LAPORAN KASUS

Anesthesiology of Supratentorial Tumor

OLEH:
Jeffrey Tanudjaja
1502005107

PEMBIMBING:
dr. I.B. Krisna Jaya Sutawan, Sp.An. M. Kes

DALAM RANGKA MENGIKUTI KEPANITERAAN KLINIK MADYA

BAGIAN/SMF ILMU ANESTESI DAN TERAPI INTENSIF
FK UNUD/RSUP SANGLAH
OKTOBER 2015

ABSTRACT
General anesthesia of the supratentorial tumor is a common
yet complicated procedure. The process of obtaining useful
information pre-operative is crucial for the success of the
neurosurgical procedure. The most concerning factor for
supratentorial tumor peri-operative are increase in ICP and
maintaining proper fluid level due to blood loss. We present a case
of a 64-year-old patient with chief complaint of right temporal
headache and diagnosed with meningioma of the sphenoid wing.
The important steps and strategies of general anesthesia and their
medications are discussed below.
CASE REPORT
The patient was a 64-year-old male, who was transferred from
RSUD Buleleng, presented with headache that started 2 months
ago. The headache was described as dull and achy on the right
side of the temporal region and didnt get better after taking
medications. The patient also complained of nausea, vomiting and
weakness of the left upper and lower limb 1 week before arriving at
the hospital. The patient had no history of systemic diseases, no
allergies towards medications and no prior surgeries performed.
Physical examination showed the patient was conscious and
alert with normal cranial nerve examination. Bilateral pupils were
3mm, equal and reactive to light. Respiratory rate was 18
breath/min with vesicular sounds on both lungs. Her blood pressure
was 130/90 mmHg with a heart rate of 72 beats/min and no more
murmur were heard upon auscultation. Muscle examination revealed
a slight weakness on the left upper and lower limb with a grade 444
while the right side muscle grade was normal. Other physical
examinations were normal.
MRI showed mass lesion, suspect meningioma, in the right
sphenoid wing with surrounding parenchymal edema, 1,5cm mid
line shift to the left and non-communicating hydrocephalus. Initial
diagnosis was meningioma of the sphenoid wing. ECG and
laboratory values showed elevated AST & ALT level with others
within normal range. Chest X-ray revealed cardiomegaly 60% and
infiltrate on both lungs, suspecting pneumonia. Echocardiogram
showed mild mitral regurgitation with otherwise normal heart
functions. Table 1 summarizes the pre-operative laboratory values.
Table 1: Summary of pre-operative laboratory values
Complete Blood
WBC 9,07 x103/uL ; Hb 14,5 gr/dL; Ht
42,1 % ; PLT 178x 103/uL; Neu 96,5%
Count
Hemostasis
PT 10,6(11) detik; APTT 28,1 (32,3);
INR 0,98

Blood Chemistry

Blood Gas
Analysis

AST 80,3 U/L; ALT 371,2 U/L; Alb 3,28

g/dl; BS 116 mg/dL; BUN 16 mg/dL; Cr
0,5 mg/dL; Na 138 mmol/L; K 3,75
mmol/L
pH 7,45/ pCO2 35 mmHg/ pO2 97
mmHg/ HCO3- 24,3 mmol/L/ BE 0,3
mmol/L/ SO2c 98%

Pre-operative planning include informed consent, 8 hours

fasting prior to surgery, Foley catheter, STATICS, blood transfusion
products, IV access, arterial lines, preparation of postop ICU bed and
ventilator.
Pre medication include sedative midazolam 2mg iv, analgesic
fentanyl 150 mcg iv and dexamethasone 10mg iv. In the operating
room, patient was in supine position and induction of anesthesia
was initiated with propofol iv until induction onset. Rocuronium 50
mg was then administered and intubation was performed after the
patient was asleep
General anesthesia was maintained with sevoflurane and
propofol was continued at 50-100 mcg/kg/min. 2 mcg/kg of fentanyl
was administered every 30 minutes for analgesia along with 0.1
mg/kg of rocuronium every 45 minutes. Other medications
administered during the operation include mannitol 0.5-1 g/kg,
ondansentron 8 mg, paracetamol 1 gv iv and furosemide 40 mg. The
blood pressure was maintained at 100/65 mmHg and Heart rate was
at 60~65 beats/min, SaO2 99% under ventilator, pCO2 at 30~28
mmHg.
The patient was emerged normally without any bucking,
coughing or hemodynamic responses. There was an estimated blood
loss of 450 ml, and the patient was resuscitated with 1700 ml of
crystalloid, 500 ml of colloid and 500 ml of packed red blood cells.
The approximate urine output was 950 ml and the operation lasted
around 4 hours.
The patient was immediately transferred to the ICU for
intensive care and postoperative medications analgesic fentanyl
400mcg/24 hour via syringe pump and paracetamol 1 gr every 8
hours iv was given for the recovery period.
DISCUSSION
Supratentorial craniotomy is one of the most common
neurosurgical procedure, which may be emergent or scheduled
operation. It is important to perform full pre-operative evaluation,
focusing on signs and symptoms of elevated intracranial pressure

(ICP), neurological deficits and risk off air embolism. Pre-operative

blood work out should be performed to reveal any abnormalities in
hematocrit level, coagulation panel, sodium irregularities and
glucose level1,2,3. Diagnostic imaging is equally important for
anesthesiologist to identify the type of tumor, the location, presence
of midline shift and hydrocephalus3. Also thorough preparation of
continuous blood pressure measurement, core temperature
monitoring, arterial catheter, central venous catheter and Foley
catheter are important parts of monitoring for the anesthesiologist
2,4
.
In our case, a complete pre-operative physical examination
along with full blood work out and diagnostic imaging was
performed. The MRI scan showed tumor lesion on the right sphenoid
wing and the patient was scheduled for tumor resection on the 27
October 2015. Preoperative checklist was prepared with IV bore
line, arterial line, continuous blood pressure monitoring and blood
transfusion packed red blood cell in case of massive bleeding.
The anesthetic concern for this operation would be the
increased ICP and maintaining proper fluid status during the
procedure involving blood loss 4,5. ICP should be lowered to facilitate
surgical access and blood loss should be replaced with blood
products, crystalloid or colloid to keep hematocrit above 28%1,5. This
patient has clinical symptoms (headache, nausea & vomiting,
unilateral muscle weakness) and MRI scans (midline shift, noncommunicating hydrocephalus) point to an increase in ICP, and
hence, maximal reduction of ICP is the main importance for both
anesthetic strategy and surgical exposure.
Due to the increase in mass effect of the intracranial tumor,
the patient was quickly sedated with midazolam and analgesic
fentanyl was given to prevent increase in blood pressure, which may
lead to further increase in ICP. It must be noted that sedative can
cause respiratory depression and hence the patient must be
monitored continuously as a decrease in ventilation can cause an
increase in pCO2 and again an increase in ICP via cerebral
vasodilation. Care was also given when laying the patient on the
operating table. The patient was positioned in a supine and head
rotated towards the left with caution of not obstructing the jugular
venous drainage. Pressure points were also identified and padded
carefully so that nerves were not compressed during the operations.
Dexamethasone was administered to reduce or limit the
edema. The efficacy of steroids in reducing the edema associated
with tumors occurs within 24 hours after administration and reports
have shown that steroids improve the viscoelastic properties before
reduction of edema occurs1,4,5.

The goal of induction for neurosurgical cases is ventilator

control, blood pressure control, and optimal head and neck position,
while the goal of maintenance of anesthesia include control of brain
tension, neuroprotection and normothermia,6,7. Table 2 shows the
typical induction and maintenance scheme.
Table 2: Suggested anesthesia and maintenance induction
Induction
Adequate preoperative anxiolysis
ECG, capnograph, pulse oximeter, noninvasive blood pressure
Venous, arterial lines
Preoxygenation, then remifentanil 0.1mcg/kg/min or TCI (target: 3-5
ng/mL) or sufentanil bolus 0.15-0.30 mcg/kg
Propofol 1.25 -2.5 mg/kg or thiopental 3-6 mg/kg
Nondepolarizing muscle relaxant
Hyperventilation (PaCO2 35 mm Hg)
Intubation
Maintenance
Sevoflurane 0.5%-1.5%, desflurane 3%-6%, propofol 50-150
mcg/kg/min
Analgesia: remifentanil 0.1-0.15 mcg/kg/min or sufentanil
Pin holder placement: local anesthesia or remifentanil 0.5-1 mcg/kg
Position: head up 10-20, jugular veins free
Mannitol 0.5-0.75 g/kg or lumbar CSF drainage
Normovolemia: isotonic crystalloids or 6% hydroxyethyl starch to
replace blood losses
Brain dissection: decrease narcotic dosage (remifentanil 0.05-0.1
mcg/kg/min or target 2-4 ng/mL
Our choice of medication for induction would be propofol,
titrated till the patient reach a hypnotic stage. Once the patient is
unconscious, continuous blood pressure is monitored within 20% of
baseline. The pre-operative blood pressure was measure at 122/76
mmHg and hence after induction the blood pressure is maintained
at 100-110/60-56 mmHg. A medium to short-acting muscle relaxant
such as rocuronium is injected to facilitate the intubation process.
Sevoflurane 0.8% inhalation technique is used as the
maintenance general anesthesia in this case. Compared to other
products like nitrous, desflurane and isoflurane, sevoflurane has the
least effect on cerebral blood vessels dilation, which wont increase
the cerebral blood volume and ICP much 1,4,5,8.
The choice of analgesic is Fentanyl 2mcg/kg administered
every 30 minutes. Major stimulating events in this case include
intubation, skin incision, removal of bone flap, durotomy and skim
reincision. An early focus of analgesia during the case is important

as it can affect the blood pressure and heart rate of the patient,
which in return increase the ICP2.
The administration of mannitol and furosemide aid in the
relaxation of the brain tension and facilitate the surgeon for better
access to the tumor area and brain trauma during retraction3.
Mannitol 0.5-1 g/kg was given 30 minutes before and durotomy and
furosemide helps the maintenance of the osmotic gradient caused
the mannitol by hastening the excretion of fluid from the
intravascular space4,7.
For neurosurgical cases, emergence is a crucial part of the
process as any sudden change in hemodynamic may increase the
chance of intracranial hemorrhage and increased edema formation.
The importance on minimizing coughing/straining and hypertension
will aid the recovery of the patient. There are two main strategies in
preventing and stabilizing the patients hemodynamics. The first is
by using or switching to short-acting anesthetics and analgesics 5,6,8.
The second method is to decrease the stimulus of the endotracheal
tube 5,6,8. The anesthesiologist sprayed lidocaine 120 mg down the
tube, anesthetizing the airway and thereby minimizing the irritation
during consciousness.
CONCLUSION
Although supratentorial tumor surgical case is the most
common neurological operation, preoperative planning and
evaluation is important for not only the neurosurgeons but also for
the anesthesiologist. Focus and care should be emphasized on the
ICP and with tumor cases like meningioma, blood products should be
prepared at all time in case of major bleeding occurs. Other risk
factors such as air embolism, venous drainage obstruction and
minimizing coughin/straining should also be addressed and
identified pre-operative management. Anesthesiology strategy not
only involves peri-operative monitoring but also post-operative care
to optimize the patient care.
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