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Neuro Flashcards

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1
Q

What volatile anesthetic would you choose for a Neuro case and why?

A

Isoflurane because it causes the greatest drop in CMR

And it facilitates absorption of CSF

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2
Q

What are the dangers of using volatile anesthetic in a Neuro case with suspected ischemia?

A

Volatiles increase CBF by vasodilation, but not in ischemic areas so you could make this worse by circulatory steal

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3
Q

Would you use lidocaine infusion in a Neuro case? Why or why not?

A

I would because lidocaine decreases CBF and may also have neuroprotective effects
It also decreases MAC and opioid requirements –> reduces emergence delirium

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4
Q

What physical exam signs do you look for ICP?

A 
Papilledema
Focal signs
CN deficits
Lethargy
Cognition
Pupil size
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5
Q

How do you treat high ICP.

A

Head of bed up
Steroids if vasogenic edema (not in trauma)
Diuretics - goal of serum osmolality of 300-315 mOsm/L
Moderate hyperventilation (PaCO2 30-33 mmHg)
Anesthetics
Normothermia
Hypertonic saline
EVD

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6
Q

What are the contraindications for using mannitol?

A 
Intracranial aneurysm 
AVM
ICH 
Subdural hematoma
(Until cranium is opened)
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7
Q

What are the potential dangers of using mannitol?

A

Rebound edema
Transient increase in intravascular volume –> pulmonary edema
Rupture of aneurysm/AVM/bridging veins due to abrupt change in transmural wall pressure and expansion of hematoma
Hypotension

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8
Q

What kind of preoperatively tests do you want for craniotomy surgery?

A

CT or MRI - looking for evidence of brain edema, size and location of tumors or aneurysm, midline shift or compression of the ventricles
Labs: glucose level, BMP for electrolytes (SIADH or diuretic therapy), Hct

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9
Q

How will you T this patient with a cranial mass up for surgery?

A

Make sure they get their anticonvulsant and steroid

Correct electrolytes

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10
Q

What other monitors do you want for a craniotomy case?

A

Arterial line - zeroed at external auditory meatus for measurement of CPP at circle of Willis
Central line for fluids, vasopressors and aspiration of catheter in case of VAE
Foley catheter

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11
Q

How will you induce a patient with high ICP?

A

Modest hyperventilation PaCO 30-33
Propofol + lidocaine + fentanyl + rocuronium - modified RSI
Fentanyl to blunt tachycardia response to DL versus esmolol
Propofol for deceased CMR and CBF
Lidocaine for decreased dosages of fentanyl/propofol and decreased CBF
Modified RSI to maintain normocarbia and prevent aspiration

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12
Q

Could you use succinylcholine in a patient with high ICP?

A

Yes, you could because the increase in ICP caused by succinylcholine is transient and failed airway, aspiration, hypoxemia and hypercarbia will be detrimental to this patient and also cause increased ICP

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13
Q

Patient with high ICP is tachycardic and hypertensive after intubation, what do you do?

A

Bolus of propofol (deepen anesthetic)

Beta blockade

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14
Q

How will you maintain a patient with high ICP for craniotomy?

A

TIVA
Or MAC < 0.5 volatile plus IV anesthetics: propofol, lidocaine, remifentanil
Continue hyperventilating (PaCO2 30-35)
IVF - no glucose! Causes increased ischemic brain injury

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15
Q

Why not hyperventilate below PaCO2 of 30?

A

Little to no benefit

Can cause cerebral ischemia and impair oxygen dissociation from hemoglobin

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16
Q

How will you emerge this patient?

A

Want to avoid coughing on tube - lidocaine down ETT
Resume spontaneous breathing
Reverse

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17
Q

What is your differential diagnosis for delayed wakening in a crani case?

A

Drugs: opioid, inhalational, NMB
Stroke
Metabolic derangement: glucose, hypoNa
Pneumocephalus

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18
Q

What monitors would you use for a posterior craniotomy?

A

TEE
Precordial Doppler
Central line with tip at junction of RA and SVC, syringe attached

Other monitors for VAE?
Esophageal stethoscope
PAC (increase in PAP)
Mass spec of nitrogen on the monitor
Drop on ETCO2 or oxygen
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19
Q

Where should CPP be kept in a crani case with increased ICP?

A

70-110

This correlates with a MAP 140-110 for ICP of 30

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20
Q

At the end of a longer spine case a patient wakes up and has visual loss, but no pain? What are you worried about? How did this happen?

A

Intraoperative optic nerve damage

Due to increase orbital venous pressure and decreased perfusion

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21
Q

What are the anesthetic considerations for prone positioning?

A

Airway and facial edema
POVL 2/2 impaired venous drainage
Cortical blindness due to decreased perfusion of the visual cortex
Abdominal compression–> impede venous return, contribute to blood loss thru engorgement of epidural veins!
Femoral artery occlusion –> a vascular necrosis
Genitals, knees, eyes, ENT
Brachial plexus injury

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22
Q

How will you reduce the risk of POVL?

A

Reverse Trendelenburg position
Avoid hypotension
Padding of pressured areas
Neutral head position for draining of head/neck

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23
Q

For an aneurysm case, what kind of monitors do you want?

A

Arterial line - tight BP control to avoid aneurysm rupture
Central line in femoral - cordis for volume resuscitation due to massive blood loss. Femoral to avoid imparing head/neck drainage with subclavian/jugular

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24
Q

How does mannitol work?

A

Osmotic diuresis

Must have intact bbb!

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25
Why keep MAC < 0.5 in intracranial cases?
Because levels of volatiles above this cause cerebral vasodilation
26
Surgeon asks for hypotension during an aneurysm case, how will you do this?
I would start a nicardipine drip since it is titratable Would also bolus propofol to decrease CMRO2 Keep Mac < 0.5
27
What is diabetes insipid us?
Brain is not releasing ADH
28
What is the treatment of diabetes insipidus?
Volume replacement Vasopressin Monitor sodium and fluid status
29
Tell me everything about motor evoked potentials?
Assess the lateral corticospinal tract Minimally affected by IV anesthetics: ketamine, etomidate, opioid, dexmed
30
What factors effect evoked potentials?
Hypoxia Hypothermia/hyperthermia Anemia
31
Which evoked potentials are most sensitive to anesthetic?
Visual> SSEP > motor > auditory
32
What are the anesthetic goals in TBI?
``` CPP between 50-70 PaCO2 35-40 (avoid hyperventilation) Treat ICP greater than 20 Keep Bg below 180 Use anticonvulsants for within 1st week of head injury (phenytoin and carbamazepine have been should to reduce the incidence of early post-traumatic seizures ``` Do not use albumin or fluid with dextrose Steroids don't improve outcome and therefore are not recommended
33
What would you do if a paraplegic patient suddenly became hypertensive and Bradycardic?
Ask surgeon to stop stimulation Deepen anesthetic Give IV hydralazine, NTG, nitroprusside, magnesium, nicardipine SL nifedipine if no IV access Ensure bladder is emptying in Foley Place arterial line Monitor patient for sequelae: ICH, stroke, MI, seizure, arrythmia, pulm edema
34
What is the pathophysiology of autonomic hyperreflexia?
Unopposed sympathetic efferent flow below the level of the lesion due to lack of inhibitory signals from higher CNS Activation of ascending spinothalamic and posterior columns causing lower extremity and splanchnic vasoconstriction thru unopposed sympathetic reflex Reflex Brady
35
When is the risk of succinylcholine induced hyperkalemic arrest highest after a spinal cord injury?
Between 4 weeks and 5 months
36
What is the pathophysiology of neurogenic pulmonary edema?
Head or cervical injury resulting in sympathetic mediated systemic vasoconstriction --> decreased LV compliance and subsequent pulm edema
37
What are your concerns with a cervical spine injury?
Difficult Airway Loss of diaphragmatic function --> need for vent Inability to cough/handle secretions/impaired airway reflexes Aspiration risk due to paralytic ileus Temperature regulation issues (loss of vasoconstriction below the level of the lesion) End organ damage : increased ICP, MI, Arrythmia due to autonomic dysfunction Positioning difficulty or injury (sacral ulcers) Stasis --> DVT
38
Would you administer steroids to someone with spinal cord injury? Why or why not?
No, due to lack of evidence for benefit. Also, side effects: infection, GIB, respiratory compromise, death, HTN, fluid retention, hyperglycemia, impaired wound healing and immunosuppression
39
What is spinal shock?
Flaccid paralysis Paralytic ileus Loss of sensation, reflexes, SNS vasomotor tone, temperature regulation below the level of the injury Loss of cardiac accelerator fibers - inability to compensate for hypovolemia and decreased SVR
40
What are the symptoms of an anterior cerebral artery stroke?
Lower extremity weakness and sensory loss on contralateral side
41
What are deficits from a MCA stroke?
Aphasia | Facial and upper and lower extremity weakness and numbness on the contralateral side
42
If you suspect a stroke, what should you do?
``` 1. ABCs! Call for help Support BP, maintaining MAP > 70 IV access 2. Mini Neuro exam, check glucose Get CT/MRI Consult neurologist ```
43
In what time frame can you give tPA?
Under 4.5 hours
44
What's included in the work up for stroke?
TTE with bubble study Carotid US Thrombophilia study Anti platelet therapy
45
What is the difference between CSW and SIADH?
SIADH - euvolemia | CSW - hypovolemia, urine sodium > 100
46
What is the treatment for SIADH?
Fluid restriction Diuresis Demeclocycline to block ADH in the kidney
47
What is the treatment for CSW?
Fluid and electrolyte resuscitation
48
What are the criteria to clear a C-spine?
1. No cervical pain or tenderness 2. No distracting pain 3. No paresthesias or Neuro deficits 4. Normal mental status 5. Greater than 4 yo If not met, need C-spine lateral and AP views T/L spine lateral and AP views Open mouth Odontoid view
49
Why is a CPP in a TBI patient of 50-70 best?
> 70 is associated with higher incidence of ARDS | < 50 is associated with cerebral ischemia
50
Why wouldn't you use nitrous oxide in a Neuro case with TBI or high ICP?
1. You want patient breathing 100% FiO2 2. Nitrous oxide causes increase in CBF alone or with other agents 3. Nitrous oxide is sympathomimetic 4. Nitrous oxide can cause expansion of air pockets further elevating ICP
51
Which cranial nerve does a blown pupil indicate?
Cranial nerve 3 palsy from uncal herniation
52
What is cushing's triad?
Increase in BP due to cerebral ischemia and reflex bradycardia from this systemic increase, plus irregular respiration
53
What are the 3 reasons to give mannitol?
1. Osmotic diuresis, shifting from intracranial compartment to the intravascular compartment 2. Decreasing the production of CSF 3. Inducing reflex cerebral vasoconstriction from decreased blood viscosity
54
What are the CV effects of myasthenia gravis?
``` Mild HTN Afib 1st degree AV block Cardiomyopathy Myocarditis Dyspnea Diastolic dysfunction ```
55
What are some of the symptoms of myasthenia gravis?
Diplopia (blurry vision) Ptosis Bulbar weakness a difficulty swallowing, dysphagia, dysarthria Easy fatigued - eyes, face, neck and limbs Weakness Dyspnea
56
What are the risk factors for postoperative ventilation?
1. Disease duration of over 6 years 2. Pyridostigmine dose > 750 mg/day 3. Vital capacity < 2.9 L or 4 ml/kg 4. Concomitant pulmonary disease 5. PIP < -25 H2O 6. NIF < - 20
57
How could you tell the difference between cholinergic crisis and myasthenia crisis?
``` Pupil size Muscle fasciculations (cholinergic) Edrophonium test (if gets better = MG) ```
58
What are the signs and symptoms of cholinergic crisis?
``` Salivation Miosis N/V Urinary urgency/frequency Muscle fasciculations Bradycardia ```
59
What would you use EMG for in a spine surgery
Monitoring peripheral nerves to prevent nerve root injury during pedicel screw placement
60
Where do you place a Precordial Doppler?
Right of the sternum between 2-4 ribs
61
What's the optimum position for central line for VAE?
2 cm below the SVC-atrial junction
62
With pituitary resection, what is the patient at risk for?
Massive hemorrhage from cavernous sinus and internal carotid artery
63
Is PEEP recommended in the treatment of VAE?
Can be helpful to increase venous pressure at the surgical site, but it is not as effective as jugular venous occlusion Can shift atrial pressures and cause paradoxical embolism in a patient with PFO
64
How do you diagnose diabetes insipidus?
Urine specific gravity less than 1.005 Rising sodium Urine osmolality increases with admin of exogenous ADH No hyperglycemia
65
What is the differential for polyuria?
Hyperglycemia Diuretic use Mobilization of third space Diabetes insipidus
66
How do you treat DI?
Replace loss with hypoosmolar fluid at equal rate to hourly maintenance requirements + 2/3 UOP Desmopressin if require >350 ml/HR of replacement
67
What is the blood supply to the spinal cord?
Two posterior spinal arteries supply posterior 1/3 (sensory) 1 anterior spinal artery supply anterior 2/3 (motor) from vertebral and basilar arteries. 6-8 radicular arteries feed anterior spinal artery Artery of Adamkiewicz = major supplier to anterior lower 2/3 cord.
68
What is the artery of Adamkiewicz usually located?
T9-12 (60%) Otherwise anywhere from T5-L5
69
How would you assess for residual heparin effects?
Heparin-protamine titration assay or ACT
70
Why is lasix better than mannitol?
Because mannitol causes a transient increase in ICP by shifting volume intravascularly Have to have an intact BBB with mannitol
71
How can you tell the difference between brain stem ischemia and VAE?
Difference in ETCO2 High CVP or PA pressures in VAE Should be hypercarbia in brain stem ischemia due to Hypoventilation in inadequately relaxed patient
72
What are the absolute contraindications to tPA?
uncontrolled HTN with SBP > 185, DBP > 110 Serious head trauma or stroke within last 3 months Coagulopathy or TCP Acute ICH Therapeutic LMWH w/in 24h Factor Xa inhibitors, direct thrombin inhibitors Hypoglycemia < 50 Hyperglycemia > 400
73
What are the relative contraindications to tPa?
``` Advanced age (>80) Severe stroke and coma Recent major surgery Arterial puncture of a non compressible vessel within the last 7 days Recent GI Gu bleed Recent MI (3 months) Seizure at onset Presence of neoplasm, AVM, aneurysm ```
74
Why isn't hyperventilation a long term treatment option for increased ICP.
Because ions will move into the CSF in 6-12 hours to normalize the ph and thereby decrease vasoconstriction effects

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