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Vascular Injuries

The inadvertent rupture of a vessel is not an uncommon complication during neurosurgical procedures. Other than major blood loss and its resultant complications, it carries a high risk of ischemia and permanent neurological deficits. This requires prompt management to minimize the morbidity and mortality associated with it. Vascular injuries may be classified based on the following: 1. Location: intracranial or spinal 2. Type: arterial, venous, or…

Hemodynamic Instability

The utmost objective of anesthetic management of neurosurgical patients is the maintenance of adequate cerebral perfusion pressure (CPP) that prevents any secondary injury to the brain and spinal cord. Hemodynamic instability is often encountered intraoperatively or postoperatively and encompasses both hypotension and hypertension along with changes in heart rate. Specifically related to the brain, hypotension may decrease cerebral blood flow (CBF) causing ischemia, while hypertension may…

Electrocardiogram Abnormalities

Definition The close association between the brain and the heart makes the heart vulnerable during any neurologic insult. This may be reflected in the electrocardiogram (ECG) and could vary between sinus tachycardia to asystole (flat ECG). The abnormalities could be a change in the rhythm or the morphology of the ECG. Variants Morphologic ECG changes noted in neurologically compromised patients may be isolated P, Q, U,…

Vasospasm

Cerebral vasospasm implies narrowing of blood vessels resulting in decreased cerebral blood flow to distal tissues resulting in ischemia. It has been variously defined in the literature by different authors: 1. Clinical vasospasm defined as neurological deterioration deemed secondary to vasospasm after other causes are eliminated. It is seen in 20–40% of patients. 2. Delayed cerebral ischemia (DCI) defined as clinically symptomatic vasospasm or infarction on…

Aneurysm/Arteriovenous Malformation Rupture

Definition Rupture of the intracranial aneurysm or an arteriovenous malformation during surgical clipping or coil embolization is one of the most devastating complications in neurosurgery. It is defined as a fresh or new leak in the existing vascular pathology occurring during the intraoperative course. The complication may occur any time from induction of anesthesia to application of the negative pressure vacuum drain at the end of…

Spinal Shock

Definition Spinal shock occurs following an acute spinal cord injury and involves a reversible loss of all neurological function, including reflexes and rectal tone, below a particular level. It is defined as a state of transient physiologic (rather than anatomic) reflex depression of cord function below the level of injury, with associated loss of all sensorimotor functions. It is not a “shock” in the sense of…

Postoperative Paraplegia and Quadriplegia

Postoperative paraplegia refers to new onset neurological deficit which occurs as a result of damage/insult to the spinal cord below T1 whereas quadriplegia/tetraplegia with or without respiratory dysfunction will occur when the insult is above the first thoracic vertebra. Usually it affects the cervical spinal nerves resulting in complete paralysis of both arms and legs. In addition to the arms and legs being paralyzed, the chest…

Postoperative Respiratory Failure

Case Synopsis A 75-year-old man is taken to the operating room for urgent cholecystectomy. He becomes hypotensive intraoperatively despite adequate fluid resuscitation. At the end of the case, his arterial partial pressure of oxygen (Pa o 2 ) is 80 mm Hg with a fraction of inspired oxygen (Fi o 2 ) of 100%. He is taken to the intensive care unit, where a chest radiograph…

Postoperative Pulmonary Hypertension

Case Synopsis A 50-year-old woman with chronic thromboembolic pulmonary hypertension is to undergo open partial colectomy with primary reanastomosis for colonic adenocarcinoma. She is on warfarin therapy, which she was instructed to stop 7 days before surgery. She is on no other medications for pulmonary hypertension. She is able to walk less than one block before she needs to stop because of dyspnea. Her preoperative echocardiogram…

Postoperative Peripheral Neuropathy

Case Synopsis A 28-year-old man with insulin-dependent diabetes mellitus for 15 years was diagnosed with testicular cancer. His chemotherapy regimen consisted of bleomycin and cisplatin. He underwent postchemotherapy retroperitoneal lymph node dissection under general anesthesia. The surgery, which took 2 hours, was unremarkable, as was his stay in the postanesthesia care unit. On postoperative day 3, the patient noted a decreased level of sensation in the…

Postoperative Hepatic Dysfunction

Case Synopsis A 60-year-old man with a history of hepatitis C and hepatocellular carcinoma is scheduled for elective partial liver resection. Preoperative hemoglobin is 10 g Albumin, creatinine, liver enzymes, and prothrombin time (PT) are within normal limits. The surgery is uneventful except for an intraoperative blood loss of 2 L, requiring transfusion with 5 units of packed red blood cells (RBCs). The patient is transferred…

Postoperative Hemodynamic Instability

Case Synopsis A 90-kg, 75-year-old man (body mass index 35) with a history of smoking, well-controlled hypertension, and chemotherapy in the distant past for lung cancer is transported to the postanesthesia care unit (PACU) and intubated after a complex, 6-hour hand surgery. Preoperative medications include metoprolol and hydrochlorothiazide. Intraoperative urine output is 300 mL. An arterial line is in place. In the PACU he receives a…

Postoperative Delirium

Case Synopsis An 90-year-old man with a history of stable angina, renal insufficiency, chronic obstructive pulmonary disease, hypertension, depression, and hearing impairment undergoes general anesthesia for pinning of a femur fracture. The surgery and anesthetic are uneventful. In the postanesthesia care unit (PACU), the patient becomes disoriented and combative. Problem Analysis Definition Postoperative delirium is an acute disorder of attention and cognition detected typically in the…

Postoperative Acute Kidney Injury

Case Synopsis A 75-year-old man with long-standing hypertension and type 2 diabetes mellitus underwent open repair of an infrarenal aortic aneurysm. His baseline creatinine was 1.6 mg/dL, and this rose to 2.0 mg/dL on the second postoperative day. On the fifth postoperative day, he developed progressive hypoxemia, fever, and hypotension. A contrast-enhanced scan of the pulmonary vessels was not suggestive of pulmonary embolism. He was started…

Postobstruction Pulmonary Edema

Case Synopsis A 37-year-old, 77-kg, previously healthy man develops laryngospasm immediately after tracheal extubation, after an otherwise uneventful general anesthetic for repair of orbital floor fracture. Laryngospasm is managed with intravenous administration of succinylcholine after an unsuccessful attempt at bag-mask positive pressure ventilation. Fifteen minutes later he breathes spontaneously, with adequate tidal volume, but he coughs, his O 2 saturation is 92% while breathing O 2…

Persistent Paresthesia

Case Synopsis A 63-year-old woman with a history of breast cancer who has undergone chemotherapy will be undergoing a left carpometacarpal arthroplasty. An infraclavicular brachial plexus block is done using 30 mL of 0.5% ropivacaine. On her postoperative visit, she complains of numbness in the lateral hand. Electromyography and nerve conduction tests are performed 12 weeks after surgery and show a sensorimotor neuropathy of her left…

Peripartum Neurologic Complications

Case Synopsis A 32-year-old woman, gravida 1, para 0, had uneventful epidural analgesia for labor using 0.125% bupivacaine and fentanyl 2 μg A 10-mL intravenous bolus was administered, followed by infusion of the same mixture at 10 mL per hour. Subsequently she required midforceps delivery with manual fetal version for occiput posterior vertex presentation. Before version and extraction of the infant, 20 mL of 2% lidocaine…

Perioperative Tachyarrhythmias

Case Synopsis A 68-year-old man develops sudden-onset fast atrial fibrillation during an emergency laparotomy under general anesthesia for an ischemic small bowel. The patient is hypotensive, with an irregular narrow complex tachycardia and a ventricular rate of 140 beats per minute. Cardiovascular stability is restored with an intravenous fluid bolus, vasopressors, electrolyte replacement, and an amiodarone infusion. Postoperatively the patient is transferred to the intensive care…

Perioperative Myocardial Ischemia and Infarction

Case Synopsis A 62-year-old man is scheduled for cystectomy. He has a history of coronary artery disease (CAD) and underwent coronary artery bypass grafting 8 years ago. He has diabetes mellitus, hypertension, and hyperlipidemia. He takes aspirin, atenolol, pravastatin, and losartan. He is able to walk up a flight of stairs without symptoms. His intraoperative course is uneventful except for tachycardia during extubation. In recovery, he…

Perioperative Hypoxia

Case Synopsis A 42-year-old, 70-inch-tall, 95-kg man with chronic obstructive pulmonary disease and hypertension is undergoing a laparoscopic appendectomy. A satisfactory rapid-sequence induction with propofol and succinylcholine is performed, appropriate antibiotics are administered, and the abdomen is insufflated. Fifteen minutes into the procedure, the low oxygen pressure alarm sounds, the Fi o 2 displays 16%, and oxygen saturation by pulse oximetry (Sp o 2 ) reads…