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  3. Core Topics in Neuroanaesthesia and Neurointensive Care
  • Cited by 9
  • Edited by Basil F. Matta, Addenbrooke's Hospital, Cambridge, David K. Menon, Addenbrooke's Hospital, Cambridge, Martin Smith, Department of Neuroanaesthesia and Neurocritical Care, the National Hospital for Neurology and Neurosurgery, University College London Hospitals
Publisher:
Cambridge University Press
Online publication date:
December 2011
Print publication year:
2011
Online ISBN:
9780511977558
DOI:
https://doi.org/10.1017/CBO9780511977558
Subjects:
Anesthesia, Intensive Care, Pain Management, Neurology and Clinical Neuroscience, Medicine
Information

Book description

Core Topics in Neuroanesthesia and Neurointensive Care is an authoritative and practical clinical text that offers clear diagnostic and management guidance for a wide range of neuroanesthesia and neurocritical care problems. With coverage of every aspect of the discipline by outstanding world experts, this should be the first book to which practitioners turn for easily accessible and definitive advice. Initial sections cover relevant anatomy, physiology and pharmacology, intraoperative and critical care monitoring and neuroimaging. These are followed by detailed sections covering all aspects of neuroanesthesia and neurointensive care in both adult and pediatric patients. The final chapter discusses ethical and legal issues. Each chapter delivers a state-of-the art review of clinical practice, including outcome data when available. Enhanced throughout with numerous clinical photographs and line drawings, this practical and accessible text is key reading for trainee and consultant anesthetists and critical care specialists.

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Contents

Page 2 of 2

Contents
  • 20 - Post-operative care of neurosurgical patients
    pp 301-314
  • View abstract

    Summary

    This chapter discusses the role of structural imaging using CT and MRI, conventional angiography and CT angiography, and physiological imaging using CT perfusion, 131Xenon CT, MRI and magnetic resonance spectroscopy (MRS), single-photon emission computed tomography (SPECT) and positron emission tomography (PET) in the assessment, management and prediction of outcome neurological injury. Acute CT is useful in identifying those individuals in whom deterioration is as a result of a mass lesion and can demonstrate extradural, subdural or intracranial haemorrhage and midline shift, or subarachnoid haemorrhage and ventricular abnormality. Contrast-enhanced CT imaging is also used to produce CT angiography and perfusion imaging. MRI data are produced using powerful static magnetic fields and intermittent oscillating radiofrequency electromagnetic fields that elicit signals from the nuclei of certain atoms. Single-photon emission CT uses conventional gamma-emitting nuclear medicine isotopes with multiple detectors to generate tomographic images.
  • 21 - Traumatic brain injury
    pp 315-340
  • View abstract

    Summary

    The risk of morbidity/mortality exists with any surgical/ anaesthetic procedure, but the risk to the central nervous system may be compounded in a patient undergoing a major neurosurgical procedure. The purpose of the pre-operative assessment includes the identification of modifiable risk factors, optimization of the patient's condition, explanation of the risks and formulating the best possible anaesthetic plan for the patient. The general physical examination should focus on the patient's level of consciousness, degree of neurological impairment, mental status, nutrition and vital parameters for baseline. Focused neurological assessment and careful documentation allow the establishment of baseline status and facilitate anaesthetic planning, as well as anticipation of potential perioperative complications. The risk of perioperative respiratory complications is increased in the presence of pre-existing obstructive or restrictive pulmonary disease. Patients at risk of aspiration include those with full stomachs, delayed gastric emptying, bowel obstruction, and gastro-oesophageal reflux.
  • 23 - Intracerebral haemorrhage
    pp 359-368
  • View abstract

    Summary

    Space-occupying lesions such as tumours, intracranial haematomas and abscesses are the most common indications for supratentorial surgery. Anaesthesia management is directed towards haemodynamic stability, facilitation of electrophysiological monitoring, and provision of optimal operative conditions and a rapid, high-quality recovery. The aim of pre-operative assessment is to identify potential anaesthetic problems and coexisting medical conditions, quantify risk and plan perioperative care. The assessment of the neurosurgical patient is identical to that of other patient groups but must additionally include a complete neurological assessment. Neuroanaesthesia is a specialty where the knowledge and skill of the anaesthetist affects both the operative field and ultimate outcome for the patient. Awake craniotomy allows the intraoperative assessment of a patient's neurological status and the identification of safe resection margins during epilepsy surgery and excision of space-occupying lesions in eloquent cortex, as well as the accurate localization of electrodes for deep brain stimulation.
  • 24 - Spinal cord injury
    pp 369-384
  • View abstract

    Summary

    This chapter discusses the anaesthetic management of intracranial vascular abnormalities with particular emphasis on subarachnoid haemorrhage (SAH), arteriovenous malformations (AVMs) and carotid artery stenosis. Cerebral aneurysms occur mainly at vascular bifurcations within the circle of Willis or proximal cerebral artery. Patients with salt-wasting syndrome are hypovolaemic and require fluid to prevent intravascular volume contraction. Interventional neuroradiology is being used increasingly to treat central nervous system (CNS) disease by either delivering therapeutic devices or by administering drugs at the point of need. During periods of acute vascular occlusion or vasospasm, induced hypertension can maintain cerebral perfusion by increasing flow across the circle of Willis. Patients presenting for carotid surgery are elderly and often have coexisting medical problems common to patients with vascular disease. These include coronary artery disease, chronic pulmonary airway disease and diabetes mellitus.
  • 25 - Occlusive cerebrovascular disease
    pp 385-396
  • View abstract

    Summary

    Age-dependent differences in cranial bone development, cerebral vascular physiology and neurological lesions distinguish neonates, infants and children from their adult counterparts. In particular, the central nervous system (CNS) undergoes a tremendous amount of structural and physiological change during the first 2 years of life. This chapter highlights these age-dependent differences and their effect on the perioperative management of the paediatric neurosurgical patient. Children in this age group can present with a wide variety of pathologies requiring surgical intervention including trauma, congenital abnormalities such as craniosynostosis, hydrocephalus, intracranial tumours, intracranial vascular lesions and seizure disorders. Age-dependent differences in cerebrovascular physiology have a significant impact on the perioperative management of neurosurgical patients. Given the systemic effects of general anaesthesia and the physiological stress of surgery, an organ system-based approach is optimal for anticipating potential physiological derangements and coexisting disease states that may increase the risk of perioperative complications.
  • 26 - Neuromuscular disorders
    pp 397-412
  • View abstract

    Summary

    Most surgical endeavours are directed towards relieving stenosis of root canals or the spinal canal and/or stabilizing the spinal column. Correction of spinal curvatures is one of the major endeavours of spine surgeons. The spine can be regarded as two columns: anterior and posterior. The anterior column comprises the ligaments and bones back to the posterior longitudinal ligament (PLL) and the posterior column the elements posterior to the PLL. The spinal cord derives its blood supply from anterior and posterior longitudinal arteries arising from the vertebral arteries, and radicular arteries arising from the aorta. Trauma is the major cause of non-operative spinal cord injury (SCI) and, although vertebral fracture or dislocation is frequently present, SCI can occur when there is no radiographic abnormality. Epidural clonidine infusion has been shown to be effective and may avoid the possibility of staff attributing myelopathic symptoms to local anaesthetic effects.
  • 27 - Seizures
    pp 413-429
  • View abstract

    Summary

    Anaesthesia for the posterior fossa provides a unique challenge for anaesthetists and neurosurgeons. Optimal patient positioning should facilitate surgical access without compromising patient safety. The important considerations are surgical access, securing and maintaining the airway, maintenance of adequate anaesthetic depth, haemodynamic stability and oxygenation. Care should be taken to limit the 'blackout state' during which the patient is not monitored or connected to the breathing circuits during patient transfer or positioning on the operating table. The hazards during positioning can be reduced by meticulous planning, careful positioning and vigilance to facilitate early detection of complications. The aim of maintenance of anaesthesia is to reduce the intracranial pressure (ICP) and to maintain haemodynamic stability. Anaesthesia can be maintained with either volatile agents or intravenous agents such as propofol. The choice of the anaesthetic agent is at the discretion of the individual anaesthetist.
  • 28 - Central nervous system infections and inflammation
    pp 430-444
  • View abstract

    Summary

    This chapter explains anaesthetic procedures for selected neurosurgeries without craniotomy. It discusses neurosurgeries that include the transsphenoidal pituitary surgery, ventriculoperitoneal shunts and allied procedures, third ventriculostomy, stereotactic neurosurgery, functional neurosurgery, and deep brain stimulation (DBS). In contrast to most neuro anaesthetic procedures, the anaesthetist can be required to increase intracranial pressure (ICP) in order to facilitate exposure and surgical excision of the pituitary tumour. The chapter describes various anaesthetic techniques, including local anaesthesia with or without conscious sedation on an awake patient and methods that involve general anaesthesia, either throughout the entire procedure or temporarily as in an asleep-awake-asleep technique. The decision for general anaesthesia is best made before surgery after careful pre-operative assessment, as the presence of a stereotactic head frame can complicate airway management, and any unplanned conversion to general anaesthesia in the midst of the procedure carries significant risk.
  • 29 - Intensive care of cardiac arrest survivors
    pp 445-456
  • View abstract

    Summary

    This chapter reviews the history, evolution and organization of neurointensive care units. It emphasizes the key role that neurointensive care teams play in delivering improved outcomes for patients. Neurointensive care has evolved from its original single-system focus on the central nervous system (CNS) to a multisystem speciality providing all aspects of a patient's care. Despite the widespread availability and relative simplicity of many neuromonitoring techniques, there is considerable variation in their placement and in the application of monitoring-guided therapeutic strategies. The overall goals of neurointensive care are to resuscitate and support the acutely ill patient, minimize secondary neurological injury, and prevent or treat systemic (non-neurological) complications. Protocol-guided treatment improves clinical outcome in all areas of medicine and is effective in reducing mortality and improving outcome after brain injury. Expertise in neurointensive care involves procedural skills, proficiency with standard (systemic) monitoring and management, as well as specialized neuromonitoring techniques and interventions.
  • 31 - Ethical and legal issues
    pp 475-487
  • View abstract

    Summary

    Non-neurological complications are common after brain injury and their importance as independent contributors to morbidity and mortality are well recognized. This chapter reviews the aetiology of systemic complications in critically ill neurological patients, identifies options for their prevention and treatment, and considers their effects on outcome. Several central nervous system (CNS)-driven changes contribute to systemic organ dysfunction after brain injury. These include catecholamine- and inflammatory- related effects, as well as endocrine and coagulation abnormalities. The chapter outlines the sequelae of brain injury that are related to endogenous catecholamine release, activation of adrenoceptors and neuroinflammation. It also considers the neuroendocrine and electrolyte disturbance, and other causes of non-neurological organ dysfunction. The complex interaction between the brain and immune system, including the systemic effects of neuroinflammation, is mediated through neuroendocrine pathways including the hypothalamic-pituitary-adrenal axis and autonomic nervous system. Haematological complications, particularly coagulopathy, occur in 20-36% of patients after brain injury.
  • 32 - Assessment and management of coma
    pp 488-497
  • View abstract

    Summary

    Specific aspects in the post-operative care of neurosurgical patients that will influence the decision to admit a neurosurgical patient to an intensive care unit (ICU) include the need for tight blood pressure control, delayed recovery and respiratory dysfunction. The indications for post-operative admission to an ICU, a high-dependency unit or a specialized neurosurgical ward will vary from institution to institution depending on local structures and characteristics of the available units. Besides frequent standardized neurological assessment and scoring, systemic and specific neuromonitoring are important tools to identify patients who are deteriorating post-operatively. Blood pressure derangements may be caused by central neurogenic effects on the heart, by changes in systemic vascular resistance due to circulating or local factors, or by dysfunction of brainstem pressor and depressor centres due to direct injury or neurohumoral stimulation. The suggested blood pressure management in selected post-operative complications is tabulated.

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