Craniectomy
- Access
- Post-induction arterial line. PIV x2
- Airway
- Oral ETT
- Induction
- Standard
- Maintenance
- TIVA (propofol/remifentanil/phenylephrine)
- Emergence
- Awake. Prompt neuro exam
- Antibiotics
- Cefazolin
- Position
- 90 L or 90 R. If lesion on R head, then usually head of table goes 90 R
Instead of propofol: could do gas (but 1.0 MAC usually raises ICP, so TIVA is often the safer option. If there is no evidence of high ICP such as midline shift, sulci effacement, then can consider).
Instead of remifentanil:
- Could do sufentanil (but akinesia may be insufficient if dosing not high enough, usually 0.2-0.4 mcg/kg/min) (can bolus 100 mcg with induction and then 0.1 mcg/kg bolus PRN intra-op)
- Could do fentanyl (50 mcg/mL, 1000 mcg total) and bolus 100 mcg PRN during tachycardia
- Can have hydromorphone or fentanyl for post-op pain control (but fentanyl half-life similar to naloxone, may enable better neuro exam)
Sometimes background gas (especially if no BIS on).
Sometimes paralytic (unless neuromonitoring, which requires bite block).
Notes
EtCO2 target per surgeon (around 26-28). SBP < 140-160, MAP < 90.
10 mg dexamethasone, 1 g levetiracetam (Keppra), 0.5 or 1.0 g/kg of mannitol (which requires either dark blue Alaris pump filter or a special green filter at the end) (rate of 999 mL/hr).