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TERAPIA ENDOVASCULAR NEUROLÓGICA. IMPLICACIONES ANESTÉSICAS. ENRIQUE ANAYA ANESTESIA – CES . PROCEDIMIENTOS. Oclusivos Aneurismas, MAV, fistulas, tumores. Oclusión arterial. Abertura o Dilatación Vaso espasmo Angioplastia / Stent ACV Isquémico Trombolísis química o mecánica. - PowerPoint PPT Presentation

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TERAPIA ENDOVASCULAR NEUROLGICA.

TERAPIA ENDOVASCULAR NEUROLGICA.IMPLICACIONES ANESTSICASENRIQUE ANAYAANESTESIA CES

PROCEDIMIENTOSOclusivos Aneurismas, MAV, fistulas, tumores.Oclusin arterial.Abertura o Dilatacin Vaso espasmo Angioplastia / Stent ACV IsqumicoTrombolsis qumica o mecnica

Anaesthetic considerations for interventional neuroradiology Br J Anaesth 2007; 99:7585CACCESOS VASCULARESIntroductor femoral5 7,5 Fr

Catter Coaxial4 7 Fr

Micro catter1,2 2,8 Fr

Anesthetic Management of Interventional Neuroradiological Procedures. Advances in Anesthesia 27 (2009) 1243For diagnostic angiography, the femoral puncture site is inltrated with local anaesthetic and a large introducer sheath, usually 6.0 French gauge (FG), inserted into the femoral artery. Through this introducer, an end-hole cath-eter (4.06.0 FG) is then manipulated, under uoroscopic control, into the carotid or vertebral arteries. A 1.22.8 FG superselective microcatheter is introduced through the guide catheter into the cerebral circulation. The superselective catheter can be used to deliver drugs or embolic agents. Modied microcatheters are used for balloon angioplasty and stenting of intra- and extra-cranial vessels.MATERIALES USADOS Coils Desmontables Coils bioactivos acido poligliclico

Partculas de alcohol polivinil (PVA) Oclusin temporal

Anaesthetic considerations for interventional neuroradiology Br J Anaesth 2007; 99:7585

Techniques and Devices In Neuroendovascular Procedures Neurosurg Clin N Am 20 (2009) 315340MATERIALES USADOSONYXCo-polmero etil vinil alcohol (EVOH) disuelto en dimetil sulfxido + polvo tantalio Cianoacrilatos Adhesivos de polimerizacin rpida Exotrmico, retiro de catter

Anaesthetic considerations for interventional neuroradiology Br J Anaesth 2007; 99:7585

Techniques and Devices In Neuroendovascular Procedures Neurosurg Clin N Am 20 (2009) 315340MATERIALES USADOSOtrosGelfoam.

Agentes trombolticos.

Vasodilatadores.

Agentes de quimioterapia.

Anesthesia for Endovascular Neurosurgery and Interventional Neuroradiology. Anesthesiology Clin 25 (2007) 391412

IMGENESFluoroscopio de alta resolucin

Angiografa de substraccin digital alta velocidad

Scout film

Mapeo

Seguridad

Anesthetic Management of Interventional Neuroradiological Procedures. Advances in Anesthesia 27 (2009) 124TECNOLOGIA EN IMAGENESa scout lm is taken before each sequence of uoroscopy. The scout lm serves as a mask, which is subtracted by the computer from all subsequentimages so that only vessels opacied by contrast are visible. To facilitate placement of superselective catheters into the distal circulation, a technique called road mapping is used. To make a road map, a bolus of contrast is injected into the circulation from the guide catheter (e.g. internal carotid or vertebral artery) to obtain an image of the vascular anatomy. The computer then superimposes this image onto live, bone-subtracted uoroscopy so that the radiologists can see the progress of radio-opaque microcatheter (especially the tip) against the road map (Fig. 1). Good-quality road maps are dependent on the patient being motionless.7IMGENES

Angiograma por RNM en 3D.Techniques and Devices In Neuroendovascular Procedures Neurosurg Clin N Am 20 (2009) 315340

Exposicin del anestesilogo fue 3 veces mayor que la del radilogo. (6.5 mcSv x proced.)

Siempre utilizar equipos de proteccin incluyendo proteccin ocular.

OBJETIVOS ANESTSICOSInmovilidad y estabilidad fisiolgica.

Manipulacin optima del flujo sanguneo sistmico y regional.

Anti coagulacin.

Manejo adecuado de complicaciones.

Evaluacin neurolgica precoz.

Anesthesia for Endovascular Neurosurgery and Interventional Neuroradiology. Anesthesiology Clin 25 (2007) 391412PRE OPERATORIOLugar

Via area

Alergias y enf asociadas

Dficit neurolgico

Reserva cardiovascular

Laboratorio

Premedicacin

Posicin

Accesos IV

Seguridad

Anesthesia for Endovascular Neurosurgery and Interventional Neuroradiology. Anesthesiology Clin 25 (2007) 391412MONITORIAASA bsico

PAI PVC

SNC

Gasto urinario

Laboratorio

Anaesthetic considerations for interventional neuroradiology Br J Anaesth 2007; 99:758513TCNICA ANESTSICASEDACIN DINMICAAnsiolisis

Dolor

Comodidad

Inmovilidad

Recuperacin rpida

Anaesthesia for endovascular management of cerebral aneurysms. European Journal of Anaesthesiology 2006; 23: 902913SEDACIN DINMICAPropofol10 20 mcg/kg/min

DexmedetomidinaDosis de carga: 0,5 1 U mcg/kg x 10 min.Mantenimiento: 0,2 0,7 mcg/kg/Hr.

MidazolamPre medicacin.Test de memoria??

OpiodesFentanilo RemifentaniloDepresin respiratoria.Anesthetic Management of Interventional Neuroradiological Procedures. Advances in Anesthesia 27 (2009) 124ANESTESIA GENERALComodidad del paciente

Seguridad del anestesilogo y del neurocirujano.

Mejorar la calidad de las imgenes.

Anesthetic Management of Interventional Neuroradiological Procedures. Advances in Anesthesia 27 (2009) 124ANESTESIA GENERALVENTAJASImgenes

Seguridad de la VA.

Mejor control de variables respiratorias y hemodinmicas.DESVENTAJASEvaluacin neurolgica intraoperatoria.

Aumento de PA y de la PIC durante la intubacin y extubacin.Anesthetic Management of Interventional Neuroradiological Procedures. Advances in Anesthesia 27 (2009) 124ANESTESIA GENERALTIVA vs Balanceada.

Sevofluorane o Desfluorane.

Evitar oxido nitroso.

TOT o ML.Anesthetic Management of Interventional Neuroradiological Procedures. Advances in Anesthesia 27 (2009) 124

TCNICAS ADYUVANTES

ANTI COAGULACINPrevencin de eventos trombticos.

ACT de inicio

Heparina 70 U/kg (3000 5000 U)3 a 5 min despus nuevo ACT (2-3 basal)Sulfato de Protamina ( 1 mg/100 U)

Hirudinas - Clopidogrel ticlopinida ASA

Tirofiban eptifibatide Abciximab

Desmopresina / Factor VIIa Etamsilato / Plaquetas

Retiro de catterAnesthetic Management of Interventional Neuroradiological Procedures. Advances in Anesthesia 27 (2009) 124HIPOTENSIN INDUCIDATest de oclusin de cartida para evaluacin de la reserva cerebro vascular

Disminucin del flujo en MAV antes de la embolizacin con pegamento.

Anesthetic Issues and Perioperative Blood Pressure Management in Cerebrovascular Diseases Undergoing Surgical Procedures Neurol Clin 24 (2006) 647659HIPOTENSIN INDUCIDABloqueadores adrenrgicos.

Calcio antagonistas.

Nitro prusiato / Nitroglicerina.

Profilaxis anti emtica.

Paro cardiaco Adenosina

Anesthetic Issues and Perioperative Blood Pressure Management in Cerebrovascular Diseases Undergoing Surgical Procedures Neurol Clin 24 (2006) 647659

HIPERTENSIN INDUCIDADurante oclusin arteria cerebral o vasoespasmo.

30 40% sobre la PA basal o hasta la resolucin de los sntomas de isquemia.

Fenilefrina / Dopamina / Noradrenalina

EKG

Anesthetic Issues and Perioperative Blood Pressure Management in Cerebrovascular Diseases Undergoing Surgical Procedures Neurol Clin 24 (2006) 647659HIPERCAPNIA INDUCIDAPaCO2 50 60 mmHg

MAV de cabeza y cuello.

Redistribucin del flujo hacia vasos extra craneales.

Hipo ventilacin Capnografa.Anesthetic Management of Interventional Neuroradiological Procedures. Advances in Anesthesia 27 (2009) 124Manejo de catstrofesMANEJO CRISISAdecuada comunicacin.

Mantener oxigenacin y estabilidad cardiovascular.

Asegurar VA.

Determinar si el problema es hemorrgico u oclusivo.Anaesthetic considerations for interventional neuroradiology Br J Anaesth 2007; 99:7585CRISIS OCLUSIVASAumentar la perfusin distal.Hipertensin.Hipercapnia.Expansin de volumen.Manejo intervencionista.Vasodilatadores intra-arteriales.Trombolsis.Extraccin mecnica del trombo.Angioplastia o stent.Anaesthetic considerations for interventional neuroradiology Br J Anaesth 2007; 99:7585CRISIS HEMORRGICASCefalea Nauseas Vomito.

Bradicardia HTA Extravasacin del medio de contraste.

Reversin de la anti coagulacin.

Hiperventilacin Manitol SS hipertnica.

Hipotensin Vs Hipertensin.

Taponamiento con el catter coils stent.

Ventriculostomia / Craneotoma + clipaje

Anaesthetic considerations for interventional neuroradiology Br J Anaesth 2007; 99:7585Procedimientos especficos

MAVCongnitas

12% sintomticas Sangrado

Coadyuvante para Qx o manejo nico.

Objetivo es obliterar las arterias nutricias y las fistulas.Anesthesia for Endovascular Neurosurgery and Interventional Neuroradiology. Anesthesiology Clin 25 (2007) 391412Interventional neuroradiologyanesthetic considerations Anesthesiology Clin N Am 20 (2002) 347 359

MAVDuracin: 4-5 horas

MaterialesCianoacrilato, Onix, alcohol Flujo lento o detenido.

Mejora neurolgicaDisminucin del robo sanguneoTamao de masa

Anesthesia for Endovascular Neurosurgery and Interventional Neuroradiology. Anesthesiology Clin 25 (2007) 391412Interventional neuroradiologyanesthetic considerations Anesthesiology Clin N Am 20 (2002) 347 359

ABLACIN DE ANEURISMASIncidencia 0,2 9,9%

85% HSA.25% muertes cerebro vasculares

50% mortalidad sangrado inicial.

Gran morbilidad.Anesthesia for Endovascular Neurosurgery and Interventional Neuroradiology. Anesthesiology Clin 25 (2007) 391412Interventional neuroradiologyanesthetic considerations Anesthesiology Clin N Am 20 (2002) 347 359ABLACIN DE ANEURISMAS40% ACM. y CA.

20% ACI. y AB.

30% Mltipl