Cerebral Aneurysm clipping: anes management

Clinical - Neurologic

Anesthetic goals in this patient population revolve around 1) preventing large changes in blood pressure 2) facilitating surgical exposure [via hyperventilation and osmotic diuresis] 3) ensuring adequate collateral circulation if temporary clips are placed during surgery 4) minimizing deleterious increases in ICP and 5) allowing for rapid wakeup and neurologic examination. As with other patients with CNS injury, remember to avoid hypoventilation (ie use opiates with caution). With regards to the above:

Consider short-lived hyperventilation prior to induction, as well as when requested by surgeons (to assist in relaxation). Keep in mind, however, that excessive hyperventilation can be harmful – hyperventilation is known to lower ICP however CBF drops 3-4% for every 1 mm Hg decrease in PCO2 (Ref. 1) – this is dangerous as CBF may drop by as much as 50% following TBI (Ref. 2, 3). Hyperventilation is highly controversial (Ref. 4), with the 2007 Cochrane Database Review concluding that there is inadequate data to assess whether benefit or harm exists. (Ref. 5) The Brain Trauma Foundation recommends against chronic hyperventilation. (Ref. 6) – Andrews recommends 35 mm Hg

Randomized, multicenter (30) trial of 1001 patients with a WFNS score of 1-3 preoperatively following SAH, scheduled for clipping within 14 days of rupture, randomly assigned to target temperature 33C vs 36.5C. There were no significant differences in the duration of ICU stay, total length of hospitalization, rates of death at follow-up, or the destination at discharge. Postoperative bacteremia was more common in the hypothermia group (5 percent vs. 3 percent, P=0.05) (Ref. 7)

Anesthesia for Aneurysm Clipping

Sources

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2009

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