Posterior Fossa Craniotomy

[Doughy315]

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I have a interesting case today, it is scheduled for a prone Posterior Fossa Craniotomy with pins and arm tucked. How do you guys monitor neuromuscular blockade in these patients?

Thanks

 

[Planktonmd]

I have a interesting case today, it is scheduled for a prone Posterior Fossa Craniotomy with pins and arm tucked. How do you guys monitor neuromuscular blockade in these patients?

Thanks

Why do you need neuromuscular blockade?

 

[Libertas]

I have a interesting case today, it is scheduled for a prone Posterior Fossa Craniotomy with pins and arm tucked. How do you guys monitor neuromuscular blockade in these patients?

Thanks

Why not posterior tibial?

 

[Shimmy8]

Remi

 

[AdmiralChz]

The same way you would for a cervical spine case. We monitor SSEPs and MEPs so NMB is pretty much out the door except for (maybe) the beginning of the case/positioning. A solid sufenta (spines) or remi (intracranial) infusion will work well for you.

 

[AdmiralChz]

Unrelated and off track a bit, but anyone here have surgeons that do these procedures in high beach chair these days? I know VAE makes this much less attractive, but wondered if it was still done out in the community.

 

[Ronin2258]

All the beach chair craniotomies didn't get done in my presence. They were shied away from by most neruosurgeons I worked with.

Beach chair shoulders, on the other hand, have been fast and furious. I know one 'pod that does them lateral.

 

[deleted162650]

Unrelated and off track a bit, but anyone here have surgeons that do these procedures in high beach chair these days? I know VAE makes this much less attractive, but wondered if it was still done out in the community.

At my last gig there was 1 guy that still did all his posterior fossa stuff in beach chair. So it's still done, but rarely. I think it's been a while since they have been training people to do it that way.


Agree with posterior tibial since these pts are usually 180 anyways and you've got the feet right there. Crani's don't really require much anesthetic since there is minimal stimulation once they're past the dura and an open dura = free amnesia so paralyzed and runnin' light is how I like to roll.

 

[Skip2myLou]

if they are doing ssep, emg's, the technician can check the twitches for you.


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[pjl]

We do them sitting, with all that entails...


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[Ronin786]

At my last gig there was 1 guy that still did all his posterior fossa stuff in beach chair. So it's still done, but rarely. I think it's been a while since they have been training people to do it that way.


Agree with posterior tibial since these pts are usually 180 anyways and you've got the feet right there. Crani's don't really require much anesthetic since there is minimal stimulation once they're past the dura and an open dura = free amnesia so paralyzed and runnin' light is how I like to roll.

Why do you say that?

 

[Arch Guillotti]

Why do you say that?

My guess is all the beating and banging on the brain itself.

 

[BLADEMDA]

We do them sitting, with all that entails...


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Decades ago we had a neurosurgeon do these cases in the sitting position. That all changed when one his patients suffered a massive CVA.

 

[deleted162650]

Why do you say that?

Because its true. 😉

Honestly, that's what I was taught - I thought it was generally accepted but maybe not?? Our neuro faculty in residency would run people crazy light once dura was open - I'm talking like on just N2O or just prop at 50 (albeit after a very generous helping of opioid up front). Midaz was a cardinal sin in the neuro room. Recall was never an issue.

 

[BLADEMDA]

Because its true. 😉

Honestly, that's what I was taught - I thought it was generally accepted but maybe not?? Our neuro faculty in residency would run people crazy light once dura was open - I'm talking like on just N2O or just prop at 50 (albeit after a very generous helping of opioid up front). Midaz was a cardinal sin in the neuro room. Recall was never an issue.

It's true. I did the same during residency. Nitrous Oxide plus 0.3 MAC ISO and never any recall.
We used to bolus up front with opioids (20 mls of Fentanyl).

 

[pjl]

It's true. I did the same during residency. Nitrous Oxide plus 0.3 MAC ISO and never any recall.
We used to bolus up front with opioids (20 mls of Fentanyl).

You guys ever do awake cranis? All you do is numb the skull and have them nap for the bone drilling (super noisy). If the extracranial stuff is comfortable, there is basically zero stim. Narcs are 100% optional.

Asleep cranis are the same, but you need them comfortable enough for tube and position. Normally I do 200 fentanyl upfront and 50 at the end. Lowish gas. Similar to what Blade and Salty said above.

Blade, our guy who does sitting is not open to different options most of the time.

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