Perioperative Care of the Surgical Patient: Brain

Cancer of the central nervous system is the 10th leading cause of death in the United States. In 2019 an estimated 27,540 adults and children will be diagnosed with a primary tumor of the brain or spine. Patients undergoing craniotomy for tumor resection present numerous anesthetic challenges. To minimize morbidity and mortality, these patients warrant careful preoperative assessment, meticulous intraoperative planning and care, and precise postoperative management. Preoperative evaluation should identify and assess baseline neurologic deficits, signs and symptoms associated with the intracranial tumor, and previous cancer diagnoses and treatment including surgery, chemotherapy, and radiation therapy. Patients may also require pretreatment for hyperglycemia and/or nausea. Intraoperative planning and care should focus on the appropriate anesthetic technique given not only the patient-specific characteristics but also the surgical needs and challenges. While asleep craniotomy under general anesthesia is predominately used, an awake technique may be indicated in tumors that involve eloquent areas of the brain. An awake technique maximizes tumor resection but preserves speech and motor function postoperatively. To maintain hemodynamic stability and facilitate rapid emergence, titrate anesthetic and analgesic agents to effect and avoid medications that cause prolonged sedation. The use of a regional block, termed a scalp block, can be incorporated in the anesthetic care plan as part of a multimodal approach to perioperative pain control in patients undergoing craniotomy. Postoperative strategies should focus on strict blood pressure control and prevention or prompt treatment of postoperative nausea and vomiting (PONV). Postoperative hypertension and emesis-associated retching can cause elevated intracranial pressure, intracranial bleeding, or decreased intracranial perfusion. Multimodal treatment of PONV is the standard of care.