[Management of neurosurgical patient operated upon for intracranial tumour].
1. Neurological state of patient.


METHODS
(low risk of ICP problems or ischemia, little need for brain relaxation). - Volatile-based technique; "high-risk" procedures (anticipated ICP problems, significant risk of intraoperative cerebral ischemia, need for excellent brain relaxation): use total intravenous anaesthesia. EXTRACRANIAL MONITORING: For example, cardiovascular or renal, venous air embolism. Intracranial monitoring. - General environment vs. specific functions-metabolic (jugular venous bulb), neurophysiological (EEG/EP), functional (transcranial Doppler). 4. Induction of anaesthesia.


OBJECTIVE
Ventilatory control (early mild hyperventilation; avoid hypercapnia, hypoxemia); blood pressure control (avoid CNS arousal: adequate antinociception, anaesthesia); optimal position on ICP-volume curve. PATIENT POSITIONING: Pin holder application --> maximal nociceptive stimulus, block by deeper anaesthesia or analgesia and local anesthetic pin site infiltration. Alternative: antihypertensives. 5. Maintenance of anaesthesia.


OBJECTIVE
Controlling brain tension via control of CMR and CBF: preventing CNS arousal (depth of anaesthesia, antinociception); treating consequences of CNS arousal (sympatholysis, antihypertensives); the "chemical brain retractor concept". NEUROPROTECTION: Maintenance of an optimal intracranial environment (matching cerebral substrate demand and supply). 6. Emergence from anaesthesia.


OBJECTIVE
Maintain intra/extracranial homeostasis. Avoid factors --> intracranial bleeding and/or increasing CBF/ICP. The patient should be calm, co-operative and responsive to verbal commands soon after emergence. EARLY VS. LATE EMERGENCE: Ideal: rapid emergence to permit early assessment of surgical results and postoperative neurological follow-up, but there are still some categories of patients where early emergence is not appropriate.
Ravussin
P
P
Département d'anesthésiologie et de réanimation, hôpital de Sion, CH-1950 Sion, Suisse. patrick.ravussin@chr.ch
D000758:Anesthesia; D001932:Brain Neoplasms / Q000601:surgery*; D006801:Humans; D007427:Intracranial Pressure; D016343:Monitoring, Intraoperative; D018696:Neuroprotective Agents / Q000627:therapeutic use; D019635:Neurosurgical Procedures
D018696:Neuroprotective Agents