Description: Management of cranial lesions in (interventional) Radiology
- IR (formerly, and perhaps still referred to as, the Angiography Suite)
- Phone # Angio Suite 662-4540
- Proceduralists: Robert Ecker, Chris Baker
- PreOp preparation:
- Elective cases seen in PAT: NPO, etc
- Urgent Cases may already be admitted / in SCU.
- Types of Cases, Usual Management:
- Aneurysms: GA +/- arterial line
- AVMalformations: MAC +/- arterial line (infusions likely necessary for sedation/stillness as well as BP
- AV fistulas: MAC
- Stroke: MAC vs. GA depending on clinical situation + arterial line
- Carotid Stents: MAC + arterial line (vasopressors after stenting)
- Dr. Baker has really only been using arterial lines with AVM embolizations
- Get controlled meds from Radiology Pyxis (ask Radiology Nurse)
- A second IV is helpful for vasoactive infusions; manifold if multiple drugs anticipated
- Have syringe pump or IV Infusion pump (Plum, Symbiq) available.
- Anesthesia Tech assistance: Phone 662-1761
- Always speak with the proceduralist to get a good picture of the clinical
situation and discuss any potential variations from the above preconceptions
- Always ask the proceduralist about desired goals for hemodynamics
- Be prepared for:
- conversion to General Anesthesia
- the need to increase monitoring (i.e.
- Vasoactive Drugs (bolus and infusions) that you may need:
- phenylephrine (80mcg/ml)
- nitroglycerin 50mg-100mg / 250cc D5W (0.3-10 mcg/kg/min)
- nicardipine can be an excellent choice for BP control (either as bolus or infusion -- and Dr.
Ecker also likes it).
- must be ordered from Pharmacy [20mg in 200cc, 0.1mg/cc]
- usual starting dose
- titrate up or down (often in 2.5mg/hr increments)
- nitroprusside 50mg / 250cc D5W (0.3-10 mcg/kg/min)
- Dexmedetomidine can also be considered for long MACs (or as an adjunct for BP control at
emergence during GA).
- Consider omitting the loading dose in order to avoid
some of the hemodynamic issues (bradycardia, hypotension/hypertension).
- Consider starting
at a relatively low dose (0.1 or 0.2 mcg/kg/hr), but this can be increased depending on needs
(can go as high as 0.7mcg/kg/hr) – exercise caution on escalating too rapidly.
- Catastrophic Intra-op rupture/bleeding may occur.
Anesthesiologist interventions are aimed at:
- decreasing ICP, and
- immediate reversal of heparinization.
- Therapy can include hyperventilation, further decrease of BP, protamine, STP, mannitol, Dilantin, Decadron, etc.
- Intra-op stroke/occlusion: you may be asked to elevate SBP 30-40% above baseline to augment perfusion distal to occlusion
- Always discuss post-anesthetic disposition
- If GA, will the patient be extubated and awakened for a prompt neuro exam?
- PACU or ICU?
- Hemodynamic or positional concerns post-op?
- Dr. Ecker may ask for the “magic anti-nausea recipe”. It’s really just all of our anti-emetic tricks
- ondansetron 4mg
- dexamethasone 4-10mg
- haloperidol 0.5mg
- low dose prop gtt (20-25mcg/kg/min)
- metoclopramide 5mg
Stroke, Acute Ischemic: Additional Considerations
- In acute ischemic stroke cases, please be mindful of time and assist in enabling the procedure to
begin expediently. “Time is brain”.
- Potential therapeutic interventions include:
- mechanical thrombectomy/clot retrieval
- combination of therapies
- Data shows improved outcomes if treatment occurs sooner (ideally within 3 hours of symptom
- Other recommended guidelines during stroke cases include:
- Avoid hypertension (<185/110) to decrease risk of hemorrhage with rTPA administration
- Hypotension should also be avoided
- Normoglycemia (80-140mg/dL)
- Anesthesia for Outpatient Diagnostic or Therapeutic Radiology
Cutter, ASA Refresher Courses 2013 (pdf)