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AnesthesiaProtocolsforSurgeryduringNeuromonitoring

Anesthesiology,UniversityofColoradoDenver:tod.sloan@ucdenver.edu
April1,2009

Avarietyofanesthesiamethodscanbeusedduringsurgerywhereintraoperativeneurophysiological
monitoringisused.Clearlytheanesthesiamustbetitratedtoeachpatienttoadjustforthevarious
comorbidities,includingthedegreeofneuralcompromisethatmayimpactmonitoring,aswellas
searchingtofindananestheticthatallowsanadequatemonitoringsignalwhilekeepingthepatient
adequatelyanesthetized.Ingeneral,withrespecttomonitoring,thechoiceofanesthesiadependsonthe
particularmonitoringmodalitiesbeingused.Themajorlimitationsarewhentechniquesaresensitiveto
inhalationalagents(IH)andwhentheyaresensitivetoneuromuscularblockingagents(NMB).Some
modalitiesareinsensitivetoboth(e.g.ABR),othersaresensitivetomusclerelaxantsonly(e.g.EMG),or
inhalationalagentsonly(e.g.corticalSSEP),andsomearesensitivetobothinhalationalagentsandmuscle
relaxants(e.g.transcranialmotorevokedpotentials(MEP)).Themostrestrictivetechniquesamongthe
techniquesusedforaspecificsurgerydefinetheoverallanestheticapproachandtheprotocolsbeloware
theprotocolswhichIusuallystartwithforvarioustypesofmonitoring.Ihavealsomentionedsome
alternativestotheapproachIuse.Theseprotocolsareforadults;childrenmayrequiredifferentdosesor
approaches.

MonitoringDuringPosteriorFossaSurgery

WhensurgeryintheposteriorfossainvolvesonlytheAuditoryBrainstemResponse(ABR),thereare
noanestheticconsiderationssincethisisneithersensitivetoinhalationalagentsormusclerelaxants;any
anesthetictechniqueisfinewithrespecttomonitoringandshouldbeguidedtothepatientandsurgery.In
theunlikelyeventthattheEustaceantubeisblockedthenNitrousOxidecouldcauseamiddleeartension
thatwouldmakeitsuseaproblem.

AnesthesiaforABR(techniquesinsensitivetoIHorNMB)
Inductionasusual
Maintenanceasusual(IHandNMBasdesired)

ThemostcommonadditiontoABRismonitoringusingEMGofvariouscranialnerves,especiallythe
facialnerve.Assuchthemonitoringthenbecomessensitivetomusclerelaxants.ForsomeEMG
techniqueswherethenervoussystemisstimulated(e.g.MEP,Pediclescrews),partialmusclerelaxationis
oftenacceptable(seebelow),butwhenmonitoringisdesignedtobesensitivetomechanicalstimulation
ofthenerves(asisusuallythecasewithcranialnerves)musclerelaxantsreducetheEMGamplitudeand
makethemonitoringlesssensitivetoimpendingneuralinjury.ForthisreasonItrytoavoidmuscle
relaxationduringthecase.InsurgerieswhereABRiscombinedwithEMG,sincethereisnoinhalational
agentrestriction,Iusuallyuseabalancedanesthetic(e.g.someopioidsandinhalationalagents)andallow
themusclerelaxantsthatwereusedwithintubationtowearoff.Sincehigherdosesofinhalationalagents
canbeused,thisanestheticworksfine.ThesituationgetsabitmorecomplexwhentheSSEPisusedasin
corticalsurgery.

AnesthesiaforABRwithEMG(insensitivetoIHsensitivetoNMB)
Inductionasusual
Maintenanceasusual(IHasdesired)
LetNMBwearoffafterinduction

MonitoringtheCerebralCortex

Avarietyofproceduresinvolvemonitoringforpotentialneuralcompromisetothecerebralcortex.A
goodexampleisCarotidEndarterectomy.IftheonlymonitoringmodalityisEEG,theanesthesiaismade
rathereasysinceitisinsensitivetomusclerelaxantsandonlysensitivetohighdosesofinhalational
agents.HencethechoiceofanesthesiaisusuallydesignedtoproducearhythmicEEGinthealpharange
(812Hz)thatisassociatedwithlighttomoderateanesthesiawithinhalationalagents.Higherdoseswill
produceburstsuppressionorelectricalsilencewhichimpairsmonitoringsoinhalationaldosesinthe1
MACorlowerrangeisusuallyfineandcanbetitratedtotheEEG.Thisusuallyproducesexcellent
anesthesiaprovidedthatadditionalopioidsareusedtosupplementtheanalgesia(withtheinhalational
agentsproducingamnesiaandsedation).AprocessedEEGmonitormaybeusedtohelpinsureadequate
sedationinmostpatientsiftheIHdoseislow(lessthanMAC).Theopioidshavetheadditional
advantageofslowingtheheartrateandbluntinghypertensiveepisodeswhichareimportantinreducing
thecardiacriskinthesepatients.Thistechniquealsoallowsmaintenanceofthebloodpressureinthe
patientsusualrangeandisexcellentforTCDmonitoring.ForthisreasonIusuallyloadthesepatientswith
1ug/kgormoreoffentanyl(orasimilardoseofanotheropioid)withinductionandrunabalanced
anestheticwithinhalationalagents.

AnesthesiaforEEG(moderatelysensitivetoIHinsensitivetoNMB)
Inductionasusual
BalancedMaintenance(6%Des~1MAC)
OpioidsandNMBasneeded

AnesthesiacomesabitmoredifficultifSSEPisusedwiththeEEGforcorticalmonitoringaswouldbe
doneinintracranialaneurysmsurgery.Heretheinhalationalagentmustbekeptlowenoughtokeepthe
corticalSSEPresponsesmonitorable.Ingeneral,corticalSSEPamplitudeswillbeacceptablewith
inhalationalagentconcentrationsbetweenand1MAC,howevertheeffectisnonlinear;thereisusually
aconcentrationthresholdinthatrangeabovewhichthecorticalSSEPresponseismarkedlyreducedin
amplitude.Theproblemisthateachpatientmayhaveadifferentthresholdsotheinhalationalagentmust
betitratedtoeffect.Myapproachistoplanabalancedanestheticwithsomeopioid,musclerelaxantsas
needed,andadjusttheinhalationalagent,observingtheresponse.IuseDesfluraneorSevofluranewhen
possiblebecausetheirinsolubilityallowsrapidincreaseanddecreaseofeffect.Foryoung,healthypatients
withminimalneurologicaldebilityIusuallystartat1MACandtitratedown,andforolderand
neurologicallycompromisedpatientsIstartatMACandtitrateup.Recallthatinhalationaldosesin
excessof1MACmayproducebrainswellingfromincreasedcerebrovasculararterialvolume(aswellas
amplitudedepressionoftheSSEP)soIdontgoabove1MACwithintracranialcases.Ifthedoseof
inhalationalagentsmustbekeptlowtoallowmonitoring,Ioftenwilladdapropofolinfusiontoinsure
adequatesedationandopioidsasneeded.AprocessedEEGmonitorisoftenhelpfulwiththis,providedthe
electrodecontactswiththebrainarenotalteredbythecraniotomyandthebraindoesnotmoveaway
fromthefrontalbone.Forintracranialsurgerythisadditionalinfusionofpropofoltopreventawareness
andsedationisoftennotnecessary(itsomethingaboutoperatingonthebrain),butthereisahigh
possibilityofthisinspinalsurgerywhereSSEPisusedsinceawarenessappearstobemorecommon.

AnesthesiaforCorticalSurgerywithSSEP(sensitivetoIHinsensitivetoNMB)
Inductionasusual,preferablyPropofol
BalancedMaintenance(36%Des1MAC)
OpioidsandNMBasneeded
PropofolinfusionifneededbyEEG

MonitoringduringSpinalSurgeryusingtheSSEP

WhenIamprovidinganesthesiaforspinalsurgerywhereonlytheSSEPisused(suchasspinal
correctivesurgerybelowL2),Iapproachthechoiceasaboveabalancedanestheticusingopioidsand
musclerelaxationasneededandto1MACinhalationalagent(Des)asacceptabletoacquireacortical
response(titratingasdescribedabove).Asopposedtointracranialsurgery,IfindIusuallyneeda
supplementalinfusionofpropofolandusuallyuseaninfusionofopioid.Thepropofolusuallyrunsat60
120ug/kg/min(oftentitratedwiththehelpofaprocessedEEG).FortheopioidIusuallyusesufentanil
(unlessitsanelderlyfrailpatientwhereIbolusfentanyltoeffect).Sufentanilinfusionsusuallyrun0.150.3
ug/kg/hr,butcanbehigherdependingonthepatientstolerancefrompreoperativeanalgesicuse.Note
thesufentanilinfusionneedstobeturnedoffabout30minutesbeforeending.Notethatfentanyl
(infusion45ug/kg/hr)canbeusedascanremifentanil(0.20.5ug/kg/min).Fortunatelytheinhalational
agentshelpalotwiththeanesthetic.

AnesthesiaforSpinalSurgerywithSSEP(sensitivetoIHinsensitivetoNMB)
Inductionasusual(preferablePropofol)
BalancedMaintenance(36%Des1MAC)
Opioidssufentanilbolusasneededthan0.150.3ug/kg/hrturnoff30minutesbeforeend
PropofolinfusionguidedbyEEG(60120ug/kg/min)
NMBasneededifEMGnotmonitored

Analternativeapproachhereistousedexmeditomidineinsteadof,orsupplementarytothe
propofol.SomeindividualsuseDexinfusionsof0.20.5ug/kg/hr.IusuallydontloadtheDex(whichcuts
thecost)ifitsstartedatthebeginningofthecase.TheinfusionofPropofolwillbealowerdoseduetothe
sedationfromtheDex.Becausethemechanismofactionisnotopioidlike(itsacentralalpha
2
stimulant),
itappearstobehelpfulinopioidtolerantpatients.

AlternateanesthesiaforSpinalSurgerywithSSEP(sensitivetoIHinsensitivetoNMB)
Inductionasusual(preferablePropofol)
BalancedMaintenance(36%Des1MAC)
Opioidssufentanilbolusasneededthan0.150.3ug/kg/hrturnoff30minutesbeforeend
Dexmeditomidine(0.20.5ug/kg/hr)
Propofolinfusion(60100ug/kg/min)
NMBasneededifnoEMG

IfEMGisalsomonitoredwiththeSSEP(whichisusuallythecasewithoursurgeries),themuscle
relaxantsmustberestricted.Iprefertoletthemusclerelaxantswearoffafterthebeginningofsurgery.
Afterthebaselinerecordingsaredone,sometimeswewillusesomerelaxationfortheopeningofalarge
spinalsurgerytoreducethemuscleactivityorassistintheexposureofananteriorabdominalcase.
AlthoughIprefertousenorelaxationduringthemonitoringportionoftheprocedure,acceptableEMG
monitoringcanbedonewith2twitchesinatrainoffour,optimallyusingatitratedinfusionofan
intermediateactingdrugsuchasrocuronium(510ug/kg/min)orvecuronium(0.50.8ug/kg/min).Data
suggeststhatadeeperblock(only1twitch),mayartificiallyincreasethepediclescrewthresholdwhich
couldreducetheabilitytosignaltheneedforrepositioningofthescrews.Inaddition,thedetectionof
nerverootcompromisefrommechanicalmeansmightbereducedsimilartofacialnervemonitoring
above,suchthatnorelaxationisdesirable.Ingeneral,sincethesensitivityofmusclegroupstomuscle
relaxantsvaries,wheretheTOFismonitoredisimportant.Sincedistalmusclesaremostsensitive(and
frequentlywheremonitoringisdone),ifwemonitortheTOFusingtheulnarnerveandhandresponseis
probablybestsincemoreproximalmuscles(suchasontheface)mayunderestimatetheeffectinthe
periphery.ThebestneuromuscularmonitoringofTOFwillbedonebythemonitoringteaminthemuscles
theyaremonitoring(notetheyneedtousethesametechniqueasanesthesiawithaTOFat2Hz).

AnesthesiaforSpinalSurgerywithSSEP&EMG(sensitivetoIH&NMB)
Inductionasusual(preferablePropofol)
BalancedMaintenance(36%Des1MAC)
Opioidssufentanilbolusasneededthan0.150.3ug/kg/hrturnoff30minutesbeforeend
PropofolinfusionguidedbyEEG(50150ug/kg/min)
NMBasneededforinduction,possiblyformuscledissectionthennone
(acceptable2+/4twitchesinTOFinmusclesmonitoredformonitoringnervestimulation)

MonitoringtheSSEPwhenaReductionorEliminationoftheInhalationalAgentsisNeeded

Ingeneral,theabilitytouseinhalationalagentsandpartialmusclerelaxationisveryhelpfulin
anesthetizingthespinesurgerypatients(particularlyiftheyareopioidtolerant).Thesituationbecomes
muchmoredifficultwhentheresponsesaresopoorthattheinhalationalagentmustbereducedor
eliminated.Inthiscasetheanesthesiabecomesatotalintravenousanesthetic(TIVA)withthesedation
beingprovidedbypropofol(75150ug/kg/min,usuallytitratedtoprocessedEEG)withanopioidinfusion
(e.g.sufentanil0.30.5ug/kg/hr).IftheSSEPremainstoosmallformonitoring,aninfusionofetomidate
(0.6mg/kg/hr)canbeusedinsteadofthepropofol(asetomidateenhancesthecorticalSSEPatlowdoses).
Alternativelyaketamineinfusion(12mg/kg/hr)canbeusedwiththeopioidinfusion(seebelowforour
approachtoketamine)sinceketaminealsoincreasesthecorticalSSEPresponse.Sinceourspinesurgeries
mostoftenusetranscranialmotorevokedresponseswhenweneedtoeliminatetheinhalationalagents,
wetaketheTIVAapproachdescribedbelowwhenlowdoseofinhalationalagentsarenotacceptablefor
MEP.

MonitoringwhenMotorevokedPotentialsareused

Themostchallenginganestheticisrequiredduringmonitoringofsurgerywhenmotorevoked
potentialsarebeingusedbecauseboththeinhalationalagentsandneuromuscularblockingagentsmust
beseverelyrestrictedornotused.WiththesecasesSSEPandEMGarealsousuallybeingmonitored,but
theMEPdefinesthemajorrestrictions.Foramedicallyhealthypatientwhoiswithoutmarked
neurologicalproblems(i.e.usuallypresentswithseverepainthatpromptssurgery),Iusuallystartwitha
TIVAtechniquesupplementedwithMACofinhalationalagent(e.g.3%Des).Somefolksstartwithpure
TIVA,butfrequentlyasmallamountofDesorSevoisacceptableandIbelieveitishelpful,especiallywith
patientswhoareopioidtolerant.Hence,afterastandardinductionwithpropofolandashortor
intermediateactingmusclerelaxant(whichIletwearoff),Iwilluse3%Des,asufentanilinfusion(0.30.5
ug/kg/hr)andapropofolinfusion(75150ug/kg/mintitratedtoprocessedEEG).Notethatsome
individualswouldprefertouse5060%nitrousoxideinsteadoftheDes(butnotbothIHandN2Otogether
atthesametimesincetheyaresynergisticandtheeffectisusuallytoomuch).ThisworkssimilarlybutI
prefertonothavemyFiO2restrictedbynitrousoxideandthatwhenturningthenitrousoffinatimeof
concernmaycauseanabruptchangeinanesthesiaandmonitoring.
Thistechniqueusuallyworkswell,butoccasionallytheMEPresponsesaretoosmallwhich
necessitatesturningofftheDesandadjustingthePropofolandsufentanilinfusionsasneeded.Its
importanttonotethatmoderatedosesofbenzodiazepinesandbarbiturateshavebeenreportedtoreduce
theMEPresponseandthatthismaylastalongtime(muchlongerthanthedrugdurationofaction).Itis
notclearhowthispertainstothemodernmultipulsetechnique;however,smalldosesofmidazolam
appearquiteacceptablesuchasthosethatarecustomarilyusedforpreinductionoroccasionallyduring
thecase.

AnesthesiaforSpinalSurgerywithMEP&EMG(verysensitivetoIH&NMB)
Inductionasusual(preferablePropofol)
LowdoseIH(3%Des)
Opioidssufentanilbolusasneededthan0.150.3ug/kg/hrturnoff30minutesbeforeend
PropofolinfusionguidedbyEEG(75150ug/kg/min)
NMBasneededforinduction,possiblyformuscledissectionthennone
(acceptable2+/4twitchesinTOFinmusclesmonitoredformonitoringnervestimulation)

MonitoringMEPwithOpioidTolerantPatientsorWhohaveSignificantNeurologicalDisability

Inpatientswhoarenotyoungandhealthyorhavemoderateneuraldisabilityorwhereturningoff
theDesisrequiredintheabovetechnique,IusuallyusepureTIVAusingpropofolandsufentanil.

AnesthesiaforSpinalSurgerywithMEP&EMG(verysensitivetoIH&NMB)
Inductionasusual(preferablePropofol)
PureTIVAnoIH
Opioidssufentanilbolusasneededthan0.150.3ug/kg/hrturnoff30minutesbeforeend
PropofolinfusionguidedbyEEG(75175ug/kg/min)
NMBasneededforinduction,possiblyformuscledissectionthennone
(acceptable2+/4twitchesinTOFinmusclesmonitoredformonitoringnervestimulation)

Ifthisisntsufficienttoallowmonitoring,orinpatientswhoareveryopioidtolerantorwhohave
significantneurologicaldebilitywheretheresponsesarelikelytobepoorIuseTIVAenhancedwith
ketamine.InthiscaseIuseketaminetosupplementtheanalgesia(recallithasNMDAactionthatthe
opioidsdonot).Italsosupplementsthesedationwhichallowsareductioninthepropofolinfusionrate
(andareductioninthedepressanteffectofthepropofol).Thenotablethingaboutketamineisthatitis
metabolizedslowerthanpropofolsothattheinfusionmustbeturneddownearlierthanthepropofol.One
approachistorunaseparateinfusionofketamine(12mg/kg/hr),butsincewecurrentlytitratethe
sedationtotheprocessedEEG,itsmoreconvenienttomixtheketaminewiththepropofol.Assuch,we
mixketamineinthepropofolforaninitialinfusionthathas2mgofketamineineachccofpropofol(e.g.
100mgketamineina50ccsyringeofpropofol).ThisinfusionistitratedtotheEEG(sinceketaminecan
increasethenumericvalueoftheprocessedEEG,ItitratetothehighendoftheacceptableprocessedEEG
range).Thisconcentrationofketamineisreducedwitheachsubsequent50ccsyringeofpropofol.Fora
shortercaseIusuallygo2,then1.5,then1,then0.5mgofketamineperccandusenoketamineinthe
finalsyringes.ForamuchlongercaseItapermoreslowly.NotethattheketaminewillincreasetheSSEP
amplitudesoyoumayseeaslowdeclineinSSEPamplitudeoverthecase(oftento50%)andthisis
expectedandmustbedifferentiatedfromapathologicchange.

AnesthesiaforSpinalSurgerywithMEP&EMG(verysensitivetoIH&NMB)
Inductionasusual(preferablePropofol)
PureTIVAnoIH
Opioidssufentanilbolusasneededthan0.30.5ug/kg/hrturnoff30minutesbeforeend
PropofolinfusionguidedbyEEG(75175ug/kg/min)
KetaminemixedinthePropofol(initial2mg/cc)andtaperedtooff
NMBasneededforinduction,possiblyformuscledissectionthennone
(acceptable2+/4twitchesinTOFinmusclesmonitoredformonitoringnervestimulation)

Themajoralternativetothisistousedexmeditomidineasdescribedabove.Hencesomeindividuals
use<0.5ug/kg/hrDexmeditomidineinsteadofthepropofol(orwithasmalldoseofPropofol5060
ug/kg/min).However,ImustnotethatmanyindividualsreportthatMEParedifficulttoobtainwithDex.
AssuchtheuseofDexisevolving.

AnesthesiaforSpinalSurgerywithMEP&EMG(verysensitivetoIH&NMB)
Inductionasusual(preferablePropofol)
PureTIVAnoIH
Opioidssufentanilbolusasneededthan0.30.5ug/kg/hrturnoff30minutesbeforeend
PropofolinfusionguidedbyEEG(60100ug/kg/min)
Dexmeditomidine(0.30.5ug/kg/hr)
NMBasneededforinduction,possiblyformuscledissectionthennone
(acceptable2+/4twitchesinTOFinmusclesmonitoredformonitoringnervestimulation)

Dexmeditomidinewouldalsobeanacceptablealternativeinpatientswherepropofolis
contraindicated(suchasallergytosoyoreggsorahistoryofpropofolinfusionsyndrome).Similarly,
etomidatecouldbeused.LowdoseIHornitrousoxidemightalsobeacceptableaslongasthedepressant
effectwasnotexcessive.
Itisalsoworthmentioningthatinpatientswhereanintravenouslineisnotavailableforinductiona
maskinductionwithsevofluranewithorwithoutnitrousoxideworksfine.Usuallythesecanbeeliminated
aftertransitiontointravenoustechniquesintimefortheneedforintraoperativemonitoring.

Conclusion

Ingeneral,Ipicktheinitialanesthetictechniquebasedonthepatientcomorbidities(choiceof
anesthesiadrugsindependenttomonitoring),patienttolerancetoanalgesicsusedpreoperatively,the
degreeofpatientneuraldisabilities,theactualsurgerytobeperformed,andthespecificmonitoring
modalitiestobeused.Assuchthedosesaboveareonlyapproximateandshouldbeverifiedasappropriate
andadjustedforeachindividualpatient.Mygoalistogetthemaintenanceanestheticonboardandsee
howthemonitoringresponsesaredoing,makingrequiredchangesinthetechniqueasrapidlyaspossible
sothatIcanhaveasteadystateanestheticeffectduringtheperiodofthesurgerywhenmonitoringneeds
tofocusonchangesthatmightbetheresultofsurgicalorphysiologicalchanges(henceinfusionsare
extremelyvaluable).
IuniformlyusetheprocessedEEGtotitrate/insuresedation(BIS,Sedline,SNAP,etc.),relyingon
bloodpressureandheartratetoguideadequateanalgesia.AlthoughIrecognizethatthesedeviceswillnot
alwaysinsureadequatesedationoranmesia,especiallywhenketamineispresentsinceitincreasesthe
processedindices.However,ifrecallwastooccur,IcansayingoodfaiththatIdidwhatmightbehelpful.I
mostoftenusesufentanilwithbolusdosesaroundinductionandthenbyinfusion.Fentanyland
remifentanilworkfinewhenusedinasimilarfashion.IfavorDesfluranebecauseitsinsolubilityallows
rapidchanges,howeverIsoflurane,SevofluraneandNitrousOxidewillalsowork.Ifamaskinductionis
usedthenSevofluraneispreferable.Ialsopreferpropofolforinductionsothatthepatientisloadedforan
infusion(ketamineanddexmeditomidinearedescribedasneedingloadingdoses,butdonotappearto
needthemwhenusedasabove).Obviouslysubstitutionsmaybenecessaryforindividualdrugsensitivities
andsomeindividualsexpressconcernwithpropofolinchildren(propofolinfusionsyndrome).Ialsofavor
nomusclerelaxationwhenthetechniqueissensitive(especiallyspontaneousEMG).Irecognizethatthere
isampleliteratureshowingpartialrelaxationisacceptable,however,Iamconcernedaboutregulatingthe
degreeofrelaxationleadingtoaniatrogeniclossofresponse.
Usuallytheseprotocolsworkquitewell,althoughIoccasionallyhaveapatientacoupletimesayear
whoIjustcantkeepdown.Myapproachisusuallytoaddinhalationalagentssothatwemaintainthe
SSEPandEMGmonitoring,sacrificingtheMEPratherthanusingNMBandlosingtheEMGandMEP.