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May 16, 2017

Euroanaesthesia 2017

Awake craniotomy - the anaesthesiologist´s view


Inga Mladić Batinica1;

K. Rotim2;

T. Sajko2;

M. Zmajević Schonwald2;

S. Salkičević3

awake surgery







awake surgery




Awake craniotomy - the anaesthesiologist's view Inga Mladić Batinica1, K. Rotim2, T. Sajko2, M. Zmajević Schonwald2, S. Salkičević3 1Department of Anaesthesiology, Intensive Care and Pain Therapy, University Hospital Center “Sisters of Mercy”, Zagreb, Croatia; 2Department of Neurosurgery, University Hospital Center “Sisters of Mercy”, Zagreb, Croatia; 3Department of Psychology, Faculty of Humanities and Social Sciences, University of Zagreb, Croatia E-mail: ingamblue@gmail.com Background: Compared with surgery under general anaesthesia (GA), awake craniotomy (AC) is associated with advantageous outcomes. It is standard of care for tumors in eloquent brain areas. For anaesthesiologist it is a challenge because there is no standardized anaesthestic technique. Clinical case-series: During last three years, AC with monitored anaesthesia care (MAC) is successfully implemented in Croatia. We present single centre experience with thirteen patients (age 32-64 yrs; 7M, 6F; ASA II). After selection by multidisciplinary team (neurosurgeon, anaesthesiologist, neurologist, psychologist), patients were sedated and breathed spontaneously during the procedure. We used target controlled infusion pumps for fine titration of remifentanil and propofol, and for local infiltration at the site of pin insertion, skin incision and nerve blocks mixture of 0.5% bupivacaine and 2% lidocaine with adrenalin. Monitoring included: ECG, invasive and non-invasive BP, SPO2, RR, ETCO2, BIS and hourly urinary output. There were no surgical, neither anaesthesiological complications. Maximum alert and minimally stressed patients were optimal for awake brain mapping. Discussion: In anaesthetic management exists large variability and implementing AC is challenging for anaesthesiologist. Avoidance of GA prevents associated physiological disturbance, need for mechanical ventilation and utilization of anaesthetics that can play a role on antitumor immunity and tumor progression. It is difficult to differentiate the benefits related to anaesthetic care from those attributable to surgical technique. Using MAC, surgeon’s credit is an ability to increase the extent of resection and survival, while preserving neurological function. Anaesthesiologist’s credit is competence to avoid a complications of general endotracheal anaesthesia. Avoiding these factors may contribute to better outcome after AC. Our experience shows patients’ satisfaction (evaluated by psychologist), with optimal intraoperative working conditions for neurosurgeon. Learning points: Crucial steps in establishment of an awake surgery is creation of a competent neuroanaesthesiologist, who are able to provide care for awake patients. Drugs fine titration, accurate respiratory function monitoring, good plan in dealing with possible respiratory complication and constant training in management of difficult airways are milestones of favourable outcome. In view of that, anaesthesiologist contribution to AC is essential.

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© Copyright 2019 Morressier GmbH.
All rights reserved.