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Adv Prin II > Neuro II > Flashcards

Neuro II Flashcards

1
Q

Things to ask neurosurgeon about/find out preop (non med related) 3

A

Hemodynamic and ventilation goals, positioning

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2
Q

Things to ask neurosurgeon about preop (med related) 4

A

Need for abx, steroids, diuretics, anticonvulsants

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3
Q

Glucose and sodium control in neuro pts

A

Glucose 90-180 in diabetics. Avoid changes in na >3-4 meq/L per hour (central pontine myelinosis)

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4
Q

Ways to eval ICP without a monitor (5)

A

Headache, nausea, papilledema, pupil size, respiratory pattern

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5
Q

Main IR neuro goals (4)

A

May do conscious sed if able, control anesthetic level for prompt neuro eval if needed, keep pt from moving, and manip cerebral hemodynamics as needed

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6
Q

IR neuro: what kind of anticoagulation dose used/how long. ACT goal

A

24 hours 3000-5000u heparin + gtt to keep act 1.5-2.5x baseline

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7
Q

IR neuro: what two things may need to manipulate as needed, consider p-ox where

A

End tidal and arterial BP. Bilateral lower extremities

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8
Q

IR neuro: what 4 things may alter anesthetic plan

A

EEG, evoked potentials, transcranial Doppler, awake pt feedback

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9
Q

Dose of protamine in case vessel knicked while on heparin

A

1 mg per 1000u heparin given

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10
Q

IR neuro complications: do what if bleeding, do what if occlusive crisis

A

Bleed: protamine and controlled hypotension. Clot: htn +/- thrombolysis

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11
Q

Types of tumors that may be supratentorial 4 (one of them has two subtypes)

A

Meningiomas, glioma (oligodendroglioma and astrocytoma), metastatic lesion, and chronic subdural hematoma

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12
Q

Supratentorial tumors: when symptoms show, small changes in ___ lead to big changes in ___ and ___

A

When compensatory mechanisms exhausted by growing lesion. Small BP changes= big CBF/ICP changes

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13
Q

Supratentorial tumors: lesions are often ___ and have a ___ ___ core or a wide border of brain ___. Increased ___ and inc area of impaired ___.

A

Vascular, necrotic and hemorrhagic core. Edema. Inc bulk and imp autoreg

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14
Q

Supratentorial tumors: __ risk is low unless lesions encroach on __ __. Subfrontal approach leads to what

A

VAE, saggital sinus. “Frontal lobey”/sluggish to wake up

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15
Q

Supratentorial tumor sx: what is top priority. Diuretics/doses

A

ICP control. Mannitol 1-1.5 g/kg or 3% saline 50-100 ml/hr with hourly na checks

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16
Q

Osmolarity of: plasmalyte and normosol, LR, normal saline

A

Pla/norm= 290. LR= 273. NaCl= 308

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17
Q

Supratentorial IC tumor: ask hx of ___, ___ reg, consider giving what drug/how often/dose except in which pts

A

Seizures. Decadron 10 mg q6. UNLESS lymphoma is a potential dx.

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18
Q

Supratentorial IC tumors: 3 things that warrant a right atrial line

A

CVP measurement, if major blood loss concern, or VAE risk

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19
Q

Infratentorial/post fossa tumors common in children (4)

A

Medulloblastoma, pilocytic astrocytoma, ependymoma, brainstem glioma

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20
Q

Infratentorial/post fossa tumors in adults (4)

A

Acoustic neuroma, mets, meningioma, hemangioblastoma

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21
Q

In post fossa tumors, look for warning signs of damage to what two things

A

Adjacent cranial nerves and respiratory centers

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22
Q

CV Signs of damage to cranial nerves/resp centers during sx (4)

A

Bradycardia+hypotension. Tachycardia+hypertension. Bradycardia+hypertension. Ventricular dysrhythmias.

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23
Q

Post fossa tumor sx: risk dissection on floor of __ ventricle. Can result in loss of 3

A

4th. Upper airway patency, cranial nerve function, and respiratory drive

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24
Q

Positioning for post fossa tumor 5

A

Sitting, lateral, prone, park bench, or 3/4 prone

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25
Q

Post fossa tumor positioning risks/complications (5)

A

Quadriplegia, macroglossia, pneumocephalus, VAE, PAE

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26
Q

Post fossa tumor monitoring: what ecg for __ and __ changes. Watch a line for alt due to __ and __ __

A

Rate and rhythm. CPP and brain stem.

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27
Q

Nerve/neuro monitoring that may occur in post fossa tumor sx 3

A

BAEP, SSEP, EMG facial nerve monitoring (need at least 2 twitches)

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28
Q

Infratentorial posterior fossa IC tumor: main induc/maintenance/emergence considerations

A

CN assessments. May RSI if chronic asp. Prob not versed. Dont do precedex. A line. Check for cv instability. Emergence: back up airway available.

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29
Q

Hormones released by posterior pituitary

A

Vasopressin (adh) and oxytocin

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30
Q

Nonfunctioning pituitary tumors: 3 ex, dx when

A

Chromosphere adenoma, craniopharyngioma, meningioma. When large and impinging adjacent structures

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31
Q

Functioning pituitary tumors: ex. Diagnosed when

A

Prolactinomas followed by GH and ACTH descreting adenomas. Small symptoms r/t produc of excess of 1 or more anterior pituitary hormones

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32
Q

Pituitary tumor endo assessment: what to look for in panhypopituitarism (3)

A

Correct hypocortisolism, hyponatremia, hypothyroid

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33
Q

Pituitary tumor endo assessment: acromegaly (3)

A

Airway, cardiac func: arrhythmias, hypertrophic CM

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34
Q

Pituitary tumor endo assessment: cushing’s disease 5

A

DM, hyperaldosteronism (low K/metab acidosis), HTN, CHF, obesity

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35
Q

Pituitary tumor assessment: which have no mass effect, which lead to SIADH

A

Microadenoma- no fx. Sellar tumor- SIADH.

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36
Q

Pituitary tumor assessment: which you need to eval for inc ICP. Clear what with surgeon, assess which nerve

A

Suprasellar. Decadron use (could give false + test postop). If visual exam assess optic nerve

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37
Q

If transphenoidal approach need what two things

A

Nasal culture and abx

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38
Q

Which drug inhibits ADH at renal tubules

A

Demeclocycline (tetracycline)

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39
Q

Pituitary: positioning/prec, ____ pack, airway consid

A

Supine, VAE risk if >15 degrees sx site above heart. Pharyngeal. Rae to lower jaw, opposite dominant side.

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40
Q

Transphenoidal: where incision is made, local used, what he for what

A

Upper lip through septum. 4% cocaine 2% lido w epi. Dysrhythmias,

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41
Q

Pit sx anes consid: emergence. Airway cleared of what. Test what before extub.

A

Smooth. Debris/clots. Visual acuity.

42
Q

Surrounding structures that may be damaged in pituitary surgery 5

A

CN 3-6, cavernous sinus, internal carotid, hypothalamus, optic nerve/chiasm

43
Q

DI: when it occurs, 3 main signs

A

4-12 hrs postop. Polyuria (>2L), serum osmolarity >300, specific gravity <1.005

44
Q

Tx DI 2

A

1/2 NSD5W hourly maintenance req + 2/3 prev hour’s urine output. If hourly req >350-400 ml DDAVP 0.5-1 mcg IV/SQ

45
Q

SAH grading systems/what they look at: fed of neurosurgeons __ and ___, hunt and Hess ___ ___, fisher grade ___ ___

A

GCS and motor deficit. Clinical symptoms. Radiologic bleeding

46
Q

SAH symptoms 5

A

NV, severe headache, stiff neck, photophobia, LOC

47
Q

What happens when subarachnoid space bleeds acutely: 3

A

Abrupt ICP increase leading to htn and dysrhythmias

48
Q

SAH: what is considered small vs giant. What size demands treatment.

A

Small <10 mm. Giant >24 mm. Large= in between. Tx if over 6 mm

49
Q

Ecg changes w SAH: main one, 5 others

A

Canyon t waves (upside down). ST dep/elev, t wave flattening, u waves, prolonged QT, dysrhythmias

50
Q

IC aneurysm/SAH complic: 4

A

IC htn, hydrocephalus, rebleed, vasospasm

51
Q

When IC aneurysms pts can go to OR

A

Preferable 18-24 hr (<48 hr), if not then delayed 10-14 days to avoid vasospasm risk

52
Q

Cerebral vasospasm signs: 7

A

Headache, htn, confusion, lethargy, motor and speech deficits, coma

53
Q

How to dx cerebral vasospasm. Prophylactic meds (2)

A

Angio or transcranial Doppler. Nomodipine is standard, statins may help

54
Q

What is triple H therapy, when its used

A

Hemodilution, htn, hypervolemia. In IC aneurysm/SAH prevent vasospasm

55
Q

Intra arterial vasodilators used in vasospasm 4

A

Verapamil, nicardipine, milrinone, papaverine

56
Q

SAH/IC aneurysm preop consid: assess for __ ___ and ___ over activity. Assess ___ status (2 ex)

A

Hypothalamic dysfunc and sympathetic over activity. Fluid. SIADH (vol restrict), cerebral salt wasting syndrome (no vol restrict)

57
Q

What is max safe clamp time while controlling aneurysm bleed

A

14 min

58
Q

When controlled hypotension is contraindicated (6). Max reduction

A

Cv disease, cerebrovascular disease, intracerebral hematoma, fever, anemia, renal disease. 20-30 mmHg

59
Q

Adenosine at what dose can be used during clipping

A

0.3-0.4 mg/kg

60
Q

Use what for burst suppression. If a rupture occurs lower map to what range

A

Propofol. 30-50

61
Q

AVM- abn communication leads to what. S/s

A

No capillary bed in between leads to shunting blood from surrounding brain- ischemia. Bleed/SAH, focal epilepsy/sz, sensory-motor deficits

62
Q

AVM main anesthesia points (4), similar to what mgmt

A

Sim to SAH. ICP control, hypotension to reduce bf, avoid acute htn, manip bp w bleeding

63
Q

AVM dysautoreg: ___ is best, how to

A

Prevention. Keep sedated/intubated or aggressive bp control at emergence and have labetolol/hydralazine/nicardipine ready to go

64
Q

AVM dysautoreg: 5 treatment strategies

A

High dose barbs, osmotic diuretics, hyperventilation, low-normal map, +/- hypothermia

65
Q

GCS 3 key points and grading. Which score is severe and requires what

A

Eye opening (1 never 4 spont), verbal response (1 none 5 oriented) , motor response (1 none 6 obeys commands). 8 or less is severe, requires intubation for airway and ICP control

66
Q

Head injury main goal

A

Prevention of secondary injury

67
Q

Head injury: aggravating factors (7), which one super prominent

A

Hypotension*, hypoxia, hypercarbia, anemia, hyperglycemia, seizures, infection

68
Q

Head injury: fracture where would make us avoid nasal ett

A

Skull base fracture

69
Q

Which hematoma is the most urgent

A

Epidural (meningeal artery tear)

70
Q

Head trauma: BP goal, hypothermia POV

A

Maintain CPP >60 1st 3 days. No benefit in hypothermia

71
Q

Head trauma anes: hyperventilation (when its encouraged (4)/discouraged)

A

Routine use discourage esp first 1-2 days. May use for acute ICP mgmt, herniation prevention, minimize retractor p, and to improve surgical access

72
Q

Head trauma: fluid goal, prevent what, check what, which products good and not good

A

Maintain volume. Prevent reduced serum osmolarity. Check labs (preop mannitol/fluid therapy). 0.9% saline, 5% albumin, and blood all better than LR (hypoosmolar)

73
Q

Head trauma: specific coag abn

A

Brain thromboplastin release can lead to DIC

74
Q

Head trauma: ____ circulatory response. 4 signs. Treat with

A

Hyperdynamic. Tachycardia, htn, inc CO, arrythmia. Labetolol or esmolol

75
Q

Head trauma: ___ ___ - need ICP reduction. Ways to do it (6)

A

Cushing’s triad. Diuretics, HOB 30 degrees, barbs, Paco2 30-35, ventricular drainage, mild hypothermia 34-35 c

76
Q

Spinal cord sx: 4 things that may alt our plan

A

Wake up test (45 min warning, short acting agents), SSEP (IAs), MEPs (NMR/IAs), pedicle EMG (NMR)

77
Q

Supine/anterior cervical discectom: risks related to location

A

Retractor compressing airway and carotid arteries, postop swelling and airway compression/CN dysfunction

78
Q

Cervical sx: two risks w complete cord injury, ___ intubation if unstable, keep map where for how long after injury

A

Low bp (spinal shock) and resp insuff. Awake/axial stabiliz. >85 for 7 days

79
Q

Cervical sx: ____ at ___ mg/kg over 1 hour then ___ mg/kg for 23 hr is a treatment option

A

Methylprednisolone, 30. 5.4

80
Q

Vertebral mets: major risk. Positioning. Airway consid

A

Large blood loss. Prone or anterolateral/retroperitoneal. Double lumen ett for lesions above L1

81
Q

Spinal cord tumor: have what during contraction, ___ position

A

High normal MAP, prone

82
Q

Csf shunting sx: ___ __ is helpful, insert what/why

A

Muscle relaxant. OGT to prevent distended stomac/gastrostomy inadvertently

83
Q

VP shunt: catheter into ___ ventricle, reservoir where, drainage limb via tunnel to where

A

Lateral. Res in sq adjacent to burr hole. Point near epigastrum where inserted into peritoneal space through small laparotomy.

84
Q

CSF shunt: what isn’t usually required. Positioning of pt and bed.

A

Invasive monitoring. Supine, bed turned 90

85
Q

Csf shunt: avoid increases in ___/how. Avoid dramatic ____ drop. BP may do what after ventricular cannulation and consid

A

ICP, drop paco2 to 25-30. ICP drop (for surgeon visualization). May drop, brief pressor support

86
Q

Csf shunt: positioning after, prevents what

A

Nursed flat. Subdural hematoma

87
Q

Pedi neuro: neuronal development continues through when, SC ends where/when it is at adult level

A

3rd year of life. L3, adult level when 8

88
Q

Pedi neuro: CBF of infants and children __ml/100g/min. CMRO2 ___ ml/100g/min. ICP ___-___

A
  1. 5-6. 2-4.
89
Q

Pedi anesthesia: how to monitor ICP

A

Palpate fontanelle

90
Q

When posterior fontanelle closes

A

2-3 months

91
Q

When anterior fontanelle closes

A

12-16 months

92
Q

Cranuisynostosis: what it is, when it occurs, need what, risks

A

Premature cranial suture fusion, 2-8 months. IVs and a line (blood loss). VAE risk (need precordial Doppler)

93
Q

Meningomyelocele: assoc w what two things. What allergy. Consider what for induction

A

Arnold chiari malformation and hydrocephalus. Latex. Prone

94
Q

Meningomyelocele: do what w fluids, maintain ___, ebl

A

Account for csf leak/3rd space loss. Temp. 15-50cc, more if big defect

95
Q

Tethered cord: main thing to avoid, check w surgeon on what, may be positioned how post op

A

Sux. Check before giving NMB (nerve func monitoring intraop). Prone.

96
Q

Anes consid for stereotactic sx: restriction of ___ access. Restriction in what else

A

Airway access due to frame. Sedation/anes depth bc need to assess pt and ep recordings.

97
Q

Anes for stereotactic sx: need to detect/manage 2 complic intraop

A

Seizures and IC hematoma

98
Q

Stereotactic sx: preop eval ___ status and edu pt on what

A

Coag (ask about meds and herbals/discontinuing). Movement restraints and procedure length

99
Q

Stereotactic anesthesia: two sedatives that are ok to give. Avoid what

A

Precedex and remi. Avoid benzos.

100
Q

Stereotactic sx: control what bc of intracerebral hematoma risk. Prepare for what just in case. Other risk

A

Htn . Craniotomy in case hematoma occurs. VAE risk r/t spontaneous ventilation

Adv Prin II (2 decks)

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