Beruflich Dokumente
Kultur Dokumente
NEUROPHYSIOLOGY AND
NEUROMONITORING
Ramsis F. Ghaly, MD, FACS
and
INTRAVENOUS AGENTS
FAST ACTIVITY- SLOW & HIGH VOLTAGE
EPILEPTIFORM ACTIVITY (KETAMINE-METHOHEXITAL)
Med.
Lemniscus
Cervico-
Medullary
Junction
Spinal
stimulus Cord
Auditory Brainstem
Response
VISUAL EVOKED
POTENTIALS (VEPS)
EYE GOGGLES AND OCCIPITAL
ELECTRODES
RETINA-OPTIC NERVE-OPTIC- MED.
GENICULATE-OCCIPITAL CORTEX (VP 100)
PITUITARY, SELLAR AND SUPRASELLAR
SURGERIES
VARIABLE AND VULNERABLE UNDER
ANESTHESIA
ANESTHETIC EFFECTS ON
EPS
LATENCY DELAY
AMPLITUDE REDUCTION (EXCEPT
ETOMIDATE AND KETAMINE)
VARIABLE AMONG AGENTS
WORSE IN INHALATIONAL AGENTS AND
DOSE DEPENDANT
ADDITIVE EFFECTS OF AGENTS
VEP>SEP>BAER
FACTORS AFFECTING EPS
RECORDING UNDER ANESTHESIA
HYPOTHERMIA
HYPOXIA
HYPOTENSION/ISCHEMIA
ANESTHETIC AGENTS
SURGICAL FACTORS: INJURY-
COMPRESSION- RETRACTION
INTRAOPERATIVE MEP &
EMG INCLUDING CRANIAL
NERVE MONITORING
ElectroMyoGraphy
SSEP cannot
evaluate individual
nerve roots
•Operative Monitoring
–Nerve irritation
–Nerve identification (stimulation)
–Pedicle screw testing
–Reflex testing
–(Motor evoked potentials)
Methods for Cranial Nerve Monitoring
II Optic sensory: VEP
III Oculomotor motor:inferior rectus m
IV Trochlear motor: superior oblique m
V Trigeminal motor: masseter and/or
temporalis m
VI Abducens motor: lateral rectus m
VII Facial motor: obicularis oculi and/or
obicularis oris m
VIII Auditory sensory: ABR
IX Glossopharyngeal motor: posterior soft palate
(stylopharygeus m)
X Vagus motor: vocal folds, cricothyroid m
XI Spinal Accessory motor: sternocleidomastoid m
and/or trapezious m
XII Hypoglossal motor: tongue, genioglossus m
Facial Nerve Bursts 100 msec
Monitoring
Neurotonic 30 sec
Muscle relaxation is
usually avoided in
monitoring
spontaneous EMG
(amplitude dec.) cn 9,10,11,12
cn 10
cn 3,4,6 cn 9,12
Which Nerves?
Cervical
C2, C3, C4Trapezius, Sternocleidomastoid
Spinal portion of the spinal accessory n.
C5, C6 Biceps, Deltoid
C6, C7 Flexor Carpi Radialis
C8, T1 Abductor Pollicis Brevis, Abductor
Digiti Minimi
Thoracic
T5, T6 Upper Rectus Abdominis
T7, T8 Middle Rectus Abdominis
T9, T10, T11 Lower Rectus Abdominis
T12 Inferior Rectus Abdominis
Lumbosacral
L2, L3, L4 Vastus Medialis
L4, L5, S1 Tibialis Anterior
L5, S1 Peroneus longus
Sacral
S1, S2 Gastrocnemius
S2, S3, S4 External anal sphincter
Stimulator
ANESTHETIC REGIMEN
FOR INTRAOPERATIVE
NEUROPHYSIOLOGICAL
MONITORING
Anesthesia Components: Analgesia
and Sedation/Amnesia
Opioids Ketamine
•Morphine Dexmeditomidine
•Demerol
•Fentanyl
•Alfentanil
•Sufentanil
•Remifentanil
Fentanyl
MEP
SSEP
Ketamine
Perspective:
Provides amnesia and analgesia
Inexpensive as infusion in TIVA
Problem of hallucinations
Increases ICP with
intracranial pathology
May inc seizures
Anesthesia Components:
Analgesia and
Sedation/Amnesia
Barbiturates (thiopental, methohexitol)
Benzodiazepines (midazolam)
Propofol
Etomidate
• Droperidol
• [Ketamine]
• [Dexmeditomidine
Propofol is the most common
TIVA sedative
Muscle Relaxation
Paralysis ok during intubation and some other
times (e.g. back incision)
Full paralysis may be necessary to reduce EMG
interference near recording electrodes
( e.g. SSEP cervical response, epidural or neural
response)
Full or partial paralysis may reduce patient
movement with stimulation
Partial paralysis may be acceptable for
electrically stimulated pathways
Absence of paralysis may be necessary with
mechanical stimulation or with pathology
Motor Evoked Responses: Start
with TIVA
- Induction with appropriate medications
(limit barbiturates and benzodiazepines)
Using short to intermediate acting relaxants
Propofol 1-2 mg/kg
Succinylcholine, vecuronium, rocuronium, etc.
Desflurane 3%
- Basic maintenance with TIVA
inhaled (1/2
Propofol 120-140 mg/kg/min
Sufentanil 0.3-0.5 ug/kg/hr
MAC) may be
tolerated in
- Use EEG to guide propofol
healthy
- No nitrous oxide, No potent inhalational
patients
- No muscle relaxation
Summary: Effective Anesthesia
Work with monitoring to develop an anesthetic
plan based on monitor techniques used
Start the case with the best anesthesia possible
and begin monitoring (use a bite block!)
Review the responses
Liberalize or improve anesthesia
Hold the physiology and anesthesia steady
Develop an anesthesia
“protocol”
THANK YOU FOR
LISTENING
QUESTIONS?