This document provides a history of the development of neuroanesthesia. It discusses early discoveries and practices from ancient times through the 19th century. It then summarizes major advances in the 20th century related to anesthetic agents, monitoring, airway management, and techniques to protect the brain during surgery. These include the development of muscle relaxants, inhalational agents, intravenous medications, hypothermia, and methods to prevent increases in intracranial pressure and glucose levels.
Neuromonitoring techniques can monitor the brain's function, cerebral blood flow and intracranial pressure, and brain oxygenation and metabolism. Electroencephalography (EEG) measures electrical brain activity and is useful for detecting ischemia. Evoked potentials like somatosensory evoked potentials (SSEPs) monitor sensory pathways from stimulus to cortex. Jugular venous oximetry and near infrared spectroscopy (NIRS) provide noninvasive monitoring of cerebral oxygenation. These techniques guide anesthesia management and detect intraoperative brain injury.
The document discusses the anatomy and functions of the brain, focusing on the supratentorial and infratentorial compartments. It then discusses considerations for anesthesia during brain surgery, including techniques to minimize increases in intracranial pressure and prevent complications like venous air embolism. Key goals are to keep the patient hemodynamically stable and allow for postoperative neurological assessment.
The document discusses the anesthetic management of patients undergoing treatment for cerebral aneurysms, including definitions, epidemiology, presentation, diagnosis, management of vasospasm, intracranial pressure, pre-operative assessment and testing, and radiological procedures such as coiling of aneurysms. Precise management of hemodynamics, fluid balance, and respiratory status is important due to the risks of re-bleeding, cerebral ischemia, and impaired autoregulation in these patients.
Advances in neuro anesthesia monitoringWesam Mousa
The document discusses various techniques for monitoring the brain during anesthesia to prevent neurological insults. It describes electroencephalography (EEG) techniques like raw EEG, bispectral index, and entropy which can detect cerebral ischemia. It also discusses evoked potentials like somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) using electrical stimulation to assess spinal cord and brain function. Additional monitoring methods covered are intracranial pressure (ICP), cerebral blood flow (CBF), brain oxygenation, and electromyography (EMG) for nerve function. The document emphasizes multimodal monitoring as the gold standard to reduce intraoperative neurological injury.
This document provides an overview and update on issues in neuroanesthesia. It discusses recurrent issues such as patient positioning, monitoring, fluid management and more that have not changed significantly over time. It also reviews cerebral physiology concepts like blood flow regulation and the effects of anesthetic agents. The document outlines current surgical trends like minimally invasive procedures and equipment trends like intraoperative CT. It concludes by emphasizing the importance of multidisciplinary team training to continually improve neuroanesthesia care.
1. Supratentorial surgeries require careful anesthetic management to maintain adequate cerebral perfusion and oxygenation while optimizing conditions for tumor resection.
2. Key goals include preventing increases in intracranial pressure through careful induction, positioning, ventilation, and emergence from anesthesia.
3. Emergence should be smooth to avoid straining or bucking which can abruptly increase intracranial pressure and risk hemorrhage or herniation.
The document discusses the posterior fossa, including its boundaries, contents, blood supply, clinical presentation of lesions, and considerations for anesthesia. The posterior fossa is bounded anteriorly by the clivus and petrous bone, posteriorly by the occipital bone, and laterally by the temporal bone. It contains the cerebellar hemispheres, brainstem, and cranial nerves III-XII. Lesions can cause a variety of signs and symptoms depending on location, including ataxia, nystagmus, limb weakness, and cranial nerve deficits. Anesthesia for posterior fossa surgery requires careful monitoring and positioning to maintain stability while allowing surgical access.
Neuromonitoring techniques can monitor the brain's function, cerebral blood flow and intracranial pressure, and brain oxygenation and metabolism. Electroencephalography (EEG) measures electrical brain activity and is useful for detecting ischemia. Evoked potentials like somatosensory evoked potentials (SSEPs) monitor sensory pathways from stimulus to cortex. Jugular venous oximetry and near infrared spectroscopy (NIRS) provide noninvasive monitoring of cerebral oxygenation. These techniques guide anesthesia management and detect intraoperative brain injury.
The document discusses the anatomy and functions of the brain, focusing on the supratentorial and infratentorial compartments. It then discusses considerations for anesthesia during brain surgery, including techniques to minimize increases in intracranial pressure and prevent complications like venous air embolism. Key goals are to keep the patient hemodynamically stable and allow for postoperative neurological assessment.
The document discusses the anesthetic management of patients undergoing treatment for cerebral aneurysms, including definitions, epidemiology, presentation, diagnosis, management of vasospasm, intracranial pressure, pre-operative assessment and testing, and radiological procedures such as coiling of aneurysms. Precise management of hemodynamics, fluid balance, and respiratory status is important due to the risks of re-bleeding, cerebral ischemia, and impaired autoregulation in these patients.
Advances in neuro anesthesia monitoringWesam Mousa
The document discusses various techniques for monitoring the brain during anesthesia to prevent neurological insults. It describes electroencephalography (EEG) techniques like raw EEG, bispectral index, and entropy which can detect cerebral ischemia. It also discusses evoked potentials like somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) using electrical stimulation to assess spinal cord and brain function. Additional monitoring methods covered are intracranial pressure (ICP), cerebral blood flow (CBF), brain oxygenation, and electromyography (EMG) for nerve function. The document emphasizes multimodal monitoring as the gold standard to reduce intraoperative neurological injury.
This document provides an overview and update on issues in neuroanesthesia. It discusses recurrent issues such as patient positioning, monitoring, fluid management and more that have not changed significantly over time. It also reviews cerebral physiology concepts like blood flow regulation and the effects of anesthetic agents. The document outlines current surgical trends like minimally invasive procedures and equipment trends like intraoperative CT. It concludes by emphasizing the importance of multidisciplinary team training to continually improve neuroanesthesia care.
1. Supratentorial surgeries require careful anesthetic management to maintain adequate cerebral perfusion and oxygenation while optimizing conditions for tumor resection.
2. Key goals include preventing increases in intracranial pressure through careful induction, positioning, ventilation, and emergence from anesthesia.
3. Emergence should be smooth to avoid straining or bucking which can abruptly increase intracranial pressure and risk hemorrhage or herniation.
The document discusses the posterior fossa, including its boundaries, contents, blood supply, clinical presentation of lesions, and considerations for anesthesia. The posterior fossa is bounded anteriorly by the clivus and petrous bone, posteriorly by the occipital bone, and laterally by the temporal bone. It contains the cerebellar hemispheres, brainstem, and cranial nerves III-XII. Lesions can cause a variety of signs and symptoms depending on location, including ataxia, nystagmus, limb weakness, and cranial nerve deficits. Anesthesia for posterior fossa surgery requires careful monitoring and positioning to maintain stability while allowing surgical access.
Anesthesia management for pituitary tumorAbhijit Nair
This document discusses anesthesia management for pituitary tumor surgery. Pituitary adenomas are common benign tumors that can invade surrounding structures. Risk factors include genetic conditions. Pre-operative evaluation assesses hormonal levels and effects, as well as comorbidities related to hormonal hypersecretion like acromegaly and Cushing's syndrome. Anesthetic management aims to maintain hemodynamic stability, cerebral oxygenation, and facilitate surgery while preventing complications. Special considerations include potential airway difficulties and post-operative hormone replacement or complications such as diabetes insipidus or hyponatremia.
This document discusses the scalp block technique. It begins by describing scalp block as local anesthesia of the scalp nerves. It then discusses the history and development of scalp block, including the original description in 1986 and studies in the 1980s that demonstrated its effectiveness in reducing hemodynamic changes during craniotomy. The document outlines the specific nerves blocked in scalp block and techniques for each, and notes bupivacaine is often used. Advantages include decreased blood pressure and intracranial pressure changes during surgery. Potential complications are also reviewed. Finally, it briefly discusses recent updates to the Glasgow Coma Scale including the addition of a pupil reactivity score in 2018.
Neurological complaints are a common cause of morbidity following cardiac surgery. Adverse central nervous system outcomes include stroke, neurocognitive decline, and delirium. The risk of stroke increases with age and may be as high as 7-9% in patients over 75 years old. Neurocognitive decline can occur in 60% of patients at 1 week post-op and 25-30% between 2 months and 1 year post-op. Neurological injuries following cardiac surgery can be caused by embolization, hypoperfusion, tissue ischemia, or neurodegeneration. Near-infrared spectroscopy is a non-invasive method for monitoring regional cerebral oxygen saturation and detecting cerebral desaturations in real-time, which has been shown
1. Awake craniotomy is a surgical procedure performed with the patient awake to allow mapping of brain functions while removing a brain tumor.
2. During surgery, a neurosurgeon performs cortical mapping to identify vital brain areas that should not be disturbed while removing the tumor.
3. Awake craniotomy provides benefits over surgery under general anesthesia such as higher rates of total tumor resection, fewer permanent neurological deficits, and shorter hospital stays. However, it requires careful patient selection and management of anesthesia to balance pain and cooperation.
This document discusses various methods for monitoring the depth of anesthesia. It describes clinical techniques such as assessing autonomic responses and muscle movement. It also discusses pharmacological principles like minimum alveolar concentration for different anesthetic responses. Methods for monitoring brain electrical activity are outlined, including spontaneous EEG, compressed spectral analysis, bispectral index, and entropy monitors. Brain electrical activity monitors provide quantitative measures of anesthetic effect but can be influenced by other physiological factors. Overall, the document provides an overview of traditional and advanced techniques for assessing depth of anesthesia.
This document classifies myasthenia gravis into different categories based on the muscles affected and severity of symptoms. Category I involves only ocular muscles with negative tests on other muscles, while Category Ia includes ocular involvement and positive peripheral muscle tests without symptoms. Categories II-IV classify generalized myasthenia gravis as mild, moderate, acute fulminating, or late severe based on impact. Repetitive nerve stimulation and single fiber electromyography are described as electrophysiological tests used in diagnosis.
This document provides information on interscalene brachial plexus blocks, including indications, contraindications, anatomy, techniques, complications, and references. It describes Winnie's anterior approach using landmarks to identify the interscalene groove for injection, as well as a posterior approach. Areas of blockade, continuous techniques, and use of nerve stimulation are also summarized. Supraclavicular blockade as an alternative is outlined with similar details.
This document provides an overview of monitoring depth of anesthesia. It discusses the aims of monitoring to ensure patient safety and prevent awareness during surgery. It reviews the historical background of defining anesthesia stages. Modern concepts view anesthesia as a complex interaction between stimuli, patient responses, and drug-induced effects. Factors like patient characteristics, drug combinations, and surgery duration impact correct drug dosing. Memory is gradually impaired with deeper anesthesia levels before autonomic responses. The document outlines stages of awareness and discusses specific drugs' relationships to anesthesia depth.
Intracranial pressure - waveforms and monitoringjoemdas
The document discusses intracranial pressure (ICP) waveforms and monitoring. It defines the components of the intracranial vault and describes the normal ICP waveform consisting of P1, P2, and P3 waves representing arterial pulsation, intracranial compliance, and venous pulsation, respectively. It also discusses Lundberg waves including A waves resulting from increased cerebrovascular volume due to vasodilation, B waves related to respiratory fluctuations in PaCO2, and C waves corresponding to Traube-Hering-Meyer fluctuations. The gold standard for ICP monitoring is external ventricular drainage connected to an external strain gauge, which allows CSF drainage but carries risks of infection and hemorrhage. Int
Perioperative myocardial infarction is a common cause of morbidity and mortality in patients undergoing noncardiac surgery. It can occur through acute coronary syndrome or prolonged myocardial ischemia in patients with stable coronary artery disease. Diagnosis is difficult as symptoms often do not present in anesthetized patients. Risk is determined by patient clinical factors, exercise capacity, and surgery risk. Management may include beta blockers, statins, aspirin, and evaluating need for revascularization based on standard criteria.
Cerebral physiology and effects of anaesthetic agentsRicha Kumar
The document discusses cerebral physiology and the effects of anesthetic agents. It covers topics such as:
- Anatomy of the cerebral circulation including the circle of Willis.
- Regulation of cerebral blood flow including chemical, myogenic, and neurogenic factors.
- Effects of increased intracranial pressure on cerebral perfusion.
- How different anesthetic agents like barbiturates, propofol, etomidate, narcotics, benzodiazepines, ketamine, and volatile anesthetics affect cerebral blood flow and cerebral metabolic rate.
Neuromuscular monitoring, also known as train of four monitoring, is a technique used during recovery from the application of general anesthesia to objectively determine how well a patient's muscles are able to function. It involves the application of electrical stimulation to nerves and recording of muscle response using, for example, an acceleromyograph. Neuromuscular monitoring is typically used when neuromuscular-blocking drugs have been part of the general anesthesia and the doctor wishes to avoid postoperative residual curarization (PORC) in the patient, that is, the residual paralysis of muscles stemming from these drugs.
The document provides information on traumatic brain injury (TBI):
- TBI is defined as an insult to the brain from an external force, which can lead to temporary or permanent impairment. It affects over 1.7 million people annually in the US.
- Severity is classified using the Glasgow Coma Scale. More severe injuries have higher mortality rates. Predictors of poor outcome include lower GCS, age over 60, abnormal CT findings, and hypotension.
- Treatment aims to prevent secondary injury from hypotension, hypoxia, increased ICP, and includes monitoring vital signs, ICP, CPP, and providing interventions like osmotherapy, surgery, and medications to control ICP and maintain
Anesthesia management for Mega liposuction.Abhijit Nair
This document discusses anesthesia management considerations for mega liposuction or large volume liposuction procedures. Key points include:
1) Mega liposuction removes more than 5 liters of fat and fluid from the patient and requires careful fluid resuscitation to avoid complications from fluid shifts.
2) Safety is the top priority, requiring a trained surgeon, anesthesiologist, facility, and careful patient selection and monitoring.
3) Anesthesia management includes use of short-acting agents, fluid management to replace deficits without overhydrating, and monitoring for hemodynamic changes and fluid balance.
Pituitary Tumors account for 15% of Braun tumors. Trans sphenoidal endoscopic approach are more common. Post surgery fluid and electrolyte balance is important.
Anaesthesia for interventional neuroradiologyDr Kumar
The document provides information on anaesthesia for interventional neuroradiology procedures. It discusses:
1. The indications for anaesthesia including maintaining immobility, rapid recovery, managing anticoagulation, and treating complications.
2. Pre-operative assessment considerations like pulmonary and cardiovascular risks in subarachnoid hemorrhage patients.
3. Techniques for induction, maintenance and recovery from anaesthesia aimed at maintaining stability while allowing the procedure, including use of propofol, remifentanil and sevoflurane.
4. Managing risks like hypertension, hypotension and temperature during the procedure.
This document discusses regional anesthesia techniques in pediatrics. It provides a brief history of regional anesthesia in children and outlines key advantages like reduced stress response and improved outcomes. It notes important differences between children and adults physiologically, psychologically, pharmacologically and anatomically that are important to consider. The document then describes various regional anesthesia procedures that can be used in children like caudal blocks, epidurals and peripheral nerve blocks. It emphasizes the importance of skill and proper equipment when performing regional techniques in children.
This document discusses anaesthetic considerations for posterior fossa surgery. The posterior fossa is a rigid compartment containing important structures like the brainstem and cerebellum. Tumours are a common pathology requiring posterior fossa surgery. Different surgical positions like sitting and park bench are used but come with challenges and risks for anaesthetists, including venous air embolism in the sitting position. Careful patient evaluation, monitoring, maintenance of haemodynamic stability and early detection of complications are important aspects of anaesthetic management for posterior fossa surgery.
Meningomyelocele is a neural tube defect affecting 1 in 1000 births where the meninges and neural components protrude through the spine. It most commonly occurs in the lumbar or sacral region. Associated conditions include orthopedic problems, urological issues, and Arnold Chiari malformation. Prenatal diagnosis is possible using ultrasound and biochemical tests. Surgical closure is typically performed within 24 hours to reduce neurological deficits, along with shunt placement if hydrocephalus develops. Perioperative care focuses on infection prevention and hemodynamic stability, with postoperative monitoring for complications like respiratory distress, apnea, or hydrocephalus symptoms.
The document describes the Baska Mask, a new supraglottic airway device that aims to address limitations of existing laryngeal masks by having a smaller opening to reduce risk of aspiration, a tab to aid in placement, dual gastric channels for ventilation and suctioning, and a cuffless design that inflates with ventilation rather than requiring separate cuff inflation. Standard placement and removal techniques for the Baska Mask are provided.
The document discusses the importance of connecting with buyers in an inbound way and how to execute the connect stage of the inbound sales methodology. It recommends defining buyer personas, outreach sequences for each persona, and personalized outreach content. It provides examples of developing buyer personas, sequences, and content for different lead sources like inbound leads and common connections. The document also provides examples of scripts for connect calls with different lead types and how to get buyer buy-in for longer exploratory conversations.
Modern Prospecting Techniques for Connecting with Prospects (from Sales Hacke...HubSpot
Sales is a difficult world to be in because buyers aren't putting up with salespeople anymore. Instead of helping and building relationships, sales reps are still focused on closing prospects - even when they aren't ready to buy! So buyers ignore them. Because of that, even great sales reps would be lucky to get on the phone with someone.
While buyers have evolved and become more sophisticated, sales reps and training programs have been slow to adapt to that change.
Learn actionable modern prospecting techniques you can apply immediately from two best selling authors and sales experts: Max Altschuler CEO of Sales Hacker, and Mark Roberge CRO of HubSpot.
Anesthesia management for pituitary tumorAbhijit Nair
This document discusses anesthesia management for pituitary tumor surgery. Pituitary adenomas are common benign tumors that can invade surrounding structures. Risk factors include genetic conditions. Pre-operative evaluation assesses hormonal levels and effects, as well as comorbidities related to hormonal hypersecretion like acromegaly and Cushing's syndrome. Anesthetic management aims to maintain hemodynamic stability, cerebral oxygenation, and facilitate surgery while preventing complications. Special considerations include potential airway difficulties and post-operative hormone replacement or complications such as diabetes insipidus or hyponatremia.
This document discusses the scalp block technique. It begins by describing scalp block as local anesthesia of the scalp nerves. It then discusses the history and development of scalp block, including the original description in 1986 and studies in the 1980s that demonstrated its effectiveness in reducing hemodynamic changes during craniotomy. The document outlines the specific nerves blocked in scalp block and techniques for each, and notes bupivacaine is often used. Advantages include decreased blood pressure and intracranial pressure changes during surgery. Potential complications are also reviewed. Finally, it briefly discusses recent updates to the Glasgow Coma Scale including the addition of a pupil reactivity score in 2018.
Neurological complaints are a common cause of morbidity following cardiac surgery. Adverse central nervous system outcomes include stroke, neurocognitive decline, and delirium. The risk of stroke increases with age and may be as high as 7-9% in patients over 75 years old. Neurocognitive decline can occur in 60% of patients at 1 week post-op and 25-30% between 2 months and 1 year post-op. Neurological injuries following cardiac surgery can be caused by embolization, hypoperfusion, tissue ischemia, or neurodegeneration. Near-infrared spectroscopy is a non-invasive method for monitoring regional cerebral oxygen saturation and detecting cerebral desaturations in real-time, which has been shown
1. Awake craniotomy is a surgical procedure performed with the patient awake to allow mapping of brain functions while removing a brain tumor.
2. During surgery, a neurosurgeon performs cortical mapping to identify vital brain areas that should not be disturbed while removing the tumor.
3. Awake craniotomy provides benefits over surgery under general anesthesia such as higher rates of total tumor resection, fewer permanent neurological deficits, and shorter hospital stays. However, it requires careful patient selection and management of anesthesia to balance pain and cooperation.
This document discusses various methods for monitoring the depth of anesthesia. It describes clinical techniques such as assessing autonomic responses and muscle movement. It also discusses pharmacological principles like minimum alveolar concentration for different anesthetic responses. Methods for monitoring brain electrical activity are outlined, including spontaneous EEG, compressed spectral analysis, bispectral index, and entropy monitors. Brain electrical activity monitors provide quantitative measures of anesthetic effect but can be influenced by other physiological factors. Overall, the document provides an overview of traditional and advanced techniques for assessing depth of anesthesia.
This document classifies myasthenia gravis into different categories based on the muscles affected and severity of symptoms. Category I involves only ocular muscles with negative tests on other muscles, while Category Ia includes ocular involvement and positive peripheral muscle tests without symptoms. Categories II-IV classify generalized myasthenia gravis as mild, moderate, acute fulminating, or late severe based on impact. Repetitive nerve stimulation and single fiber electromyography are described as electrophysiological tests used in diagnosis.
This document provides information on interscalene brachial plexus blocks, including indications, contraindications, anatomy, techniques, complications, and references. It describes Winnie's anterior approach using landmarks to identify the interscalene groove for injection, as well as a posterior approach. Areas of blockade, continuous techniques, and use of nerve stimulation are also summarized. Supraclavicular blockade as an alternative is outlined with similar details.
This document provides an overview of monitoring depth of anesthesia. It discusses the aims of monitoring to ensure patient safety and prevent awareness during surgery. It reviews the historical background of defining anesthesia stages. Modern concepts view anesthesia as a complex interaction between stimuli, patient responses, and drug-induced effects. Factors like patient characteristics, drug combinations, and surgery duration impact correct drug dosing. Memory is gradually impaired with deeper anesthesia levels before autonomic responses. The document outlines stages of awareness and discusses specific drugs' relationships to anesthesia depth.
Intracranial pressure - waveforms and monitoringjoemdas
The document discusses intracranial pressure (ICP) waveforms and monitoring. It defines the components of the intracranial vault and describes the normal ICP waveform consisting of P1, P2, and P3 waves representing arterial pulsation, intracranial compliance, and venous pulsation, respectively. It also discusses Lundberg waves including A waves resulting from increased cerebrovascular volume due to vasodilation, B waves related to respiratory fluctuations in PaCO2, and C waves corresponding to Traube-Hering-Meyer fluctuations. The gold standard for ICP monitoring is external ventricular drainage connected to an external strain gauge, which allows CSF drainage but carries risks of infection and hemorrhage. Int
Perioperative myocardial infarction is a common cause of morbidity and mortality in patients undergoing noncardiac surgery. It can occur through acute coronary syndrome or prolonged myocardial ischemia in patients with stable coronary artery disease. Diagnosis is difficult as symptoms often do not present in anesthetized patients. Risk is determined by patient clinical factors, exercise capacity, and surgery risk. Management may include beta blockers, statins, aspirin, and evaluating need for revascularization based on standard criteria.
Cerebral physiology and effects of anaesthetic agentsRicha Kumar
The document discusses cerebral physiology and the effects of anesthetic agents. It covers topics such as:
- Anatomy of the cerebral circulation including the circle of Willis.
- Regulation of cerebral blood flow including chemical, myogenic, and neurogenic factors.
- Effects of increased intracranial pressure on cerebral perfusion.
- How different anesthetic agents like barbiturates, propofol, etomidate, narcotics, benzodiazepines, ketamine, and volatile anesthetics affect cerebral blood flow and cerebral metabolic rate.
Neuromuscular monitoring, also known as train of four monitoring, is a technique used during recovery from the application of general anesthesia to objectively determine how well a patient's muscles are able to function. It involves the application of electrical stimulation to nerves and recording of muscle response using, for example, an acceleromyograph. Neuromuscular monitoring is typically used when neuromuscular-blocking drugs have been part of the general anesthesia and the doctor wishes to avoid postoperative residual curarization (PORC) in the patient, that is, the residual paralysis of muscles stemming from these drugs.
The document provides information on traumatic brain injury (TBI):
- TBI is defined as an insult to the brain from an external force, which can lead to temporary or permanent impairment. It affects over 1.7 million people annually in the US.
- Severity is classified using the Glasgow Coma Scale. More severe injuries have higher mortality rates. Predictors of poor outcome include lower GCS, age over 60, abnormal CT findings, and hypotension.
- Treatment aims to prevent secondary injury from hypotension, hypoxia, increased ICP, and includes monitoring vital signs, ICP, CPP, and providing interventions like osmotherapy, surgery, and medications to control ICP and maintain
Anesthesia management for Mega liposuction.Abhijit Nair
This document discusses anesthesia management considerations for mega liposuction or large volume liposuction procedures. Key points include:
1) Mega liposuction removes more than 5 liters of fat and fluid from the patient and requires careful fluid resuscitation to avoid complications from fluid shifts.
2) Safety is the top priority, requiring a trained surgeon, anesthesiologist, facility, and careful patient selection and monitoring.
3) Anesthesia management includes use of short-acting agents, fluid management to replace deficits without overhydrating, and monitoring for hemodynamic changes and fluid balance.
Pituitary Tumors account for 15% of Braun tumors. Trans sphenoidal endoscopic approach are more common. Post surgery fluid and electrolyte balance is important.
Anaesthesia for interventional neuroradiologyDr Kumar
The document provides information on anaesthesia for interventional neuroradiology procedures. It discusses:
1. The indications for anaesthesia including maintaining immobility, rapid recovery, managing anticoagulation, and treating complications.
2. Pre-operative assessment considerations like pulmonary and cardiovascular risks in subarachnoid hemorrhage patients.
3. Techniques for induction, maintenance and recovery from anaesthesia aimed at maintaining stability while allowing the procedure, including use of propofol, remifentanil and sevoflurane.
4. Managing risks like hypertension, hypotension and temperature during the procedure.
This document discusses regional anesthesia techniques in pediatrics. It provides a brief history of regional anesthesia in children and outlines key advantages like reduced stress response and improved outcomes. It notes important differences between children and adults physiologically, psychologically, pharmacologically and anatomically that are important to consider. The document then describes various regional anesthesia procedures that can be used in children like caudal blocks, epidurals and peripheral nerve blocks. It emphasizes the importance of skill and proper equipment when performing regional techniques in children.
This document discusses anaesthetic considerations for posterior fossa surgery. The posterior fossa is a rigid compartment containing important structures like the brainstem and cerebellum. Tumours are a common pathology requiring posterior fossa surgery. Different surgical positions like sitting and park bench are used but come with challenges and risks for anaesthetists, including venous air embolism in the sitting position. Careful patient evaluation, monitoring, maintenance of haemodynamic stability and early detection of complications are important aspects of anaesthetic management for posterior fossa surgery.
Meningomyelocele is a neural tube defect affecting 1 in 1000 births where the meninges and neural components protrude through the spine. It most commonly occurs in the lumbar or sacral region. Associated conditions include orthopedic problems, urological issues, and Arnold Chiari malformation. Prenatal diagnosis is possible using ultrasound and biochemical tests. Surgical closure is typically performed within 24 hours to reduce neurological deficits, along with shunt placement if hydrocephalus develops. Perioperative care focuses on infection prevention and hemodynamic stability, with postoperative monitoring for complications like respiratory distress, apnea, or hydrocephalus symptoms.
The document describes the Baska Mask, a new supraglottic airway device that aims to address limitations of existing laryngeal masks by having a smaller opening to reduce risk of aspiration, a tab to aid in placement, dual gastric channels for ventilation and suctioning, and a cuffless design that inflates with ventilation rather than requiring separate cuff inflation. Standard placement and removal techniques for the Baska Mask are provided.
The document discusses the importance of connecting with buyers in an inbound way and how to execute the connect stage of the inbound sales methodology. It recommends defining buyer personas, outreach sequences for each persona, and personalized outreach content. It provides examples of developing buyer personas, sequences, and content for different lead sources like inbound leads and common connections. The document also provides examples of scripts for connect calls with different lead types and how to get buyer buy-in for longer exploratory conversations.
Modern Prospecting Techniques for Connecting with Prospects (from Sales Hacke...HubSpot
Sales is a difficult world to be in because buyers aren't putting up with salespeople anymore. Instead of helping and building relationships, sales reps are still focused on closing prospects - even when they aren't ready to buy! So buyers ignore them. Because of that, even great sales reps would be lucky to get on the phone with someone.
While buyers have evolved and become more sophisticated, sales reps and training programs have been slow to adapt to that change.
Learn actionable modern prospecting techniques you can apply immediately from two best selling authors and sales experts: Max Altschuler CEO of Sales Hacker, and Mark Roberge CRO of HubSpot.
This document summarizes diversity data from HubSpot in 2016. It shows the breakdown of employees by gender, age, ethnicity, and management level across different departments. While diversity is still lacking, especially in technical roles and leadership, progress was made in 2016 with increases in female representation and hiring of underrepresented ethnic groups. Continued efforts are needed to create a more inclusive workforce.
Why People Block Ads (And What It Means for Marketers and Advertisers) [New R...HubSpot
HubSpot Research shares new data on why people use ad blockers and what marketers and advertisers need to do to keep people from blocking out ads completely. Hint: it's stop using interruptive and annoying ads.
3 Proven Sales Email Templates Used by Successful CompaniesHubSpot
76% of emails never get opened. That makes life for salespeople very difficult. So we've partnered up with Breakthrough Email to bring you email templates that are proven to engage prospects and close more deals. Start using them today and grow your revenue.
Class 1: Email Marketing Certification course: Email Marketing and Your BusinessHubSpot
*From HubSpot Academy*
Over the past few decades, people have radically changed the way they live, work and buy. This class will give you an overview of an adaptive, inbound approach to sending emails that provide value and drive growth for your business. It will also teach you about the four big themes of a modern email marketing program: segmentation, personalization, mobile, and optimization.
The lack of visible female role models is pervasive in the tech industry, particularly on Wikipedia, where just under 17% of Wikipedia biographies were on women. That's why HubSpot wrote fourteen Wikipedia entries for remarkable women in tech to help inspire young women to reach positions at the highest levels of STEM.
Disney powerpoint template has been created to showcase the beauty bestowed in the kingdom of dreams. The world yearns to be at this place and live its dream. Coffee is the ultimate connection in every love story. The ambience of coffee shop and restaurants sometimes drives the love connection between two people.
O documento fornece uma lista de contatos de sócios e advogados de uma firma de advocacia, bem como um resumo de decisões relevantes do CARF nos meses de novembro e dezembro de 2016, incluindo questões sobre preços de transferência, limites de compensação de prejuízo fiscal e regularidade da segregação de atividades entre empresas do mesmo grupo.
This document is a survey that collects information about respondents' gender, age, preferred movie genres and sub-genres, factors they consider most important in movies, tolerance for violence and gore, favorite horror films, and elements that catch their attention in horror movie trailers. It asks for selections between multiple choice answers on topics like gender, age range, preferred genres, most important movie elements, tolerance for violence, favorite factors and films within the horror genre.
Building a community of Open Source intranet usersLuke Oatham
This document discusses building a community of open source intranet users. It covers topics like learning WordPress, the GovIntranet theme and plugins used, content types for an intranet, using third-party plugins, open sourcing versions of the software, active clients using the software, developing for a wider audience with different systems, continuous development and community involvement.
Wealth and race/ethnicity are two major determinants of social stratification in the Caribbean. Wealth determines one's social class, with those who own the means of production dominating the upper class and those with little wealth in the lower class. Race/ethnicity also structures stratification, as seen during periods of slavery and indentureship, with different ethnic groups like whites, Africans, Indians, and Chinese maintaining distinct social patterns. While some argue class has become more important, others believe race/ethnicity continues to influence Caribbean social stratification.
ArtigARTIGO DE NATANAEL DADIVA SOBRE A ESCRAVIDÃO DA MNETEo de natanael dadiv...Natanael Da Silva
O documento discute as possibilidades futuras da neurotecnologia e como ela pode levar a uma nova forma de escravidão no século 21. Ele faz uma comparação entre a escravidão do passado usando armas de fogo e a possibilidade de escravidão mental no futuro usando interfaces cérebro-máquina. O autor também resume vários experimentos científicos que demonstraram a comunicação direta entre cérebros humanos e a possibilidade de controle remoto de um cérebro pelo outro através da internet.
Awake craniotomy allows surgeons to map eloquent brain areas and remove tumors near these areas while the patient is awake. It has advantages over surgery under general anesthesia by avoiding postoperative deficits. The technique requires careful planning and multidisciplinary coordination between the surgeon, anesthesiologist, and patient. Anesthesiologists aim to keep the patient comfortable and cooperative while limiting interference with brain mapping. Local anesthesia, sedation, and nerve blocks are used to achieve this balance. Complications can occur but are often avoided with experience and vigilance. Awake craniotomy offers benefits but demands expertise from all involved parties.
Spinal anaesthesia involves injecting local anaesthetic into the subarachnoid space to block nerve impulses from the lower half of the body. It was first performed in 1898 and involves accessing the spinal canal between vertebrae to administer drugs. Proper patient positioning, needle selection, and drug choice are important to achieve the desired level and duration of anaesthesia while avoiding complications like hypotension, neurological issues, or infection. Close monitoring is needed due to potential effects on heart rate, breathing, and blood pressure.
Decompressive craniectomy in Traumatic Brain Injuryjoemdas
Decompressive craniectomy is a surgical technique used to relieve increased intracranial pressure by removing a portion of the skull bone and opening the dura mater. It allows swollen brain tissue room to expand and reduces pressure. The document discusses the history of the procedure, indications such as severe traumatic brain injury and malignant stroke, types including decompressive hemicraniectomy and bifrontal craniectomy, potential complications like subdural fluid collections, and the role of later cranioplasty. While controversies remain, decompressive craniectomy can be life-saving for carefully selected patients with medically refractory elevated intracranial pressure.
This document discusses various neuroimaging techniques used in psychiatry. It begins with a brief history of neuroimaging, including early techniques like ventriculography and CT scans, as well as key developments in MRI, PET, SPECT, and other modalities. The document then explains several common neuroimaging techniques in more detail, such as CT, MRI sequences (T1WI, T2WI, FLAIR, DWI), and MRS. It provides information on the principles, applications, and appearance of structures on different sequences. In summary, neuroimaging allows measurement of brain structure, function and chemistry, and has provided useful insights into psychiatric pathophysiology that could aid diagnosis and treatment development.
Brain death and care for cadaveric organ donarKrishna R
The document discusses the history and criteria for determining brain death. It begins by outlining the evolution of the concept of brain death from the 1960s onwards. Key events included distinguishing brain death from cardiac death with the advent of life support technologies. The document then discusses the anatomy and functions of the brainstem and how brainstem death criteria focus on irreversible loss of brainstem function. It provides details on the tests and criteria used in India to determine brain death, including loss of consciousness, absence of brainstem reflexes, apnea testing, and rule out of confounding factors. Spinal cord reflexes that can occur after brain death are also addressed.
Prehospital induced hypothermia post cardiac arrest jun 2010[1]Robert Cole
The document discusses the benefits of induced hypothermia for patients who regain spontaneous circulation after cardiac arrest. Two landmark studies from 2002 showed that cooling patients to 32-34°C for 12-24 hours improved both survival rates and neurological outcomes compared to normothermia. The studies found that induced hypothermia reduced mortality by around 30% and doubled the number of patients with good neurological recoveries. Subsequently, international resuscitation guidelines recommended induced hypothermia for comatose cardiac arrest patients whose initial rhythm was ventricular fibrillation. The document explores the theoretical mechanisms by which mild hypothermia may protect the brain, such as reducing cerebral metabolism and modulating apoptotic and excitotoxic pathways after global ischemia.
1) Anesthesia has come a long way from the days when surgery was performed without pain relief. Various crude methods were used to relieve pain before the discovery of modern anesthesia in the 1840s.
2) Key milestones in anesthesia history include the first use of ether in 1846, the introduction of injectable cocaine and local anesthesia in 1884, and the development of muscle relaxants and modern inhalational agents.
3) Anesthesia continues to advance with new drugs, monitoring techniques, and the increasing role of technology including automated drug delivery systems and one day possibly robotic anesthesia administration. The future may see further developments in areas like artificial intelligence, personalized medicine, and remote anesthesia delivery via telemedicine.
This document discusses brain death, including its historical definition, current diagnostic criteria, pathophysiology, and management of organ donors. Key points include:
- Brain death is defined as irreversible cessation of all functions of the entire brain, including the brain stem.
- Diagnosis requires two examinations at least 6 hours apart showing coma, absence of brainstem reflexes, and apnea during a standardized test. Ancillary tests like EEG can be used if clinical criteria are inconclusive.
- After brain death, pathophysiological changes occur like hypotension, diabetes insipidus, and coagulopathies due to loss of autonomic and endocrine functions regulated by the brain.
A detailed presentation on Brain Death and Ongan transplantation.
Criteria for Brain Death are explained in detail. Legislative laws regarding the organ transplant, organ preservation are also explained.
NEUROIMAGING IN PSYCHIATRY777777777777.pptxssuser7567ef
This document provides an overview of various neuroimaging techniques used in psychiatry, including their principles, applications, and advantages/disadvantages. It discusses structural neuroimaging methods like CT and MRI, as well as functional techniques including fMRI, PET, and SPECT. CT and MRI provide high-resolution images of brain structure. Functional methods like fMRI, PET, and SPECT allow measurement of brain activity by detecting changes in blood flow and glucose metabolism associated with neuronal activation. Together, these neuroimaging modalities have improved understanding of psychiatric pathophysiology and have diagnostic and research applications in conditions such as dementia, psychosis, and mood disorders.
This document discusses anaesthesia considerations for functional neurosurgery. It defines functional neurosurgery and stereotaxis, and describes the history of localization techniques. It outlines CT and MRI based stereotactic localization methods. Common functional stereotactic procedures are listed including those for movement disorders, chronic pain, and psychiatric and seizure disorders. Techniques like MAC and AAA are discussed. Intraoperative monitoring, brain mapping, and depth of anaesthesia monitoring are also summarized.
This document provides information about neuraxial anesthesia techniques including spinal and epidural anesthesia. It discusses the history, advantages, techniques, levels of blockade, complications, pharmacology, and cardiovascular and respiratory effects of these procedures. Key aspects covered include identification of relevant vertebral anatomy, administration of local anesthetics in the subarachnoid space for spinal or epidural space, and management of potential complications like hypotension.
History of neurotransmission and introduction to ansdrdeepika87
This document provides a history of the discovery of neurons, neurotransmission, and the autonomic nervous system (ANS) through the work of various scientists. It describes 26 scientists and their key experiments from the 17th century to mid 20th century that were instrumental in advancing the understanding of:
1) The existence and structure of neurons through microscopy observations
2) The "neuron doctrine" established by Cajal that neurons are individual cells that are not continuous
3) The existence of synapses and evidence for chemical neurotransmission provided by Loewi and others
4) Components and functions of the ANS described by Langley and others.
This document provides an overview of spinal anaesthesia. It begins with definitions and history, then covers anatomy including the subarachnoid space and structures pierced during spinal anaesthesia. It describes the mechanism of action of spinal anaesthesia and how local anaesthetics work. Indications, contraindications, preparation, positioning, and complications are discussed. Pharmacology of local anaesthetics for spinal anaesthesia and additives are outlined. Monitoring during the procedure and factors affecting the spread of local anaesthetics are also summarized.
The document discusses the history of anesthesia from ancient times when pain was seen as punishment to modern times when anesthesia allowed for safer surgeries. It describes key events like the first use of ether and other substances for anesthesia. The role of anesthesiologists is also summarized, from providing pain management and life support during surgery to treating acute and chronic pain.
This document provides an overview of epidural analgesia, including its history, anatomy, physiology, pharmacology, techniques, troubleshooting, indications, contraindications, and complications. It discusses the loss of resistance technique used to identify the epidural space when administering an epidural, as well as various local anesthetics and adjuvants used in epidural analgesia and their onset times and durations of action. Patient positioning and infection control procedures for epidural placement are also outlined.
This document summarizes a clinical trial that investigated the use of sonothrombolysis as an adjunctive treatment to intravenous alteplase in acute ischemic stroke patients. The CLOTBUST-ER trial randomized over 600 patients to either active ultrasound treatment or a sham control for 120 minutes in addition to alteplase. The trial was stopped early due to futility, as no differences were found between the groups in functional outcomes or safety measures like hemorrhage rates at 90 days. While sonothrombolysis appeared safe, the operator-independent device used may not have provided sufficient thrombus exposure to show benefits compared to previous studies using handheld devices.
CURRENT TREATMENT MODALITIES AND ROLE OF NURSE.pptxHemant620457
The document provides an overview of the history of psychiatric treatment from ancient times to modern day. It describes early practices like trepanation, bloodletting, isolation, and treatments for hysteria. It then outlines 19th century developments like moral therapy, phrenology, and mesmerism. A variety of disturbing 20th century somatic therapies are also detailed such as insulin coma therapy, lobotomy, electroconvulsive therapy, and Metrazol therapy. The document concludes by discussing current psychotherapeutic and psychopharmacological treatment modalities.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
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share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the 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 lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
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. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
3. Discovery of trephined Neolithic skulls in 1873 at
Lozère (France), dating the first craniotomies
Historians believed - openings were made to
alleviate pain or to allow the escape of demons,
spirits, and supernatural elements from the head
Devoid of modern anesthetic agents or techniques.
Descriptions of the pain-relieving properties of
coca leaves and daturas in early historical
records.
4. • The Greek physician Hippocrates (460–370 BC)
described trephination for several pathologies of the
central nervous system performed in ancient
Greece;
• Blood under cranium - removed by perforating the
skull epidural and subdural hematomas.
• He used linen dressings soaked in wine for their
soporific effects in analgesia.
De material medica by Dioscorides (40–90 AD), a Greek
physician, pharmacologist, and botanist, the narcotic effects of
mandrake, henbane, and opium, as well as the effects of
alcohol,
use of laudanum, a tincture containing approximately 10%
opium by weight.
5. • Carbon dioxide, hydrogen, and nitrogen were
discovered toward the end of the 18th century
• Sir Humphry Davy (1778–1829), who
established the Pneumatic Institute in Bristol,
England, in 1799
• He noted that nitrous oxide could produce a
state of insensibility and relive surgical pain.
• Wells, a dentist ,Connecticut, in 1844,
teeth extraction under nitrous oxide.
6. • W.T.G.Morton’s public demonstration of ether anesthesia on October 16, 1846, at
the Massachusetts General Hospital,17 when Dr. John C. Warren (1778–1856)
removed a vascular tumor from the submandibular region in a patient
anesthetized with sulphuric ether.
7. • At the turn of the 20th century, debates regarding the relative merits of chloroform and
ether.
• Victor Horsley (1857–1916) series of experiments in animals from 1883 to 1885
although ether was safer, it was not to be recommended in favor of chloroform,
because it produced a rise in blood pressure and an increase in blood viscosity, with a
consequent potential for hemorrhage.
• Fedor Krause (1857–1937) used chloroform alone, while Emil Theodor Kocher
(1841–1917) hesitated to do so because of its tendency to lower the blood pressure.
• Harvey Cushing (1869–1939), on the other hand, was impressed with chloroform’s
efficacy but preferred a cautious approach to anesthesia, favouring ether and
restricting his use of chloroform to children.
8. • Cocaine had been formally discovered in 1860 and was
introduced into surgery in 1884.
• Use of procaine, which was first synthesized in 1905,
immediately became commonplace among surgical
anesthetics.
• Most neurosurgeons used local infiltration anesthesia for
select cases, but beginning in 1913 with its popularization by
de Martel, it became a common practice to use it for all
craniotomies.
• By 1917, Harvey Cushing recommended the use of local
anesthesia for all neurosurgical cases.
10. RESEARCH
• Neuroanesthesiology research has prospered most when addressing 3
broad topics:
(1) the mechanisms of brain injury and cerebral protection,
(2) the pharmacology and physiology of neuroanesthesia-related
interventions, and
(3) facilitating the clinical practices and understanding of disease pathology,
as related to neurosurgeons and neurointensivists.
11. HISTORY
• 1949- Albert Faulconer, Mayo Clinic (father of neuroanesthesiology). With neurologist, Reginald Bickford,
began work on the electroencephalogram (EEG) responses to anesthetics.
• He experimented with a controller device that would adjust the dosing of a barbiturate infusion, and in turn
anesthetic depth, based on EEG pattern
• EEG use to predict outcomes after cerebral hypoxia
12. • 1961- John D. “Jack” Michenfelder, MD
(father of modern neuroanesthesiology)
discover profound hypothermia to facilitate the
clipping of cerebral aneurysms.
• Developed the canine sagittal sinus outflow
model for quantifying cerebrocortical blood flow
and oxygen consumption in virtually real time
• The model was also expanded to allow
measurements of intracranial pressure (ICP)
and the EEG.
• Metabolic depression by barbiturates peaked
when the EEG became isoelectric, correlated
with brain electrical activity.
13. • In 1965, Allan Brown of Edinburgh, Scotland, and Andrew Hunter of Manchester, England, co-
founded the aforementioned Neuroanesthesia Traveling Club of Great Britain and Ireland.
1961 Commission on Neuroanesthesia, sponsored by the World Federation of Neurology, and a
June 1973 organizational meeting in Philadelphia of the Neurosurgical Anesthesia Society
(NAS).
• At the first annual meeting of the organization in October 1973, the NAS’s name was changed to
the Society of Neurosurgical Anesthesia and Neurological Supportive Care (SNANSC)
• In 1986, the name of the organization was changed to Society of Neurosurgical Anesthesiology
and Critical Care (SNACC) and the SNACC abbreviation was retained in 2009.
• February 1999- Formation of the Indian Society of Neuroanaesthesiology and Critical Care
(ISNACC)
14. HYPOTHERMIA
• In 1999, Todd and Warner* invited some 2-dozen neuroanesthesia researchers to Iowa City, 3-day
meeting. The group would label itself the Unincorporated Neuroanesthesia the International
Neuroanesthesia Research Group
Induced Hypothermia for Aneurysms Surgery Trial (IHAST)
• in 3-month outcome data on 1000, 30-center, 3-continents
• Subgroup analysis of the relationship of hypothermia with outcomes of anesthetic technique and
glucose concentrations.
• Ironically, although the IHAST research proved negative No better outcome in hypothermia
group, increased incidence of bacteremia
Induced hypothermia improving neurological outcomes in adult survivors of out-of-hospital
cardiac arrest
in neonates who have sustained hypoxic-ischemic encephalopathy
*Todd MM, Hindman BJ, Clarke WR, et al. Intraoperative Hypothermia for Aneurysm Surgery Trial (IHAST) Investigators. Mild intraoperative hypothermia
during surgery for intracranial aneurysm. N Engl J Med. 2005;352:135–145
15. GLUCOSE & CORTICOSTEROIDS
• 1987 -- William Lanier reported in Anesthesiology^^ that small, clinically relevant
volumes of 5% glucose-containing solution (ie, 1.05L per 70kg body weight)
meaningfully worsened outcome after a cerebral ischemic event in a non-human
primate model.
• 1996 -- Wass and Lanier et al* corticosteroids—once indiscriminately used in
neurosurgical patients—could produce adverse postischemic outcomes as a
result of glucose-dependent and glucose-independent effects. This research
also had an effect on lessening corticosteroid use clinically
^^Wass CT, Lanier WL. Glucose modulation of ischemic brain injury: review and clinical recommendations. Mayo Clin Proc. 1996;71:801–812.
*Wass CT, Scheithauer BW, Bronk JT, et al. Insulin treatment of corticosteroid-associated hyperglycemia and its effect on outcome after forebrain ischemia in rats.
Anesthesiology. 1996;84:644–651.
16. CALCIUM CHANNEL BLOCKERS
• Petter Steen and Sven Gisvold (a colleague of Peter Safar) from Trondheim, Norway,
joined forces in Rochester, in 1983 to introduce a slightly improved version of Safar’s
primate global brain ischemia model to the Michenfelder laboratory. This model was
then used to demonstrate the protective effects of the calcium entry blocker,
nimodipine.
• Calcium entry blockers, were evaluated by neuroanesthesiologists as a treatment for
improving neurological outcomes after cardiac arrest.
• This study later on made neurosurgeons adopt it as a method for improving outcomes
from vasospasm after subarachnoid hemorrhage
Steen PA, Gisvold SE, Milde JH, et al. Nimodipine improves outcome when given after complete cerebral ischemia in primates. Anesthesiology. 1985;62:406–
414
17. VENOUS AIR EMBOLISM
Maurice S. Albin* –
• VAE occurrence is not limited only to the sitting position, but can occur as well during
prone, supine, and lateral surgical procedures
• 1976 Tung air bubble illumination unit
- illuminated box with a magnified glass anterior surface.
- clamped on a segment of the air aspiration catheter
- helps to magnify and illuminate any passing air bubbles.
• Te99 lung scans >25ml of air were aspirated from a right atrial catheter and the
patient appeared to be doing well symptomatically, pulmonary perfusion defects,
some quite severe, were present as long as 11 days after surgery
• Optimal air aspiration occurred with the multiorificed catheter tip position within the
area 2.0 cm below the junction of the superior vena cava and the right atrium .
*Albin MS, Carroll RG, Maroon JC: Clinical considerations concerning detection of venous air embolism. Neurosurgery 1978; 3:380–4.
18. PICCS ARE PASSÉ
• 122 patients 67.2% PICC were optimally placed –
below the carina (chest x-ray) at junction of SVC &
RA.
• Misplaced or Malpositioned – 40 out of 122
• Above the carina 27
• Rt. Atrium 6
• IJV/ opposite subclavian 7
• CVC optimal position 90-95%
19. ADVANCES IN INTRAVENOUS AGENTS
• Barbiturates
- used in neurosurgical procedures for more than 80 years
- neuroprotective – decreases CBF, CMRO2, ICP
• Etomidate
- minimal cardiorespiratory effects,
- neuroprotective
20. PROPOFOL
• it is a powerful hypnotic that does not increase the intracranial pressure.
• delay of recovery is short even after several hours of continuous infusion
early neurologic examination.
• Lesser incidence of PONV
• Continuous infusion should be preferred to bolus in order to prevent
hypotension and decrease of the cerebral perfusion pressure.
21. • Target-controlled infusion models based on effect site concentrations are now
available through several softwares.
• Useful for awake craniotomy and functional neurosurgery.
• Useful during evoked potential monitoring.
• The level of consciousness is easily fixed between deep anaesthesia and light
sedation permitting to ask the patient to move following orders.
22. OPIOIDS
• Morphie , norphine
• Advent of the semisynthetic opioids
fentanyl, sufentanil, and alfentanil
lacked histamine release
emergence more predictable
• Sufentanil and fentanyl delayed and recurring respiratory depression
• REMIFENTANIL
- earlier return of some functions than with sufentanil or fentanyl.
- One of the most desirable - rapid anesthetic emergence
- rapid post-operative recovery is essential to assess neurologic function
- No respiratory depression post-op
23. KETAMINE
• Assumed has no role in neuroanesthesia potential for undesirable
cerebral hemodynamic effects.
• Neuroprotection Non-competitive inhibition of N-methyl-D-aspartate
(NMDA) receptors & reduction in glutamate excitotoxicity
• Ketamine not be considered absolutely contraindicated in TBI
patients.
24. MUSCLE RELAXANTS
Long acting muscle relaxants Pancuronium, Doxacurium
Intermediate non-depolarizing muscle relaxants used in neurosurgical
anaesthesia Atracurium, cisatracurium, vecuronium and rocuronium
Cisatracurium- in less cerebral and cardiovascular side-effects compared with
an equipotent dose of atracurium
25. TO USE OR NOT???
Endotracheal intubation can be easily performed without muscle relaxants, although sometimes
at the expense of haemodynamic alterations
Artificial ventilation easily controlled during anaesthesia without muscle relaxants.
No muscle inside the skull that could be paralysed to improve the neurosurgeon’s
performance.
Numerous neurosurgical procedures do not absolutely require muscle relaxants or even
contraindicate their use
intraoperative monitoring of motor evoked responses
intraoperative facial nerve monitoring during cerebellopontine angle surgery
Awake craniotomies for epilepsy surgery or surgery involving the eloquent cortex
26. DEXMEDETOMIDINE
• Stability of intracranial hemodynamics
• Attenuates hemodynamic response to laryngoscopy, intubation & pin insertion
• Reduces norepinephrine levels post ischaemia & anesthesia emergence
• Conscious sedation Early awakening
Infusion used for Functional neurosurgery, Carotid endarterectomy
adjuvant during general anesthesia
• Less agitation and respiratory depression
29. Sevoflurane
1970
Desflurane
1993
Desflurane –
• Fast onset and recovery
• Early awakening facilitates
early neurological evaluation
• Lower concentrations (MAC)
can be used to monitor cranial
nerve function, SSEPs, MEPs
• More profound effect in
increasing CBF & ICP
38. FIBREOPTIC BRONCHOSCOPE
• Least cervical spine movement GOLD STANDARD
• Better neurological outcomes compared to other methods
• Needs experience
• Chance for neurologic examination in patients at risk of
secondary cervical injury
39. SUPRAGLOTTIC AIRWAY
• Anticipated/ unanticipated difficult airway
• Inadvertent extubation occurs
• Direct laryngoscopy is impossible
reestablish oxygenation and ventilation,
even in the prone or lateral position.
• Facilitate fibreoptic endotracheal intubation
40. • Sleep-awake-sleep method
• Stereostatic surgery
• Epilepsy surgery continuous patient feed-back under conscious sedation
maximize resection of the seizure focus while minimizing subsequent disability in
nearby motor or language centers of the brain.
41. MONITORING
• Brain can be monitored in terms of
(a) function,
(b) blood flow
(c) metabolism
• General - electrocardiography, direct arterial blood pressure monitoring, pulse oximetry,
end tidal capnography, urine output, temperature, central venous pressure
• Specialised
- Bispectral index ,
- Electroencephalography,
- Trans Esophageal Echocardiography
42. MONITORING OF FUNCTION
• Electroencephalogram
Raw electroencephalogram
Computer processed
Bispectral Analysis
• Evoked potentials
Sensory evoked potentials:
Somatosensory EP
Brainstem auditory EP
Visual EP
Motor evoked potentials
Transcranial electric MEP
Direct spinal cord stimulation
• Electromyography
Cranial nerve functions (V, VII, IX, X, XI, XII)
• Inhalational agents lower
concentration (0.2-0.5 MAC)
• Total Intravenous anesthesia
(TIVA)
• Dexmedetomidine
Avoid muscle relaxants
44. TRANSCRANIAL DOPPLER
• Non-invasive, continuous measurement
of CBF velocity
• Intraoperatively velocity in the MCA (Vmca)
• Relative changes in CBF in a quantitative manner, provides a qualitative
assessment of ICP/cerebral perfusion pressure (CPP).
• Occurrence of air or particulate emboli can be detected.
• Used to determine cerebral autoregulation and carbon dioxide (CO2)
reactivity.
• Carotid endarterectomy – detect ischaemia and hyperperfusion syndrome
45. MONITORING OF METABOLISM
Invasive monitor
Intracerebral pO2 electrode (Paratrend, Licox)
• Intraparenchymal electrode reveals regional or local, rather than global, oxygen levels.
pO2 10 mm Hg (threshold for brain hypoxia)
• Restoration increasing supply of oxygen (supplemental O2, raising CPP, treating
anemia)
decreasing demand (propofol or barbiturate therapy).
hyperoxia - absolute or relative cerebral hyperemia d/t loss of cerebral autoregulation.
46. MONITORING OF METABOLISM
Noninvasive monitor
• Jugular venous oximetry - normal Sjvo2 is between 60% and 70%.
• Increased values- Sjvo2 >90% absolute or relative hyperemia reduced
metabolic need (e.g., a comatose or brain-dead patient) or from excessive flow.
• Decreased values. On the other hand, Sjvo2 is sensitive to global cerebral
ischemia. A value of <50% reflects increased O2 extraction and indicates a
potential risk of ischemic injury
• Transcranial cerebral oximetry (Near-Infrared Spectroscopy)
- measures cerebral regional O2 saturation by measuring near-infrared light
reflected off the chromophobes in the brain -oxyhemoglobin, deoxyhemoglobin.
47. ULTRASOUND
• Transthoracic echo can identify catheters in the SVC- RA junction , detect Venous
air embolism
• Cardiac US imaging – detect ASD/PFO, abnormal ventricular function/ pericardial
effusion
• Vascular US – Screening of deep vein thrombosis
- Safe central venous catheterisation – jugular, femoral,
cubital.
- Confirm tip in SVC
• Lung US – effusion, consolidation, pneumothorax, guiding percutaneous
tracheostomy
49. ELECTIVE VENTILATION
• Not every patient operated for intracranial pathology requires elective
postoperative ventilation
• Prolonged mechanical ventilation may exacerbate the postoperative
morbidities
• ICU stay of more than 48 hrs was associated with development of
pneumonia, subsequent increase in hospital stay and poor neurologic
outcome. Mahajan et al Journal of Neuroanaesthesiology and Critical Care | Vol. 1 • Issue 2 • May-Aug 2014
• INDICATIONS - • Pre-op lower
cranial nerve palsy
• Massive blood loss
• Brainstem handling
• Intra-op acute brain
bulge
• Infarct
• Tension
• Residual tumor
• Hematoma
• Prolonged surgery
51. MODERN VENTILATORS NEWER MODES
• They use ventilatory physics improve patient-ventilator synchrony
• Assist in weaning and improve outcome.
• Dual control modes(volume assured-pressure support)
• Adaptive support ventilation
• Proportional assist ventilation
• Bi-level airway pressure release ventilation (Bi-PAP)
• Neurally Adjusted Ventilatory Assist (NAVA)
- diaphragmatic electromyography
- parameters – inspiratory time, I:E ratio are patient controlled
52. SEDATION IN ICU
• Benzodiazepines – Midazolam, Lorazepam, Diazepam
• Propofol - usually given continuously,
- awakening occurs in 10-15 minutes even after prolonged sedation.
- reduce cerebral oxygen consumption and lower ICP
- treatment of refractory status epilepticus
• Dexmedetomidine
• Inhalationals
• Neuromuscular Blockers to facilitate tracheal intubation and
avoid consequences of coughing and movements on intracranial hemodynamics.
53. ALPHA 2 AGONISTS
Dexmedetomidine –
Concious sedation
dose dependent sedative and anxiolysis
hemodynamic stability
reduces catecholamine levels
no respiratory depression
non-interference with neurological monitoring
54. Anaesthesia Conserving Device –
• designed to deliver isoflurane and sevoflurane to
mechanically ventilated patients
• Small device placed between ETT & Y-piece
55. POSTOPERATIVE PAIN
• Scalp blocks:
• Regional anesthesia of the nerves that supply sensation to the scalp.
• Local anethetics used Lignocaine, Bupivacaine, Levobupivacaine,
Ropivacaine
• Combining general anesthesia with a scalp block provides the advantage of
blunting hemodynamic response during particularly stimulating portions of
neurosurgery head pinning, skin incision & postoperative pain control.
56. ANALGESIA DELIVERY SYSTEMS
Patient Controlled
Analgesia Pump
• Patient presses button for analgesic dose as
and when he experiences pain
• Delivered via IV connected to computerised
pump
• Adjustable dosing , lockout period
• Better pain management than nurse
controlled analgesic administration.
57. WHAT’S DANGEROUS IS NOT TO EVOLVE.
• With the knowledge of advances in neurophysiology,
neuropharmacology and neuromonitoring , neuroanaesthesia is
evolving from its nascent state nearly a half century ago, and further
contributing to better neurosurgical outcome
Neurosurgical procedures have been performed since prehistoric times, but the relatively recent advances in anesthesia and perioperative care have contributed to development of neurosx.
Historian believed tht Neolithic skulls were trephined to allow escape of demons… pain relieving agents used were coca leaves & dhatura
William Thomas Green Morton- inventor & revealer of inhalational anesthetics. By whom pain in surgery was averted and annulled. Before whom in all time surgery was agony. Since whom science has control of pain.Changed the way surgeries were performed
Surgeons chose one over the other depending on their benefits and safety.
Around the same time, the use of local anesthesia gained prominence.
advances in research and clinical practice in management of neurosurgical patients
Basis of modern day Target Controlled infusions.
Faculty of Mayo Clinic in 1961, profound hypothermia with the help of extracorporeal blood oxygenator machines, was provided for aneurysmal clipping.
Development of subspeciality societies led to dissemination of research information
Further contributory research studies done by neuroanethesiologists… 1999 pilot study doneLater NIH sponsored study IHAST
They created a model of right atrium and studied the optimal position at which air can be aspirated efficiently.
PICC inserted via the cubital route for patients posted for neurosurgery.
Older agents like ether and chloroform were administered by face masks (yankauer’s n schimmelbush) covered with gaugesophisticated vapouriser like EMO was developed, inhalational agents delivered through bellows and corrugated tubings.
Inhalational agents increase CBF and ICP, Isoflurane & sevoflurane increase them to a lesser extent.Early emergence with Sevoflurane
As newer inhalational agents were introduced, vapuorisers too developed and were improvised.
Direct Laryngoscopy (DL): used most commonly to secure airway, DL has many advantages. The experience of most of the providers hence it is easy to use and performed very quickly. DL must be considered when the provider is not skilled with the other techniques or emergent intubation is needed.
Laryngoscopy blades Macintosh, Miller, McCoy (flexible tip)
Earlier red rubber endotracheal tubes were used which were replaced by transparent PVC ETT, later on reinforced flexometallic tubes came to be used to avoid kinking .
Flexible and angulated stylets are used to facilitate endotracheal intubation.In patients whose tracheas were difficult to intubate or in patients who underwent fusion of the cervical spine or are in cervical traction, the trachea can be extubated over a jet stylet or endotracheal tube changer to facilitate reintubation if required. The hollow jet stylet allows for jet ventilation if reintubation proves impossible.
Videolaryngoscopes are new devices, they may improve glottic view and ease intubation. Recording of laryngoscopic view is possible. They decrease cervical spine motion. Also during intubation blood and secretions may cause difficulties for videolaryngoscopy.
Cervical spine movement is least with FI. However, there is no published data that shows FI has better neurological outcomes
compared to other methods. Ezri et al. [7] reported that 75% of American anesthesiologists agree with fiberoptic intubation at cervical spinal surgery. Nevertheless, just 59% of respondents declared that they are comfortable using the fiberoptic. Fiberoptic intubation needs experience, and it may cause airway obstruction and increase intracranial pressure. Malcharek et al. [8] showed that awake fiberoptic intubation and self-positioning to the prone position is feasible, successful and gives a chance for neurologic examination in neurosurgical patients at risk for secondary cervical injury.
General Routine monitoring during neuroanaesthesia, in recent days includesBIS to monitor depth of anesthesia and also as a guide of dose adjustment of sedativesEEG cerebral function monitor, and also to measure EEG suppression while using barbiturate therapy cerebral protection & when the brain is at risk for ischemia TEE to measure venous air embolism
Intra‑operative neurophysiologic monitoring (IONM) under anaesthesia is gaining popularity.
It helps prevent/ minimize neurologic morbidity from surgical manipulations
to identify changes in nervous system function prior to irreversible damage.
MCA - transtemporally over the zygomatic arch
esophageal catheter at level of diaphragm records time of initiation & strength of contraction
To decrease agitation and improve elective ventilation tolerance
Miniature porous evaporator rod- converts volatile agent from liquid to vapor
Liquid anesthetic agent is continuously infused into the evaporator by an infusion pump incorporating a syringe
Apart from the nurse delivered analgesia in the form of paracetamol and opioids.