What are the real challenges during an awake craniotomy? Why a neurosurgeon should view this with both a surgical and an anaesthesia perspective?

1. Decoding a misnomer:
Awake Craniotomy
Dr Unnikrishnan P MD,PDCC,MBA
Associate Professor
Neuroanaesthesia Division
SCTIMST

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3. Conventional terminology may mask reality
Awake Craniotomy
Craniotomy with
Intraoperative
awakening
It’s a team work

4. Challenging task for the
anaesthesiologist
╺ Invasive procedures in a patient who is not anaesthetized
╺ A meticulous scalp block
╺ Carefully titrated sedation/anaesthesia
╺ Unique complications to deal with
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5. Careful selection of the patient
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╺ OSAS
╺ Anticipated difficult airway
╺ Psychiatric disorder
╺ Chronic cough
╺ Sinus infiltration

6. Be on the right side; you
need some artistic skills
too!
╺ A realistic explanation of what to expect
╺ Psychological preparation and support
╺ Controlling the nuances in the
anaesthetic and analgesic levels
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7. Be a perfectionist while
positioning
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╺ Cushioning
╺ Tent
╺ Access: to face and airway
╺ O2 mask
╺ EtCO2 sampling line
╺ Claustrophobia
╺ House keeping

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You will miss GA
╺ Position
╺ Do fast
╺ Ventilation: ? tight brain
╺ Bleeding
╺ Well sedated? Well…
╺ Extreme head rotation
Please don’t post for AC

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10. Powerless positions
╺ Limited airway access with the clamp
╺ Fluid management difficult
╺ Management of bleeding difficult
╺ Positioned at foot end and patient is without any
airway gadget
╺ Hyperventilation (X)
╺ Certain positions less tolerated

11. A hotline is necessary
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╺ LA
╺ Time gap-Mapping/Resection
╺ Dura
╺ Pain
╺ Closure

12. You need to be
Dr Strange
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╺ Seizures (No airway gadget in place):
Rx ice cold saline
╺ Pain (Further narcotics will affect
testing): transcortical resection
╺ Loss of airway (Head on clamps): SGA

13. Possible costly misses by an
occasional practitioner
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╺ Missing the C/I eg OSAS, psychological issues
╺ Different preparation of the OT
╺ Subtle points during positioning: eg L clamp
╺ Fine titration and timing of stoppage of the agents
╺ Continuous communication

14. Possible costly misses by an
occasional practitioner
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╺ Selection of the drug
╺ Under dosing
╺ Over dosing
╺ OSAS patient
╺ Opioids
╺ Phenytoin
╺ Antiemetics
╺ Airway loss management
╺ Seizures

15. That
concludes
the
story
of
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16. Thanks!
Any questions?
You can find me at drunnikrishnanp@gmail.com
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