Rome, Italy
II International Congress of Anesthesiologists and Intensivists of the
Republic of Kazakhstan, Astana29th April 2018
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Postoperative Management after Craniotomy
Содержание
- 1. Postoperative Management after Craniotomy
- 2. Sabbioneta, “ideal city of the Renaissance”, was
- 3. Every year 612.000 patients have a diagnosis
- 4. ICH can complicate uneventful craniotomy and lead
- 5. Слайд 5
- 6. Timing of awakeningNeurocognitive statusExtubationHemodynamic and ventilationMetabolismFluids/CoagulationDiuretics/ElectrolytesSeizures, Pain, PONV Deep Veins ThrombosisEducation/Research
- 7. Слайд 7
- 8. Effects of delayed recovery after brain surgery
- 9. In neurosurgical patients, weaning protocol used after
- 10. What I do after brain tumor surgery:
- 11. Слайд 11
- 12. Слайд 12
- 13. Arterial hypertension in the intraoperative period, during
- 14. New onset postoperative AF after elective or
- 15. In overweight/obese neurosurgical patients, the recovery of
- 16. What I do after extubation: tailored neurological monitoring, normal (low) pressure, check for normoventilation.
- 17. What I do: START IIT BGC>180 mg/dl, STOP IIT BGC
- 18. Слайд 18
- 19. Слайд 19
- 20. What I do: isotonic 0.9% saline, 1ml/kg/h
- 21. Слайд 21
- 22. Слайд 22
- 23. Слайд 23
- 24. What I do, association of diuretics: mannitol + furosemide+ K+sparing
- 25. What I do: seizures prophylaxis in selected patients
- 26. Слайд 26
- 27. Слайд 27
- 28. Слайд 28
- 29. What I do for postoperative pain: scalp block + paracetamol
- 30. What I do: premedication with ondansetron 4/8 mg and repeated x3/d
- 31. Out 4293 patients, 126(3%) developed DVT/PE. Factors
- 32. Слайд 32
- 33. Conclusions:Early awakening, when possibleTight –and tailored- neurological
- 34. Скачать презентанцию
Sabbioneta, “ideal city of the Renaissance”, was designed and built by: Duke Vespasiano Gonzaga Colonna (1531-1591)-a master of military architecture-In 1570 he underwent brain surgery –at the University of Parma- and
Слайды и текст этой презентации
Слайд 1Postoperative Management
after Craniotomy
Federico Bilotta, MD, PhD
‘Sapienza’ University of Rome,
Rome, Italy
Republic of Kazakhstan, Astana29th April 2018
Слайд 2Sabbioneta, “ideal city of the Renaissance”, was designed and built
by:
Duke Vespasiano Gonzaga Colonna (1531-1591)
-a master of military architecture-
In
1570 he underwent brain surgery –at the University of Parma-
and survived 20 years after the procedure.
Слайд 3Every year 612.000 patients have a diagnosis of brain tumor
in the USA,
malignant brain tumors cause 13.000 deaths annually,
5-years survival rate 35%.Retrospective cohort from National Inpatient Sample (years 1999-2008),
age 18 to 65, low-risk & no co-morbidity, in-hospital mortality.
Слайд 4ICH can complicate uneventful craniotomy and lead to major brain
damage.
50% of ICH develop within 20 hrs after extubation, 40%
within 80 hrs.
Слайд 6Timing of awakening
Neurocognitive status
Extubation
Hemodynamic and ventilation
Metabolism
Fluids/Coagulation
Diuretics/Electrolytes
Seizures, Pain, PONV
Deep Veins
Thrombosis
Education/Research
Слайд 8Effects of delayed recovery after brain surgery (immediate vs. 2h
delay) on oxygen consumption (VO2) and plasma catecholamine
Early awakening
–when feasible- IS recommended also to limit metabolic and hemodynamic consequences due to emergence after neurosurgery.
Слайд 9In neurosurgical patients, weaning protocol used after respiratory failure has
substantial limitation owing to neurologic impairment.
The neurologic status –measured with
GCS- is a consistent and independent predictor of successful extubation: 75% in GCS≥8; 33% in GCS<8.
Слайд 10What I do after brain tumor surgery: early awakening is
the “standard of care” because neurological monitoring is the best
clinical assessment methodExplosive emergence and lack of haemodynamic control during extubation
may lead to cerebral complications (oedema and haemorrhage)!!!
Слайд 13Arterial hypertension in the intraoperative period, during emergence or in
the early postoperative period is associated with 2 to 3
fold higher risk for post craniotomy intracranial hemorrhage complication
Слайд 14New onset postoperative AF after elective or emergency brain surgery,
using clinical matched control, is associated with similar neurological outcome
at 6 months follow up (modified Rankin Scale grade 0-3, 81% vs. 88.7%; p= 0.09) but lower survival rate (85% vs. 95%; p<0.05).
Слайд 15In overweight/obese neurosurgical patients, the recovery of cognitive function is
associated with gas exchange pattern.
In neurosurgical patients this is especially
relevant because of the relationship between PaCO2 and CBF
Слайд 16What I do after extubation: tailored neurological monitoring,
normal (low)
pressure, check for normoventilation.
Слайд 20What I do: isotonic 0.9% saline, 1ml/kg/h for 24 postop
hours,
check diuresis hourly to replace excessive fluid loss (diuretic
therapy).Should hyperNA develops (diabetes insipidus) replace with 5% glucose.
Within 24 hours include parenteral/enteral nutrition.
Слайд 31Out 4293 patients, 126(3%) developed DVT/PE.
Factors associated with DVTs/PEs
were:
- poorer Karnofsky performance scale (P
high grade glioma (P = 0.005)- older age (P<0.0001),
- hypertension (P = 0.006)
- motor deficit (P = 0.002)
86% were receiving unfractionated or LMWH
Poor functional status, older age, motor deficit, high grade glioma, and arterial hypertension independently increase the risk of peri-operative DVTs/PEs.
Слайд 33Conclusions:
Early awakening, when possible
Tight –and tailored- neurological suirveillance;
Aggressive prevention of
cardiovascular abnormalities: arterial hypertention and AF;
Normal O2 & CO2!
BGC
NOT infuse insulin BGC<140;Fluids: normovolemic, isotonic.
Avoid colloids.
When diuretics are needed, use association: mannitol + furosemide + K+sparing
Check and correct electrolytes.
Seizues, pain, PONV and DVT!!!!
High standards of care and training are
associated with lower morbidity and mortality
