Awake Craniotomy (Max Kelz notes per Asteak)

Last updated: February 9, 2026

  1. Scalp block

    1. Two 30 mL 0.25% bupivacaine, epinephrine 1 mg/mL
    2. Draw up 150 microliters (0.15 mL in TB syringe) from epinephrine and put into each 30 mL bupivacaine vial, which works out to 5 mcg/mL of epinephrine
    3. Get 7 10 mL syringes and fill with local anesthetic/epinephrine mixture
    4. Attach syringes to 3-way stopcock with IV extension tubing on end and 25-gauge needle
    5. Do scalp blocks (Paper by Irene Osborne as guide published in Journal of Neurosurgical Anesthesia)

  2. Airway

    1. Nasal trumpets with viscous lidocaine (2% brown tubs from pharmacy) and concentrated phenylephrine (10 mg/mL). Mix by combining 0.5 mL concentrated phenylephrine and 9.5 mL viscous lidocaine (can give half in pre-op up the nose)

  3. Anesthetic

    1. Heavy dexmedetomidine, almost no propofol
    2. Dexmedetomidine 1 mcg/kg load, infusion at 1 mcg/kg/hr
    3. Remifentanil at 0.02-0.04 mcg/kg/min
    4. Very little propofol, up to ~15 mcg/kg/min
    5. Pin with eyes wide open and awake to make sure scalp block is working
    6. Turn off dexmedetomidine after dura is resected or when nearing wake up and leave remifentanil on