XXVI. Tumors
T2-Weighted MRI of Right Frontal Tumor with
Edema and Some Mass Effect
XXVII. Transphenoidal
A. Hormonal Imbalance
1. Cushing's Disease: HPT, DM, osteoporosis,
obesity, friable skin
2. Acromegaly: HPT, cardiomyopathy, DM,
difficult airway
3. Diabetes Insipidus post-op and intra-op
a. Simultaneous urine and serum
osmolality and sodium.
b. DDAVP dose is 10 units
c. CVP not needed as patient can drink to
keep up with fluids.
4. Stress doses of steroids
B. Intracranial Hypertension
1. Rare to have a mass effect but exceptions
do exist - craniopharyngiomas and
suprasellar masses.
2. With no ICP elevation, a PaCO2 of 32-37
and no mannitol is sufficient.
C. Anesthetic considerations
1. Stress doses of steroids are administered.
2. The table turns so that the patient's left
hand comes to the anesthesia machine
3. Tape the ET tube to the left side of the
mouth. Leave the elbow in the ET tube and
place in the same plane as the head to
avoid flipping the tube out of the mouth.
The upper lip will be retracted so the
tape cannot go over the top of the mouth.
Bring a piece of tape over the chin to aid
in keeping the ET tube in place.
4. Orogastric tube to gravity drain. Do not
simply place and cap off.
5. Blood loss is usually ~250cc but can be
massive and sudden since major vessels are
in the area.
6. A lumbar subarachnoid catheter may be
placed for pneomoencephalogramm. This will
restrict the use of N2O.
7. Air embolism may occur. Some sources
recommend placing a precordial doppler in
place.
8. Bradycardia secondary to trigemminal or
vagal stimulation may occur.
D. Left arm goes down long axis of body so C-Arm
can fit.
E. A large amount of lidocaine with epinephrine
or cocaine are injected into the submucosa
by the surgeon. Hypertension should be
anticipated and can be treated with labetalol
or esmolol.
F. The surgery will end suddenly. It is important
to have an idea of where the surgeons are in
the procedure at all times.
G. Throat pack out and all reflexes back before
extubaion. Blood may have been swallowed.
H. Management of Carotid Injury
1. Blood replacement
2. EEG placement for evaluation of collateral
flow. If flow is adequate, probably don't
need pentothal coma.
3.
Spinal Cord Surgery