cause ischemia, but exsanguination and brain trauma/injury trying to get control are guaranteed. Temporary ischemia is usually well tolerated isn’t it?
Now all we have is propofol. I actually had one rupture recently, but it was a non event as it was small and locally controlled in the time it took to have a brief profanity laden rant.


--
Il Destriero

 

[BLADEMDA]

While temporary clipping is a valuable tool, it cannot be applied in all cases. This is especially true for large or deep aneurysms in narrow corridors or near the skull base where temporary clip ligation can further obscure a limited view or is even entirely impossible.2 3 7 11 15 17 In these situations, adenosine-induced cardiac arrest relaxes the brain and may improve visualisation in narrow corridors.22 Moreover, temporary clip ligation only decreases blood flow from one direction, while adenosine-induced hypotension is more global and, in certain instances, can more effectively decompress the aneurysmal dome.23

Intraoperative aneurysmal rupture significantly increases morbidity and mortality, likely secondary to the bleeding itself or the ineffective or dangerous tactics employed by the surgeon.24 In this scenario, while temporary clipping is considered the gold standard, adenosine can be used as an effective synergistic tool.7 17

See Table 1


Adenosine to facilitate the clipping of cerebral aneurysms: literature review

 

[Noyac]

Adenosine-induced cardiac arrest during intraoperative cerebral aneurysm rupture. - PubMed - NCBI

Adenosine-induced flow arrest to facilitate intracranial aneurysm clip ligation does not worsen neurologic outcome. - PubMed - NCBI

I’m also on the side of do not increase the BP.

But the idea behind adenosine isn’t that it decreases BP as much as it can induce temporary cardiac arrest. Doses of 12-36mg can induce approximately 30 sec of temporary cardiac arrest which is somewhat cardiac protective as well since there is no cardiac activity. Therefore, safer in CAD pts than hypotension alone. But that 30 sec is gonna feel like forever.

 

[T-burglar]

I wonder if rapid pacing like they do in TAVRs wouldnt be better than adenosine.

I know nobody does it but it could work better

 

[UrbanAchievers]

I wonder if rapid pacing like they do in TAVRs wouldnt be better than adenosine.

I know nobody does it but it could work better

Actually have heard of some places doing exactly that in certain situations. Also, there are some studies demonstrating the efficacy and safety of this approach.

We don't do rapid pacing at our institution for clippings, but I have given adenosine. The key with the adenosine is you are giving a much larger dose than the standard 6 mg. More on the range of .3mg/kg range.

 

[Shimmy8]

For anyone who's had to give adenosine in this situation, did you throw pads on the patient before adenosine? I'm assuming not given time constraints, but if they're gonna code anyway...And on that note, if you had pads on, could you pace this patient up to 180 bpm like a TAVR to get zero flow? Would that even work?

Regarding the maintain BP vs give adenosine debate above, I guess if I ran into this on my oral exam next week I'd just say I would be prepared to do both, and do whatever facilitated surgeon to control bleeding?

 

[Noyac]

I wonder if rapid pacing like they do in TAVRs wouldnt be better than adenosine.

I know nobody does it but it could work better

In the case of a pt with questionable cardiac status, like CAD, I think asystole for half a minute would be better tolerated than rapid pacing from a cardiac ischemia standpoint. But I’d rather not find out either way.

 

[anbuitachi]

For anyone who's had to give adenosine in this situation, did you throw pads on the patient before adenosine? I'm assuming not given time constraints, but if they're gonna code anyway...And on that note, if you had pads on, could you pace this patient up to 180 bpm like a TAVR to get zero flow? Would that even work?

Regarding the maintain BP vs give adenosine debate above, I guess if I ran into this on my oral exam next week I'd just say I would be prepared to do both, and do whatever facilitated surgeon to control bleeding?

Rapid pacing with pads? Does that work? Never seen that before.. Sounds a lot more dangerous than adenosine

 

[sevoflurane]

In the case of a pt with questionable cardiac status, like CAD, I think asystole for half a minute would be better tolerated than rapid pacing from a cardiac ischemia standpoint. But I’d rather not find out either way.

I would think this as well as your O2 consumption is not nearly as much during 30 seconds of asystole versus a blood pressure of nearly nil due to rapid pacing at 180 bpm.

That being said, I do a fair amount of TAVRs. Some of my patients have EFs of 15-20%, Severe MR, CAD, COPD, DM, PVD and are undergoing alternative access for some of these cases (trans-aortic, trans-apical, subclavian, etc). We pace them at 180bpm for 20 seconds, drive their pressure down to nothing and they almost always recover w/o the need for pressors. Pretty remarkable even in the awake patient.

 

[sevoflurane]

Rapid pacing with pads? Does that work? Never seen that before.. Sounds a lot more dangerous than adenosine

Transvenous pacer placed by either us or cards. It's actually very easy to do with fluoro.

 

[anbuitachi]

Transvenous pacer placed by either us or cards.

Do some people actually put TV pacer for every clipping case...

 

[deleted162650]

Do some people actually put TV pacer for every clipping case...

No, he was talking about TAVR’s.

 

[sevoflurane]

Do some people actually put TV pacer for every clipping case...

I'm talking about TAVR. Never done that for a clipping case. I would say that adenosine is better for this due to O2 consumption risks... but I wouldn't be surprised to hear that some clippings have rapid pacing abilities during certain parts of the procedure. Very predictable and you can turn it on and off whenever you want.

 

[deleted59964]

What meds would you use if it ruptures and in that 1 hour period between rupture and transport to OR + Open skull?

yeah - that's what I was getting at ... what do you do in the interventional suite while preparing for transfer to theatre

 

[Shimmy8]

I’d probably get out my Rosary.

 

[nimbus]

I’d probably get out my Rosary.

I know a story about an anesthesiologist who pulled out a bible. The surgeon was not impressed.

 

[T-burglar]

Yeah before the invention of the TAVR I would have been worried more about rapid pacing in theory than adenosine, but frail TAVR patients prove that it’s pretty safe. I haven’t yet seen the pacing cause an issue after hundreds of these, usually it’s the BAV that causes problems

 

[Psai]

I know a story about an anesthesiologist who pulled out a bible. The surgeon was not impressed.

Did the surgeon sign his autobiography

 

[Noyac]

Did the surgeon sign his autobiography

 

[Scotty_G]

Call me silly but why don't you give a bolus of propofol for protection/CMR etc and give a dose of vasopressor together. Maintain the BP before it goes down rapidly and see if the surgeon can get control over the few minutes you bought them. You already have an a-line....I feel like adenosine is not used as much anymore. Would I use it yes.... but not first.

 

[Ronin786]

The most important thing in a bleeding aneurysm is to provide a blood-less field so the surgeon can clamp. Deal with the consequences later. That's why adenosine is great in these situations. Giving a vasopressor is only going to make the field even bloodier.

 

[deleted59964]

My approach to a ruptured aneurysm during coiling in cath lab.


Get help - arrange for surgery, and transport to OR

A- Secure airway

B- ventilate to low normal co2

C - BP control MAP 60-80, rupture usually assoc with htn either as cause of rupture or as Cushing response. Use b blocker, and propofol (decreases cmr)

D- reverse heparin, consider platelets if on antiplatelets, consider mannitol or hypertonic saline to reduce ICP, give seizure prophylaxis

 

[deleted162650]

My approach to a ruptured aneurysm during coiling in cath lab.


Get help - arrange for surgery, and transport to OR

A- Secure airway

B- ventilate to low normal co2

C - BP control MAP 60-80, rupture usually assoc with htn either as cause of rupture or as Cushing response. Use b blocker, and propofol (decreases cmr)

D- reverse heparin, consider platelets if on antiplatelets, consider mannitol or hypertonic saline to reduce ICP, give seizure prophylaxis

Your IR cerebral coilings are not intubated from the get go?? Everyplace I’ve worked these are done under GA with the pt paralyzed.

 

[deleted59964]

Your IR cerebral coilings are not intubated from the get go?? Everyplace I’ve worked these are done under GA with the pt paralyzed.

Nope la and judicious sedation mostly

 

[Psai]

Your IR cerebral coilings are not intubated from the get go?? Everyplace I’ve worked these are done under GA with the pt paralyzed.

Not necessary to do ga but there is a higher rate of complications like dissection and rupture.

 

[anbuitachi]

Nope la and judicious sedation mostly

That sucks. To even intubate urgently in one of those hybrid ORs.. Takes 5 minute just to climb over everything to get to the patient and you are intubating with your anesthesia machine 5 miles away.

 

[deleted59964]

That sucks. To even intubate urgently in one of those hybrid ORs.. Takes 5 minute just to climb over everything to get to the patient and you are intubating with your anesthesia machine 5 miles away.

Not necessary to do ga but there is a higher rate of complications like dissection and rupture.

Institution dependant I think.
Our rockstar IR is fine with sedation, and the decision is very patient dependant...

anyway my approach would be as above for a rupture in the IR suite, agreed all all the better if you can skip to b.