Pituitary surgery

 

Intra-op issues:

Airway

·     Remote

·     Shared

·     Bloody

->Oral RAE ETT

->Tape + tegaderm

->Throat pack

->Suction pharynx + shake out Coroner’s clot

Topicalisation

·     Cocaine/lignocaine/adrenaline -> hypertension, arrhythmias

->Arterial line

->Labetalol drawn up

->Communication with surgeon

Bleeding

·     Near cavernous sinus and carotid arteries

->Prepare for bleeding: BGHO, large IVC, A-line, warming

->Prepare for tight brain: mannitol, hypertonic saline available

Microsurgery

·     Requires immobility

->Remifentanil infusion

->Relaxant infusion if long duration

Venous air embolism

·     Ax: elevation + non-collapsible veins

·     Dx: ↓etCO2, praecordial doppler

Treatment:

·     Support: FiO2 1.0, fluid, pressors, CPR

·     Stop entrainment: flood + flatten + Valsalva + neck pressure

·     Stop transit: left lateral + head down

·     Remove the air: aspirate via CVC

Emergence

·     Require immediate neuro assessment

·     Avoid coughing

->Propofol/remifentanil infusions

->BIS-guidance

 

Post-op issues:

Sodium disorders

·     Central DI in 40%

·     SIADH

Dural breach

Required for surgical access

·     ±CSF leak

·     ±Pneumocephalus (CPAP relatively contraindicated)

·     ±Meningitis

 

 

Feedback welcome at ketaminenightmares@gmail.com