NEUROANESTHESIOLOGY AT HOSPITAL UNIVERSITARIO CENTRAL DE ASTURIAS

(HUCA), SPAIN

Natalia Pérez de Arriba, MDDepartment of Anesthesiology, Surgical Critical Care and Chronic

Pain, Hospital Universitario Central de Asturias (HUCA), Spain

WELCOME TO THE HOSPITAL

UNIVERSITARIO CENTRAL DE ASTURIAS

(HUCA)• 1039 beds (hospitalization)

• All medical/surgical specialities

• 36 surgery rooms: 2 Neurosurgery rooms 1 Neuroradiology room

Department of Anesthesiology, Surgical Critical Care and Chronic

Pain(HUCA)• 65 Staff

• 18 physicians in training Number of surgical procedures with hospital

admission (2013): 13597 (2/3 scheduled, 1/3 emergency)

Number of ambulatory surgical procedures (2013): 5997

Surgical Care Unit (HUCA)• 28 beds of high level of care

16 beds of low level of care• All surgical specialities (except Cardiac Surgery,

Trauma, Heart and Liver Transplantation, some Neurocritical Patient and Pediatric Critical Care)

Department of Neurosurgery (HUCA)• Surgical procedures: 1100/year (2/3 schedules, 1/3 emergency)

• Brain tumors, “Awake Craneotomy”, Cerebrovascular Surgery, Spine Disorders *, Skull and Cranial Base Surgery, Traumatic Brain Injury, Transnasal Endoscopic Surgery and Pediatric Neurosurgery

• National Referral Hospital Centre for Deep Brain Stimulation: movement disorders (Parkinson, dystonia), cluster headache, chronic pain, obsessive compulsive disease

* Adults and Children Scoliosis (Department of Orthopaedics): 15- 20/year

Interventional Neuroradiology (HUCA)

• Stroke: ischemic and haemorrhagic• Aneuruysm: stent, embolization• Arteriovenous malformation: embolization• Arteriovenous fistula• Carotid stenosis: stent• Cerebral vasospam after subarachnoid hemorrhage

Neuroanesthesia for craniotomyPREOPERATIVE ASSESSMENT

• Age, gender, race• Allergy• Diseases, Surgical procedures• Chronic treatments (antiplatelet therapy/oral

anticoagulants; corticosteroids; antiepileptic drugs)• Physical examination (neurological)• Airway management• ASA• Blood glucose, Hemogram, Urea, Creatine, Sodium,

Potassium, Coagulation, ECG, Chest Ray• CT/MR• Premedication and Blood transfusion• Information and Informed Consent (General Anesthesia

and Transfusion)

• Electrocardiogram (ECG): ST analysis• Non invasive arterial pressure• Invasive arterial pressure• Pulse oximetry (SatO2); capnography; spirometry• Anesthetic depth: bispectral index (BIS), Patient State Index

(PSI)• Neuromuscular blockade (train of four, TOF) • Urine output/hour• Temperature • Two or more big intravenous catheter• Central venous pressure• Swan-Ganz, PiCCO®, LidCO®

Neuroanesthesia for craniotomy STANDARD MONITORING

• Cerebral oximetry (near infrared spectroscopy, NIRS)

• Intracraneal pressure• Intraoperative neurophysiological

monitoring (INM)• Air venous embolism: transesophageal

echocardiography, transcranial doppler and duplex, capnography 

Neuroanesthesia for craniotomy MULTIMODAL MONITORING

• Preoxygenation • Lidocaine iv 1,5 mg/kg, beta blockers (esmolol,

labetalol), urapidil• PaCO2 35-45 mmHg if normal ICP, PaCO2 30-35

mmHg if increased ICP• TCI: propofol (Marsh), remifentanil (Minto)• Neuromuscular non-depolarizing agent: rocuronium

0,6 mg/kg • Prevention of deep vein thrombosis• Antibiotic prophylaxis (cefazolin, vancomycin),

dexamethasone, antiepiletic drugs (levetiracetam, lacosamide)

Neuroanesthesia for craniotomy INDUCTION

Neuroanesthesia for craniotomy POSITION

• TCI: propofol (Marsh, Ce mcg/mL), remifentanil (Minto, Ce ng/mL); No N2O

• Intravenous perfusion of rocuronium: 0,5 mg/kg/h (TOF ratio 0-1/4, If INM: TOF ratio 3-4/4)

• Mannitol 20% (0,25-0,5 mg/kg), Hypertonic saline (3 mEq Na in one hour), Furosemide

• Maintenance CPP: PAS > 90 mmHg, PAM 70-110 mmHg• Ventilation: PaO2 > 100 mmHg, PaCO2 30-35 mmHg (moderate

hyperventilation)• Normovolemic (Plasmalyte®); Hb > 9 g/dL (or > 10 g/dL)• Normoglycemic, Avoid fever• Prevention of cerebral ischemia (aneurysm clipping): hypothermia (<

35 ºC, barbiturate coma)• Treatment of intracranial hypertension: position, no PEEP,

cerebrospinal fluid drainage, osmotic agent, short periods of hyperventilation (25-35 mmHg), anesthesia deeping

Neuroanesthesia for craniotomy INTRAOPERATIVE MANAGEMENT

• “Haemostasis Pressure”• Prophylaxis of nausea and vomiting:

dexamethasone, ondansetron• Prophylaxis acute pain: paracetamol + tramadol ±

metamizole, dexketoprofen• Avoid of hypertension: lidocaine, beta blockers,

urapidil, low doses of remifentanil• TOF ratio > 90%: sugammadex• No recovery in surgical room if: presurgical

Glasgow < 8, > 6 hours, haemorrhage, edema or intracranial hypertension, lesions of cranial nerve or cerebral stem, hypothermia, haemodynamic instability

Neuroanesthesia for craniotomy RECOVERY

• 3 Awake craniotomy: low grade glioma in eloquent tissue of speech in temporal lobe (dominant hemisphere)

• 2 Conscious Sedation: TCI of propofol (Ce 1-2 µg/ml)+ TIVA of remifentanil (0,01-0,1

µg/kg/min) Objective: OAA/S ≥ 3 y/o BIS >60. Stop TCI de propofol 15 minutes before mapping, descend remifentanil

to the half 15 minutes before mapping (not > 0,1 µg/kg/min) Start TCI of propofol at dural close Complications: 1 convulsion (right arm), 1 brain edema, 2 hypertension

• 1 Sleep-Awake-Sleep: Laryngeal mask airway (Supreme®) Complication: hypertension

Neuroanesthesia for awake craniotomy

• Concious sedation:

TIVA of remifentanil (0,01-0,1 µg/kg/min) + bolus of midazolam iv (not propofol if it is possible)

Complications: excess sedation/uncooperative, airway obstruction, hypertension

Neuroanesthesia for deep brain stimulation

THANK YOU FOR YOUR ATTENTION