Aneurysm Clipping
- Access
- Large PIV x2-3, pre-induction arterial line (exquisite blood pressure control), 2 warm lines
- Airway
- Oral ETT
- Induction
- Standard (lidocaine/fentanyl/propofol)
- Maintenance
- TIVA (propofol/remifentanil/nicardipine/phenylephrine)
- Emergence
- Awake
- Antibiotics
- Cefazolin
- Position
- 180
Notes
Beware hypotension when surgery deploys radial cocktail.
Two arterial lines: one for anesthesia and one for surgery to transduce.
Normocarbia (hypocarbia will decrease brain swelling, which in turn can induce aneurysm rupture).
Disaster mitigation as below.
Order blood products 4-6R/4-6F/0-2P.
When nearing aneurysm clip deployment, surgeon will ask for burst suppression (aim for SR > 50) (4 mg midazolam is great for this, elevated the propofol to 150-200 mcg/kg/min), elevated MAP goal (usually > 100, but ask surgeon). This is to ensure perfusion of brain supplied by aneurysm. When temporary clips are deployed, have blood products in room and checked, have adenosine ready. If bleeding, surgeon will request adenosine to allow for clamp to be placed.
Dyes: indocyanine green (dilute in sterile water, 25 mg/20 mL), fluorescein (100 mg/mL). SpO2 will decrease due to dye.
After clip deployed, surgeon dopplers (absence is good, means no flow to aneurysm), dyes (visualization), and an angiogram.