This document discusses the complexities and challenges of awake craniotomy procedures, emphasizing the importance of teamwork, careful patient selection, and meticulous anaesthetic management. Key considerations include addressing the patient's psychological needs, managing unique complications, and ensuring proper positioning and communication during surgery. The author shares insights on the need for artistic skills, as well as the risks associated with inadequate preparation or oversight.

1. Decoding a misnomer:
Awake Craniotomy
Dr Unnikrishnan P MD,PDCC,MBA
Associate Professor
Neuroanaesthesia Division
SCTIMST

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3. Conventional terminology may mask reality
Awake Craniotomy
Craniotomy with
Intraoperative
awakening
It’s a team work

4. Challenging task for the
anaesthesiologist
╺ Invasive procedures in a patient who is not anaesthetized
╺ A meticulous scalp block
╺ Carefully titrated sedation/anaesthesia
╺ Unique complications to deal with
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5. Careful selection of the patient
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╺ OSAS
╺ Anticipated difficult airway
╺ Psychiatric disorder
╺ Chronic cough
╺ Sinus infiltration

6. Be on the right side; you
need some artistic skills
too!
╺ A realistic explanation of what to expect
╺ Psychological preparation and support
╺ Controlling the nuances in the
anaesthetic and analgesic levels
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7. Be a perfectionist while
positioning
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╺ Cushioning
╺ Tent
╺ Access: to face and airway
╺ O2 mask
╺ EtCO2 sampling line
╺ Claustrophobia
╺ House keeping

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You will miss GA
╺ Position
╺ Do fast
╺ Ventilation: ? tight brain
╺ Bleeding
╺ Well sedated? Well…
╺ Extreme head rotation
Please don’t post for AC

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10. Powerless positions
╺ Limited airway access with the clamp
╺ Fluid management difficult
╺ Management of bleeding difficult
╺ Positioned at foot end and patient is without any
airway gadget
╺ Hyperventilation (X)
╺ Certain positions less tolerated

11. A hotline is necessary
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╺ LA
╺ Time gap-Mapping/Resection
╺ Dura
╺ Pain
╺ Closure

12. You need to be
Dr Strange
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╺ Seizures (No airway gadget in place):
Rx ice cold saline
╺ Pain (Further narcotics will affect
testing): transcortical resection
╺ Loss of airway (Head on clamps): SGA

13. Possible costly misses by an
occasional practitioner
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╺ Missing the C/I eg OSAS, psychological issues
╺ Different preparation of the OT
╺ Subtle points during positioning: eg L clamp
╺ Fine titration and timing of stoppage of the agents
╺ Continuous communication

14. Possible costly misses by an
occasional practitioner
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╺ Selection of the drug
╺ Under dosing
╺ Over dosing
╺ OSAS patient
╺ Opioids
╺ Phenytoin
╺ Antiemetics
╺ Airway loss management
╺ Seizures

15. That
concludes
the
story
of
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16. Thanks!
Any questions?
You can find me at drunnikrishnanp@gmail.com
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