Vestibular schwannoma for retrosigmoid craniotomy48-year-old woman, 72 kg, for elective retrosigmoid craniotomy for a large right vestibular schwannoma

The patient

The examiner asks

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1. Consider

   What are your concerns?

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   • A 48-year-old with a large vestibular schwannoma, for elective retrosigmoid craniotomy in park-bench. Patient
   • Coughing on drinks suggests her ninth and tenth nerves are already weak. Disease
   • Her facial nerve will be monitored, so relaxant must be gone by then. Surgery
   • Brainstem and nerve handling can swing her pressure and heart rate suddenly.
   • Head above the heart: park-bench doesn't remove the risk of air embolism.
   • Mild hydrocephalus means her ICP may already be raised. Disease

2. Prepare

   What do you check, and how do you get ready?

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   • I examine and record her gag, cough, swallow and facial power before surgery. Disease
   • Consent includes possible overnight ventilation if her airway reflexes worsen. After surgery
   • Arterial line, two large cannulas, and capnography watched for a sudden fall. Disease
   • Agreed with the surgeon: relaxant for intubation only, none during facial nerve monitoring. Surgery

3. Plan

   How will you conduct the anaesthetic?

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   • TIVA with propofol and remifentanil keeps her still without relaxant during EMG. Surgery
   • Park-bench, head up: I watch ETCO2 and pressure for air embolism, neck veins free.
   • During brainstem work I watch the ECG and tell the surgeon about any swing.
   • No nitrous oxide once the dura is closed; trapped gas can cause tension pneumocephalus.
   • Smooth emergence, systolic kept under 160 to protect the operative bed. After surgery
   • Extubate only with a strong cough and gag; otherwise she stays ventilated in ICU. Airway

4. Crisis

   Forty minutes after stopping propofol she is not waking: GCS 7, then restless and agitated; pupils equal. What do you do?

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   • Delayed waking: rule out residual relaxant, sedative drugs, low temperature and electrolytes. Crisis
   • Twitch monitor for residual block; naloxone 40 mcg every 2 min if opioid is likely.
   • Not explained: urgent CT for haematoma, ischaemia or tension pneumocephalus.
   • Keep her intubated and ventilated for the scan; protect her airway.
   • Tension pneumocephalus: the surgeon drills a twist-drill hole and punctures the dura.
   • Haematoma: straight back to theatre. After surgery

5. Crisis

   Next day, an hour after extubation and her first drink, she coughs, desaturates to 86% and has right-sided crackles. What do you do?

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   • Aspiration from lower cranial nerve palsy; her IX and X were weak before surgery. Crisis
   • Sit her up, suction, oxygen; nothing more by mouth.
   • For pneumonitis, oxygen with PEEP works best.
   • If she tires or can't clear secretions, reintubate and ventilate in ICU.
   • A normal chest X-ray early doesn't exclude it; changes take 6–12 hours.
   • Nil by mouth until a formal swallow assessment; tube feeding until then. After surgery