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Intracranial aneurysms-anaesthesia PowerPoint Presentation

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On : Mar 14, 2014

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  • Slide 1 - Anesthesia For Intracranial Aneurysms
  • Slide 2 - Objectives Understand the incidence and pathophysiology of aneurysms Considerations in management of aneurysms Anesthetic management New considerations in management of intracranial aneurysms
  • Slide 3 - Incidence 75% of subarachnoid hemorrhages 27,000 American/year 6-49 per 100,00 year depending on location Female predominance Age 40-60
  • Slide 4 - Incidence Ruptured intracranial aneurysm (IA) 20% morbidity 20% mortality Unruptured IA 4% morbidity 0-2% mortality
  • Slide 5 - Pathophysiology Arterial wall abnormalities Saccular, occur at bifurcations Disease processes associated with an increased risk of IA Polycystic kidney Erloh Danlos Fibromuscular disease Coarctation of the aorta
  • Slide 6 - Circle Of Willis
  • Slide 7 - Classification Small – less than 12 mm Large – 12-24 mm Giant - 24mm
  • Slide 8 - IA Rupture Increase ICP ICP greater than DBP Bleeding stops with decreased CBF Decreased consciousness 2 clinical scenarios typical 1. Return to normal ICP and CBF with return of function 2. High ICP continues with low CBF
  • Slide 9 - Factors associated with an increased risk of rupture Hypertension Pregnancy Smoking Heavy drinking Strenuous activity
  • Slide 10 - IA Grading Grade Criteria Perioperative Mortalit 0 Aneurysm is not ruptured 0-5 I Asymptomatic, min. headache and sl. nuchal rigidity 0-5 II Moderate to severe headache, nuchal rigidity, but no neurologic deficit other than cranial nerve palsy 2-10 III Somnolence, confusion, medium focal deficits 10-15 IV Stupor, hemiparesis medium or severe, possible early decerebrate rigidity, vegetative disturbances 60-70 V Deep coma, decerebrate rigidity, moribund appearance 70-100
  • Slide 11 - World Federation of Neurologic Surgeons (WFNS) SAH grade WFNS grade GCS Score Major focal deficit* (0 intact aneurysm) - - 1 15 absent 2 13-14 absent 3 13-14 present 4 7-12 present or absent 5 3-6 present or absent
  • Slide 12 - Vasospasm High incidence angiografically Clinical symptoms 4 – 11 days post bleed
  • Slide 13 - Vasospasm Free hemoglobin - activates cascade Histamine, serotonin, catecholamines, prostaglandins, angiotensin, and free radicals Blood vessel walls abnormal
  • Slide 14 - Vasospasm Treatment Triple H therapy Calcium channel blocker - nimodipine Early surgery with aggressive removal of blood
  • Slide 15 - Rebleed 14-30 % Peak incidence first few days post bleed and second week post bleed High risk of rebleed during angiography
  • Slide 16 - Rebleed and Vasospasm
  • Slide 17 - Cardiovascular effects ECG abnormalities Very common Many changes seen cannon t wave, Q-T prolongation, ST changes Autonomic surge may in fact cause some subendocardial injury from increase myocardial wall tension
  • Slide 18 - Cardiovascular effects Cardiac dysfunction does not appear to affect morbidity or mortality (studies from Zaroff and Browers) Prolonged Q-T with increased incidence of ventricular arrhythmias PVC’s are seen in 80%
  • Slide 19 - QTdc Difference between the longest and shortest QT interval on a 12 lead Increase reported to be associated with cardiorespiratory compromise and need for inotropes (Br. J Anesth. 82:454p-455p, 1999)
  • Slide 20 - Neurologic effects Hydrocephalous Seizures 13% Vasospasm may be cause Increased risk of rebleed Treat and prophylaxis Headache, visual field changes, motor deficits
  • Slide 21 - Endocrine Effects SIADH Cerebral salt wasting syndrome release of naturetic peptide hypovolemia, increased urine NA and volume contraction Distinguish between the two and treat accordingly
  • Slide 22 - Pulmonary Effects Neurogenic pulmonary edema 1-2% with SAH Hyperactivity of the sympathetic nervous system Pneumonia in 7-12% of hospitalized patients with SAH
  • Slide 23 - Timing of surgery 0-3 days post bleed appears to be optimal Improved outcome within 6 hours of rupture despite high H/H grade If delayed, 2 weeks post bleed after fibrinolytic phase
  • Slide 24 - Anesthetic Goals Avoid abrupt changes in BP Maintain CBF with normal to high blood pressure Be prepared for disaster
  • Slide 25 - Monitors Arterial line preinduction CVP as indicated Triple H therapy may be used post op Neurologic monitoring SSEPs and BAERs useful for posterior circulation aneurysm
  • Slide 26 - Induction REBLEEDING IS LETHAL!!! Careful blood pressure control Weigh risk of full stomach vs. adequate depth of anesthesia and relaxation Titrate induction agent Blunt response to intubation
  • Slide 27 - Induction Thiopental 3-6mg/kg reduces CBF and O2 consumption but does not blunt hemodynamic response. Need supplemental agents Propofol and etomidate good alternates Succinylcholine controversy …. Beta blockers and vasodilators on hand
  • Slide 28 - Maintenance Goals Cerebral relaxation and protection Hemodynamic stability Normovolemai to hypervolemia Control ICP … and wake up on a dime
  • Slide 29 - Maintenance Agents Inhalational agents, narcotics, oxygen, N2O controversial Can increase CBF Glucose management Hyperventilation
  • Slide 30 - Fluids Isotonic or hypertonic solutions Mannitol Increase intravascular volume Effect in 5-15 min. with peak at 30-45 Careful administration in those with reduced cardiac function
  • Slide 31 - Hypothermia Moderate hypothermia determined to be protective in some animal studies (33-35 degrees) Mild hypothermia (35.5) found to improve outcome but not statistically significant Deep hypothermic arrest for giant aneurysms
  • Slide 32 - Intraoperative hemorrhage Hypotension to control 40 -50 mmHG Temporary clips Pressure on ipsilateral carotid for anterior circulation
  • Slide 33 - Emergence Anticipate stimulating events Keep beta blockers and vasodilators on hand
  • Slide 34 - Extubation Decision to extubate made by anesthesia provider and surgeon Higher grade bleeds may need to go to ICU intubated
  • Slide 35 - New management Endovascular balloon placement Tirilazad Antioxidant Appears to decrease need for HHH therapy in men No improved outcome
  • Slide 36 - New Management Vasospasm Intraventricular SNP used in severe refractory cases, however effects are highly variable
  • Slide 37 - 4 causes of aneurysmal rupture

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