NEUROANESTHESIA

CRISIS MANUAL
Angela Builes

https://t.me/Anesthesia_Books
NEUROANESTHESIA
CRISIS MANUAL

Angela Builes

Edited by:

Miguel Arango
Luis Fernando Botero
2

Author:
Angela Maria Builes Aguilar, MD, MSc
Medicine, Epidemiology and Anesthesiology. Universidad CES-Colombia
NeuroAnesthesia and Simulation Fellowships. Western University-Canada
E-mail: angelitabuiles@gmail.com
@angiebuiles2

Editors:
Miguel Arango MD, FRCPC
NeuroAnesthesia and Assoc. Professor of Anesthesia and Fellowship Director
Department of Anesthesia & Perioperative Medicine, University of Western Ontario, London Health
Sciences Centre, London Ontario Canada - Western University
Email: Miguel.Arango@lhsc.on.ca

Luis Fernando Botero, MD

Medicine and Anesthesia. Universidad Pontificia Bolivariana-Colombia
NeuroAnesthesiologist, Hospital Henrri Mondor - Universidad XIII Creteil, Francia
NeuroAnesthesia Director. Universidad CES-Universidad Pontificia Bolivariana-Colombia
E-mail: Luisfbotero@hotmail.com

Copyrights@2018 Angela Builes

London Ontario - Canada
Version 1.0 Feb 2018
Department of Anesthesia & Perioperative Medicine. Western University.
http://www.schulich.uwo.ca/anesthesia/

This work is licensed under a Creative

Commons Attribution-NonCommercial-ShareAlike 4.0
International License

ISBN: 978-1-7752595-0-3
 3
PREFACE

The purpose of this crisis manual is to be a resource for anesthesiologists and to

prepare them for stressful situations that may arise during neurosurgical procedures.
It is meant to be a reference only and a cognitive aid in emergency situations. It is
NOT a guideline or a protocol that anesthesiologists are obligated to follow. This
manual may provide a vehicle for input and practical strategies when facing critical
events with neurosurgical patients.

We based the content on our literature review, accepted guidelines, algorithms,

academic resources and by experiences learned in practice.

This manual introduces our mental model and decision-making frame. It provides
methods to manage these emergencies, especially when treatment requires
multiple tasks performed simultaneously by different individuals.

The manual will provide a team with a checklist of the tasks that need to be
completed.

Limitations:
During our literature review, we focused on an adult population. However, most of
the principles apply to pediatric cases with appropriate considerations (including
doses) adjusted for this population.

Recommendation:
Implementation and management of emergency situations can vary according to
institutions, regulations, team compositions, or updated evidence. We suggest the
readers adapt within their own organization and discuss with the neurosurgical
teams. This manual should be a living document. As future evidence changes
procedure, an update of the manual will be necessary. Once you reach consensus
start implementing your own manuals in your neurosurgical operating rooms using
simulation-based training.

For more information on how to implement Emergency Manuals check: https://

www.implementingemergencychecklists.org
4

How to use the NeuroAnesthesia Crisis Manual?

When using the manual, we recommend delegating one person to verify that
important steps are not missed when following this guide.

Two pages will be used to cover each crisis. The first will include information
about the patient at risk, the prevention strategies that could be implemented and
the signs, symptoms, and differential diagnosis for each one. The second page is
devoted to the treatments actually performed.

Note: The author and editors disclaim all liability from the use of the material, each
clinician is responsible for the interpretation and use of the manual in the clinical
setting.

We dedicate The Neuroanesthesia Crisis Manual

to the patients that give us their trust daily.
 COLLABORATIONS AND ACKNOWLEDGMENTS 5
Co-authors:

Accidental Extubation in Prone Position and Decision Making after Prolonged Prone
Position for Extubation

Ruediger Noppens, MD, PhD, FRCPC

Assoc. Professor of Anesthesia, Director of NeuroAnesthesia
Assoc. Professor of Physiology and Pharmacology
Department of Anesthesia & Perioperative Medicine -Western University
Email: rnoppens@uwo.ca, www.uwoanesthesia.ca

Neurogenic Pulmonary Edema and Cardiac Arrest in Prone Position

Jose Luis Diaz Gomez, MD

Cardiac Anesthesia, Critical Care Medicine and Neurocritical Care
Chair, Department of Critical Care Medicine
Consultant, Department of Critical Care Medicine, Anesthesia & Perioperative Medicine and
Neurologic Surgery
Mayo Clinic-Jacksonville, Florida
E-mail: diazgomez.jose@mayo.edu

Intracranial Hypotension

Mauricio Giraldo, MD
Medicine and Anesthesia. Universidad Pontificia Bolivariana-Colombia
NeuroAnesthesia and Cardiac Anesthesia. Western University- Canada
Assistant professor of Anesthesia
Department of Anesthesia & Perioperative Medicine -Western University
E-mail: Mauricio.giraldo@lhsc.on.ca

Extravasation of IV Access

Isabel Cristina Arias, MD

Medicine. Universidad CES-Colombia
Anesthesia. Universidad Pontificia Bolivariana-Colombia
NeuroAnesthesia and Cardiac Anesthesia Fellowship. Western University- Canada
E-mail: isabelcristina.arias@gmail.com

We want to thank the Department of Anesthesia & Perioperative

Medicine-Western University for the support of this project
 TABLE OF CONTENT 7
AIRWAY
1. ACCIDENTAL EXTUBATION IN PRONE POSITION............................... 8
2. DECISION MAKING AFTER PROLONGED PRONE POSITION
FOR EXTUBATION................................................................................. 10
BREATHING
3. NEUROGENIC PULMONARY EDEMA................................................... 12
CARDIAC
4. CARDIAC ARREST IN PRONE POSITION.............................................. 14
5. AIR EMBOLISM...................................................................................... 16
DEFICITS
6. ANEURYSM RUPTURE DURING CLIPPING........................................... 18
7. ANEURYSM RUPTURE DURING COILING............................................ 20
8. INTRACRANIAL HYPERTENSION.......................................................... 22
9. DELAYED AWAKENING......................................................................... 24
10. POSTOPERATIVE INTRACRANIAL HYPOTENSION.............................. 26
11. POSTOPERATIVE SEIZURES.................................................................. 28
12. INTRAOPERATIVE SEIZURES ............................................................... 30
13. INTRAOPERATIVE STROKE .................................................................. 32
ELECTROLYTES
14. HYPONATREMIA: CEREBRAL/RENAL
SALT WASTING SYNDROME................................................................. 34
15. HYPONATREMIA: SYNDROME OF
INAPPROPRIATE ANTIDIURESIS (SIAD)............................................... 36
16. HYPERNATREMIA: DIABETES INSIPIDUS............................................ 38
OTHER
17. EXTRAVASATION OF INTRAVENOUS ACCESS..................................... 40

NEUROCRISIS REPORT FORM......................................................................... 42

REFERENCES....................................................................................................... 44
8 1. ACCIDENTAL EXTUBATION IN PRONE POSITION

Signs
Drop or complete loss of EtCO2
Gas reservoir of machine empty
Machine does not deliver adequate inspiration tidal volumes, maximal leakage

Special Consideration

Critical moments of neurosurgery require deep anesthesia and neuromuscular

ACCIDENTAL EXTUBATION IN PRONE POSITION

blockade.
AVOID valsalva maneuvers

Initial Assessment
Switch to MANUAL/ BAG ventilation
Increase FiO2 to 100%
Increase fresh gas flow to maximum
Consider use of oxygen- “flush” button for maximum flow
Test to see if manual (bag) ventilation is possible
Feel resistance during manual ventilation. If no resistance: significant problem

CHECK circuit for leaks:

Connections to the anesthesia machine
Connections to the endotracheal tube
Listen for leaks

When Preparing to Turn a Patient Ask Neurosurgeon to:

Flood surgical field with saline
Remove surgical Instruments
Pack the wound with a saline soaked swab
Cover the wound with adhesive dressing
Release clamp
Hold the head in neutral position
1. ACCIDENTAL EXTUBATION IN PRONE POSITION 9
Treatment
Complete Extubation
Announce EMERGENCY to the team
Ask for HELP
Ask for Difficult Intubation Cart
Stop Procedure
Notify Neurosurgeon: prepare for turning
Ask for a stretcher
Increase Oxygen flow to 100% FiO2

ACCIDENTAL EXTUBATION IN PRONE POSITION

Immediate oxygenation/ventilation options in Prone:
–Insert a Supraglottic Airway Device (2nd generation/intubating
supraglottic airways are preferred)
–Attempt bag mask ventilation in prone with high-flow, 100% FiO2,
consider use of nasal/oral airway
(If oxygenation is easy to maintain, consider one intubation attempt in prone position. Consider
use of flexible intubation endoscope / video laryngoscope (if provider is highly skilled and if the
approach is feasible))
Prepare for turning
Secure IV access
Airway management in Supine Position

Partial Extubation (Diagnosed by: depth of tube, capnography, ventilation parameters, presence
of leak)
-Increase fresh gas flows and FiO2 to 100%

-Advance endotracheal tube (through Bougie or Endotracheal Tube Catheter,

consider use of flexible intubation endoscope) in prone position

-Check for correct tube position

-If adequate ventilation and endotracheal intubation is achieved, announce that

situation is safe and continue surgery

-If ventilation and intubation is not achieved:

Prepare for turning
Maintain oxygenation via: endotracheal tube or supraglottic airway device
(2nd generation/intubating supraglottic airways are preferred) or bag mask
ventilation in prone position (consider use of oral/nasal airway)
Turn to supine position
Airway management in supine position
10 2. DECISION MAKING AFTER PROLONGED
PRONE POSITION FOR EXTUBATION

Risk Factors
DECISION MAKING AFTER PROLONGED PRONE POSITION FOR EXTUBATION

Surgery associated risks: surgery > 6 hours, ↑ blood loss, ↑ IV fluid, C-spine surgery
Patient associated risks: Age > 70 yrs, obesity, obstructive, sleep apnea, chronic
obstructive pulmonary disease, rheumatoid arthritis, hemoglobin < 10 mg/dl,
difficult airway, neuromuscular disease, malnutrition, hypoalbuminemia

Prevention
Consider colloids over crystalloids for fluid resuscitation
Cuff pressure measurements during procedure, aim for < 20 cm H20
Avoid Extreme Neck Flexion

Airway Edema Assessment Options

Laryngoscopic assessment of pharynx/larynx (prefer video laryngoscope with
hyperangulated blade, look for evidence of edema)
Cuff Leak Test
Airway Ultrasound
Sufficient reflexes (cough, gag, and swallow)
Physical examination:
Neurologic status (Coma Recovery Scale-Revised Visual Subscale)
Inspection of neck, eyes, and tongue for edema

Extubation Criteria
Patient conditions
No signs of airway edema / obstruction
Slow emerge from anesthesia, consider using Remifentanil iv infusion to allow tube
tolerance)
Sufficient spontaneous ventilation with adequate, regular respiratory efforts
Hemodynamic and metabolically stable
Sufficient protective reflexes (gag, swallow, cough)
Reversal of neuromuscular blockade (TOF > 90%)
Normothermia

Other
Adequate location for extubation (monitoring, difficult airway equipment readily
available)
Help and skilled personnel available
2. DECISION MAKING AFTER PROLONGED 11
PRONE POSITION FOR EXTUBATION

DECISION MAKING AFTER PROLONGED PRONE POSITION FOR EXTUBATION

Assessment of: Airway, patient’s condition, extubation potentially
PLAN
successful, equipment and skilled personnel

Optimize patient and other factors (equipment, personal, location)

PREPARE Suction secretions without trauma

No -Postpone extubation
Is Patient Safe to Extubate? -Transfer to ICU
Yes
-Consider Tracheostomy

Options:
PERFORM 1. Remifentanil technique
EXTUBATION 2. Exchange Catheter

Comprehensive documentation and handover

POSTEXTUBATION
Monitoring and care by skilled / qualified personnel
CARE
Advanced airway management equipment readily available
12 3. NEUROGENIC PULMONARY EDEMA

Risk Factors
Acute Cerebral or Cervical Spine Cord Insult:
-Aneurysmal subarachnoid hemorrhage
-Traumatic brain injury/cervical injury
-Intracranial hemorrhage
-Intracranial tumours
-Seizures
-Postoperative intracranial surgery
-Meningitis
NEUROGENIC PULMONARY EDEMA

Signs
Central Neurologic Injury + Sudden Dyspnea
Other signs:
Tachypnea
Tachycardia
Pulmonary crackles and rales on auscultation, "B" lines in lung US
Cyanosis
Pink frothy sputum
Respiratory failure

Assessment
Arterial blood gases: ↓ PaO2 /FiO2 < 200
X-Ray: Bilateral infiltrates
Point of Care Ultrasound:
-Cardiac US: Assessment of left ventricular function
-Lung US: B-lines
-Inferior Vena Cava measurement
EKG: Ischemia findings

Differential Diagnosis
-Cardiogenic Pulmonary Edema
-Aspiration Pneumonia
-Ventilator Associated Pneumonia
-Ventilator Induced Lung Injury
-Transfusion Related Acute Lung Injury
-Sepsis
-Pneumothorax
 3. NEUROGENIC PULMONARY EDEMA 13
Treatment
1. Oxygenation:
↑­ Fi02
Mechanical or Non-Invasive Ventilation if no contraindications
(Keep PEEP < 15 cm H2O) / avoid AutoPEEP
Request the ICU Ventilator if needed
Use a muscle relaxant agent if needed

2. Treat primary brain injury-associated intracranial hypertension (examples):

-Decrease ICP (if it has Increased, see crisis #8 page 22
Intracranial Hypertension)

NEUROGENIC PULMONARY EDEMA

-Evacuate hematoma
-Treat seizures
-Acute hydrocephalus: External ventricular drain

3. Avoid increase in intracranial pressure:

-Ensure adequate anesthesia depth according to surgical procedure
-Avoid bronchoscopy unless absolutely necessary

4. Maintain adequate cerebral perfusion:

Hemodynamic support: Phenylephrine, Norepinephrine infusions
Avoid hypotension, goal MAP ≥ 70 mm Hg)
Caution with therapies: diuretics and high PEEP
Maintain hemoglobin > 10 g/dl
Maintain normocapnia
Maintain normal temperature

5. Monitor patient´s intravascular volume status and fluid responsiveness to guide

fluid management in the setting of pulmonary edema:
Pulse wave pressure variability < 13
Focused cardiac US:
IVC Distensibility index < 18%,
< 3 B-lines in each lung region
LVEF visual assessment normal or increased
6. Circulation: Consider Dobutamine and inotropes if necessary

7. Other Options:
-Diuretics: Furosemide
-Corticosteroids (Brain tumors/Multiple Sclerosis) NOT IN TRAUMATIC BRAIN INJURY
- Beta and alpha adrenergic blockers, according to hemodynamic profile

8.Transfer to ICU
Considerations for Brain-Dead Organ Donors:
-Nitric Oxide (NO) if pulmonary hypertension is suspected
-ECMO
14 4. CARDIAC ARREST IN PRONE POSITION

Reversible Causes
Air Embolism (see crisis #5 Air Embolism, page 16 )
Parasympathetic Reflex- Surgical Stimulation
Sudden Increase in ICP (see crisis #8 intracrianial hypertension page 22)
Prone Position
Intracranial Hypotension (Check Drains, see crisis #10 intracranial hypotension
page 26)
Medications (Dexmedetomidine, Remifentanil, Phenytoin, Beta-blockers)
CARDIAC ARREST IN PRONE POSITION

Local Anesthesia Toxicity

Spinal Shock
Anaphylaxis
Auto-PEEP
Brain Irrigation with Warm (42 ºC) or Cold (20 ºC) Saline

Hypovolemia Tension Pneumothorax,

Hypoxia Tamponade, Cardiac
Hydrogen (Acidosis) Toxins
Hypo/Hyperkalemia Thrombosis, Pulmonary
Hypo/Hyperthermia Thrombosis, Coronary
Hypogylcemia Tension Pneumocephalus

Effectiveness of CPR
Start reverse CPR compressions (see figures): Perform sterile CPR as soon possible
Guide compressions
EtCO2 > 20 mmHg
Arterial line diastolic blood pressure > 40 mmHg
Push chest at least 5 cm
Allow recoil
Rotate person compressing the chest
Defibrillation on Prone:
Pads on Postero-lateral (left mid axillary line + right scapula)
or bi-axillary position
 4. CARDIAC ARREST IN PRONE POSITION 15
Treatment
Confirm Cardiac Arrest (Pulse-Monitors)
Activate Code Blue (Ask for HELP-Crash Cart-a Stretcher and Board for Support)
Ask Surgeon to STOP PROCEDURE

CARDIAC ARREST IN PRONE POSITION

Check Rhythm
Shockable Rhythm No Shockable Rhythm (PEA)
Shock Epinephrine 100 mcg (0.1 mg)
(Biphasic Defibrillator 200 J) Every 3-5 minutes first doses up to 1 mg, then 1 mg
Every Cycle
Continue CPR Continue CPR
Epinephrine 100 mcg (0,1mg) Treat Reversible Causes
Every 3-5 min First Doses Minimize CPR Interruptions/Allocate Expert in TEE/TTE to it:
Up to 1 mg, then 1 mg Every Cycle If Possible TEE (Preferable) /TTE
Amiodarone 300 mg (first dose, (Midesophageal 4 Chamber View/Subcostal View)
Second 150 mg. Start after Second Shock Is there Wall Motion?
Treat Reversible Causes -Yes (Pseudo-PEA)
Is there an occult VF that Appeared Asystole?
-Yes: Provide a Shock
-No: Is there evidence of Tamponade, PE or
When Possible TEE (Preferable) /TTE Air in RV/Exsanguination? If positive, treat
- No (True-PEA) Epinephrine

If CPR is Not Effective: TURN TO SUPINE

ROSC Post-Cardiac Arrest Care
Neurosurgeon Anesthesiologist
Stop stimuli Turn Off anesthetic, if feasible
Flood Surgical Field Increase FIO2 to 100%
Remove Surgical Instruments Stop infusions
Pack the Wound with Saline Soaked Swab Check ETT position, circuit integrity, machine connections
Cover Wound Adhesive Dressing Start new IV fluids wide open
Release Clamp (first), then Review administered medications
Release Pins Verify tube secretions or obstruction
Hold Head Request expert to perform emergent TEE/TTE
Get Horseshoe or Discuss Reversible Causes with the team
Free Type Support for Head Check surgical field and drains
16 5. AIR EMBOLISM

Patients at Risk
Surgical field above heart level: sitting, lateral, prone
Posterior fossa procedures
Deep brain stimulator procedures
Cervical laminectomy
Craniosynostosis
AIR EMBOLISM

Posterior spinal fusion

Hypovolemia
Spontaneous ventilation
Hydrogen peroxide for wound irrigation
Use of NO2

Prevention
Look for PFO (TEE)
Good care of IV lines
Euvolemia
Adequate irrigation
Use of waxing

Signs and Symptoms

Patient Awake Patient Asleep
Coughing Hypoxemia
Gasping respiration Hypotension
Acute dyspnea ↓ EtCO2 (sudden decrease of CO2)
Tachypnea ECG changes
Breathlessness Arrhythmias
Light-headedness Abnormal heart sounds (precordial doppler)
Wheezing Tachycardia
Chest pain ­↑CVP
Altered sensorium Jugular venous distention
Acute right heart failure (TTE)
Cardiac arrest
5. AIR EMBOLISM 17
Treatment

Announce EMERGENCY to the team

Ask Neurosurgeon to STOP PROCEDURE

Ask for Help-Crash Cart

AIR EMBOLISM
Change position to Trendelenburg (tilt left side)

↑­ FIO2 to 100%

Administer bolus of IV fluids

Stop NO2 (if used)

Ask the Neurosurgeon to:

Flood the wound with saline
Wax bone edges
Cover exposed areas with large pieces of wet sterile sponges

Verify that there is no AIR in IV lines

RAPID ASPIRATION THROUGH CENTRAL LINE

Start vasopressors (if hypotension)

Compression of both Jugular veins

If patient has cardiac arrest, start CPR (see crisis # 4 Cardiac Arrest Prone Position, page 14)

Consider TEE for monitoring (other monitors: precordial Doppler, TTE)

Consider hyperbaric oxygen therapy (in case of cerebral arterial gas embolism)

Keep hemodynamic and ventilator support, if necessary

Transfer to ICU
18 6. ANEURYSM RUPTURE DURING CLIPPING

Risk Factors

Hypertension (history or presented with high blood pressure)

Recent rupture
Smoking history
Large size
ANEURYSM RUPTURE DURING CLIPPING

Prevention
Before surgery:
——Reserve FFP, red blood cells
——Apply pads
——Reserve ICU
——Double suction setting
——Adenosine available in the OR
——Have crystalloids with pressure bag ready
——Use Neuromonitoring if possible (BIS, NIRS, Evoked Potentials), when applicable
During surgery:
——Use osmotic therapy to optimize surgical access
——Adequate use of neuromuscular agents when transferring intubated patients
——At the moment of Durotomy, keep MAP 20% below baseline (Avoid big changes
in transmural tension)

Avoid
Sympathetic responses: intubation
Abrupt changes in ICP: coughing, gagging, hypotension, hyperventilation
Excessive drainage of CSF: large dose Mannitol, valsalva
Hypertension at the moment of Durotomy

Signs
Sudden changes without other explanation
Clinical: hypertension, bradycardia, arrhythmias, and blown pupil
Surgical: evidence of bleeding, brain bulge
Monitors: Suddenly increased intracranial pressure (ICP), sudden unexplained
changes on the monitors
6. ANEURYSM RUPTURE DURING CLIPPING 19
Treatment
Announce EMERGENCY to the team

Continue to communicate with the Neurosurgeon

Suggest the most senior surgeon in the room to take over
Verify double suction setting

ANEURYSM RUPTURE DURING CLIPPING

Suggest using cotton to suppress bleeding

↑FI02 to 100%

Request red blood cells to blood bank

Management of MAP (Goal 60 to 80 mmHg)

Controlled decrease of MAP (SHORT PERIOD OF TIME (for approx. 3 minutes)
-Propofol 1 -2 mg/kg or
-Thiopental 5-10 mg/kg or
-Esmolol 1 mg/kg or
-Labetalol 10 mg IV initially, then 20 mg IV q10min; do not to exceed 300 mg

↓ Cerebral metabolic rate: (propofol 1 -2 mg/kg or Thiopental 5-10 mg/kg)

Keep intravascular volume: crystalloids, transfusion if applicable

Sustain hemodynamic changes with vasopressors, titrate accordingly

Efforts to Stop Bleeding:

——Temporary clip
——Compression of ipsilateral Carotid Artery (for Anterior Circulation Aneurysms)
——Cardiac Arrest
——Adenosine 1st dose: 6 mg, 2nd dose: 12 mg
——Rapid ventricular pacing

Consider seizure prophylaxis Levetiracetam 20 mg/kg in 100 cc NaCl 0.9% in >15

minutes or Phenytoin: 20 mg/kg in 30 min. Start EEG

Ventilation and hemodynamic support

Transfer to ICU
20 7. ANEURYSM RUPTURE DURING COILING

Patients at Risk
Hypertension (history or presented with high blood pressure)
Recent rupture
Small aneurysms
Presence of smaller associated aneurysm
ANEURYSM RUPTURE DURING COILING

Past medical history: COPD, coronary artery disease/smoker/hyperlipidemia

Avoid
Sympathetic Responses: Intubation
Abrupt changes in ICP: Coughing/gagging/hypotension/hyperventilation
Caution with osmotic therapy
Suddenly decrease in brain parenchyma volume (↓ICP): large dose Mannitol

Signs
(Sudden changes no explanation)
Clinical: hypertension, bradycardia, arrhythmias, blown pupil
Radiographic: dye extravasation, prolongation of contrast dye transit time,
mechanical perforation, diversion of blood flow
Monitors: sudden increase ICP, sudden changes in monitors
7. ANEURYSM RUPTURE DURING COILING 21
Treatment
Announce EMERGENCY to the team
Ask for Help (CT-Scan-Neurosurgeon-request OR available)

­↑FI02 to 100%

ANEURYSM RUPTURE DURING COILING

Request red blood cells to blood bank and platelets if needed

Management of MAP (Goal 60 to 80 mmHg)

-Propofol 1 -2 mg/kg or
-Thiopental 5-10 mg/kg or
-Esmolol 1 mg/kg or
-Labetalol 10 mg IV initially, then 20 mg IV q10min; do not to exceed 300 mg

↓ Cerebral metabolic rate: (Propofol 1 -2 mg/kg or Thiopental 5-10 mg/kg)

Management of ICP
No Signs of Herniation:
Avoid hyperventilation if there is hypotension
Once the rupture is solved, start management of ICP (see Crisis #8, page 22)
Signs of Herniation:
Manage ↑ ­ICP (see Crisis #8 Intracranial Hypertension, page 22)

Prompt Reverse heparin: get ACT or consider time since last dose of Heparin.
(Protamine Sulfate 1 mg for each 100 units of Heparin given)

Continue to communicate with the Neurosurgeon:

Endovascular treatment: Partial or complete packing of aneurysmal sack
with Coils is feasible? embolization to seal?

Surgical treatment: Ventriculostomy or emergent Craniotomy and Clipping or

Decompresive Hemicraniectomy
Prepare for surgery: get ACT, get CT-Scan, prepare for transport, consider
ventriculostomy catheter: drain at 15-20 cm H2O above Tragus

Consider seizure prophylaxis: Levetiracetam 20 mg/kg in 100 cc NaCl 0.9% in >15

minutes or Phenytoin: 20 mg/kg in 30 min. Start EEG

Ventilation and hemodynamic support

Transfer to ICU or Operating Room
22 8. INTRACRANIAL HYPERTENSION

Patients at Risk
Severe Traumatic Brain Injury
Hemispheric Stroke
Intracranial Hemorrhage
INTRACRANIAL HYPERTENSION

Severe Intracranial Hypertension

Acute Hydrocephalus
Meningitis

Signs
Intracranial Pressure >20 mmHg (>5min) if Measured
Signs of Herniation:
Hypertension, bradycardia, irregular respirations or apnea
Pupillary dilation
Loss of Brainstem Reflexes:
Blinking, gagging, pupils reacting to light,
Loss consciousness
Respiratory depression
Dysrhythmias
Cardiac arrest
8. INTRACRANIAL HYPERTENSION 23
Treatment
Physiologic therapies
Head elevation: 20 - 30º
Neutral neck positioning to ensure venous drainage

INTRACRANIAL HYPERTENSION
Hyperventilation (as a bridging therapy):
(PaCO2 30-35) short time (5 -10 min without hypotension)
↑FIO2 to 100%
Keep adequate blood pressure: MAP 90-110 mmhg
Decrease intrathoracic pressure (low PEEP)
Keep temperature control (normothermia)
Check normoglycemia (80-150 mg/dl)
Minimize tracheal suctioning
Measure electrolytes and arterial gases.

Avoid valsalva maneuvers: Maintain deep anesthesia and/or

use muscle relaxant agent.

Pharmacologic treatment
Mannitol 0,5-1 g/kg
Hypertonic Saline over 20 min: (NaCl 3% 3 mL/kg or NaCl 7.5% 2 mL/Kg)
Furosemide 10 to 20 mg
Propofol Bolus 1-2 mg/kg OR
Thiopental 5-10 mg/kg initial dose
Anesthesia inhaled agents MAC < 1, if it is not improving, CHANGE FOR TIVA
Consider Dexamethasone (if vasogenic edema is suspected)

Consider EEG monitoring and decide the use of:

Phenytoin 20 mg/kg in 30 min initial dose or
Pentobarbital 10mg/kg over 30 min then 5 mg/kg/h x 3 h then 1-4 mg/kg/h
or levetiracetam 20 mg/kg 100 cc NaCl 0.9% in >15 minutes

CT- SCAN
Consider: ventricular drainage, Decompressive Craniotomy
Start deep sedation and consider additional monitoring (NIRS, EEG, TCD)
Keep ventilation and hemodynamic support
Transfer to ICU
24 9. DELAYED AWAKENING

Risk Factors
Surgical associated risks
-Frontal brain resection
-Posterior fossa
DELAYED AWAKENING

-Tumor size > 30 mm

-Midline shift > 3 mm
-Cerebral edema
-Proximity to the Ascending Reticular Activating System
-Temporary occlusion of arteries
-Hematoma exceeding 2-3 cms
-Neuroendoscopic procedure
-Transsphenoidal surgery with use of Oxymetazoline
-Hypothermia

Patient associated risks

-Epileptic patients
-Parkinson Disease
-Obese
-Elderly
-Porphyria
-Mucopolysaccharide Disease
-Hypothyroidism
-Renal failure
-Liver failure

Medications
-Narcotics
-Muscle relaxants
-Toxins (Alcohol, etc)
-Antiepileptic medications
-Anticholinergic agents
-Nasal Oxymetazoline
-Benzodiazepines
-Barbituric agents
-Anti-epileptic agents (AEA)
-Parkinson medications
-Dexmedetomidine
-Haloperidol
9. DELAYED AWAKENING 25
Verify
Vital signs (ABCD)
All anesthetic agents and opioids are stopped
TOF >90%

DELAYED AWAKENING
Check: Pupils, lateralizing signs
Check: Blood gases (Na, K, Ph, Pa CO2) and glucometry, temperature, Mg++, Ca+,
BUN
Check: Amount of CSF drainage
Review medications

Treatment

Consider:
Opioid reversal: Naloxone 40 mcg IV and repeat every 2 minutes Up to 2 mg
Benzodiazepines reversal: Flumazenil 0,1 mg Iv q 2 min until 1 mg
Anticholinergic medications: Physostigmine 1 mg (rate 1mg/min)

EMERGENT CT-SCAN
Don’t extubate
Inform Neurosurgeon – Consult Neurology if necessary
Consider brain monitors: BIS, NIRS TCD, accordingly

Differential Diagnosis
——Hypoglycemia: give Dextrose 50% 50 cc IV
——Hypothermia: start re-warming
——Cerebral ischemia/stroke: MRI, hemodynamic support, consult Neurology
——Vasospasm: Request TCD
——Cerebral hemorrhage: CT-Scan and discuss with Neurosurgery according to
findings
——Tension Pneumocephalus: Emergent surgical intervention
——Rupture Aneurysm: CT-Scan and discuss with Neurosurgery according to findings
——Seizure Disorder: Start EEG
——Cerebral Hypotension (Trendelemburg positioning, (see Crisis #10 Intracranial
Hypotension, page 26)

Continue ventilation and hemodynamic support

Transfer to ICU
26 10. POSTOPERATIVE INTRACRANIAL HYPOTENSION

Patients at Risk
-Brain or spine trauma
-Spine surgery
-VP shunts
POSTOPERATIVE INTRACRANIAL HYPOTENSION

-Postoperative drainage of brain hematoma

-Any Craniotomy
-Intraoperative drainage of CSF

Signs

——Delayed recovery from anesthesia

——Mydriasis and non-reactive BILATERAL pupils
——Absence of decerebration and decortication reflexes
10. POSTOPERATIVE INTRACRANIAL HYPOTENSION 27
Treatment
Inform Neurosurgeon

TRENDELENBURG POSITION -30 degrees

POSTOPERATIVE INTRACRANIAL HYPOTENSION

IV Fluid challenge (250-500 cc)

Clinical condition should improve in 30 minutes or less

Hemodynamic and ventilator support

If there is no change in neurologic response: CT-Scan (see Crisis #9 Delayed

Awakening, page 24)
28 11. POSTOPERATIVE SEIZURES

Patients at Risk

Metabolic: hypoglycemia, hypocalcemia, hypophosphatemia, hyponatremia,

POSTOPERATIVE SEIZURES

uremia

Drug Withdrawal: Alcohol, barbiturics, benzodiazepines, opioids

Brain Injury: Traumatic brain injury, stroke, subarachnoid hemorrhage, intracranial

hemorrhage, infections

Brain surgery: Glyomas, cortical stimulation, brain tumours, surgery in motor cortex

Others: ANTIEPILEPTIC DRUG (AED) WITHDRAWAL, younger age, hyperventilation,

changes in AED, pain, stress, fever, infection, local anesthetic toxicity
 11. POSTOPERATIVE SEIZURES 29

SUPPORTIVE MEASUREMENTS

POSTOPERATIVE SEIZURES
Airway: Secure and support
Monitors: Respiratory, cardiac, temperature, EEG
0-5 IV: Secure IV access and drop blood samples for: Blood gases, Na, Ca, Mg,
minutes PO4, BUN, AED levels, alcohol, toxic panel
Glucometer: if < 60 mg/dl, 50 ml Dextrose 50%, consider Thiamine 250 mg,
for Alcohol Consumption or impaired nutrition
Oxygen and Observe: Maintain oxygenation and perform neurologic exam

ASK FOR HELP!

BENZODIAZEPINE TRIAL
FIRST 5 Lorazepam: 0.1 mg/kg max 4 mg Repeat Once or
Midazolam: 5 mg IV or IM, Intranasal, Buccal (2.5 mg for fragile, elderly or
minutes
severe comorbidities) or
Diazepam: 0.15-0.2 g/kg max 10 mg/dose

Check exams and treat reversible causes

ANTI EPILEPTIC DRUG (AED)

5 – 20 Levetiracetam 20 mg/kg in 100 cc NaCl 0.9% in >15 minutes or
minutes Phenytoin: 20 mg/kg in 30 min or
Phenobarbital: 20 mg/kg in 30 min

STAT 20 MINUTES EEG

GENERAL
If Seizures ANESTHESIA
Continue After EMERGENT CT-SCAN
Prepare for RSI
20 minutes
Propofol Infusion

Ventilation and hemodynamic support

Transfer to ICU
Continue AED infusions, consider continuous EEG

Call Neurologist or epileptic clinic consult

30 12. INTRAOPERATIVE SEIZURES

Risk Factors
Patient associated risks:
History of seizures
INTRAOPERATIVE SEIZURES

Preoperative seizures
Young patients
Uncontrolled diabetes
Hyponatremia

Surgery associated risks:

Grade ii gliomas
Frontal lobe surgery

Moment in surgery:
Brain mapping
Tumour resection
Cortical stimulation

Withdraw of Anti-Epileptic Drugs

Avoid:
Etomidate
Ketamine
Hyperventilation
Flumazenil
12. INTRAOPERATIVE SEIZURES 31
Treatment
Announce EMERGENCY to the team

INTRAOPERATIVE SEIZURES
Ask the surgeon to stop cortical stimulation

Irrigate cold saline on the brain or surgical field

If seizures stopped, continue procedure.

If seizures don’t stop:

Basic support measurements:

Patent airway
Assist ventilation
Cardiovascular stability

Medications:
Propofol: 0,5 mg/kg
Midazolam 1 or 2 mg bolus

Talk to neurosurgeon and neurophysiolist:

Assess if you can continue with micro or macro recording. (If it is safe, continue
with the procedure)

If seizures recurred, ABORT PROCEDURE

Remove head from frame and pins

Repeat Midazolam 1 or 2 mg
Start Levetiracetam 20 mg/kg in 100 cc NaCl 0.9% In >15 minutes or
Phenytoin: 20 mg/kg in 30 min

Continue seizures management (see crisis #11 Postoperative Seizures, page 28)
32 13. INTRAOPERATIVE STROKE

Risk Factors
Patients associated risks:
Atrial fibrillation
INTRAOPERATIVE STROKE

Elderly >65 y/o

MI (<6 months)
Acute renal failure
Smoker
Cardiac valve disease
Previous stroke (<9 months)
History of brain radiotherapy
Procedure:
Carotid endarterectomy
Carotid stent
Aneurysm clipping or coiling
Intraoperative hypotension
Neck surgery:
Neck rotation and extension
Arthritis cervical spine
Tumors involving Carotid Artery
Intraoperative hypotension
Patient sitting position

Signs
Awake Patient: Patient under General Emergency from
New neurologic Anesthesia: general anesthesia:
deficit Changes in neuromonitors New neurologic deficit
Fast (Face Arm NIRS (drop >20%),
Speech Test) Unexpected changes in Delayed awakening
NiHHS > 0 TCD or SSEP (see crisis #9 delayed
Angiographic evidence Angiographic evidence Awakening, page 24)
of emboli or bleeding of new bleeding or
thrombosis
Unexplained hemodynamic
changes
13. INTRAOPERATIVE STROKE 33
Treatment
Announce EMERGENCY to the team
If it is possible, STOP procedure

INTRAOPERATIVE STROKE
Talk to the Neurosurgeon
Activate Stroke protocol (If available)
Allocate one person to assess neuro-status: NIHHS score and record time
Maintain:
Hemodynamics (ABCD, intubate if needed*)
*Intubate if: GCS ≤ 8, agitation, decline of Level of consciousness, vomiting, respiratory failure
Normal glucose level (80-150 mg/dl)
Normal level of PaCO2
Normal temperature
Normal oximetry > 94%
Hemoglobin levels > 10g/dl
Adequate oxygenation
Get an ACT if Heparin has been used
Get stat labs: INR/PTT, CBC, Fibrinogen

Perform an EMERGENT CT-SCAN or Angiography (or dMRI) according to situation

Ischemic Stroke:
-Increase MAP, do not exceed < 185/110. AVOID HYPOTENSION!
-Consider stent
-Mechanic or pharmacologic thrombolysis
-Discuss with surgeon options: Abciximab or intra-arterial Vasodilators
-Consider Aspirin 81 mg/d and Clopidogrel 75mg/d, statins according to situation
Hemorrhagic Stroke:
-Decrease MAP, maintain Systolic Blood pressure < 140-150 mmHg
-Elevate head 30 degrees
-Reverse Heparin (Per ACT) with: Protamine 1 mg for every 100 IU of Heparin
-Consider transfusing platelets in those with Aspirin and Clopidogrel
-Consider cryoprecipitate (6-8 units)
-Discuss with the surgeon: attempt of Coil or Balloon Occlusion on site of
hemorrhage
Other considerations:
-Obtain a 12-lead ECG
-Perform a point of care ultrasound: Carotid imaging, left ventricle assessment
Keep adequate oxygenation and hemodynamic support
Transfer to ICU
34 14. HYPONATREMIA: CEREBRAL/RENAL
SALT WASTING SYNDROME

Patients at Risk
Subarachnoid hemorrhage
Traumatic brain injury
HYPONATREMIA: CEREBRAL/RENAL SALT WASTING SYNDROME

Brain tumors
Brain infarction
Intracranial hemorrhage
Arteriovenous malformation
Meningitis
Intracranial surgery

Diagnosis
HYPONATREMIA (plasma levels of Na+ < 135 mEq/L)
HYPOVOLEMIA (tachycardia, hypotension, thirst, dry mucous membranes, ↓ CVP)
HYPO-OSMOLARITY (Plasma osmololality < 275 mOsm/Kg)
Urinary Na+ > 40 mMol/L
Fractional excretion of urate after correction: high

Classification of Hyponatremia
Mild: Na+ 130-135
Plasma Levels of Na+
Moderate: Na+ 125-129
(mEq/L)
Severe: Na+ < 125

Moderate-chronic: nauseas, fatigue, gait and attention deficit,

falls. Severe acute: vomiting, headache, seizures, coma,
Symptoms
death, respiratory arrest, neurogenic pulmonary edema, brain
herniation

Acute < 48 hours

Time
Chronic > 48 hours

Differential Diagnosis
Diuretics
Osmotic therapy
Hyperglycemia
Media contrast diuresis
Addison’s disease
14. HYPONATREMIA: CEREBRAL/RENAL 35
SALT WASTING SYNDROME

Treatment

HYPONATREMIA: CEREBRAL/RENAL SALT WASTING SYNDROME

Draw blood sample: repeat electrolytes, glucose levels, uric acid

Measure urine osmolality, density and Na+, uric acid

Treat HYPOVOLEMIA first: Hydrate patient with NaCl 0.9 % (Normal Saline)

If severe and/or acute hyponatremia:

NaCl 3% 100 cc IV bolus over 20 minutes

Repeat Maximum 2 more times if the rise in Plasma Na+ ≤ 5 mEq/L

Aims of Na+ Correction: ↑ 3-5 mEq/L over first 2-4 hours

↑ 6-8 mEq/L over 24 hours
LIMITS ↑ 10 mEq/L 24 hours (8 mEq/L in
patients with hypokalemia, alcoholism,
malnutrition, liver disease)

Repeat plasma levels of Na+ every 2 hours until Na+ stabilized, then every 6 hours

Monitor volume status and treat hypovolemia, fluids and urinary output

Treat underlying cause, if possible

Refractory cases: Fludrocortisone 0.1-0.2 Mg orally twice a day

If patient awake: oral salt supplementation

36 15. HYPONATREMIA: SYNDROME OF
INAPPROPRIATE ANTIDIURESIS (SIAD)

Patients at Risk
HYPONATREMIA: SYNDROME OF INAPPROPRIATE ANTIDIURESIS (SIAD)

Patients at risk Neuro patients at risk

Carcinomas: Head trauma
Lung > head > neck > pancreas > prostate > Post craniotomy (pituitary,
duodenum craniopharyngiomas, hypothalamus)
Pulmonary disease: Brain tumors
COPD, asthma, pneumonia, empyema Stroke
Cavernous sinus thrombosis
Medications: CNS infection
—— Desmopressin or vasopressin AIDS
—— High doses oxytocin Hydrocephalus
—— Chlorpromazine Psychosis
—— Carbamazepine Malformations
—— Vincristine Guillain-barre syndrome
—— Fluoxetine Subarachnoid hemorrhage
—— Angiotensin converting enzyme inhibitors
—— Dopamine antagonist
—— Omeprazole
—— 3’4’ Methylenedioxymethamphetamine “Ecstasy"

Diagnosis
HYPONATREMIA (Plasma levels of Na+ < 135 mEq/L)
EUVOLEMIA (OR SLIGHTLY HYPERVOLEMIC)
HYPO-OSMOLARITY (Plasma Osmololality < 275 mOsm/Kg)
Urinary Na+ > 40 mMol/L
Fractional excretion of urate after correction: Normal

Classification of Hyponatremia
Plasma Levels Mild: Na+ 130-135
of Na+ Moderate: Na+ 125-129
(mEq/L) Severe: Na+ < 125
Moderate-chronic: nauseas, fatigue, gait and attention deficit, falls
Symptoms Severe acute: vomiting, headache, seizures, coma, death, respiratory
arrest, neurogenic pulmonary edema, brain herniation
Acute < 48 hours
Time
Chronic > 48 hours

Differential Diagnosis
Heart, liver or kidney failure
15. HYPONATREMIA: SYNDROME OF 37
INAPPROPRIATE ANTIDIURESIS (SIAD)

Treatment

HYPONATREMIA: SYNDROME OF INAPPROPRIATE ANTIDIURESIS (SIAD)

Draw blood sample: repeat electrolytes, glucose levels, uric acid

Measure urine osmolality, density and Na+, uric acid

Fluid restriction: 500 cc below average daily urine volume

If severe and/or acute hyponatremia:

NaCl 3% 100 cc IV bolus over 20 minutes

Repeat for a maximum of 2 more times if the rise in plasma is Plasma Na+ < 5 mEq/L

Aims of Na+ Correction: ↑ 3-5 mEq/L over first 2-4 hours

↑ 6-8 mEq/L over 24 hours
LIMITS ↑ 10 mEq/L 24 hours (8 mEq/L in
patients with hypokalemia, alcoholism,
malnutrition, liver disease)

Repeat plasma levels of Na+ every 2 hours until Na+ stabilized, then every 6 hours

Eliminate reversible causes: (stop medications that increase risk)

Monitor volume status and treat hypovolemia, fluids and urinary output

Treat underlying cause, if possible

Refractory cases:
1. Demeclocycline
2. Urea
3. Vaptans (caution/controversial treatment, consult an expert)
4. Fludrocortisone
5. Lithium (caution/controversial treatment, consult an expert)
38 16. HYPERNATREMIA: DIABETES INSIPIDUS

Patients at Risk
Brain: tumors, trauma, infections,
HYPERNATREMIA: DIABETES INSIPIDUS

Neoplasm:
Brain: Craniopharyngiomas, Pituitary Adenoma, Meningioma
Cancer: lung, breast, Lymphoma, Leukemia
Surgery of Hypothalamus or Supraoptic Region
Induced by: Phenytoin, Ethanol, Lithium
Chronic renal failure
Hypercalcemia
Hypokalemia

Diagnosis
HYPERNATREMIA (Plasma Levels of Na+ >145 mEq/L)
POLYURIA (> 30 cc/Kg/24 hours or >2 cc/Kg/h)
POLYDIPSIA
Urinary specific gravity < 1005

Classification of Hyponatremia
Plasma levels
of Na+ Severe: Na+ > 160 (mEq/L)

(mEq/L)
Severe / acute: seizures, coma, death, high fever, intracranial hemorrhage,
Symptoms
thrombosis of dural sinuses
Acute < 48 hours
Time
Chronic > 48 hours
16. HYPERNATREMIA: DIABETES INSIPIDUS 39
Treatment
Draw blood sample: repeat electrolytes including Ca++, glucose levels, kidney function
Measure urine osmolality, density and Na+, uric acid

HYPERNATREMIA: DIABETES INSIPIDUS

Volume Replacement with NaCl 0.9% Normal Saline

If Hypernatremia is severe and/or acute:

Dextrose 5% IV bolus 500 cc and consider hemodialysis

If it is not severe or chronic:

Aims of Na+ Correction: ↓ 2 mEq/L/h
↓ 10 mEq/L over 24 hours until plasma Na+ =145 mEq/L
Na+ Correction:
1. Calculate the Water Deficit (WD) and correct over 48 hours:
⎡⎛ Plasma †Na + ⎞ ⎤
Water †Deficit = (TBW †*
) ⎢⎜ ⎟⎠ − 1⎥
⎣⎝ 140 ⎦
TBW = 0.5 (Female) or 0.6 (Male) X Lean Body Weight
2. Calculate the change in na: estimate the effect of 1 liter of infusate on serum Na+

Change †in †Na + =

(Infusate †Na +
− Serum †Na + )
TBW + 1
3. Select replacement solution
Solution Infusate Na+ (mmol/L)
5% Dextrose 0
0,45% NaCl 77
0.9% NaCl 154
Ringer Lactate 130

Repeat plasma levels of Na+ every 4 hours until na+ stabilized, then every 8 hours
Monitor volume status and treat hypovolemia, fluids and urinary output.
Eliminate reversible causes: (stop medications that increase risk)
Treat underlying cause, if possible
Start intake of water as soon as patient is awake

Other Therapies:
1. Vasopressin: 5 units SUBCUTANEOUS every 6 to 8 hours or
2. Desmopressin: 1 mcg SUBCUTANEOUS p.r.n. or
Intranasal spray 1 BID (10 mcg/spray) or
Tablets 0.1-0.3 mg p.o. BID
40 17. EXTRAVASATION OF INTRAVENOUS ACCESS

Classification of Agents
OSMOTIC AGENTS (>650 mOsm/L)
Risk of compartment syndrome
EXTRAVASATION OF INTRAVENOUS ACCESS

Total parenteral nutrition

Mannitol
Calcium chloride -gluconate
Potassium
Sodium bicarbonate
Ampicillin

VASOCONSTRICTION AGENTS
Risk of local ischemia

Norepinephrine (NE)
Epinephrine (EPI)
Dopamine (DA)
Dobutamine (DBA)
Methylene Blue (MB)
Vasopressin (V)
Phenylephrine (PE)

PH RELATED AGENTS
Risk of ischemia and coagulation or compartment syndrome

Phenytoin (purple glove syndrome)

Sodium Thiopental
Vancomycin
Amiodarone
 17. EXTRAVASATION OF INTRAVENOUS ACCESS 41
Treatment
1. Stop the “iv” infusion
2. DO NOT REMOVE THE CATHETER

EXTRAVASATION OF INTRAVENOUS ACCESS

3. ASPIRATE through the catheter
4. Injection REVERSAL AGENTS through the catheter.
5. Remove the catheter
6. Elevate affected limb
7. Apply WARM or COLD compresses as indicated
8. Surgical consult

OSMOTIC AGENTS VASOCONSTRICTION PH RELATED

(>650 mOsm/lt) AGENTS AGENTS

Risk of Compartment Risk of local ischemia Risk of ischemia

Syndrome and coagulation or
1. PHENTOLAMINE compartment syndrome
1. HYALURONIDASE (NE,EPI,DA,DBA,PE):
15-25 Units. 1. DRY HEAT
Intradermal and 5-10 mg in 20 cc saline,
through catheter injected multiple times 2. Elevation of extremity
hypodermic needle or
2. Topical Nitroglycerin through the catheter. 3. HYALURONIDASE
2% Strips over area or
Nitroglycerin patch 2. Topical Nitroglycerin 2% 15 units intradermal
over the area. strips and/or through the
catheter.
3. COLD COMPRESSES: 3. HEAT proximal to site,
For 20 min, 3-4 times a elevation AVOID NEUTRALIZATION
day, 48 to 72 hours. OF THE SUBSTANCE
4. TERBUTALINE
4. Elevation of extremity (NE,EPI,DA,DBA):
1 mg in 10 CC saline
inject locally across
sites

AVOID HYALURONIDASE
AND ICE PACKS
42
NEUROCRISIS REPORT FORM

Date (dd/mmm/yyyy) Procedure:

____/_____/______

Important Comorbidities:
STICKER
Diabetes  Sleep apnea  Coronary Disease  Obesity
 Renal Failure  COPD Other: ________________
ASA: I  II  III  IV  V  VI
Population: Trauma
Vascular:  Traumatic Brain Injury
Stroke Spine
 Carotid Surgery Spine surgery
NEUROCRISIS REPORT FORM

 Subarachnoid Hemorrhage Functional Surgery (Parkinson, Dystonia, Depression)

Aneurysm:  Clipping  Coil  Stent  Hydrocephaly
Oncology  Epilepsy
 Brain Tumor
Position Supine Prone Sitting Park Bench Lateral Out Patient  In Patient  Elective  Urgent  Emergent Surgery

Anesthesia Technique:  General  Regional  Sedation  Awake

Preadmission clinic:  Yes  No Anticipated difficult airway Yes  No

Where did the event took place:  OR  PACU  Patients room  Neuroradiology  Other:

Event
Airway Pulmonary Cardiovascular:
 Difficult intubation  Bronco aspiration  Arrhythmias (VT with pulse, SVT)
 Severe Laryngospasm  Severe Bronchospasm  Severe bradycardia
 Dental Trauma  Respiratory Depression  Anaphylactic Shock
 Trauma of Soft Tissue  Pulmonary Edema  Hypovolemic Shock
 Pulmonary Embolism  Cardiogenic Shock
Accidental Extubation in Prone
 Respiratory Failure  Hematoma in Puncture Site
Position  Hemothorax  Refractory Hypertension
 Pneumothorax  Myocardial Ischemia or MI
 Residual Paralysis  CPR (Asystole, PEA, TV, FV)
 Arterial Puncture
 Air Embolism

Brain Position related Anesthesia Technique related

 Seizures  Periphery Nerve Lesion  Subdural Injection
 Stoke/TIA  Burn  Total Spinal
Delayed Awakening  Corneal Ulcers  Dural Rupture
Intracranial Hypotension Position Related Complication
Awareness

 Oher: Mistakes Other events

 Wrong Medication  Fall from the Bed
 Medication Mistake: Dose, Velocity, Route,  Malignant Hyperthermia
: ______________
Concentration  Hypoglycemia
 Wrong Patient  Dead
 Wrong Procedure  Pseudocolinesterase
 Wrong Anatomic Place  Allergic Reaction
 Extravasation of IV

Neuro-related complication
 Re-intervention  CSF Leak POP bleeding Pneumocephalus
Delayed Awakening Vasospasm Brain Edema
Electrolyte disturbance Air embolism Status Epilepticus New Neurologic deficits
Because of this event:  Patient had to be Admitted to an Unscheduled ICU
 admitted to hospital (and was programed as outpatient)

This Event was Mainly Related to:  Anesthesia  Surgery  Other:

Did the Team Use a Cognitive Aid during the Crisis:  Yes  No Was the Event Debriefed: :  Yes  No

Human Factors that may have Contribute to the Event:

Fixation Error  Lack of Situation Awareness  Not Enough Help
Bad Communication  Team Work Dynamics  Not use of Cognitive Aids  Other:
 43
Event analysis
Description and Analysis of Situation:

NEUROCRISIS REPORT FORM

Classification of the event:
 INCIDENT (Event happened but no harm, no injuries)
 ADVERSE EVENT (Event happened and Produce Harm, New Sequels or
Disability)  Preventable
 COMPLICATION (Event Related to the Comorbidity of the Patient)  No Preventable
 NEAR MISS: The Event did not Happen, but Almost

 Intraoperative Dead

Basic Cause of Dead: ____________________________________________________________________________

Action that will be done to improve or lessons learned:

Action Who is responsible to do this Action Time Frame to do Implement Change

Person Responsible of the Analysis:

44 AIRWAY
Godet T, Chabanne R, Marin J, Kauffmann S, Futier E, Pereira B, Constantin JM. Extubation Failure in
Brain-injured Patients Risk Factors and Development of a Prediction Score in a Preliminary
Prospective Cohort Study. Anesthesiology 2017; 126 (1):104-114. 
Chui J, Craen RA. An update on the prone position: Continuing Professional Development. Can J
Anaesth.2016;63(6):737–67. 
REFERENCES

Kutchak FM, Debesaitys AM, Rieder M de M, Meneguzzi C, Skueresky AS, Forgiarini Junior LA, et
al. Reflex cough PEF as a predictor of successful extubation in neurological patients. J bras
pneumol. 2015 Aug;41(4):358–64. 
DePasse JM, Palumbo MA, Haque M, Eberson CP, Daniels AH. Complications associated with prone
positioning in elective spinal surgery. WJO. 2015;6(3):351–9 
Wang S, Zhang L, Huang K, Lin Z, Qiao W, Pan S. Predictors of Extubation Failure in Neurocritical
Patients Identified by a Systematic Review and Meta-Analysis. PLoS ONE. 2014
8;9(12):e112198–12. 
Jagannathan S, Krovvidi H. Anaesthetic considerations for posterior fossa surgery. Continuing
Education in Anaesthesia Critical Care & Pain. 2014;14(5):202–6. 
Ushiroda J, Inoue S, Kirita T, Kawaguchi M. A comparison of airway dimensions, measured by
acoustic reflectometry and ultrasound before and after general anaesthesia. Anaesthesia.
2014 14;69(12):1355–63. 
Artime CA, Hagberg CA. Tracheal Extubation. Respiratory Care. 2014 Jun 2;59(6):991–1002
Anastasian ZH, Gaudet JG, Levitt LC, Mergeche JL, Heyer EJ, Berman MF. Factors That Correlate
With the Decision to Delay Extubation After Multilevel Prone Spine Surgery. J Neurosurg
Anesthesiol.2014;26(2);167–71. 
Wong RH, Bhansali AP, Wong AK, Rojanapremsuk T, Farhat HI. Posterior fossa surgery in
octogenarians: Special considerations. Clin Neurol Neurosurg; 2013;15(10):2200–3. 
Cavallone LF, Vannucci A. Review article: Extubation of the Difficult Airway and Extubation Failure.
Anesth Analg. 2013;116(2):368–83. 
Apfelbaum JL. Practice guidelines for management of the difficult airway: an updated report by the
American Society of Anesthesiologists Task Force on Management of the Difficult Airway.
Anesthesiology. 2013;118 (2):251-70
Wong RH, Bhansali AP, Wong AK, Rojanapremsuk T, Farhat HI. Considerations on anesthesia for
posterior fossa-surgery. Clin Neurol Neurosurg. 2013; 115 (10):2200-3. 
Roth R, Faieja Chowdhory, Frost EAM. Extubation: Making the Unpredictable Safer. Anesthesiology
News. 2012; 29:1–6. 
Popat, Mansukh & Mitchell, Viki & Dravid, Ravindra & Patel, Anil & Swampillai, C & Higgs, Andy.
Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia.
2012; 67: 318-40. 
Cook TM, Woodall N, Frerk C; Fourth National Audit Project. Major complications of airway
management in the UK: results of the Fourth National Audit Project of the Royal College of
 Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth. 2011;106(5):617-
31.
45
MD AD, MBBS W-SS, MD MS, MD RP, MD BW, MD DS, et al. Complications of posterior cranial fossa
surgery—an institutional experience of 500 patients. Surg Neurol. 2009;72(4):369–75. 
Ochoa ME, Marín Mdel C, Frutos-Vivar F, Gordo F, Latour-Pérez J, Calvo E, et al. Cuff-leak test for
the diagnosis of upper airway obstruction in adults: a systematic review and meta-analysis.
Intensive Care Med. 2009.28;35(7):1171–9.
McCaffrey J, Farrell C, Whiting P, Dan A, Bagshaw SM, Delaney AP. Corticosteroids to prevent

REFERENCES
extubation failure: a systematic review and meta-analysis. Intensive Care Med.
2009;35(6):977–86. 
Arulvelan A, Gayatri P, Smita V, Nair SN. Postoperative Stridor After Resection of Cerebellopontine
Angle Epidermoid. 2007;18:1–2. 
Smeets IM, Engelberts I. The use of leeches in a case of post-operative life-threatening macroglossia.
J Laryngol Otol 1995; 109 (5): 442-4. 
Lam AM, Vavilala MS. Macroglossia: Compartment Syndrome of the Tongue?. Anesthesiology.
2000;92(6):1832-5 
Palmon SC, Kirsch jr, Depper ja, Toung TJ. The Effect of the Prone Position on Pulmonary Mechanics Is
Frame-Dependent. Anesth Analg 1998;87(5):1175-80.
Bösel J. Who is Safe to Extubate in the Neuroscience Intensive Care Unit?.Semin Respir Crit Care
Med. 2017;38(6):830-839
Kundra P, et al. All India Difficult Airway Association 2016 guidelines for the management of
anticipated difficult extubation. Indian J Anaesth. 2016; 60(12): 915-21.
Kuriyama A, Umakoshi N, Sun R.Prophylactic Corticosteroids for Prevention of Postextubation
Stridor and Reintubation in Adults: A Systematic Review and Meta-analysis.Chest.
2017;151(5):1002-1010

BREATHING
Busl KM, Bleck TP. Neurogenic Pulmonary Edema. Critical Care Medicine. 2015;43(8):1710–5. 
Manto A, De Gennaro A, Manzo G, Serino A, Quaranta G, Cancella C. Early Endovascular Treatment of
Aneurysmal Subarachnoid Hemorrhage Complicated by Neurogenic Pulmonary Edema and
Takotsubo-Like Cardiomyopathy. Neuroradiol J. 2014;27(3):356–60. 
Davison DL, Terek M, Chawla LS. Neurogenic pulmonary edema. Crit Care. 2012;16(2):212 
Baumann A, Audibert G, McDonnell J, Mertes PM. Neurogenic pulmonary edema. Acta Anaesthesiol
Scand. 2007;51(4):447–55. 
Fontes RB, Aguiar PH, Zanetti MV, Andrade F, Mandel M, Teixeira MJ. Acute Neurogenic Pulmonary
Edema: Case Reports and Literature Review. 2003; 15(2):144–50. 
Saracen A, Kotwica Z, Woźniak-Kosek A, Kasprzak P.Neurogenic Pulmonary Edema in Aneurysmal
Subarachnoid Hemorrhage. Adv Exp Med Biol. 2016;952: 35-39.

CARDIAC
Quinn TD, Brovman EY, Aglio LS, Urman RD. Factors Associated with an Increased Risk of
Perioperative Cardiac Arrest in Emergent and Elective Craniotomy and Spine Surgery. Clin
Neurol Neurosurg. 2017;161:6-13. 
Himes BT, Mallory GW, Abcejo AS, Pasternak J, Atkinson JLD, Meyer FB, et al. Contemporary
analysis of the intraoperative and perioperative complications of neurosurgical procedures
46 performed in the sitting position. J Neurosurg. 2017;127(1):182–8. 
Kumari A, Gupta R, Bajwa SJ, Singh A. Unanticipated cardiac arrest under spinal anesthesia: An
unavoidable mystery with review of current literature. 2014; 8(1):99-102
Faberowski LW, Gravenstein D.Intraoperative cardiac arrest in a neurosurgical patient: what are the
options? J Neurosurg Anesthesiol. 2000.12;57–9. 
Dooney N, Prone CPR for transient asystole during lumbosacral spinal surgery. Anaesth Intensive
Care. 2010;38(1)212-3.
REFERENCES

Soar J, Nolan JP, Böttiger BW, Perkins GD, Lott C, Carli P, et al. European Resuscitation Council
Guidelines for Resuscitation 2015: Section 3. Adult advanced life support. Resuscitation.
2015; 95:100–47. 
Perkins GD, Travers AH, Berg RA, Castren M, Considine J, Escalante R, Gazmuri RJ, Koster
RW, Lim SH, Nation KJ, Olasveengen TM, Sakamoto T, Sayre MR, Sierra A,
Smyth MA, Stanton D, Vaillancourt C; Basic Life Support Chapter Collaborators
Part3: Adult basic life support and automated external defibrillation: 2015 International
Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
with Treatment Recommendations. Resuscitation. 2015;95:e43-69
Link MS, Berkow LC, Kudenchuk PJ, Halperin HR, Hess EP, Moitra VK, Neumar
RW, O’Neil BJ, Paxton JH, Silvers SM, White RD, Yannopoulos D, Donnino MW.
Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association
Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Circulation. 2015 Nov 3;132(18 Suppl 2):S444-64.  
Resuscitation Council. Working Group of the Resuscitation Council (UK), Neuroanaesthesia Society
of Great Britain and Ireland and Society of British Neurological Surgeons. Management of
cardiac arrest during neurosurgery in adults. Guidelines for healthcare providers. March
2015 
Kwee MM, Ho Y-H, Rozen WM. The Prone Position During Surgery and its Complications: A
Systematic Review and Evidence-Based Guidelines. Int Surg. 2015;100(2):292–303. 
Kushikata T., Hirota K. (2015) Crisis Management for Perioperative Complications (Seizure,
Hemorrhage, Neurogenic Pulmonary Edema, and Venous Embolism). In: Uchino H., Ushijima
K., Ikeda Y. (eds) Neuroanesthesia and Cerebrospinal Protection. Springer, Tokyo
Chowdhury T, Petropolis A, Cappellani RB. Cardiac Emergencies in Neurosurgical Patients. BioMed
Research International. 2015;2015(2):751320
Giraldo M, Lopera LM, Arango M. Venous air embolism in neurosurgery. Rev Colomb Anestesiol.
2015;43 Supl 1: 40-4
Taylor JCL, Buchanan CCR, Rumball MJ. Cardiac arrest during craniotomy in prone position. Anesth
and Critical Care. 2013; 3(4): 16; 224-6. 
Greif R. CPR in prone position during surgery - What do we learn out of such rare cases? Anaes
critical Care; 2013;3(4):226-7. 
Rittenberger JC, Polderman KH, Smith WS, Weingart SD. Emergency Neurological Life Support:
Resuscitation Following Cardiac Arrest. Neurocrit Care. 2012;17(S1):21–8. 
Zhang L, Li M, Lee CC. Venous Air Embolism During Neurosurgery. In: Essentials of Neurosurgical
Anesthesia & Critical Care. New York, NY: Springer New York; 2011. pp. 355–62. 
Ho JD, Dawes DM, Moore JC, Caroon LV, Miner JR. Effect of position and weight force on inferior
vena cava diameter-- Implications for arrest-related death. Forensic Sci Int.212(1-3):256–9. 
Chang EF, Cheng JS, Richardson RM, Lee C, Starr PA, Larson PS. Incidence and Management of
Venous Air Embolisms during Awake Deep Brain Stimulation Surgery in a Large Clinical
Series. Stereotact Funct Neurosurg. 2011;89(2):76–82. 
Williamson JA. Helps SC, Westhorpe RN, Mackay P. Crisis management during anaesthesia:
embolism. Qual Saf Health Care. 2005;14(3):e17 
47
Mazer SP, Weisfeldt M, Bai D, Cardinale C, Arora R, Ma C, et al. Reverse CPR: a pilot study of CPR in
the prone position. Resuscitation. 2003;57(3):279–85. 
Stewart JA. Resuscitating an idea: prone CPR. 2002; 54(3); 231–6. 
Brown J, Rogers J, Soar J. Cardiac arrest during surgery and ventilation in the prone position: a case
report and systematic review. 2001;50(2); 233-8 
Gupta D, Agarwal A, Rao PB, Srisvastava S. Physical Incompatibility of Phenytoin With Isolyte P. J

REFERENCES
Neurosurg Anesthesiol. 2007;19:1–2. 

DEFICIT
Witherspoon B, Ashby NE. The Use of Mannitol and Hypertonic Saline Therapies in Patients
with Elevated Intracranial Pressure: a Review of the Evidence. Nurs Clin North Am. 2017;
52(2):249-260. 
Hutchinson PJ, Kolias AG, Timofeev IS, Corteen EA, Czosnyka M, Timothy J, et al. Trial of
Decompressive Craniectomy for Traumatic Intracranial Hypertension. J Intensive Care Soc.
2017; 18(3):236-238.
Honeybul S, Ho KM, Lind CRP, Gillett GR. The current role of decompressive craniectomy for
severe traumatic brain injury.J Clin Neurosci. 2017; 43:11-15
Hutchinson PJ, Kolias AG, Timofeev IS, Corteen EA, Czosnyka M, Timothy J, Anderson I, Bulters DO,
Belli A, Eynon CA, Wadley J, Mendelow AD, Mitchell PM, Wilson MH, Critchley G, Sahuquillo
J, Unterberg A, Servadei F, Teasdale GM, Pickard JD, Menon DK, Murray GD, Kirkpatrick PJ;
RESCUEicp Trial Collaborators. Trial of Decompressive Craniectomy for Traumatic Intracranial
Hypertension.N Engl J Med. 2016 22;375(12):1119-30
Carney N, Totten AM, O’Reilly C, Ullman JS, Hawryluk GW, Bell MJ, Bratton SL, Chesnut R, Harris
OA, Kissoon N, Rubiano AM, Shutter L, Tasker RC, Vavilala MS, Wilberger J, Wright DW,
Ghajar J. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition.
Neurosurgery. 2017 Jan 1;80(1):6-15.
Spena G, Schucht P, Seidel K, Rutten G-J, Freyschlag CF, D’Agata F, et al. Brain tumors in eloquent
areas: A European multicenter survey of intraoperative mapping techniques, intraoperative
seizures occurrence, and antiepileptic drug prophylaxis. Neurosurgical Review. Neurosurgic Rev.
2016; 40(2):287-98. 
Krishnamoorthy V, Chaikittisilpa N, Kiatchai T, Vavilala M. Hypertension After Severe Traumatic
Brain Injury: Friend or Foe? J Neurosurg Anesthesiol. 2017;29(4):382-387
Vázquez-Alonso E, Clavero FI, Sola LV, Fábregas N, Ingelmo II, Valero R, et al. Clinical practice
guideline on thromboprophylaxis and management of anticoagulant and antiplatelet drugs
in neurosurgical and neurocritical patients. Rev Esp Anestesiol Reanim. 2016;63(7):406–18. 
Yuan Y, Peizhi Z, Xiang W, Yanhui L, Ruofei L, Shu J, Qing M. Intraoperative seizures and seizures outcome
in patients underwent awake craniotomy. J Neurosurg Sci. 2016 Nov 25. [Epub ahead of
print]
Howe J, Lu X, Thompson Z, Peterson GW, Losey TE. Intraoperative seizures during craniotomy
under general anesthesia. Seizures; 2016. 38:23-5. 
Risk of perioperative seizures in patients undergoing craniotomy with intraoperative brain
mapping.
Conte V, Carrabba G, Magni L, L’Acqua C, Magnoni S, Bello L, Colombo A, Stocchetti N. Minerva
Anestesiol. 2015;81(4):379-88.
Rabinstein AA. Neurologic complications of anesthesia. Continuum (Minneap Minn). 2011;17(1
Neurologic Complications of Systemic Disease):134-47.
48 Trombetta C, Deogaonkar A, Deogaonkar M, Ebrahim Z, Rezai A, Machado A, Fara.Delayed awakening
in dystonia patients undergoing deep brain stimulation surgery. J Clin Neurosci. 2010
Jul;17(7):865-8
Anastasaian ZH, Ornstein E, Heyer EJ. Delayed Arousal. 2009.27(3):429-50 
Jones CL, Koios J. Algorithm for the treatment of status epilepticus: an Australian perspective. Intern
Med J. 2016;46(4):500–3. 
Rodriguez VR, Rodden MF, LaRoche SM. Ictal- interictal continuum: A proposed treatment algorithm.
Clinical Neurophysiology. 2016; 127(4):2056–64. 
REFERENCES

Trombetta C, Deogaonkar A, Deogaonkar M, Ebrahim Z, Rezai A, Machado A, Farag E.

Delayed awakening in dystonia patients undergoing deep brain stimulation surgery. J Clin
Neurosci. 2010 Jul;17(7):865-8.
Ganjoo P, Sethi S, Tandon MS, Singh D, Pandey BC. Perioperative complications of intraventricular
neuroendoscopy: a 7-year experience.Turk Neurosurg. 2010 Jan;20(1):33-8.
Lin JP, Zhang SD, He FF, Liu MJ, Ma XX. The status of diagnosis and treatment to intracranial
hypotension, including SIH. J Headache Pain. 2017;18(1):4.
Frost EA. Differential diagnosis of delayed awakening from general anesthesia: a review. Middle East
J Anaesthesiol. 2014;22(6):537-48
Grover EH, Nazzal Y, Hirsch LJ. Treatment of Convulsive Status Epilepticus. Curr Treat Options
Neurol. 2016.26;18(3):11 
Kämppi L, Mustonen H, Kotisaari K, Soinila S. The essence of the first 2.5 h in the treatment of
generalized convulsive status epilepticus. Seizure. 2017. 28;55:9-16
Glauser T et al. American Epilepsy Society Guideline Evidence-Based Guideline: Treatment of
Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of
the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48–61. 
Hassaneen W, Germanwala A, Tsimpas A. Malignant cerebral edema following cranioplasty. 2016.
25:130-2
Misal US, Joshi SA, Shaikh MM. Delayed recovery from anesthesia: A postgraduate educational
review Anesth Essays Res. 2016;10(2):164-72.
Burgess S, Abu-Laban RB, Slavik RS, Vu EN, Zed PJ. A Systematic Review of Randomized Controlled
Trials Comparing Hypertonic Sodium Solutions and Mannitol for Traumatic Brain Injury.
Ann Pharmacother. 2016. 18;50(4):291–300. 
Kawsar KA, Haque MR, Chowdhury FH. Avoidance and management of perioperative complications
of endoscopic third ventriculostomy: the Dhaka experience. Journal of Neurosurgery.
2015;123(6):1414–9. 
Garvin R, Mangat HS.Emergency Neurological Life Support: Traumatic Brain Injury. Neurocrit Care.
2017;27 (Suppl 1) 159-69. 
Vanrossomme AE, Eker OF, Thiran JP, Courbebaisse GP, Zouaoui Boudjeltia K. Intracranial
Aneurysms: Wall Motion Analysis for Prediction of Rupture. AJNR Am J Neuroradiol.
2015;36(10):1796–802. 
Fuhrer H, Reinhard M, Niesen WD. Paradigm Change? Cardiac Output Better Associates
with Cerebral Perfusionthan Blood Pressure in Ischemic Stroke. Front Neurol. 2017 Dec
22;8:706
Smith M. Cerebral perfusion pressure. BJA. 2015;115(4):488–90. 
Badenes R, Gruenbaum SE, Bilotta F. Cerebral protection during neurosurgery and stroke. Curr Opin
Anaesthesiol 2015;28(5):532–6. 
Bösel J. Management of the Interventional Stroke Patient. Curr Treat Options Neurol. 2015; 17(10):45. 
Postoperative complications in elective and non-elective neurosurge
Trinka E, Cock H, Hesdorffer D, Rossetti AO, Scheffer IE, Shinnar S, et al. A definition and classification 49
of status epilepticus - Report of the ILAE Task Force on Classification of Status Epilepticus.
Epilepsia. 2015; 56(10):1515–23. 
Siqueira EM, Diccini S. Postoperative complications in elective and non-elective neurosurgery. Acta
Paul Enferm. 2017; 30(1):101-8
Paraskevas KI, Kalmykov EL, Naylor AR. Stroke/Death Rates Following Carotid Artery Stenting and
Carotid Endarterectomy in Contemporary Administrative Dataset Registries: A Systematic

REFERENCES
Review. Eur J Vasc Endovasc Surg.2016; 51(1): 3-12. 
Purdon PL, Sampson A, Pavone KJ, Brown EN. Clinical Electroencephalography for Anesthesiologists.
Part 1: Background and Basic Signatures. Anesthesiology.2015 123(4):937-60
Zuleta-Alarcon A, Castellon-Larios K, Moran KR, Soghomonyan S, Kurnutala LN, Bergese SD.
Anesthesia-Related Perioperative Seizures:  Pathophysiology, Predisposing Factors and
Practical Recommendations. Austin J Anesthesia and Analgesia.2014;2(4):1026
Tarnal V, Vlisides PE, Mashour GA. The Neurobiology of Anesthetic Emergence. J Neurorug
Anesthesiol. 2016; 28 (3):250-5
Lee GS, Park sq, Kim R, Cho SJ. Unexpected Severe Cerebral Edema after Cranioplasty : Case Report
and Literature Review. 2015 58(1):76-8. 
Zwerus R, Absalom A. Update on anesthetic neuroprotection. Curr Opin Anaesthesiol. 2015
Aug;28(4):424–30. 
Pasternak JJ, Lanier WL. Neuroanesthesiology Update. J Neurosurg Anesthesiol. 2017;29(2):97-131
Sanders RD, Jørgensen ME, Mashour GA. Perioperative stroke: a question of timing? Br J Anaesth.
2015;115(1):11–3. 
Tzabazis A, Miller C, Dobrow MF, Zheng K, Brock-Utne JG. Delayed emergence after anesthesia. J
Clin Anesth. 2015;27(4):353-60.
Betjemann JP, Lowenstein DH. Status epilepticus in adults. Lancet Neurol.2015;14(6):615–24. 
Mangubat E, Sani S. Acute Global Ischemic Stroke After Cranioplasty. Neurologist. 2015;19(5):135–9. 
Van den Berg LA, ET AL MR CLEAN pretrial study group. Type of Anesthesia and Differences in Clinical
Outcome After Intra-Arterial Treatment for Ischemic Stroke. Stroke.2015; 46(5):1257-62. 
Powers WJ, et al American Heart Association Stroke Council. 2018 Guidelines for the Early
Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare
Professionals From the American Heart Association/American Stroke Association. Stroke.
2018; STR.0000000000000158
Schuette AJ, Barrow DL, Cohen-Gadol AA. Strategies to Minimize Complications During Intraoperative
Aneurysmal Hemorrhage: A Personal Experience. World Neurosurgery. 2015;83(4):620–6. 
Weston J, Greenhalgh J, Marson AG. Antiepileptic drugs as prophylaxis for post-craniotomy seizures.
Cochrane Database of Syst Rev. 2015;67(4):CD007286 
Hood R, Budd A, Sorond FA, Hogue CW. Peri-operative neurological complications. Anaesthesia.
2018 Jan;73 Suppl 1:67-75
Brinjikji W, Pasternak J, Murad MH, Cloft HJ, Welch TL, Kallmes DF, Rabinstein AA. Anesthesia-
Related Outcomes for Endovascular Stroke Revascularization: A Systematic Review and
Meta-Analysis.Stroke. 2017;48(10):2784-2791
Mashour GA, Woodrum DT, Avidan MS. Neurological complications of surgery and anaesthesia. Br J
Anaesth. 2015;114(2):194–203. 
Wijdicks EFM. Stroke and Craniectomy. Neurocrit Care. 2017 Dec 22  doi: 10.1007/s12028-017-
0498-0. [Epub ahead of print]
50 Hayman EG, Kurland DB, Grunwald Z, Urday S, Sheth KN, Simard JM. Decompressive Craniectomy
in Neurocritical Care. Semin Neurol. 2016;36(6):508–19. 
Kuroda Y, Kawakita K, Hifumi T. The Management of Intracranial Pressure and Cerebral Edema. In:
Neuroanesthesia and Cerebrospinal Protection. Tokyo: Springer Japan; 2015. pp. 255–67. 
Sauvigny T, Göttsche J, Czorlich P, Vettorazzi E, Westphal M, Regelsberger J. Intracranial pressure
in patients undergoing decompressive craniectomy: new perspective on thresholds J
Neurosurg. 2017 Apr 14:1-9. doi: 10.3171/2016.11.JNS162263. [Epub ahead of print]
Ikeda Y, Uchino H, Miyashita R. Role and Management of Intracranial Pressure in Neuroanesthesia.
REFERENCES

In: Neuroanesthesia and Cerebrospinal Protection. Tokyo: Springer Japan; 2015. pp. 153–61. 
Anastasian ZH. Anaesthetic management of the patient with acute ischaemic stroke. Br J Anaesth.
2014 Dec;113 Suppl 2:ii9-16. doi: 10.1093/bja/aeu372
Hadizadeh DR, Kovács A, Tschampa H, Kristof R, Schramm J, Urbach H. Postsurgical intracranial
hypotension: diagnostic and prognostic imaging findings. AJNR Am J
Neuroradiol. 2010;31(1):100-5.
Wijdicks EFM, Sheth KN, Carter BS, Greer DM, Kasner SE, Kimberly WT, et al. Recommendations
for the Management of Cerebral and Cerebellar Infarction With Swelling: A Statement for
Healthcare Professionals From the American Heart Association/American Stroke Association.
Stroke. 2014;45(4):1222–38. 
Kalmar, Alain & Dewaele, Frank. (2012). Anaesthetic Management of Patients Undergoing
Intraventricular Neuro-Endoscopic Procedures. 10.5772/30681
Fanegras N, Craen RA. Anaesthesia for endoscopic neurosurgical procedures. Curr Opin
Anaesthesiol. 2010 Oct;23(5):568-75
Petropolis A, Wilkinson M, Schaller B, Sandu N, Cappellani RB. Controversies in the Anesthetic
Management of Intraoperative Rupture of Intracranial Aneurysm. Anesthesiol Res Pract.
2014;  2014:595837
Talke PO, Sharma D, Heyer EJ, Bergese SD, Blackham KA, Stevens RD. Society for Neuroscience
in Anesthesiology and Critical Care Expert consensus statement: anesthetic management of
endovascular treatment for acute ischemic stroke*: endorsed by the Society of
NeuroInterventional Surgery and the Neurocritical Care Society. J Neurosurg
Anesthesiol. 2014 Apr;26(2):95-108
Mohan Rajwani K, Crocker M, Moynihan B Decompressive craniectomy for the treatment
of malignant middle cerebral artery infarction. Br J Neurosurg. 2017 Aug;31(4):401-409
Davis SF, Bamford JA. Intraoperative Monitoring for Carotid Endarterectomy. In: Principles of
Neurophysiological Assessment, Mapping, and Monitoring. New York, NY: Springer New
York; 2013. pp. 195–206. 
Daly SC. Delayed Emergence After Aneurysm Clipping. In: Benumof J (eds) Clinical Anesthesiology.
Springer, New York, NY: Springer New York; 2014. pp. 463–70. 
Sharpe R, Sayers RD, London NJM, Bown MJ, McCarthy MJ, Nasim A, et al. Procedural Risk Following
Carotid Endarterectomy in the Hyperacute Period after Onset of Symptoms. Eur J Vasc
Endovasc Surg. 2013;46(5):519–24. 
Solera Ruiz I, Uña Orejón R, Valero I, Laroche F. Craneotomía en el paciente consciente.
Consideraciones en situaciones especiales. Revista Española de Anestesiología y Reanimación.
2013;60(7):392–8. 
Engelhard K. Anaesthetic techniques to prevent perioperative stroke. Curr Opin Anaesthes.
2013;26(3):368–74. 
Bilotta F, Gelb AW, Stazi E, Titi L, Paoloni FP, Rosa G. Pharmacological perioperative brain
neuroprotection: a qualitative review of randomized clinical trials. Br J Anaesth.
2013;110:i113–20. 
Kozasa Y, Takaseya H, Koga Y, Hiraki T, Mishima Y, Niiyama S, et al. A case of delayed emergence
from anesthesia caused by postoperative brain edema associated with unexpected cerebral
 venous sinus thrombosis. J Anesth. 2013;27(5):764–7.  51
Rössel T, Heller AR, Müller M, Müller A, Kersting S. Management of intraoperative embolic stroke
during carotid surgery under regional anesthesia.  Vasa. 2013 Mar;42(2):139-43.
Steiner T, Juvela S, Unterberg A, Jung C, Forsting M, Rinkel G. European Stroke Organization
Guidelines for the Management of Intracranial Aneurysms and Subarachnoid Haemorrhage.
Cerebrovasc Dis. 2013;35(2):93–112. 
Dhandapani S, Pal SS, Gupta SK, Mohindra S, Chhabra R, Malhotra SK. Does the impact of elective

REFERENCES
temporary clipping on intraoperative rupture really influence neurological outcome after
surgery for ruptured anterior circulation aneurysms?—A prospective multivariate study.
Acta Neurochir..2013 Feb;155(2):237-46
Moszczynski A, Murray BJ. Neurobiological Aspects of Sleep Physiology. Neurologic Clinics of NA.
2012;30(4):963–85. 
Cadena R, Shoykhet M, Ratcliff JJ. Emergency Neurological Life Support: Intracranial Hypertension
and Herniation. Neurocrit Care. 2017;27(Suppl1):82-88. 
Albes G, Weng H, Horvath D, Musahl C, Bäzner H, Henkes H. Detection and treatment of spinal CSF
leaks in idiopathic intracranial hypotension. Neuroradiology. 2012;54(12):1367–73. 
Sharma Deepak, Vavilala MS. Perioperative Management of Adult Traumatic Brain Injury.
Anesthesiology Clinics. 2012;30(2):333–46. 
Aliason I, Koh J. Challenges During Surgery for Hydrocephalus. In: Essentials of Neurosurgical
Anesthesia & Critical Care. New York, NY: Springer New York; 2011. pp. 465–73. 
Jellish WS. Arousal from Anesthesia After Neurosurgical Operations. In: Essentials of Neurosurgical
Anesthesia & Critical Care. New York, NY: Springer New York; 2011. pp. 409–17. 
Grant R, Gruenbaum SE, Gerrard J. Anesthesia for deep brain stimulation: a review. Curr Opin
Anaesthesiol. 2015 ; 28(5): 505–510.
Liujiazi Shao, Fangxiao Hong, Yi Zou, Xiaofang Hao, Haijun Hou, Ming Tian. Hypertonic Saline for
Brain Relaxation and Intracranial Pressure in Patients Undergoing Neurosurgical Procedures:
A Meta-Analysis of Randomized Controlled Trials. PLoS One. 2015; 10(1): e0117314.
Min Li, Tao Chen, Shu-da Chen, Jing Cai, Ying-hong Hu. Comparison of Equimolar Doses of
Mannitol and Hypertonic Saline for the Treatment of Elevated Intracranial Pressure After
Traumatic Brain Injury A Systematic Review and Meta-Analysis. Medicine (Baltimore) 2015
May; 94(17): e668
Yuh EL, Dillon WP. Intracranial Hypotension and Intracranial Hypertension. Neuroimaging Clin N
Am. 2010;20(4):597–617. 
Schubert A, Mascha EJ, Bloomfield EL, DeBoer GE, Gupta MK, Ebrahim ZY. Effect of Cranial Surgery
and Brain Tumor Size on Emergence from Anesthesia. Anesthesiology. 1996 ;85(3):513-21.
Trombetta C, Deogaonkar A, Deogaonkar M, Ebrahim Z, Rezai A, Machado A, et al. Delayed
awakening in dystonia patients undergoing deep brain stimulation surgery. J Clin Neurosci.
2010;17(7):865–8. 
Fàbregas N, Bruder N. Recovery and neurological evaluation. Best Practice & Research Clinical
Anaesthesiology. 2007;21(4):431–47. 
Misal US, Suchita Annasaheb Joshi, Shaikh MM. Delayed recovery from anesthesia: A postgraduate
educational review. Anesth Essays Res. 2016; 10(2): 164–172
Zhou ZB, Meng L, Gelb AW, Lee R, Huang WQ. Cerebral ischemia during surgery: an overview. J
52 Biomed Res. 2016; 30(2): 83–87
Black S, Enneking FK, Cucchiara RY. Failure to Awaken After General Anesthesia Due to
Cerebrovascular Events. J Neurosurg Anesth. 1998;10(1):10-15 
Sinclair RCF, Faleiro RJ. Delayed recovery of consciousness after anaesthesia. Continuing Education
in Anaesthesia Critical Care & Pain. 2006;6(3):114–8. 
Skucas AP, Artru AA. Anesthetic Complications of Awake Craniotomies for Epilepsy Surgery.
Anesthesia & Analgesia. 2006 Mar;102(3):882–7. 
 H.P. Adams Jr., P.H. Davis, E.C. Leira, K.-C. Chang, B.H. Bendixen, W.R. Clarke, R.F. Woolson, Hansen,
REFERENCES

MS. Baseline NIH Stroke Scale score strongly predicts outcome after stroke: A report of the
Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology. 1999; 53 (1) 126
 Brott, T., Adams, H. P., Jr., et al. (1989). “Measurements of acute cerebral infarction: a clinical
examination scale.” Stroke 20(7): 864-870
Sartorius CJ, Berger ms. Rapid termination of intraoperative stimulation-evoked seizures with
application of cold Ringer’s lactate to the cortex. 1998; 88 (2):349-51.
Scheeren TWL, Kuizenga MH, Maurer H, Struys MMRF, Heringlake. Electroencephalography and
Brain Oxygenation Monitoring in the Perioperative Period. Anesth Analg. 2018 Jan 23. doi:
10.1213/ANE.0000000000002812. [Epub ahead of print]

ELECTROLYTES
Devin JK. Hypopituitarism and Central Diabetes Insipidus. Neurosurg Clin N Am. 2012; 23: 679–689
Spasovski G, Vanholder R, Allolio B, Annane D, Ball S, Bichet D, Decaux G, Fenske W, Hoorn EJ,
Ichai C, Joannidis M, Soupart A, Zietse R, Haller M, van der Veer S, Van Biesen W, Nagler
E; Hyponatraemia Guideline Development Group.Clinical practice guideline on diagnosis
and treatment of hyponatraemia. Nephrol Dial Transplant. 2014 Apr;29 Suppl 2:i1-i39.
Kengne FG, Decaux G. Hyponatremia and the Brain. Kidney International Reports. 2017;3(1):24–35. 
Hoorn EJ, Zietse R. Diagnosis and Treatment of Hyponatremia: Compilation of the Guidelines. J Am
Soc Nephrol. 2017 May;28(5):1340-1349.
Garrahy A, Sherlock M, Thompson CJ. MANAGEMENT OF ENDOCRINE DISEASE: Neuroendocrine
surveillance and management of neurosurgical patients. Eur J Endocrinol. 2017;176(5):R217–
33. 
Meng C, Shi B.Traumatic Brain Injury Patients With a Glasgow Coma Scale Score of r8, Cerebral
Edema, and/or a Basal Skull Fracture are More Susceptible to Developing Hyponatremia. J
Neurosurg Anesthesiol. 2016 Jan;28(1):21-6
Oh JY, Shin Il J. Syndrome of inappropriate antidiuretic hormone secretion and cerebral/renal salt
wasting syndrome: similarities and differences. Front Pediatr. 2015 Jan 22;2:146.
Sterns RH. Disorders of Plasma Sodium — Causes, Consequences, and Correction. Ingelfinger JR,
editor. N Engl J Med. 2015;372(1):55–65. 
Goyagi T. Electrolyte Disorders. In: Neuroanesthesia and Cerebrospinal Protection. Tokyo: Springer
Japan; 2015. pp. 643–51. 
Momi J, Tang CM, Abcar AC, Kujubu DA, Sim JJ. Hyponatremia—What Is Cerebral Salt Wasting?. Perm
J. 2010;14(2):62-5.
Strandvik GF. Hypertonic saline in critical care: a review of the literature and guidelines for use in
hypotensive states and raised intracranial pressure. Anaesthesia. 2009;64(9):990–1003. 
Robertson GL. Diabetes insipidus: Differential diagnosis and management. Best Practice & Research
Clinical Endocrinology & Metabolism. 2016; 30: 205-218
Muhsin SA, Mount DB. Diagnosis and treatment of hypernatremia. Best Practice & Research Clinical
Endocrinology & Metabolism 30 (2016) 189e203
Kengne FG, Decaux G. Hyponatremia and the Brain. Kidney Int Rep (2018) 3, 24–35
 53
EXTRAVASATION OF INTRAVENOUS ACCESS

Reynolds PM, MacLaren R, Mueller SW, Fish DN, Kiser TH. Management of Extravasation Injuries:
A Focused Evaluation of Noncytotoxic Medications. Pharmacotherapy. 2014;34(6):617–32
Schummer, W., Schummer, C., Bayer, O., Muller, A., Bredle, D., & Karzai, W. Extravasation injury in
the perioperative setting. Anesth Analg. 2005;100(3), 722-727

REFERENCES
BOOKS
Brambrink, Ansgar M., Kirsch, Jeffrey R. Essentials of Neurosurgical Anesthesia & Critical Care. New
York, NY: Springer New York; 2012.
Hiroyuki Uchino, Kazuo Ushijima, Yukio Ikeda. Neuroanesthesia and Cerebrospinal Protection.
Japan. Springer; 2015
Gupta Arun K, Gelb Adrian W. Essentials of neuroanesthesia and neurointensive care. Philadelphia.
Saunders Elsevier;2008.
Cottrell James E. Patel Piyush. Cottrell and Patel’s Neuroanesthesia, 6th Edition. The United States
of America. Elsevier;2016
Prabhakar Hemanshu. Essentials of Neuroanesthesia. London. Elsevier; 2017
Prabhakar Hemanshu. Complications in Neuroanesthesia London. Elsevier ;2016
Miller Chad, O’Phelan Kristine (Editors). ENLS Emergency Neurological Support Version 3.0. The
United States of America. Neurocritical Care Society;2017

EMERGENCY MANUALS
Borshoff David C. The Anesthetic Crisis Manual. Edition 2.0. The United States of America. Leeuwin
Press; 2017
Stanford Anesthesia Cognitive Aid Group*. Emergency Manual: Cognitive aids for perioperative
clinical events. See
http://emergencymanual.stanford.edu for latest version. Creative Commons BY-NC-ND. 2013
(creative
commons.org/licenses/by-nc-nd/3.0/legalcode). *Core contributors in random order: Howard
SK, Chu LK, Goldhaber- Fiebert SN, Gaba DM, Harrison TK
Operating Room Crisis Checklists. Ariadne Labs: A Joint Center for Health Systems Innovation.
In:http://www.projectcheck.org/crisis-checklist-templates.html

The purpose of this crisis manual is to be a resource for anesthesiologists and
to prepare them for stressful situations that may arise during neurosurgical
procedures. It is meant to be a reference only and a cognitive aid in emergency
situations. It is NOT a guideline or a protocol that anesthesiologists are
obligated to follow. This manual may provide a vehicle for input and practical
strategies when facing critical events with neurosurgical patients.

ISBN: 978-1-7752595-1-0