SUPRATENTORIAL TUMORS-ANAESTHETIC CONSIDERATIONS.pptx

Anaesthetic consideration for supratentorial tumours

1. Supratentorial Tumours- Anesthetic Considerations Presented by- Dr. Surya Kant Moderator- Dr. Ashutosh Kaushal

2. ANESTHETIC MANAGEMENT

3. EMERGENCY ANESTHETIC MANAGEMENT Acute Neurological Deterioration- bleed in the tumor bed. herniation following a seizure/an expanding mass lesion. C/F - The patient may be unconscious with an abnormal breathing pattern hemodynamic fluctuations pupillary and localizing signs

4. EMERGENCY ANESTHETIC MANAGEMENT Schema of management of patient with acute neurological deterioration

5. NON-EMERGENT SURGERY FOR SUPRATENTORIAL TUMORS

6. ANESTHETIC CONSIDERATIONS

7. NEUROLOGICAL HISTORY Level of consciousness, somnolence. Seizures →type, frequency, treatment received. ↑ICP Features: headache, nausea, vomiting, blurred vision Focal neurologic signs: hemiparesis, sensory deficits, cranial nerve deficits , speech deficits Medication: steroids, antiepileptic drugs, osmotherapy

8. GENERAL HISTORY PAST MEDICAL HISTORY( CARDIAC, RESPIRATORY PROBLEMS) FAMILY HISTORY H/O ALLERGIES H/O ADDICTIONS H/O MAJOR SURGERIES H/O ANY KNOWN MALIGNANCIES

9. GENERAL EXAMINATION AIRWAY EXAMINATION MEASUREMENT OF VITALS P/I/O/C/J GENERAL FEATURES VASCULAR ACCESS ASSESSMENT HYDRATION STATUS

10. NEUROLOGICAL Examination

11. SYSTEMIC EVALUATION Cardiovascular system : Effects of raised ICP on cardiac conduction-bradycardia Acute intracranial pathologies affect cardiac function Heart rate variability in insular gliomas(tachycardia seen in Left insular gliomas and bradycardia seen in right sided gliomas Mishra A, John AP, Shukla D, Sathyaprabha TN, Devi BI. Autonomic Function in Insular Glioma: An Exploratory Study. World Neurosurg . 2018 Oct;118: e951-e955

12. Respiratory System : Pre-existing lung disease or poor lung reserve-(difficult to maintain ventilation, extubation ) Presence of added sounds/decreased air entry Possible lung primary for mets . Effect of chemotherapy-Bleomycin(lung fibrosis) Any ongoing respiratory infection.

13. ROUTINE INVESTIGATIONS

14. PREMEDICATION All the current medications must be reviewed and continued as needed . Anxiolytics: In patients with elevated ICP, preoperative sedatives or anxiolytics must be avoided esp in the night before. To be used in small incremental doses and given to the to the patient in pre-operative area, under observation and monitoring of O 2 saturation

15. STEROIDS: Steroids should be continued on the morning of the operation (methylprednisolone or dexamethasone). OTHER DRUGS: H2 blockers and gastric prokinetic agents should be considered to counteract the reduced gastric emptying and greater acid secretion associated with increased ICP and steroid therapy. Antihypertensive and other cardiac medications, should be continued. Various drug interactions to be considered. Adequate blood and blood products to be arranged.

16. INTRAOPerative MANAGEMENT

17. INTRAOPERATIVE ANESTHETIC CONSIDERATIONS

18. ANAESTHETIC GOALS

19. INDUCTION OF ANESTHESIA

20. INTRAOPERATIVE MONITORING

21. SPECIAL MONITORING

22. VASCULAR ACCESS IV access . Two large-bore(16G) peripheral intravenous catheters for craniotomy. Central venous access- substantial bleeding is anticipated , major cardiovascular compromise continuous infusion of vasoactive drugs. significant risk of VAE CVP monitoring

23. INDUCTION OF ANESTHESIA Suggested Anesthesia Induction sequence for Intracranial surgery: After proper preoperative preparations the patient is to be taken up for induction. Preoxygenation & voluntary hyperventilation. Opoids -Fentanyl, 1-2 mcg/kg, Morphine-0.1 mg/kg Propofol, 1.25-2.5 mg/kg, or thiopental, 3-6 mg/kg for induction. Etomidate (0.2-0.4mg/kg) may be used in frail or elderly patients. Ketamine to be avoided Nondepolarizing myorelaxant : Vecuronium(0.1mg/kg) or Atracurium(0.5mg/kg) Controlled ventilation (Paco2 ~ 30-35 mm Hg). Intubation and prevention of Intubation response.

24. PATIENT POSITIONING COMMON PATIENT POSITIONS USED FOR SUPRATENTORIAL TUMOR SURGERIES- SUPINE LATERAL SITTING Salient points about patient positioning post induction(for pterional craniotomy): Supine position Ipsilateral shoulder roll if head is turned > 30 Elevate thorax 10 - 15 → reduces venous distension. Mayfield 3 pin/Sugita 4 pin head holder applied after all precautions to maintain ICP Neck extended to 15 → allows gravity to retract frontal lobe away from skull base Head rotated from vertical (10 -60 ) depending on the location of the lesion being approached.

25. PATIENT POSITIONING Pin holder application is a maximal nociceptive stimulus and can be associated with venous air embolism. It must be managed by deepening of analgesia-by bolus of opiods or scalp block Adequate padding to be provided over all the pressure points Proper covering of the patient to prevent hypothermia.

26. PATIENT POSITIONING PATIENT ON MAYFIELD PIN PATIENT ON SUGITA 4-PIN HEAD FRAME

27. MAINTAINENCE OF ANESTHESIA

28. TIVA VS INHALATIONAL CHOICE OF TECHNIQUE: Controversy: intravenous or volatile anaesthesia for neurosurgery? No study to date has shown significant outcome differences for intravenous versus volatile-based neuro- anesthesia . The major argument for the use of volatile agent-based techniques remains controllability, predictability, and the attainability of early awakening.

29. FLUID THERAPY Maintaining normo- volemia and normotension and fluid therapy should be goal directed. Glucose-containing or hypo-osmolar solutions (e.g., lactated Ringer’s solution, 254 mOsm /kg) should be avoided. Preferebly warm fluids to be used. But studies have shown no significant difference in clinical outcome in using NS & RL

30. OSMOTHERAPY It works on the principle of creating an osmotic gradient in the intravascular compartment of the central nervous system (CNS) Using the Gradient, it draws free water from the intracranial parenchyma into the vascular compartment

31. OTHER INTRAOPERATIVE DRUGS

32. VENTILATORY REGIMEN GOALS- Goal of ventilation is to maintain normocarbia of PaCO2 between 30-35 mmHg. Transient therapeutic hyperventilation may be required to treat acute cerebral edema and should be guided with PaCO2 rather than end-tidal CO2 (EtCO2) Hyperventilation to a PaCO2 of 25–30 mmHg can improve surgical condition during SBT craniotomy But there is risk of cerebral vasoconstriction from hyperventilation which may result in ischemia of at-risk brain tissue.

33. Cerebral blood flow and metabolism- CBF measured by PET is reduced more with propofol (3.7mg/ml) compared with sevoflurane (1.5 vol%) at equipotent concentrations CMRO2 is reduced to the same extent with both anesthetics & coupling between regional cerebral blood flow and metabolism is maintained Kaisti KK, Langsjo JW, Aalto S, et al Anesthesiology 2003; 99:603–613 Propofol - Decrease in jugular bulb venous oxygen sat. upto 50 % and <50% with hypocapnia (PaCO2=33mmHg), Sevoflurane - no change in saturation with normo or hypocapnia Kawano Y, Kawaguchi M, Inoue S, et al J Neurosurg Anesthesiol 2004; 16:6–10. Recent results ,however, indicate that increasing propofol concentrations do not affect SjvO2 in neurosurgical patients. Iwata M, et al.. Anesthesiology2006; 104:33–38

34. Neuroprotection: Propofol has well-established antioxidant and antiapoptotic properties & has been shown to be neuroprotective in vivo, in both focal and global models of cerebral ischaemia . Propofol has no direct preconditioning effect, probably because of its antioxidative properties Engelhard K et al. Anesthesiology 2004; 101:912–917. Ozturk E et al. Prog Neuropsychopharmacol Biol Psychiatry 2005; 29:922–927. Volatile anaesthetics protect against both focal (e.g. obstruction of flow distal to the circle of Willis) and global (e.g. complete cessation of blood flow to the brain or forebrain) ischaemia . However, the improvement in outcome is transient in global ischaemia , whereas it is persistent in focal ischaemia . Elsersy H et al. Anesthesiology 2004; 100: 1160–6 Sakai H et al. Anesthesiology 2007; 106: 92–99

35. C.B.F Autoregulation: Impaired with higher concentrations of inhalational agents but maintained with 0.5 and 1.0 MAC sevoflurane Propofol does not impair cerebrovascular autoregulation independent of the concentration Ogawa Y, Iwasaki K, Shibata S, et al.Anesth Analg 2006; 102:552–559 CPP & ICP: In a RCT of patients subjected to craniotomy for cerebral tumours , ICP and cerebral swelling at the opening of the dura have been shown to be lower, and MAP and CPP to be higher in propofol-anaesthetized patients compared to patients anaesthetized with isoflurane or sevoflurane. Conclusion → during craniotomy for cerebral tumours , operating conditions would be better during propofol than isoflurane or sevoflurane anaesthesia . Petersen KD, et al. Anesthesiology 2003. 98:329–336 .

36. INTRAOPERATIVE COMPLICATIONS

37. Under certain circumstances during surgery, the brain may start to severely swell out of the craniotomy wound. Etiologies include: Surgery related Intracerebral hemorrhage/ tumor etiology (GBM/metastasis) Severe diffuse cerebral oedema. Improper positioning / too much flexion of the neck Anesthesia related Venous outflow obstruction (tube ties, flexion) Vasodilatation induced by hypercarbia Volatile anesthetics/nitrous/ increased CBV Inadequate Depth of Anesthesia INTRAOPERATIVE BRAIN SWELLING

38. MANAGEMENT OF BRAIN BULGE

39. MANAGEMENT OF BRAIN BULGE The chemical brain retractor concept: Mild hyperosmolality Intravenous anesthetic agent (propofol), Adequate depth of anesthesia, adequate analgesia Mild hyperventilation (PaCO2 32 -35 mm Hg) Mild hyperoxygenation , Mild controlled hypertension; MAP maintained around 100mmHg to ↓ CBV & ICP, Normovolemia , No vasodilators.

40. OTHER INTRAOPERATIVE COMPLICATIONS VENOUS AIR EMBOLISM: Risk of VAE-during Head frame Pin placement, Sitting Position Surgery Monitoring for detection of VAE-Current standard of care → combination of precordial doppler and expired CO2 monitoring. Best - TEE Management-By using CVC cannula, saline flush over the operative area BLEEDING: Intraoperative bleeding due to injury to sinus(sagittal/ transverse) Highly vascular Tumor -Meningioma Altered Coagulation profile Management-Adequate Blood And Blood Products and use of Tranexamic acid

41. EMERGENCE FROM ANESTHESIA Emergence from anesthesia following craniotomy for tumor excision is a very crucial phase that requires meticulous planning, preparation, and skills. 20% of elective craniotomy patients develop raised ICP in the early postoperative period. Constantini S et al. Intracranial pressure monitoring after elective intracranial surgery: A retrospective study of 514 consecutive patients. J Neurosurgery.1988 . The two important goals are to achieve the following: 1. Smooth emergence without coughing/bucking and sympathetic stimulation 2. Rapid and complete awakening to facilitate the neurological examination

42. AIMS OF EMERGENCE Neurosurgical awakening should maintain: Stable arterial blood pressure and thus CBF and ICP. Stable oxygenation and carbon dioxide tension. Stable CMRO2. Normothermia. Neurosurgical awakening should avoid: Coughing Tracheal suctioning Fighting against the ventilator Airway overpressure during extubation

43. EARLY VS. DELAYED AWAKENING:PROS AND CONS

44. POSTOPERATIVE MANAGEMENT Postoperative Deterioration- Possible etiologies: Hematoma- ICH, EDH, SDH Cerebral Infarction- Arterial/ venous Postoperative Seizure : May Be Due To Inadequate Anticonvulsant Levels. Acute Hydrocephalus Pneumocephalus Cerebral Edema : May Improve With Steroids Persistent Anesthetic Effect (Including Paralytics): Vasospasm

45. POST-CRANIOTOMY PAIN Post craniotomy pain incidence is around 60%, with the highest incidence observed 12h after surgery, the majority being moderate in nature and intensity. 48% of patients experience this level of pain during some portion of the second postoperative day. Gottschalk A. A prospective evaluation of pain and analgesic use following major elective intra-cranial surgery. J Neurosurg 2007;106:210–6 It is an important aspect of postoperative management and needs to be dealt with utmost care. Multimodal treatment modalities are to be used for the management of the pain

46. POSTOPERATIVE NAUSEA AND VOMITING Intracranial procedures per se carry high risk for PONV. The overall incidence of PONV within 24 h after craniotomy is approximately 50% Drugs to treat PONV-5-HT3 antagonists are considered as agent of choice. Eg - Ondansetron Dexamethasone Metoclopramide

47. SPECIAL CONSIDERATIONS-AWAKE CRANIOTOMY Awake craniotomy refers to conduct of intracranial tumor surgery under conscious sedation To enable clinical neuromonitoring, which allows the neurosurgeon to conduct tumor resection with no or minimal neurological deficit. AC has been associated with a greater extent of tumor resection, fewer later neurologic deficits, shorter hospital stays, less postoperative pain, and improved survival. Indications( in supratentorial tumors) 1. Supratentorial tumors close to eloquent areas like motor strips and speech area. 2. Epilepsy surgery Techniques for Awake Craniotomy- 1) Awake technique 2) Sleep-Awake technique 3) Sleep-Awake-Sleep technique

48. AWAKE CRANIOTOMY Steps in the Conduct of Awake Craniotomy- Proper patient selection Proper counselling regarding the surgical and anesthetic aspects of this procedure by surgeon and Anaesthesia team & preoperative cognitive function assessment Airway evaluation Special arrangements have to made to allow visualization and access to patients during conduct of surgery

49. AWAKE CRANIOTOMY ASA Standard monitoring. Invasive arterial blood pressure in the limbs Monitoring of the depth of anesthesia would allow for easy titrability of anesthetics and sedative agents. Vascular access, preferably not in the primary limb to be examined. Scalp block. Neurological examination should be carried out prior to and during tumor resection. Any alteration in neurological and cognitive function to be informed to the surgeon.

50. AWAKE CRANIOTOMY

51. SPECIAL CONSIDERATIONS-INTRAOPERATIVE (IMRI) IMRI offers near real-time imaging guidance during brain tumor resection. It has been shown to optimize the extent of tumor resection and safety of brain tumor surgery especially for gliomas. IMRI can also detect intraoperative complications. Use of MRI compatible Anesthesia equipment. MRI safety regulation is strictly enforced. Anesthesia is maintained with either volatile anesthetic or TIVA during MRI scanning. ASA standard monitoring is applied in this situation too. But high magnetic field may interfere with ECG tracing, so use of Pulse oximetry or Arterial waveforms to pulse irregularities. Emergency medications are easily available, and the anesthesiologist monitors the patient closely in the control room. Thus, iMRI contribute to enhanced clinical outcome and improved patient care.

52. SUMMARY Supratentorial tumors has profound implications for cerebral physiology including alterations in intracranial pressure and cerebral autoregulation. Goals of anesthesia management are optimize cerebral physiology by maintaining cerebral perfusion pressure, to facilitate surgical resection, to prevent brain ischemia, and to allow rapid emergence for neurologic examination. Both inhalational and total intravenous anesthesia (TIVA) with propofol for maintenance of anesthesia are acceptable techniques. However, TIVA has many advantages to alternative techniques involving volatile agents. Emergence from anesthesia after SBT resection is just as important as induction of anesthesia,.

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