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

2. 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.

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. Reduction of ICP Intravenous anesthetics Hyperventilation (30-35 mmHg)
Mannitol ( 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.

9. 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.

10. Preop Sedation=hypercapnia, hypoxia, obstruction
Stress: increased CMR, CBF
Analgesia/sedation midas mg/fentanyl ( 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.

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.

16. 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.

17. 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.

18. 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.

19. 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.

20. 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.

21. 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.

22. 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.

23. 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.

24. 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.

25. 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.

26. 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.

27. 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.

28. 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.

29. 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.

30. 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.

31. 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.

32. 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.

33. 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.

34. 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.

35. 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.

36. 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.

37. 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.

38. 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.

39. 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.