Neuroanesthesia month

[zyovka]

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I started my neuro month and had my first craniotomies. It feels sort of overwhelming with all the extra steps line/circuit extensions, 180^ turning, pinning, proning etc Then emerging after running Remi, Propofol, 0.5 MAC of gas with neurochecks. Any practical advise, or algorithm how to get all this together to be efficient, smooth and not to stumble upon pt bucking, BP raising and me thinking that this will cause post-op bleeding... It probebly comes with experience, but i did not find the attendings rather smoothly explaining a practical approach to all this, rather than giving a textbook content on the subject, if so...

 

[26B]

I started my neuro month and had my first craniotomies. It feels sort of overwhelming with all the extra steps line/circuit extensions, 180^ turning, pinning, proning etc Then emerging after running Remi, Propofol, 0.5 MAC of gas with neurochecks. Any practical advise, or algorithm how to get all this together to be efficient, smooth and not to stumble upon pt bucking, BP raising and me thinking that this will cause post-op bleeding... It probebly comes with experience, but i did not find the attendings rather smoothly explaining a practical approach to all this, rather than giving a textbook content on the subject, if so...

Save the remi/prop and do your big cranis/spines with iso/nitrous like we do at my program 😉

On a more serious note, a few things I found helpful:

-Have something available for the sympathetic response to pinning. A little esmolol, remi, etc will do the trick.
-If you're running remi, don't turn it off too early. I usually don't do it until the patient is out of pins. In fact, you can even wake patients up on a low rate of remi (like .05) and it will be some of the smoothest emergences you will ever see.
-Don't reverse if the patient is still in pins
-When setting up the room in the AM, make a quick mental note of how your lines will look after turning 180, after flipping prone, etc. Also make sure you have enough slack in your circuit tubing so that you don't end up with an extubated patient once turned (didn't happen to me personally, thankfully). For prone cases, right before the flip, do a quick 2-3 second glance at IV lines to see if anything is at risk for getting pulled out after the flip. The last thing you want right after a flip is to be holding pressure over an A-line that got ripped out.
- For patients in non-standard positions like beach chair, arterial line transducer should be at Circle of Willis, since what you care about is cerebral perfusion
- For prone patients, check the eyes frequently. Spine surgeons can be pretty rough with their retracting and other maneuvers, and your patient's head may shift and cause the eyes to no longer be in the hole of the prone pillow...which is no bueno.
- Big spines are can be quite bloody. Keep an eye on the suction canisters and laps.
- If you're going to order a scopolamine patch for a crani, consider where that patch will be placed and whether the surgeon is going to be inadvertently pressing on it the entire case. That way you'll have a good explanation when the patient has a blown pupil on emergence 🙂

 

[sevoflurane]

Sounds like you are covering the neuro basics very well. You will get comfortable there with a little more experience.

Know your infusions well so you can have a smooth flight and a smooth landing. Goes for any case, but more so in patients who are prone or in head pins.

 

[deleted171991]

I started my neuro month and had my first craniotomies. It feels sort of overwhelming with all the extra steps line/circuit extensions, 180^ turning, pinning, proning etc Then emerging after running Remi, Propofol, 0.5 MAC of gas with neurochecks. Any practical advise, or algorithm how to get all this together to be efficient, smooth and not to stumble upon pt bucking, BP raising and me thinking that this will cause post-op bleeding... It probebly comes with experience, but i did not find the attendings rather smoothly explaining a practical approach to all this, rather than giving a textbook content on the subject, if so...

It's not your fault. It seems that you have had poor teaching in the crani room. Your attendings should show you the smooth way of doing all of these things.

 

[zyovka]

Save the remi/prop and do your big cranis/spines with iso/nitrous like we do at my program 😉

On a more serious note, a few things I found helpful:

-Have something available for the sympathetic response to pinning. A little esmolol, remi, etc will do the trick.
-If you're running remi, don't turn it off too early. I usually don't do it until the patient is out of pins. In fact, you can even wake patients up on a low rate of remi (like .05) and it will be some of the smoothest emergences you will ever see.
-Don't reverse if the patient is still in pins
-When setting up the room in the AM, make a quick mental note of how your IV lines will look after turning 180, after flipping prone, etc. Also make sure you have enough slack in your circuit tubing so that you don't end up with an extubated patient once turned (didn't happen to me personally, thankfully)
-Art line transducer should be at Circle of Willis, since what you care about here is brain perfusion

Can you please reiterate on "big cranis/spines with iso/nitrous"? It sounds, well... very different and rather mind boggling...

 

[Mikkel]

I started my neuro month and had my first craniotomies. It feels sort of overwhelming with all the extra steps line/circuit extensions, 180^ turning, pinning, proning etc Then emerging after running Remi, Propofol, 0.5 MAC of gas with neurochecks. Any practical advise, or algorithm how to get all this together to be efficient, smooth and not to stumble upon pt bucking, BP raising and me thinking that this will cause post-op bleeding... It probebly comes with experience, but i did not find the attendings rather smoothly explaining a practical approach to all this, rather than giving a textbook content on the subject, if so...

Get really good at disconnecting and reconnecting everything.

Use high dose short acting agents, and low dose long acting agents.

Keep your priorities straight. But like most things in life, getting better just requires more experience. You'll figure it out on your own.

 

[deleted162650]

Can you please reiterate on "big cranis/spines with iso/nitrous"? It sounds, well... very different and rather mind boggling...

Step 1: Induce and intubate in the usual fashion
Step 2: turn on iso and nitrous
Step 3: turn off iso
Step 4: turn off nitrous
Step 5: Extubate in the usual fashion

It’s not brain surgery.





See what I did there 😉

 

[26B]

Can you please reiterate on "big cranis/spines with iso/nitrous"? It sounds, well... very different and rather mind boggling...

<0.5 MAC Iso, 0.5 MAC N2O, vec bolus or gtt to 2 twitches. Neuromonitoring will still be able to get decent SSEPs/MEPs.

 

[Planktonmd]

A neuro case is nothing but another general anesthetic.
I know they are trying to tell you otherwise and teach you that it's such a complicated process, but trust me if you know how to do general anesthesia properly you should be able to do all these cases.

 

[MoMoGesiologist]

<0.5 MAC Iso, 0.5 MAC N2O, vec bolus or gtt to 2 twitches. Neuromonitoring will still be able to get decent SSEPs/MEPs.

Our neuro monitoring people would tell us not to use nitrous and it’s taught that it reduces signals. We would never use it when monitoring. You have had no issues with signals?

 

[zyovka]

Having read all the above, i think, one can't find a real life advise in any textbook, but would be lucky to get one only from people, who care. Very grateful here😍

 

[26B]

Our neuro monitoring people would tell us not to use nitrous and it’s taught that it reduces signals. We would never use it when monitoring. You have had no issues with signals?

Yeah, we do a huge # of big neuro cases here (probably among the highest in the country), and many cases are done this way. As long as the neuromonitoring people get a good baseline and you don't change the nitrous up/down significantly during the case, it presents no major issues.

 

[dannyboy1]

If you have suggamadex just keep them paralyzed and on very low MAC/remi/nitrous. When out of pins, reverse.

 

[deleted171991]

<0.5 MAC Iso, 0.5 MAC N2O, vec bolus or gtt to 2 twitches. Neuromonitoring will still be able to get decent SSEPs/MEPs.

Who does neuromonitoring during regular cranis?

 

[abolt18]

I started my neuro month and had my first craniotomies. It feels sort of overwhelming with all the extra steps line/circuit extensions, 180^ turning, pinning, proning etc Then emerging after running Remi, Propofol, 0.5 MAC of gas with neurochecks. Any practical advise, or algorithm how to get all this together to be efficient, smooth and not to stumble upon pt bucking, BP raising and me thinking that this will cause post-op bleeding... It probebly comes with experience, but i did not find the attendings rather smoothly explaining a practical approach to all this, rather than giving a textbook content on the subject, if so...

You turn 180° AND prone in the same case? Ouch. That just plain sucks.

 

[hununuh]

As long as patients airway is fine, why cant you intubate 180? That way, you just have to turn prone afterwards.

 

[jwk]

As long as patients airway is fine, why cant you intubate 180? That way, you just have to turn prone afterwards.

How long are your arms? 😉

 

[deleted875186]

Just give general anesthesia, have some antihypertensive for emergence. Run some Remi, or just bolus fentanyl. Who cares about making all the lines and monitors look smooth, do enough cases and you’ll get there whether you want to or not.

 

[jeesapeesa]

I started my neuro month and had my first craniotomies. It feels sort of overwhelming with all the extra steps line/circuit extensions, 180^ turning, pinning, proning etc Then emerging after running Remi, Propofol, 0.5 MAC of gas with neurochecks. Any practical advise, or algorithm how to get all this together to be efficient, smooth and not to stumble upon pt bucking, BP raising and me thinking that this will cause post-op bleeding... It probebly comes with experience, but i did not find the attendings rather smoothly explaining a practical approach to all this, rather than giving a textbook content on the subject, if so...

prop/roc/fent/tube/aline/sevo.

 

[nimbus]

How about just turn 90 and you get to use NS instead of LR.

 

[deleted162650]

Tight head??

Volatile bad, prop good.

 

[Quixotic2501]

Good advice up above. One thing I'll add is to attach your extensions to the first IV in holding. It'll save you a few seconds.
If turning 180 (and no prone), make sure you have your extensions ready to go, and you should be able to have all your lines and monitors running on one side of the bed (opposite the side of the bed that it turns) so you don't have to worry about disconnecting and reconnecting.

 

[nimbus]

So much of this is housekeeping and not really technical or medical at all. But still just as important. Simple things matter.

 

[deleted171991]

So much of this is housekeeping and not really technical or medical at all. But still just as important. Simple things matter.

The problem is that the housekeeping should be taught by attendings who have personally done these cases many times.

 

[deleted162650]

The problem is that the housekeeping should be taught by attendings who have personally done these cases many times.

Sometimes the best teaching is letting the resident end up with a macrame of lines and tubes and then sit in the corner and chuckle while they try to un-braid everything.

Then after the case you present them with a Boy Scout knot tying merit badge.

 

[Ras Tafari]

If running Remi and nitrous at the end of a neuro case, typically I turn the remi off as the pt’s head is being unpinned and then nitrous is off just before we spin the bed back so I have the airway. If done properly, the patient has no long-acting analgesia except maybe Tylenol plus the scalp block, and as soon as you have monitors reconnected the patient opens their eyes with a tap to the forehead and allows you to extubate smoothly.

 

[deleted697127]

I don’t use nitrous a lot. I would probably check with your attending before using nitrous discussing how and why you’re using it if doing so during a case with a relative contraindication. You may encounter some people with strong feelings about expanding air embolisms during neuro cases. Nitrous, a 180 flip from prone and obesity sounds like a disaster waiting to happen. I would want this patient rotated back 180 and preoxygenated before flipping from prone. I wouldn’t want a rapidly decreasing level of sedation from turning off nitrous to preoxygenate during a flip.

Focus on safety while learning. Efficiency will come with experience.