Craniotomy TIVA

[deleted875186]

---

Members don't see this ad.

Back when there was a Remi shortage, say you did an all day 8 hour craniotomy with TIVA. Used propofol with fentanyl, or sufentanil. They start to close dura. Person is prone or head turned in mayfield pins. How do you try and wake this person up in a reasonable amount of time?

How long do you turn off propofol or your opioid?

Do you keep paralyzed until pins are off? Do you get them breathing even if prone?

Anyone ever use nitrous for wake up?

 

[psychbender]

It's been a long time since I've done one of these cases, but I usually shut off the fent when they opened dura. The brain itself has no nociceptors. Generally kept relaxed until pins were out, then immediately reverse. In residency, we rotated at a big name hospital that used nitrous on all cranis (from the get go, not just for wakeup), and it didn't seem to lead to significant AMS from pneomocephalus.

Sent from my SM-G930V using SDN mobile

 

[deleted162650]

Back when there was a Remi shortage, say you did an all day 8 hour craniotomy with TIVA. Used propofol with fentanyl, or sufentanil. They start to close dura. Person is prone or head turned in mayfield pins. How do you try and wake this person up in a reasonable amount of time?

How long do you turn off propofol or your opioid?

Do you keep paralyzed until pins are off? Do you get them breathing even if prone?

Anyone ever use nitrous for wake up?

Keep relaxed until you're ready for them to wake up - easy peasy now with sugga. That way you can lighten them up with impunity and not worry about them ripping their head outta the pins.

Long duration propofol gtts are the devil. Turn it way down or off as soon as possible (once ICP/brain relaxation is no longer a big concern - this is on a case by case basis. Walk around to the head, if you can park a VW inside the dura then WTF are messing around with prop for, run some gas. If the brain is tight or the surgeon needs maximal relaxation for retractors, etc. then maintain TIVA or close to it).

No problem using nitrous for wake up. As long as the surgical field is the most superior point, pneumocephalus isn't a concern as the gas will be displaced with fluid during closure. Pneumocephalus can be an issue for sitting cranis or other cases where gas could get trapped/entrained in a pocket that isn't readily open to the atmosphere and can't get irrigated easily.

There are a number of ways to titrate your opioid for cranis. Figure out which way works for you. Sufenta infusions are awesome (wish I still had that drug on formulary). To me, opioid management is the real art to a nice crani.

 

[anbuitachi]

Back when there was a Remi shortage, say you did an all day 8 hour craniotomy with TIVA. Used propofol with fentanyl, or sufentanil. They start to close dura. Person is prone or head turned in mayfield pins. How do you try and wake this person up in a reasonable amount of time?

How long do you turn off propofol or your opioid?

Do you keep paralyzed until pins are off? Do you get them breathing even if prone?

Anyone ever use nitrous for wake up?

Never used nitrous. No reason for me to take a risk like that. I don't paralyze half the time because the neurosurgeons do neuromonitoring for their cranies here occasionally. Don't need to keep paralyzed for pins.. and yes get them breathing even in prone. You can always add some low dose sevo to decrease propofol dose.

 

[Arch Guillotti]

Never used nitrous. No reason for me to take a risk like that.

What's the big risk?

 

[jwk]

Back when there was a Remi shortage, say you did an all day 8 hour craniotomy with TIVA. Used propofol with fentanyl, or sufentanil. They start to close dura. Person is prone or head turned in mayfield pins. How do you try and wake this person up in a reasonable amount of time?

How long do you turn off propofol or your opioid?

Do you keep paralyzed until pins are off? Do you get them breathing even if prone?

Anyone ever use nitrous for wake up?

After an 8hr procedure, nobody should be expecting them to wake up quickly. Take the time to do it safely. Bucking in the Mayfield is a disaster to be avoided. If it takes a few extra minutes to wake them up, so be it.

 

[Mman]

Never used nitrous. No reason for me to take a risk like that. I don't paralyze half the time because the neurosurgeons do neuromonitoring for their cranies here occasionally. Don't need to keep paralyzed for pins.. and yes get them breathing even in prone. You can always add some low dose sevo to decrease propofol dose.

Nitrous-narcotic techniques have probably been used for more cranis than any other technique around the world so I'm not sure what the big risk is, especially for a short duration at the end of a case.

 

[dannyboy1]

After an 8hr procedure, nobody should be expecting them to wake up quickly. Take the time to do it safely. Bucking in the Mayfield is a disaster to be avoided. If it takes a few extra minutes to wake them up, so be it.

This. Now sugammadex makes it alot easier. Anyone notice that cranis take much longer to wake up than spine cases even when running the same TIVA doses for a similar amount of time.

 

[deleted162650]

This. Now sugammadex makes it alot easier. Anyone notice that cranis take much longer to wake up than spine cases even when running the same TIVA doses for a similar amount of time.

Ya. That'll happen when somebody pokes around on your brain for a while. Open dura = free amnesia. It's crazy how light you can run cranis.

 

[NICMAN]

We always ran Remi/iso/N2O in residency and became pretty adept at waking up within 5-10 min of target (except with the occasional 80 y/o with a subarachnoid heme. Ran the remi high 0.2 mcg/kg/min or higher to offload the Iso as they closed the dura and then shut it off right after pins came off and before the head wrap along with NMB reversal.

 

[anbuitachi]

What's the big risk?

Nitrous-narcotic techniques have probably been used for more cranis than any other technique around the world so I'm not sure what the big risk is, especially for a short duration at the end of a case.

didn't say theres a big risk. there's just a risk. sure its not big. but i still dont see why i'd do nitrous over something like sevo. there have been reports of tension pneumocephalus causing shifts, and if there is a pneumo anything with nitrous on, you know who will be blamed.

 

[DrOwnage]

Does anyone use fentanyl for their crani as multiple boluses rather than infusion? I had an attending tell me he was going to teach me "how to use opioids" during a crani. He basically had the theory that interspersing boluses finally reaching around ~7mcg/kg would reach a decent context sensitive half time and you wouldn't have to redose.

 

[POW16]

Does anyone use fentanyl for their crani as multiple boluses rather than infusion? I had an attending tell me he was going to teach me "how to use opioids" during a crani. He basically had the theory that interspersing boluses finally reaching around ~7mcg/kg would reach a decent context sensitive half time and you wouldn't have to redose.

That's exactly how I was trained to do cranis. Bolusing all the fentanyl up front up until opening of dura.

 

[partydoc]

i used to run precedex for these in residency, worked pretty well

 

[anbuitachi]

Does anyone use fentanyl for their crani as multiple boluses rather than infusion? I had an attending tell me he was going to teach me "how to use opioids" during a crani. He basically had the theory that interspersing boluses finally reaching around ~7mcg/kg would reach a decent context sensitive half time and you wouldn't have to redose.

it is sad to say that it has been a while since ive done these calculations. mind refreshing my memory and tell us how you calculated that number?

 

[deleted162650]

Does anyone use fentanyl for their crani as multiple boluses rather than infusion? I had an attending tell me he was going to teach me "how to use opioids" during a crani. He basically had the theory that interspersing boluses finally reaching around ~7mcg/kg would reach a decent context sensitive half time and you wouldn't have to redose.

Fentanyl titrated to somnolence (like the point where you have to remind them to breathe). Induce. However much fent you have already given, throw in another 25% (ish) for head pins. No more opioid for the rest of the case.

 

[Lecithin5]

This. Now sugammadex makes it alot easier. Anyone notice that cranis take much longer to wake up than spine cases even when running the same TIVA doses for a similar amount of time.

All that mucking around in the brain for several hours can make for a longer wake up

 

[anbuitachi]

24-year-old woman shares warning on Facebook after laughing gas left her paralysed

another risk to using nitrous!

 

[Noyac]

Fentanyl titrated to somnolence (like the point where you have to remind them to breathe). Induce. However much fent you have already given, throw in another 25% (ish) for head pins. No more opioid for the rest of the case.

Bingo

 

[thinkorswim]

I am likely in the monority here, but I like to start getting the patient breathing spontaneously early, even when in pins. You just need to make sure to keep them deep.

When they start to close dura, propofol off and keep the patient deep by turning the nitrous and sevo/iso up while titrating in fentanyl to a respiratory rate of 6-8. Reverse (or turn remi off if not paralyzing) once they hand the patient back to you. I find it makes for a nice quick wake up after a long case.

 

[AKMD_1984]

I am likely in the monority here, but I like to start getting the patient breathing spontaneously early, even when in pins. You just need to make sure to keep them deep.
.

why would you want to keep the patient spontaneously breathing while they are in pins? removal of pins is also stimulating. if they are already breathing, that additional stimulus may be a disaster. i dont see how this accomplishes a faster wake up - risk seems higher than the benefit.

There are many ways to do the anesthetic, but I make sure that the patient is paralyzed before the pins are out and I also keep propofol for boluses are the pins are being removed (as they are placed).

Secondly, in obese patients, I titrate the propofol down gradually much earlier.

It also depends on how the surgery went and patient's preexisting condition. there is no such thing as one size fits all...