Premedication and Preparation

The modalities of preoperative treatment intended to reduce anxiety and achieve an adequate level of sedation will depend on the neurologic condition and clinical grade of the patient immediately prior to surgery and, therefore, must be individualized. The benefits of preventing anxiety-related arterial hypertension, which could lead to aneurysmal rebleeding, must be balanced against the risk of oversedation, which prevents appropriate preoperative neurologic assessment and depresses ventilation. The latter could also result in hypercarbia and subsequent increase in CBF and intracranial pressure (ICP). Patients who present with Hunt and Hess (H&H) (6) or World Federation of Neurological Surgeons (WFNS) (7) Grades I and II benefit from a reassuring preoperative visit by the anesthesiologist. A patient who appears anxious might benefit from a small intravenous (IV) dose of a benzodiazepine and/or opioids (midazolam 1-2 mg; fentanyl 50-100 mcg) administered. In contrast, patients with a decreased level of consciousness (clinical Grades III and IV) are unlikely to suffer from significant anxiety. In fact, many patients with higher grades are intubated and mechanically ventilated and might need higher doses of benzodiazepines and opioids (IV administration of midazolam 5-10 mg and fentanyl 100-200 mcg) together with a muscle relaxant (e.g., vecuronium and rocuronium) to tolerate transport from the ICU to the operating room (OR). However, it is critical to avoid any sudden or profound decrease in systemic blood pressure and/or increase in ICP, because it might compromise cerebral perfusion pressure (CPP) and result in cerebral ischemia. It is, therefore, paramount to maintain and adapt as necessary the administration of vasoactive drugs (e.g., catecholamines and nimodipine) throughout transport and anesthesia care. The potential risk for aneurysmal rupture during the course of the operation requires at least four units of blood crossmatched and available to the OR at start of surgery for all patients.

Anxiety and Depression 101

Anxiety and Depression 101

Everything you ever wanted to know about. We have been discussing depression and anxiety and how different information that is out on the market only seems to target one particular cure for these two common conditions that seem to walk hand in hand.

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