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1、功能神经外科麻醉Awake CraniotomyQianjin LiuDepartment of Anesthesiology, School of Medicine Washington University in St. Louis, U.S.AAn awake craniotomy is an amazing procedure, which seems almost unbelievable at first thought. The procedure is very similar to a standard craniotomy, but with one difference-
2、 the patient is fully awake during the middle of the procedure.Traditionally, the technique of awake craniotomy was used for removal of epileptic foci and tumors involving functional cortex. Recently, awake craniotomy has been described as an approach for removal of all supratentorial tumors, regard
3、less of the involvement of eloquent cortex. This technique had a small complication rate and resulted in a considerable reduction in resource use by minimizing intensive care time and total hospital stay without compromising patient care. A Canada group reported 241 patients underwent awake cranioto
4、my about 40% of the patients were discharged within 24 hour hospital stay (7 % were discharged within 6 hours) versus average of 4 days hospitalization to those undergoing standard craniotomy.Awake craniotomy allows cortical mapping with patient cooperation and helps prevent neurological dysfunction
5、 during brain tumor resection. For example, speech function is usually in the left half of the brain and to minimize brain damage and maximize the amount of tumor that can be safely taken, its helpful to have the patient talk, read and follow commands while a tumor is removed in that part of the bra
6、in. Despite the widespread use of this surgical technique, its optimal anesthetic management remains a challenge. It requires an adequate depth of anesthesia for craniotomy, which should be followed immediately by clear consciousness for cortical mapping. During this dramatic change in conscious lev
7、el, the patient must be kept immobile and comfortable, while lung ventilation is properly maintained.Perioperative Anesthesia ManagementCommunications to the surgeon and the patients Anesthesiologist needs to discuss with surgeon about lesson location, preferred position, estimate length of procedur
8、e and amount of blood loss etc. Patients should be instructed in details about what they may be encountered during the surgery and what they are expected to be cooperated with. The communication is the key of the successful factors.Intraoperative Monitoring Routine monitors and invasive monitors suc
9、h as A-line and Foley urine catheter. In our institution more than 50% of patients underwent awake craniotomy without A-line.Mode of AnesthesiaCommonly there are three kinds of approached used in awake craniotomy. 1) sedation-awake-sedation2) sedation-awake-sleep*3) sleep-awake-sleep *sleep means ge
10、neral anesthesiaLocal or regional anesthesia can be performed by either surgeon or anesthesiologist. Management of intraoperative common problemsThe most common problems are nausea and vomiting, airway compromising, surgeons complaining of brain swelling, and patient sezureing. These problems can be
11、 managed with well-prepared planning preoperatively. LMA plays a very important role in dealing with airway problems . During the mapping time patients are required completely awake. Anesthesiologist needs to cooperate with the surgeon and the patient. Short acting sedatives greatly improve the qual
12、ities of patient sedation and mapping. Propofol and remifentanil are widely used in the procedure and more and more institutions include Dexmedetomidine in their protocols for the medicine has combined functions of sedation and analgesia. More importantly it has minimal respiratory suppression.Usage
13、 of Neuronavigator or image-guide system is significantly assistant to localize the tumor and shorten the surgical time.SummeryAn awake craniotomy a widely accept and standard procedure. There is an increasing trend towards performing craniotomy awake. The challenge for the anesthesiologists is to p
14、rovide adequate analgesia and sedation, hemodynamic stability, and a safe airway, with an awake, cooperative patient for neurological testing. Technically awake craniotomy is the same as standard craniotomy. The cooperation among the surgeon, the anesthesiologist, and the patient is the key of a successful procedure.
