Anesthetic management of patients with aneurysmal subarachnoid hemorrhage is challenging due to the emergency presentation, complex pathology, varied intracranial and systemic manifestations, and special management requirements. Successful outcomes rely on understanding the pathophysiology, associated complications, preoperative optimization, definitive therapy choice, vigilant monitoring, and optimal postoperative care. Key concerns include effects of the ruptured aneurysm, maintaining a relaxed brain during surgery, monitoring for ischemia during temporary vessel occlusion, and detecting postoperative complications.
Enumerates the effect of different anesthetic agents on the CNS and compares their relative efficacy and safety in providing good outcome in neuroanesthesia
Intro to Hypoxic pulmonary vasoconstriction Arun Shetty
Hypoxic pulmonary vasoconstriction, a seldom heard phenomenon but very effective physiologic property which helps lungs utilise ventilation to the maximum
Pituitary Tumors account for 15% of Braun tumors. Trans sphenoidal endoscopic approach are more common. Post surgery fluid and electrolyte balance is important.
Enumerates the effect of different anesthetic agents on the CNS and compares their relative efficacy and safety in providing good outcome in neuroanesthesia
Intro to Hypoxic pulmonary vasoconstriction Arun Shetty
Hypoxic pulmonary vasoconstriction, a seldom heard phenomenon but very effective physiologic property which helps lungs utilise ventilation to the maximum
Pituitary Tumors account for 15% of Braun tumors. Trans sphenoidal endoscopic approach are more common. Post surgery fluid and electrolyte balance is important.
Brief and concise presentation on oxygen therapy. Safety and toxicity to staff anf managment of Battor Catholic Hospital, A very reputable and efficient hospital in Ghana in the Volta Region
Malignant Hyperthermia - Essential Charactistics:
>An inherited disorder of skeletal muscle triggered in susceptibles (human or animal) in most instances by inhalation agents and/or succinylcholine, resulting in hypermetabolism, skeletal muscle damage, hyperthermia, and death if untreated.
>Underlying physiologic mechanism – abnormal handling of intracellular calcium levels.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Concerns and challenges during anesthetic management of aneurysmal
1. Concerns And Challenges During
Anesthetic Management Of
Aneurysmal Subarachnoid
Hemorrhage
BY
DR. CHAMIKA HURUGGAMUWA
REGISTRAR IN ANAESTHESIOLOGY
2. Anesthetic management of patients with aneurysmal
subarachnoid hemorrhage is challenging because
Emergency nature of the presentation,
Complex pathology,
Varied intracranial and systemic manifestations
Need for special requirements during the course of management
3. Successful perioperative outcome depends on
overcoming these challenges by ,
Thorough understanding of pathophysiology of Subarachnoid hemorrhage,
Knowledge about associated complications, preoperative optimization,
Choice of definitive therapy,
A good anesthetic and surgical technique,
Vigilant monitoring and
Optimal post-operative care
4. INTRODUCTION
Aneurysmal subarachnoid hemorrhage (aSAH) is an emergency
neurological condition with a very high mortality (>25%) and
significant morbidity (>50%)
The estimated worldwide incidence of SAH is 9/ 100,000 persons/y
with regional variation.
SAH accounts for only 5% of all strokes,but it has high mortality
and permanent disability rates
5. Ruptured cerebral aneurysms account for 75% to 85% of
SAH for nontraumatic SAH.
Other causes include,
AV malformations,tumours
Non-aneurysmal perimesenchephalic haemorrhage.
6. RISK FACTORS FOR DEVELOPMENT AND
RUPTURE OF INTRACRANIAL ANEURYSMS
RF For development,
Hypertension,
Smoking,
Chronic alcohol use,
Family history of intracranial aneurysms in first-degree
relatives
Female sex.
7. RF for Rupture
Female sex
Japanese or Finnish descent,
Size and location of aneurysms,
Hypertension,
Smoking
Older patients
Cocaine abuse.
8.
9. Concerns/challenges in patients with
intracranial aneurysm
1. Systemic and intracranial effects of ruptured aneurysm.
2. Full brain during surgery.
3. Monitoring for ischemia and providing cerebral protection during
temporary vessel occlusion (TVO).
4. Post clipping evaluation of circulation.
5. IOAR.
6. Hemodynamic manipulation.
7. Smooth induction and early recovery.
8. Detection and management of complications
10. Clinical Presentation
Most aneurysms remain undetected during one’s lifetime or until
rupture
An aneurysm is often an incidental finding.
The most common presenting feature of an aneurysm is SAH
“This is the worst headache of my life.”/ thunderclap headache
An SAH headache is most often associated with nausea, vomiting,
neck rigidity, and photophobia.
11.
12. As many as 30% to 40% of the patients may present with a sentinel
headache; a warning headache occurring a few weeks before the
major bleed possibly due to a warning leak.
Depending on the severity of SAH, the patient may present with
drowsiness, confusion, focal neurological deficits, hemiparesis, and
even coma
16. Mortality is commonly caused by neurological injury resulting
from the initial bleeding and rebleeding and from delayed
cerebral ischemia (DCI).
Mortality is a function of the volume of initial hemorrhage and
initial neurological status following SAH.
Elderly patients and patients with coexisting medical conditions
are at higher risk for mortality.
The clinical goal is to prevent rebleeding and DCI.
17. Cardiac Manifestations
The likely cause is sympathetic activation along with
parasympathetic dysfunction resulting in inflammation of cardiac
myocytes
ECG abnormalities- ST and T wave changes, suggestive of
myocardial ischemia and QT prolongation and U waves
SAH may present with supraventricular and ventricular
arrhythmias, elevated troponin levels, and myocardial dysfunction
without coronary vasospasm
.The degree of troponin elevation is associated with an increased
risk for cardiovascular complications and vasospasm-induced DCI
and poor neurological outcome
18. association between QT prolongation, tachycardia, and
development of angiographic vasospasm.
Thus these cardiac changes primarily reflect the severity
of neurological injury, but are reversible in the majority of
cases and are likely to resolve
19. Neurogenic Pulmonary Edema (NPE)
Massive catecholamine release during ictus can cause pulmonary
hypertension, increased hydrostatic pressure and pulmonary edema,
increasing the risk of morbidity and mortality
Associated with reduced global and segmental left ventricular
systolic function.
NPE reflects the severity of the subarachnoid bleed and is
associated with poor outcome.
.
20. Hypertension
Sympathetic activation following SAH is an important cause of
hypertension
Elevated blood pressure (BP) following aSAH is associated with
higher mortality.
Labetalol, esmolol, and nicardipine are commonly used agents to
reduce hypertension in patients with aSAH.
Vasodilators such as nitroglycerine, hydralazine, and sodium
nitroprusside should be avoided because vasodilatation may increase
cerebral blood flow and is likely to worsen ICP
21. Hyperglycemia
Hyperglycemia was found to be associated with increased length of ICU stay, and
increased risk of death and disability in one retrospective cohort study.
Analysis of data from 1000 patients in the Intraoperative Hypothermia for
Aneurysms Surgery Trial (IHAST II) revealed that patients with SAH, secondary
to ruptured aneurysm, who underwent clipping, and whose blood sugar levels
were >129 mg/dL, had long-term cognitive dysfunction. Patients with blood
sugar levels >152 mg/dL had deficits in gross neurological function.
Glycemic control with aggressive hyperglycemia management is associated with
improved outcome.
22. Metabolic derangements
Hyponatremia is a common complication occurring in one third of aSAH
patients. This is secondary to
syndrome of inappropriate diuretic hormone (SIADH) or cerebral salt
wasting (CSW).
Other electrolyte disturbances in these patients include hypomagnesemia,
hypokalemia and hypocalcemia.
Fever is a common occurrence (70%) especially in poor grades,
contributes to adverse outcome and may not always respond to
conventional treatment.
24. Planning of intervention-coiling or clipping
surgically managed patients include those with parenchymal
hematoma and large aneurysm, while endovascular therapy is
preferred in elderly, patients with significant co-morbidity, poor
grades and basilar artery aneurysm
The International Subarachnoid Aneurysm Trial showed better
outcomes with endovascular treatment compared to surgery.
Since then, increasing number of patients are managed by
endovascular technique shifting the anesthetic management outside
the operating room.
25.
26. Time of surgery
Practice of delayed surgery to avoid edematous brain has been
replaced by early surgery to minimize risk from rebleeding and
vasospasm.
Mahaney et al. in their analysis of intraoperative hypothermia for
aneurysm surgery trial (IHAST) data observed that patients
operated early (day 0-2) or late (day 7-14) fared significantly better
than those operated during intermediate phase (day 3-6).
27. Challenges during anesthetic induction and
intubation
General goals include
smooth induction and
hemodynamic control to prevent rebleeding.
Propofol or thiopentone in liberal doses attenuates hemodynamic
response and rebleeding risk in good grade patients.
The risk from hemodynamic and hypoxic stress associated with
repeated attempts at intubation can have an adverse bearing on the
outcome.
28. Maintenance of anesthesia
Both intravenous and inhalational anesthetic technique may be
used for maintenance.
Cerebral perfusion increases with isoflurane when compared with
propofol without increase in ICP in aSAH.
Hypocapnia is not essential in good grade patients as it can reduce
ICP and increase transmural pressure within aneurysmal sac
predisposing it to rupture.
In poor grade patients, hyperventilation however is beneficial to
reduce ICP and provide lax brain.
29. Challenges from a full brain
Both 20% mannitol and 3% hypertonic saline are suitable
osmotic agents for intraoperative brain relaxation in the
dose of 2-4 ml/kg.
Head end elevation, avoiding jugular venous
compression, avoiding high concentration of inhalational
agents and nitrous-oxide and mild hyperventilation are
other measures to achieve a lax brain.
30. Monitoring for ischemia and cerebral
protection during temporary vessel
occlusion
Whenever possible, direct clipping is preferred.
However, when it is not possible or anticipated to be
difficult, TVO is performed to facilitate peri-aneurysmal
dissection and safe permanent occlusion of the aneurysm.
Hypotension, used earlier, reduced the pressure within the
aneurysmal neck and facilitated clipping. However,
hypotension in an already injured brain increased
ischemic complications.
31. If the TVO duration is prolonged (>20 min), it predisposes distal
areas of the brain to ischemia.
In general, a TVO time of 5 min followed by reperfusion for 5 min
before repeat TVO is ideal.
As it may not always be possible to adhere to these timelines,
cerebral protective measures may be required.
Induced hypertension, and/or suppression of cerebral activity with
hypothermia and/or pharmacological agents help reduce cerebral
metabolism and improve tolerance to ischemia.
32. Monitoring during aneurysm surgery
Somato-sensory evoked potential (SSEP) has been used to predict
postoperative stroke in patients undergoing aneurysm clipping.
SSEP monitoring helps in detecting effect of changes in the
anesthetic depth, TVO, hemodynamic changes and surgical
manipulation.
It allows detection of cerebral ischemia, facilitates timely corrective
measures and predicts postoperative neurological deficits.
33. Bispectral index (BIS) monitoring might facilitate
identification of lower limit of cerebral autoregulation
during aneurysm surgery and help maintain safe level of
BP to prevent ischemic insult.
BIS and electroencephalogram not only help in detecting
ischemic changes during TVO, but also help in titrating
anesthetic to achieve metabolic endpoint.
34. Postclipping evaluation
Another challenge during aneurysm surgery is to ensure
noninclusion of normal vessel/perforators within the clip
and perform complete aneurysmal isolation.
intraoperative microvascular Doppler (IMD) or
Indocyanine green video-angiography (ICG-VA) are used
as they are simple and safe.
35. Challenges during intraoperative aneurysm
rupture and its management
Intraoperative aneurysm rupture is a nightmare for both
surgeon and the anesthesiologist.
securing the aneurysm quickly and safely is the primary
focus of the surgeon, anesthesiologist needs to protect the
brain from possible ischemia during the unplanned
prolonged TVO and correct hemodynamic changes.
TVO/A transient low normal BP /Intravascular volume
resuscitation with isotonic fluids and blood.
36. Challenges during recovery from
anesthesia
Recovery and extubation depends on the preoperative
status and intraoperative events.
Poor preoperative aSAH grade, prolonged TVO and severe
intraoperative vasospasm are possible indications for
postoperative ventilation.
Anesthetic maintenance should permit swift but smooth
extubation for early neurological assessment with minimal
hemodynamic fluctuation.
37. Detection and management of
complications
Anticonvulsants, osmotherapy and nimodipine must be continued.
Hydrocephalus, vasospasm, seizures, and electrolyte disturbances
can occur necessitating close observation and prompt management.
Vasospasm is an important cause for mortality following aSAH
affecting as many as 70% of patients.
It usually occurs between 4th and 21st days of aSAH and is
responsible for DIND and cerebral infarcts
38. Triple H (hypertension, hypervolemia and hemodilution) therapy results in
clinical improvement when administered within 2 h of neurological deterioration.
Recent evidence however suggests increased pulmonary and cardiac
complications with this therapy.
Therefore, only hypertension component of triple H therapy is currently
recommended.
Hypervolemic therapy results in a decrease in brain tissue oxygenation, fluid
overload, and is associated with deleterious cardiac and pulmonary events.
Isovolumic and hypervolemic hemodilution increases global cerebral blood flow,
but is associated with decreased oxygen delivery.
39. Other treatment modalities for vasospasm include
Magnesium targeted to serum level of 2-2.5 mmol/l (blocks Calcium and n-methyl-D-
aspartate [NMDA] channels and reduces vasospasm),
Statins (decreases microthrombi, causes NMDA antagonism, fibrinolysis and
immunomodulation),
Erythropoietin (by promoting hematopoiesis, increasing BP and neuroprotective
mechanism),
Stellate ganglion block,
Intra-arterial nimodipine and
Balloon angioplasty.
40. Anemia is common in patients with aSAH (50% incidence)
Acute neurological deterioration occurs in >40% of aSAH patients
and hence close monitoring is required.
Factors associated include age, timing of surgery, Fisher grade,
preoperative interventions such as ventriculostomy, intraoperative
BP, ST segment changes and blood loss,
duration of TVO and difficulty in aneurysm exposure.
Of the patients who had neurological deterioration only 50% had
good outcome at 3 months.
41. CONCLUSION
Patients with aSAH are challenging to manage and require a
thorough knowledge about the pathophysiology of aSAH and
treatment options.
Vigilant peri-operative monitoring,
adherence to good surgical and anesthetic technique and
prompt detection and management of complications
are likely to improve the outcome.
42. References
REVIEW ARTICLE: Concerns and challenges during anesthetic
management of aneurysmal subarachnoid hemorrhage
Kamath Sriganesh, Sudhir Venkataramaiah
Saudi Journal of Anaesthesia, Year 2015, Volume 9, Issue 3 [p. 306-313]
Aneurysmal Subarachnoid Hemorrhage Stanlies D’Souza, MBBS, FRCA,
FCARCSI /J Neurosurg Anesthesiol Volume 27,
43.
44. 2002 Feb
Discuss the perioperative anaesthetic management of a 25 year old pt presenting for clipping
of intra-cranial arterial aneurysm.
2010 AUG
A 40 yr old lady is admitted to ICU with a diagnosis of WFNS grade
IV SAH.she was intubated and ventilated.
i) Describe the principles of ICU management of this pt with unprotected cerebral
aneurysm.
ii) What are the signs of cerebral vasospasm in pt with SAH?
iii) Outline the principles of management to prevent the development of vasospasm.