Craniotomy
15/9/09
OHOA page 390-391
= excision or debulking of tumour, brain biopsy or abscess
Preoperative
– assess for signs of increased ICP
– document neurological signs
– check GAG reflex
– disease burden (lesion may be met)
– review scans
– discuss with surgeons exact nature of surgery
– check disordered electrolytes (SIADH, salt wasting, no ADH)
– dexamethasone (?hyperglycaemic)
– IVF fluids (cautious if cerebral oedema exists)
– avoid sedation in patients with raised ICP
– DVT prophylaxis
– prophylactic phenytoin may be required (15mg/kg load -> 4mg/kg od)
Intraoperative
– 1-12 hours
– +++ pain
– supine, head up or lateral decubitus
– IPPV
– invasive monitoring (PICC or CVL – doesn’t increase ICP)
– temperature monitoring (normothermia)
– induction; propofol or thiopentone, remi 0.2-0.5mg/kg/min
– NDNMB for relaxation
– lignocaine 1.5mg/kg or esmolol to attenuate ETT
– armoured ETT (tape)
– cover and protect eyes
– volatile; sevo or iso @
– TCI; propofol 3-6mcg/mL, remi 0.15-0.25mcg/kg/min
– monitor positioning of head
– pining; ask for LA to be used and increase depth
– aim for normotension and low normal CO2
– N/S for IVF
– replace blood loss with colloid or RBC’s
– pneumatic calve compressors
– IV morphine when closing
– avoid coughing
Post operative
– most can go to neuroward
– if obtunded preop -> ICU
– severadol + paracetamol -> PCA
– caution with NSAIDS as they enhance opioid analgesia and increase bleeding risk and patients may be hypovolaemic
