Anesthesia for Supratentorial Tumors Pekka O. Talke, MD Department of Anesthesia and Neurosurgery, Cottrell Chief of Neuroanesthesia University of California, San Francisco

Title 35.000 brain tumors/yr 85% primary 60% primary and supratentorial 15% mets (1/6 of tumors) Perioperative management of the geriatric surgical patients is becoming an increasingly important component of anesthetic practice in the 21st century. This phenomenon is due to the fact that people aged 65 years or older is the segment with the fastest growth in the population. It is estimated that by the year 2025, 20% of the U.S. population will be > 65 years of age . Currently, the elderly comprises one third of all operations being performed . Of those older than 65 years, one out of two will undergo an operation in their lifetime.

General Considerations Surgical exposure (retraction) Intracranial pressure (ICP) Secondary insult to brain Hemorrhage, seizures, air emboli Rapid emergence Stress response This changing demographics of the surgical patient population has tremendous impact for the practice of anesthesia. In the past decades, surgery for the elderly was not recommended because of their frailty and the increased risks undergoing major surgery. However, recent advances in anesthetic practice and surgical techniques including minimally invasive surgical approaches have greatly improved perioperative morbidity and mortality. As a result, the number of older and sicker patients presenting for surgery has increased substantially in recent years. The concern now is that this changing demographics of sicker and older patients presenting for surgery may have resulted in an increase in perioperative morbidity and mortality rates. As a result, a renewed interest has arisen in identifying factors associated with adverse postoperative outcomes in order to develop strategies to improve the perioperative care of geriatric surgical patients.

ICP Tissue, blood, CSF Intracranial-Volume relationship Effects of anesthetics on ICP Tumor mass and edema (steroids) As anesthesiologists and perioperative physicians, our roles will likely be focused on stabilization and optimization of preoperative medical conditions, selection of appropriate intraoperative anesthetic technique and management, and management of postoperative pain and stabilization of other immediate postoperative conditions. The goal of this lecture is to review several important and controversial areas to provide clinicians with current available evidence guiding the perioperative management of geriatric surgical patients.

Anesthetics Intravenous anesthetics (not ketamine) are cerebral vasoconstrictors Reduce CMR CO2 reactivity intact In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Anesthetics cont. Volatile anesthetics are cerebral vasodilators Increase ICP Reduce CMR CO2 reactivity intact In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Anesthetics cont. Nitrous oxide increases CMR and ICP Can be controlled by hypocapnia Opioids reduce CMR CO2 reactivity intact Nitroglycerine, nitroprusside, hydralazine are cerebral vasodilators In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Reduction of ICP Intravenous anesthetics Hyperventilation (30-35 mmHg) Mannitol (0.5-1.0 gm/kg, 320 mOsm/kg), (hypernatremia, hypokalemia, hypovolemia) hypertonic saline Lasix CSF drainage Hypoxia, hypovolemia Head position (venous drainage) Increase MAP In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Preop Plan Vascular access Fluid therapy Anesthetics Ventilation Monitoring Neuromonitoring In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Preop Sedation=hypercapnia, hypoxia, obstruction Stress: increased CMR, CBF Analgesia/sedation midas 0.5.-2.0 mg/fentanyl (25- 100 ug) Steroids Anticonvulsants (relaxants, loading SLOW) In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Preop cont. Two large Ivs A-line (CPP, ABG, glucose, osm) Asleep? To avoid stress In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Monitoring BP, HR, CVP? Pulse ox ERTCo2 Temperature (hypothermia?) Urine Relaxometry (hemiplegia, dilantin, tegretol) Glucose, Hg, Hct In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Monitoring cont. EEG SSEP ICP? Motor mapping In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Induction Avoid hypoxia, hypercarbia, stress response Propofol/pentothal/hyperventilate Opioids/relaxants Head position (venous obstruction) More drugs for intubation/pinning In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Maintenance Control CMR, CBF Good depth of anesthesia Adequate CPP In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Maintenance cont. Volatile (<1 MAC)/intravenous anesthetics/N2O Mild hyperventilation Aim for speedy emergence (CT scan) In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Increased ICP Hyperventilate Venous drainage Relaxation Change to IV anesthesia Delete N2O Diuretics In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Fluids Not hypoosmolar Colloids (bleeding) Mannitol (320 mOsm/g) In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Emergence Attenuate stress response (autoregulation impaired/labetalol) Avoid hypercarbia, hypoxia (opioids) Avoid coughing Slow awakening (CT) Seizure, edema, hematoma, pheumocephalus, vessel occlusion, ischemia, metabolic In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Title In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Title In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Title In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Intracranial Increased intracranial pressure Midline shift: tearing of the cerebral vessels Herniation: falx, transtentorial, trans-foramen Magnum, transcraniotomy Epilepsy Vasospasm In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Systemic Hypercapnia Hypoxemia Hypotension or hypertension Hypoosmolality or hyperosmolality Hypoglycemia Hyperglycemia Shivering or pyrexia Low cardiac output In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Prevention No overhydration Sedation, analgesia, anxiolysis No noxious stimulus applied without sedation and Local Anesthesia Head-up position, no compression of the jugular veins, head straight Osmotic agents: mannitol, hypertonic saline In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Prevention cont. Beta-blockers or clonidine or lidocaine Steroids, if a tumor is present Adequate hemodynamics: MAP, CVP, PCWP, HR Adequate ventilation: Paco2>100 mm Hg, Paco2 35 mm Hg Intrathoracic pressure as low as possible Hyperventilation on demand before induction Use of intravenous anesthetic agents for induction and maintenance in case of tensed brain In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Treatment CSF drainage if ventricular or lumbar catheter in situ Osmotic agents Hyperventilation Augmentation of anesthesia with intravenous anesthetic agents: propofol, thiopentone, etomidate Muscle relaxant Venous drainage: head up no PEEP, reduction of inspiratory time Mild controlled hypertension if autoregulation present In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

History Seizure Increased intracranial pressure (ICP): headache, nausea, vomiting, blurred vision Decreased level of consciousness, somnolence Focal neurologic signs: hemiparesis, sensory deficits, cranial nerve deficits, and so on Paraneoplastic syndromes including presence of thrombosis In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Physical Evaluation Mental status Papilledema (increased ICP) Signs of Cushing’s response: hypertensive bradycardia Pupil size, speech deficit, Glasgow coma score, focal signs Medication Steroids Antiepileptic drugs In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Technical Examination (CT or MRI Scan) Size and location of the tumor: silent or eloquent area, near a major vessel, and so on Intracranial mass effect: midline shift, decreased size of the ventricles, temporal lobe hernia Intracranial mass effect: hydrocephalus, cerebrospinal fluid space around brainstem Others: edema, brainstem involvement, pneumocephalus (recraniotomy) In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Evaluation of Hydration Status Duration of bed rest Fluid intake Diuretics Inappropriate secretion of antidiuretic hormone In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Induction Adequate anxiolysis in the anesthetic room Adequate fluid loading (5 to 7 ml/kg of NaCl 0.9%) ECG leads in place; capnometer, pulse oximeter, and noninvasive blood pressure monitors Insertion of intravenous and arterial lines under local anesthesia Fentanyl 1 to 2 g/kg or alfentanil, sufentanil, or remifentanil In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Induction cont. Preoxygenation and voluntary hyperventilation Propofol 1.25 to 2.5 mg/kg or thiopentone 3 to 6 mg/kg for induction Nondepolarizing muscle relaxant: vecuronium, rocuronium, or other controlled ventilation at Paco2 of 35 mm Hg Propofol 50 to 150 g /kg/min or isoflurance 0.5% to 1.5% (or sevoflurane of desflurane) for maintenance and fentanyl (or alfentanil, sufentanil, or remifentanil) 1 to 2 g/kg or alfentanil, sufentanil, or remifentanil In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Induction cont. Lignocaine 1.5 mg/kg Intubation Local anesthesia and intravenous fentanyl 2 g/kg for skull-pin head-holder placement and skin incision adequate head-up positioning; no compression of the jugular veins Mannitol 0.5 to 0.75 g/kg Insertion of a lumbar drain Possibly N2O when the dura is open and brain is slack Normovolemia with the use of NaCl 0.9% or starch 6%—no Ringer’s lactate In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

ICP Control Mild hyperosmolality (use NaCl 0.9% [304 mOsm/kg] as baseline infusion; give mannitol [1319 mOsm/kg] 0.5 to 0.75 g/kg or hypertonic saline [7.5% 2533 mOsm/kg] 3 to 5 ml/kg before bone flap removal) Intravenous anesthetic agent (propofol), adequate depth of anesthesia Mild hyperventilation, mild hyperoxygenation In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

ICP Control cont. Mild controlled hypertension: MAP maintained around 100 mm Hg in order to decrease CBV and ICP Normovolemia; no vasodilators Mild hyperoxia Together with: Adequate head-up positioning Free venous drainage; no compression of the jugular veins No PEEP, no ventilator fight (myorelaxants) Lumbar drainage Avoidance of brain retractors In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Awakening Neurosurgical awakening should maintain: Stable arterial blood pressure and thus cerebral blood flow and intracranial pressure Stable oxygenation and carbon dioxide tension Stable CMRO2 Normothermia In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Awakening cont. Neurosurgical awakening should avoid: Coughing Tracheal suctioning Airway overpressure during extubation Patient-ventilator dyssynchrony In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.

Awakening cont. Neurosurgical awakening should provide: Optimal conditions for neurologic examination In order to optimize patient’s health condition for surgery and anesthesia, preoperative laboratory testing is performed as part of preoperative assessment. Current recommendations are that healthy elderly patients (>60 years of age) should be routinely tested for hemoglobin/hematocrit, glucose, renal function, 12-lead ECG and chest X-rays abnormalities. However, the usefulness of routine preoperative laboratory testing as a part of preoperative assessment has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical patients is therefore costly, especially evidence is lacking that such testing may predict or improve perioperative outcomes.