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Slide 1 - The Child with Brain Tumor: Important Anesthetic Concepts Hany El-Zahaby, MD Ain Shams University
Slide 2 - Aim “Highlight the current neuro-physiological concepts and how to apply it to best of the anesthetic practice for the child with brain tumor.”
Slide 3 - Brain tumors The second most common solid tumor in childhood. Posterior fossa tumor Supratentorial tumor Suprasellar tumor
Slide 4 - Translocation of CSF to the distensible spinal subarachnoid space Translocation of blood to scalp veins.
Slide 5 - The infant with open fontanels and cranial sutures would have a more compliant intracranial space especially with gradual increase in volume. Full-term neonates ICP is 2-6 mmHg with increasing head circumference as the first clinical sign of increased ICP. Infants presenting with signs and symptoms of intracranial hypertension have fairly advanced pathology. Intracranial Compliance
Slide 6 - Classic signs of high ICP as papilledema, pupillary dilatation, hypertension, bradycardia may be absent. Headache, irritability & morning vomiting. ↓ level of consciousness & abnormal responses to painful stimuli.
Slide 7 - Monitoring Intraventricular catheters Subarachnoid bolts/screws
Slide 8 - Epidural monitor Fiberoptic ICP monitor
Slide 9 - ppt slide no 9 content not found
Slide 10 - Herniation Syndromes 1- Defect of calvarium. 2- Interhemispheric falx: Internal capsule-posterior cerebral A.-blindness. 3- Trans-tentorial herniation: 3rd CN & brain stem compression leading to pupillary dilatation, hemiplegia & loss of consciousness “The uncal syndrome”. 4- Cerebellar herniation: Brain stem compression & obstruction of CSF circulation leading cardiorespiratory failure.
Slide 11 - Cerebral Blood Volume and Cerebral Blood Flow Penlucida Penumbra CPP = MAP – ICP Maintaining COP & CPP is of utmost importance
Slide 12 - Cerebrovascular Autoregulation Myogenic control of arteriolar resistance enables brain perfusion to remain stable despite moderate changes in MAP & ICP. It is lost in acidosis, vessels supplying tumors, cerebral edema. Abrupt ↑BP →hemorrhage/cerebral edema. Worsening cerebral ischemia with moderate hyperventilation in children with compromised cerebral perfusion. Cerebral autoregulation range in neonate is 20-60 mmHg
Slide 13 - Posterior fossa (infra-tentorial) tumor (50%) Medulloblastoma, cerebellar astrocytoma, brain stem gliomas CSF flow obstruction increasing ICP Cranial nerve affection-ataxia Arrhythmias-respiratory affection (late) Bradycardia-hypertension-acute blood loss may complicate the procedure.
Slide 14 - Supra-tentorial tumors (25-30%) Astrocytomas, oligodendrogliomas, ependymomas, and glioblastomas. Focal deficits, seizures. UMNL → avoid succinyl choline. Anticonvulsants. Somatosensory evoked potential needs no Ms. relaxation.
Slide 15 - Supra-sellar tumors (15-20%) Craniopharyngioma, optic gliomas, pituitary adenomas, hypothalamic tumors. Hypothyroidism/steroid therapy/ diabetes insipidus. Nocturnal enuresis → serum electrolytes and osmolality. Trans-sphenoidal approach.
Slide 16 - History Specific Seizures Headache, Lethargy Vomiting, enuresis, anorexia Swallowing incoordination Visual/hearing impairment Motor disability/abnormal movement Medications General Respiratory Cardiovascular GIT Endocrinal Hematologic Allergies
Slide 17 - Examination Level of consciousness Motor/sensory function Reflexes Cranial nerves ICP Pupillary size/reflex Gag reflex/aspiration pneumonia Muscle atrophy (receptor up-regulation)
Slide 18 - Investigations Routine + S. osmolality. On individual basis: ABG, CXR, ECG. Neuro-radiological studies. Preoperative discussions: neurosurgeon, neurophysiologists & parents.
Slide 19 - Premedication/Monitoring Transport in head-up position. Sedation only in OR. Routine monitoring. Nerve stimulator on a limb with normal neurologic function. Arterial catheter: Refering the transducer to external auditary meatus to estimate CPP.
Slide 20 - CVP ↑ICP → no head-down → Femoral vein. If no ↑ICP → subclavian vein is a reasonable choice. Peripherally inserted central lines. Wide-bore long saphenous vein catheter. “Early removal of all lines especially the arterial line”.
Slide 21 - Induction Uncooperative child with intracranial tumor and moderately decreased intracranial compliance who is agitated, resistant to parental separation child with no IV?? IV-IV-IV Thiopental/propofol Sevoflurane Fentanyl 2-3 µ/kg Atracurium/cisatracurium/rocuronium
Slide 22 - Airway Management and Intubation Aim: Effective and smooth airway management avoids increase ICP, hypoxemia, hypercarbia, and coughing. Oral for supine/nasal for prone. Securing ETT – folded gauze. Check bilateral air entry with head flexion & after final positioning. Open OGT. Pad the eyes. Access to ETT/connections/vascular catheter sites.
Slide 23 - Prone position Avoid abdominal compression. Venous congestion of face, tongue, and neck . Decreased lung compliance. Avoid extreme flexion of head: brainstem compression. cervical cord ischemia. endobronchial intubation.
Slide 24 - Local infiltration: 0.25% bupivacaine with 1 : 200,000 epinephrine 1 ml/kg. LA: equal volumes of bupivacaine 0.5% and epinephrine 1:100,000 (1mg/100ml saline)
Slide 25 - Anesthetics that decrease ICP and CMRO2 and maintain CPP are desirable.
Slide 26 - “The choice of anesthetic agents for maintenance of anesthesia has been shown not to affect the outcome of neurosurgical procedures.” “Todd MM, Warner DS, Sokoll MD, et al. A prospective, comparative trial of three anesthetics for elective supratentorial craniotomy. Anesthesiology 1993;78:1005– 20.”
Slide 27 - Blood and Fluid Management Early transfusion avoids severe anemia & hypoperfusion. Doubling oncotic pressure has less effect on preventing brain edema than 1 meq/L increase in serum sodium. Cerebral edema through disrupted BBB is worsened by excessive administration of hypotonic IV fluids. Normal saline/Ringer’s solution (308 mOsm/L) is preferred than LR (285mOsm/L).
Slide 28 - No glucose-containing solution is used even for extended surgeries except in: Diabetic child. Severely debilitated child. Child on TPN. When given, no more than the maintenance. Normovolemia should be maintained throughout the procedure.
Slide 29 - Temperature control Maintaining normal temperature is the goal despite beneficial effect of mild hypothermia on CMRO2. Forced hot air warming mattresses is the most effective mean.
Slide 30 - VAE Occurs when there is pressure gradient between the operative site and the heart especially with low CVP. Flood with saline, bone wax, Trendelenburg position, fluid bolus, PEEP and aspirate air through a central venous catheter.
Slide 31 - Emergence PONV: Opioids and blood in the CSF versus dexamethazone and granisetrone. No residual muscle paralysis is accepted on extubation. Full awakening before extubation. Neurological assessment in OR.
Slide 32 - “The child with brain tumor is expected to leave OR at least as neurologically as before operation”. In unconscious child postoperatively, ICP should be monitored, ventilation continued and immediate CT-scan should be done.
Slide 33 - Postoperative Regular paracetamol & small doses of opioids. Intraoperative fentanyl usually covers the early postoperative period. Diabetes incipidus may need vasopressin (1-10 mU/kg/hr). CT and MRI are often performed 1 or 2 days after craniotomy.
Slide 34 - Neuro-protection Goals: Avoid cerebral edema Avoid cerebral hypoxia Avoid cerebral hypo-perfusion Avoid cerebral hyper-metabolism Avoid neuronal membrane damage
Slide 35 - ppt slide no 35 content not found
Slide 36 - Take-home messages Maintain Normo-volemia. Normo-osmolality. Normo-thermia. Normo-ventilation. Normal CPP.
Slide 37 - 2012 Thank You