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The majority of septoplasties and rhinoplasties are performed on healthy patients in the outpatient setting; however, occasionally patients present with medical comorbidities or obstructive sleep apnea (OSA). These surgeries can be performed with local anesthesia and sedation or general anesthesia with an LMA or endotracheal tube. The indication for surgery may be purely cosmetic, post trauma, reconstructive after tumor resection or to improve nasal breathing. Many nasal procedures can successfully be performed under local anesthesia with sedation. Operative and recovery times have been shown to be shorter for patients undergoing surgery with local anesthesia with sedation compared with general anesthesia. Bleeding is one of the biggest complications of nasal surgery. Minimization of intraoperative blood loss allows the surgeon to have an operative field which he can visualize well. The main intraoperative concern includes the minimization of bleeding with use of vasoconstrictors and submucosal epinephrine, controlled hypotension and a smooth emergence.
This chapter presents a case study of a 62-year-old female presented to the operating room with a diagnosis of two large intracranial aneurysms. The case is a discussion of the application of deep hypothermic circulatory arrest (DHCA) for patients undergoing large and/or complex intracranial aneurysm clipping and repair. The patient was brought to the operating room, noninvasive monitors placed, and under local anesthesia a right radial arterial line was established. The rationale behind the technique of DHCA stems from the significant advantage the surgeon has once blood flow has stopped circulating to the aneurysm. The margin for error is small, and success depends upon an experienced and knowledgeable team. The safe practice and management of DHCA requires an extensive understanding of cardiac and neurosurgical anesthetic practice, cardiopulmonary bypass (CPB), as well as careful consideration and proper planning.
Indocyanine green (ICG) is a tricarbocyanine organic dye that has diverse clinical uses including cardiac dye-dilution studies, liver function and blood flow determination, and ophthalmic angiography. This chapter presents a case study of a 67-year-old American Society of Anesthesiologists Class III female scheduled to undergo elective left pterional craniotomy for clipping of intracranial aneurysms. Adverse reactions to ICG dye vary both in system involvement and severity. Treatment in case reports has included intravenous crystalloid and colloids, airway management if necessary, corticosteroids, epinephrine, diphenhydramine, beta-agonist nebulizers, and theophylline. It was initially proposed that patients with iodine sensitivity were susceptible because of the solubilizing iodine component of the pharmaceutical product, but this has been refuted by a large case series. Both anaphylactoid and nonallergic reactions have been proposed as possible mechanisms for ICG dye reactions. Awareness of adverse reactions associated with ICG dye is imperative given its increasing use in neurosurgery.
There are significant cardiac abnormalities observed following subarachnoid hemorrhage (SAH) that varies depending upon the grade of SAH, but correlate with the degree of elevation of cardiac troponin I (cTnI). These effects are likely mitigated through sympathetic and parasympathetic dysfunction that results from global cerebral dysfunction following SAH. This chapter presents a case study of a 54-year-old male with no significant past medical history who suddenly developed a thunderclap headache. The patient underwent an uneventful ventriculoperitoneal shunt placement and after 2 more weeks in the neurosurgical intensive care unit (ICU) was transferred to the general care ward. The histopathology of neurogenic cardiac lesions is distinct from the coagulation necrosis observed following myocardial infarction. Both sympathetic overactivity and parasympathetic dysfunction result in a pro-arrhythmogenic state as well that worsens electrocardiogram (ECG) changes associated with myocardial necrosis.