Manajemen Anestesi pada Pasien dengan Tumor Regio Pineal yang Menjalani Kraniotomi Pengangkatan Tumor dengan Posisi Duduk

Incidence of pineal regio tumor is 0.4-1% of intracranial tumors. Its location which is buried between two cerebral hemispheres, close to brainstem and hypothalamus become a difficult challenge for the neurosurgeon. Surgery with supracerebellar approach in sitting position is the best method to access the lesion. Sitting position also facilitates the optimal visual field with minimal retractions. However, for anesthesiologist, sitting position is challenging since it has its own complexities during positioning the patient and the risk of complications. Venous air embolism is one of the main concern and if not detected early and treated appropriately would leads to cardiovascular collapse instantly. This is a case of a 38-year-old male with chief complaint of severe headache and blurred vision started 4 months before admission. The Magnetic Resonance Imaging showed a pineal region tumor with perifocal edema, without midline deviation. The patient underwent craniotomy tumor removal with sitting position. The procedure lasted for 10 hours and uneventful. The principle of ABCDE neuroanesthesia, sitting position and its implications, and difficult tumor location are some anesthesia considerations for this patient. A thorough preoperative evaluation, good communication and coordination between surgery and anesthesia team are needed for a smooth uneventful procedure performed in sitting position.

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Preoperative Evaluation for Risk of Venous Air Embolism in the Sitting Position

Journal of Neurosurgical Anesthesiology ◽

10.1097/00008506-199504000-00009 ◽

1995 ◽

Vol 7 (2) ◽

pp. 124-126 ◽

Cited By ~ 3

Author(s):

Takanori Sakamoto ◽

Masahiko Kawaguchi ◽

Hitoshi Furuya ◽

Hideyuki Ohnishi ◽

Jun Karasawa

Keyword(s):

Preoperative Evaluation ◽

Air Embolism ◽

Sitting Position ◽

Venous Air Embolism

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A case report of anaesthesia for craniotomy in sitting position

Indian Journal of Clinical Anaesthesia ◽

10.18231/j.ijca.2021.130 ◽

2021 ◽

Vol 8 (4) ◽

pp. 611-614

Author(s):

Dinesh Suryanarayana Rao ◽

Veena Velmurugan

Keyword(s):

Case Report ◽

High Risk ◽

Air Embolism ◽

Hemodynamic Instability ◽

Anaesthetic Management ◽

Sitting Position ◽

Venous Air Embolism ◽

Long Duration ◽

Exact Position ◽

Space Occupying Lesion

Tumors in the posterior fossa can be done in lateral, supine, prone, sitting and in park bench positions. Depending on the exact position of the lesion and the technical preference of the surgeon, sitting position may be preferred. Sitting position grants best possible access to deeper structures with minimal retraction. However, maintenance of anaesthesia in this position for long duration pose some serious challenges to the anaesthesiologist including high risk of venous air embolism (VAE), hemodynamic instability and respiratory disturbances. Here, we present a case report of a 36year old male diagnosed with pineal gland space occupying lesion (SOL), operated in the sitting position under general anaesthesia. We discuss about anaesthetic management and possible complications that can be encountered.

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Massive venous air embolism in the semi-sitting position during surgery for a cervical spinal cord tumor: anatomic and surgical pitfalls

Journal of Clinical Neuroscience ◽

10.1016/j.jocn.2008.10.005 ◽

2009 ◽

Vol 16 (7) ◽

pp. 972-975 ◽

Cited By ~ 13

Author(s):

Luca Basaldella ◽

Valentina Ortolani ◽

Ulisse Corbanese ◽

Carlo Sorbara ◽

Pierluigi Longatti

Keyword(s):

Spinal Cord ◽

Cervical Spinal Cord ◽

Spinal Cord Tumor ◽

Air Embolism ◽

Sitting Position ◽

Venous Air Embolism

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Comparison of Surgical and Anesthetic Complications in Neurosurgical Patients Experiencing Venous Air Embolism in the Sitting Position

Survey of Anesthesiology ◽

10.1097/00132586-198706000-00019 ◽

1987 ◽

Vol XXXI (3) ◽

pp. 153

Author(s):

M. L. YOUNG ◽

D. S. SMITH ◽

F. MURTAGH ◽

A. VASQUEZ ◽

J. LEVITT

Keyword(s):

Air Embolism ◽

Sitting Position ◽

Venous Air Embolism ◽

Neurosurgical Patients ◽

Anesthetic Complications

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Effects of positive end-expiratory pressure ventilation on cerebral venous pressure with head elevation in dogs

Journal of Applied Physiology ◽

10.1152/jappl.2000.88.2.655 ◽

2000 ◽

Vol 88 (2) ◽

pp. 655-661 ◽

Cited By ~ 29

Author(s):

Thomas J. K. Toung ◽

H. Aizawa ◽

Richard J. Traystman

Keyword(s):

Prone Position ◽

Venous Pressure ◽

Air Embolism ◽

Right Atrial ◽

Sitting Position ◽

Positive End Expiratory Pressure ◽

Jugular Veins ◽

Venous Air Embolism ◽

Head Elevation ◽

Cerebral Venous Pressure

Mechanical ventilation with positive end-expiratory pressure (PEEP) may prevent venous air embolism in the sitting position because cerebral venous pressure (Pcev) could be increased by the PEEP-induced increase in right atrial pressure (Pra). Whereas it is clear that there is a linear transmission of the PEEP-induced increase in Pra to Pcev while the dog is in the prone position, the mechanism of the transmission with the dog in the head-elevated position is unclear. We tested the hypothesis that a Starling resistor-type mechanism exists in the jugular veins when the head is elevated. In one group of dogs, increasing PEEP linearly increased Pcev with the dog in the prone position (head at heart level, slope = 0.851) but did not increase Pcev when the head was elevated. In another group of dogs, an external chest binder was used to produce a larger PEEP-induced increase in Pra. Further increasing Pra increased Pcev only after Pra exceeded a pressure of 19 mmHg (break pressure). This sharp inflection in the upstream (Pcev)-downstream (Pra) relationship suggests that this may be caused by a Starling resistor-type mechanism. We conclude that jugular venous collapse serves as a significant resistance in the transmission of Pra to Pcev in the head-elevated position.

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Anaesthesia for Neurosurgery in the Sitting Position: A Practical Approach

Anaesthesia and Intensive Care ◽

10.1177/0310057x0503300307 ◽

2005 ◽

Vol 33 (3) ◽

pp. 323-331 ◽

Cited By ~ 33

Author(s):

C. M. Domaingue

Keyword(s):

Superior Vena ◽

Venous Pressure ◽

Vena Cava ◽

Air Embolism ◽

Transoesophageal Echocardiography ◽

Systemic Circulation ◽

Right Atrial ◽

Sitting Position ◽

Volume Loading ◽

Venous Air Embolism

Neurosurgery in the sitting position offers advantages for certain operations. However, the approach is associated with potential complications, in particular venous air embolism. As the venous pressure at wound level is usually negative, air can be entrained. This air may follow any of four pathways. Most commonly it passes through the right heart into the pulmonary circulation, diffuses through the alveolar-capillary membrane and appears in expelled gas. It may pass through a pulmonary-systemic shunt such as a probe patent foramen ovale (paradoxical air embolism); it may collect at the superior vena cava-right atrial junction. Rarely it may traverse through lung capillaries into the systemic circulation. Many monitors, such as the precordial Doppler, capnography, pulmonary artery catheter, transoesophageal echocardiography are useful for venous air embolism detection, with transoesophageal echocardiography being today's gold standard. Various manoeuvres, including neck compression and volume loading, are also useful in reducing the incidence of venous air embolism. Volume loading, in particular, is very helpful as it reduces the risk of hypotension. Other particular concerns to the anaesthetist are airway management, avoidance of pressure injuries, and the risk of pneumocephalus, oral trauma, and quadriplegia. Newer anaesthetic agents have made the choice of anaesthetic technique easier. An appreciation of the implications of neurosurgery in the sitting position can make the procedure safer.

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