1. Neuro-Anaesthesia Outside the Operating Room April 2013 Mark Angle, M.D. Kuwait City 1

2. Outside the Operating Room Neuro-Interventional Suite : ▫Coiling of cerebral aneurysm ▫Obliteration of AVM’s ▫Balloon occlusion ▫Vascular stenting ▫Thrombolysis ▫Thrombectomy ▫Speech and memory testing MRI Mark Angle, April 13th 2013 2

3. Outside the Operating Room Procedural Sedation vs General Anaesthesia ▫Quality of the image ▫Completion of the procedure ▫Duration of the procedure ▫Safety of the procedure ▫Resource consumption ▫Outcome Mark Angle, April 13th 2013 3

4. Outside the Operating Room Does general anaesthesia worsen outcome after stroke intervention ? ▫Davis et al. (February 2012, Anaesthesiology) 96 included 48 sedation 60% good outcome 48 general anaesthesia 15 % good outcome Mark Angle, April 13th 2013 4

5. Outside the Operating Room ▫Potential contributors to outcome gap: 1.Neurotoxicity of anaesthetic agents 2.Lasting dysregulation of cerebral circulation 3.Selection bias 4.Procedural hypotension Mark Angle, April 13th 2013 5

6. Outside the Operating Room ▫Stroke outcome and blood pressure (NINDS)  18 % increase in deaths per each 10 mmHg below 150 mmHg  4% increase in deaths per each 10 mmHg above 150 mmHg Mark Angle, April 13th 2013 6

7. Outside the Operating Room ▫Operator’s desires:  Immobility  Silence  Compliance  Stable but manipulable hemodynamics  Medical back-up Mark Angle, April 13th 2013 7

8. Outside the Operating Room ▫General Conduct:  Standard team  Standard monitoring  Arterial line optional (rare)  Intubation optional (rare)  Laryngeal mask  Paralysis optional (rare) Mark Angle, April 13th 2013 8

9. Outside the Operating Room ▫Sub-arachnoid hemorrhage :  Principles:  Procedural sedation (IV, art. line, ng, Foley, EVD, transport)  Heavy sedation post-intubation in ICU or ER  Tight BP control Mark Angle, April 13th 2013 9

10. Outside the Operating Room ▫Sub-arachnoid hemorrhage :  MNH Protocol:  Midazolam 4 mg  Propofol 2-4 mg/kg  Esmolol 50-100 mg  LMA  PC Ventilation, EtCO 2 28-32  Isoflurane (low-grade)  Propofol / Remifentanyl (high-grade)  Maintenance BP @ 100-120 sys. Mark Angle, April 13th 2013 10

11. Outside the Operating Room ▫Sub-arachnoid hemorrhage :  Events :  Heparinization  Heparin reversal  Local thrombosis  Vasospasm (catheter-induced)  Rupture Mark Angle, April 13th 2013 11

12. Outside the Operating Room ▫Stroke:  Intra-arterial thrombolysis  Sedation vs anaesthesia Embolectomy  General anaesthesia (LMA, TIVA) ▫Issues :  Efficacy (NEJM 2013)  Resource consumption Mark Angle, April 13th 2013 12

13. Outside the Operating room ▫Vasospasm : considerations  Often intubated  Usually with EVD  Always on pressors / milrinone  Exquisitely BP dependent  Angio plasty Intra-arterial milrinone 3-8 mg Mark Angle, April 13th 2013 13

14. Outside the Operating room ▫AVM :  Usually asleep : LMA / Inhalational  Rarely awake : Dexmedetomidine, Remifentanyl  Occasional functional testing -Supra-selective catheterization and IA etomidate Hypotension or circulatory arrest for high flow lesions Mark Angle, April 13th 2013 14

15. Outside the Operating room ▫MRI:  Indications : -Claustrophobia -Pain -Physiological instability -Abnormal movements -Non-compliance  Technique: -Propofol -LMA -Inhalational Mark Angle, April 13th 2013 15

16. Outside the Operating room ▫Etomidate Speech and Memory Test (Neurology 2006)  Evolved from the WADA protocol (bolus methohexital)  Hemispheric anaesthesia produced by intra-carotid injection  Etomidate bolus and infusion Mark Angle, April 13th 2013 16

17. Outside the Operating room ▫Carotid stenting / balloon occlusion  Awake  Minimal sedation (Nabilone, low-dose dexmedetomadine, midazolam, propofol)  Trans-cutaneous pacemaker  Glycopyrrolate Mark Angle, April 13th 2013 17

18. Outside the Operating room ▫Other issues  Contrast allergy  Contrast nephropathy  Protamine reaction  Radiation safety Mark Angle, April 13th 2013 18

19. Outside the Operating room ▫Conclusions :  just neuro-anaesthesia in a less confortable zone …  Communication with the operator is paramount  Familiarity with the procedure and its goals are essential  Simplicity and the LMA should be the rule Mark Angle, April 13th 2013 19