NeuroAnesthesiology Rotation
Curricular Milestones
Perform pre-operative assessment of the neurosurgical patient (Basic)
1. Obtain relevant neurologic medical history, including recent or evolving neurologic
symptoms, response to current medical management, significant imaging findings
(mass effect, location of tumor, etc), previous anesthetics
2. Perform a focused neurological exam, and understand the basics of anatomic
localization of focal findings
3. Discuss with surgeon patient medical condition and understand surgical concerns
and requirements for the procedure
4. Summarize and interpret pertinent patient diagnostic and imaging findings
Perform pre-operative assessment of the neurosurgical patient (Advanced)
1. Determine if additional diagnostic tests are needed and order/ interpret as
appropriate
2. Develop a management plan that takes into account the potential non-neurologic
consequences of neurologic injury (eg, aneurysm and myocardial injury)
3. Develop a plan to mitigate secondary injury due to hypoperfusion, hyperthermia,
hyperglycemia, and metabolic or electrolyte abnormalities.
4. Demonstrate the ability to provide a concise but adequately detailed casepresentation
Formulation of an appropriate anesthetic plan (Basic)
1. Understand the relevance of imaging findings (mass effect, cortical versus cerebellar
lesions, hematoma vs. tumor, etc.)
2. Identify and formulate a management plan for patients at greater risk for neurologic
complications including:
o Intracranial hypertension or surgical conditions requiring significant brain
relaxation
o Intraoperative intracranial hemorrhage (subdural, aneurysm rupture,
surgical bleeding)
o Normal pressure hyperemia
o Seizures during awake brain mapping
o Airway management in awake craniotomy
3. Understand the implications of sedative/hypnotic premedication (i.e. possible
hypoventilation)
4. Understand the indications and rationale for mannitol, hypertonic saline,
furosemide, anti-epileptic drugs (AEDs), dexamethasone, propofol and other
hypnotic drugs
Formulation of an appropriate anesthetic plan (Advanced)
1. Identify potential ethical issues (e.g. consent issues in the neurologically
compromised patient, transfusion refusal, etc.)
2. Prepare an appropriate anesthetic plan that minimizes secondary brain or spinal
cord injury, optimizes intraoperative surgical conditions and facilitates post-op
neurological examination
3. Provide an anesthetic that optimizes neuromonitoring (somatosensory and motor
evoked potentials, EMG, EEG), spinal cord and brain mapping, and placement of
deep brain electrodes
Induction of anesthesia and airway management in the brain or spine injured
patient
1. Select an appropriate technique for airway management based on a thorough
understanding of the rationale and indications for rapid sequence induction,
fiberoptic and videscope intubation, and demonstrate mastery of these and other
emergent airway management skills.
2. Understand and perform proper airway management for patients with acute and
chronic spinal cord pathology including myelopathy, unstable injuries and patients
in immobilization/traction devices
3. Have an appropriate pan for securing the airway in DBS or other procedure with a
head frame in place
4. Understand and perform proper airway management including airway rescue in
patients with increased intracranial pressure, intracranial mass lesions, and awake
intracranial procedures.
5. Understand the effects of lidocaine, fentanyl, atropine dexmedetomidine,propofol, ,
benzodiazepines, ketamine, and muscle relaxants (nondepolarizing and
depolarizing) on cerebral and spinal cord physiology and intracranial pressure
during induction
Invasive monitoring and procedures (Basic)
1. Understand the basic methods of intracranial pressure monitoring (EVD, bolt,
camino, spinal drain.) and the rationale for their selection
2. Properly transduce and manage a ventriculostomy and spinal CSF drainage system
3. Understand the indications for precordial Doppler, and central venous cannulation
(antecubetal, subclavian and internal jugular vein) in intracranial and anticipated
large blood-loss procedures (eg, spine, carotid body tumors)
4. Provide appropriate positioning to protect the eyes, nerves, and skin from injury
5. Properly place, secure, and monitor arterial lines and understand the factors that
affect accuracy
Invasive monitoring and procedures (Advanced)
1. Be able to place and use right atrial catheters for the treatment of patients at high
risk of venous air embolism (VAE) and detect VAE
2. Understand the indications for and be able to perform lumbar spinal drain
placement
3. Understand the basic techniques involved in performance of a scalp block for awake
neurosurgery
4. Master the proper routing and management of lines, tubes and cables during patient
positioning, including supine to prone and 180 degree table turn
5. Master the proper positioning of patients in prone, supine, lateral, recumbent and
sitting positions
6. Be able to anticipate positioning based on patient pathology and surgical preference
Maintenance of anesthesia for Craniotomy (Basic)
1. Understand the concept of “brain relaxation” including the effects of inhaled and
intravenous agents, PaCO2, hyperosmolar solutions, and fluid selection.
2. Understand the indications and rationale for the use of total intravenous anesthesia
for brain surgery as well as recognition of those cases where this technique is not
required
3. Understand the effects of propofol, benzodiazepines, inhaled anesthetics, opioids,
barbiturates, ketamine, and inhaled anesthetics on cerebral physiology
4. Understand the basic pharmacology of anti-epileptic drugs and the indications for
and safe administration of phenytoin, phosphenytoin and keppra
5. Learn to recognize and treat possible complications of neurosurgery including
venous air embolism, intracranial hemorrhage, intraoperative aneurysm rupture or
trapping, seizure, and herniation syndromes
6. Be able to perform an appropriate wake up with minimal coughing, hypertension,
and preservation of the neurologic exam
Maintenance of anesthesia for Craniotomy (Advanced)
1. Understand the CNS consequences of vasopressors, inotropes, and
antihypertensives
2. Develop a plan to manage BP, heart rate, and fluid resuscitation (goal directed
therapy) that optimize CNS, cardiac, renal and GI outcomes
3. Maintain the appropriate depth of anesthesia that allows optimal hemodynamic
management during induction, head pinning, emergence and that minimizes
surgical stress, maintains adequate physiologic parameters and allows timely
emergence from anesthesia
4. Manage sedation for awake neurosurgical procedures including regional anesthesia,
airway considerations, and awake functional testing
5. Manage acute and chronic pituitary injury and associated neuroendocrine pathology
Maintenance of anesthesia (Spine Surgery)
1. Understand the indications and rationale for the use of total intravenous anesthesia
for both spine surgery
2. Understand the effects of propofol, benzodiazepines, inhaled anesthetics, opioids,
barbiturates, ketamine, and inhaled anesthetics on spinal, and peripheral nerve
physiology
3. Understand the indications and limitations of processed EEG monitoring including
the digital EEG, spectral edge, and processed number and demonstrate the ability to
apply this information to management of anesthesia.
4. Understand the physiology of massive hemorrhage and transfusion, the role of
antifibrinolytics, and coagulation testing, and be able to provide anesthetic
management to control coagulopathy, limit cardiovascular instability, preserve
perfusion, and minimize lung injury from transfusion.
5. Understand how to monitor and effectively manage coagulopathy due to
disseminated intravascular coagulation, blood loss abnormal platelet function or
product availability
Maintenance of anesthesia (DBS and Neuro IR)
1. Understand the basic physiology and pharmacologic treatment of movement
disorders and the implications for management during Deep Brain Stimulator
placement
2. Manage sedation and general anesthesia for patients in neuro-interventional
radiology, with particular understanding of management goals during catheterdirected lysis/thrombectomy for stroke, aneurysm coiling or embolization,
treatment of cerebral vasospasm, and hemodynamic management during
embolization of an AVM or deployment of an intra-arterial stent
Intraoperative Neuromonitoring
1. Understand the basic modalities of intraoperative neuromonitoring and the
rationale for their use (SSEP, MEP, EMG, EEG)
2. Understand the effects of commonly used anesthetic drugs on CNS physiology and
consequences for monitoring
3. Understand how to manage BP, anemia, and hypovolemia to optimize neurologic
function and monitoring modalities.
4. Understand and apply the concepts of latency, amplitude and configuration to
neuromonitoring studies.
5. Recognize, trouble shoot, and respond to alerts from the neuromonitoring team
when signals are degraded or lost, including basic interpretation of monitoring data
and recognition of the ways this data might suggest positioning changes, blood
pressure management, or alterations in anesthetic drug concentrations
Professionalism and multi-disciplinary communication and teamwork
1. Practice coordination of care and active communication with the surgical teams
with special attention to “pre-flip baselines,” and brain relaxation management
2. Master effective communication and teamwork with operating room staff,
neuromonitoring technicians, and radiology technicians
3. Master efficient but thorough signout to the neuro ICU team including all important
details of the intraoperative and immediate post-operative course and highlighting
any ongoing concerns at time of transfer of care
4. Establish and execute a protocol (pathway) to manage patient care from
preoperative through postoperative phases of care (eg, patient needs follow up on
hyperglycemia)