BP in brain stims?

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waterbottle10

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So we do a lot of brain stims for Parkinson's. And the surgeon requires a blood pressure of sbp<130 thru the entire case BC she says it is unsafe and can lead to hemorrhage above that SBP.

Anyone with experience in these cases? We don't have many surgeons doing this here so I am wondering what your experiences are for these cases.

It can get a bit annoying since patient goes from sedated to fully awake to test the stim and some of them freak out/get rly anxious and their bp goes up and you can't give sedatives

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Low dose nicardipine bolus is your friend. Can also have a good base of BB on board and give gentle neo while sedated then turn it off before the awake portions. Many ways to skin this cat, and the tight BP control is pretty universal on these cases hence the a-line.
 
I use a nitroglycerin drip. As stated above, there are many ways to skin a cat. My only recommendation would be to use something short acting so that if/when you fully anesthetize them for the generator placement, their BP isn't in the pits.

Couple of other random thoughts as well, and I apologize as I mean no offense by the following: intracranial hemorrhage is one of the major risks for these cases and expert consensus is to keep the SBP < 140mmHg. "The surgeon says it's unsafe" and "It's annoying because I can't give sedatives" makes you sound like a propofol monkey (read: nurse) that doesn't understand the anesthetic considerations for the case. You should KNOW that it is unsafe to have a patient's BP sky high, and you should understand why you shouldn't be giving sedatives. I understand you may be unfamiliar with these cases but do a literature search and read up on it if you don't understand them. Here is a great review article: http://www.flanesthesia.com/wp-cont...Management_of_Patients_Undergoing_Deep.26.pdf

Additionally, calling it a "brain stim" further adds to this unsettling feeling I have. Please refer to the procedure as a deep brain stimulator insertion.
 
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I use a nitroglycerin drip. As stated above, there are many ways to skin a cat. My only recommendation would be to use something short acting so that if/when you fully anesthetize them for the generator placement, their BP isn't in the pits.

Couple of other random thoughts as well, and I apologize as I mean no offense by the following: intracranial hemorrhage is one of the major risks for these cases and expert consensus is to keep the SBP < 140mmHg. "The surgeon says it's unsafe" and "It's annoying because I can't give sedatives" makes you sound like a propofol monkey (read: nurse) that doesn't understand the anesthetic considerations for the case. You should KNOW that it is unsafe to have a patient's BP sky high, and you should understand why you shouldn't be giving sedatives. I understand you may be unfamiliar with these cases but do a literature search and read up on it if you don't understand them. Here is a great review article: http://www.flanesthesia.com/wp-cont...Management_of_Patients_Undergoing_Deep.26.pdf

Additionally, calling it a "brain stim" further adds to this unsettling feeling I have. Please refer to the procedure as a deep brain stimulator insertion.

No offense taken. Thanks for info. I did some searches but I didn't see any studies but did some see 'expert opinions' that's why I was wondering where this sbp# came from. I'll read that link

And didn't realize ppl routinely put arterial lines for these
 
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We don't put art lines- but our DBS cases involve a fair amount of intraoperative testing to optimize lead placement, so freely moving arms is a plus. BP can go quite high without intervention, but typically not that fast so I don't really see the need anyway.

Talk to your surgeon- some have strong preferences against using BBs, as they can improve PD symptoms on a day when you want see maximal effect from stimulation. We use hydral, then ntg


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We used to do a lot at my old place (5-6/week sometimes) normally under sedation without an a-line. Our surgeons were a little bit more lax with blood pressure control; they pretty much wanted it somewhere under 150. As a neuroanesthesiologist/intensivist I can honestly say I don't worry about short periods where the BP might be slightly above some arbitrary goal set by the neurosurgeon. Just try and prevent extreme and sustained hypertension and for this I agree with the use of nicardipine if the typical bolus antihypertensives (hydralazine/labetalol) fail. We rarely use nitroglycerine for blood pressure control in Neuro as it causes cerebral venous dilation to a greater degree than nicardipine and thus increased ICPs (Monroe-Kellie Doctrine).
 
I used clivedipine for the last one I did. For funsies
 
We always did an A-line in residency and our functional neurosurgeon here in PP wants a-lines too. Maybe we're just a bunch of pansies?
 
Man, had a patient the other day everything was going fine, and then it was time to wake patient up for lead testing, then patient freaks out and starts crying and her BP shoots up by almost 50. the surgeon was so pissed... started nicardipine but it takes time to work, and bolused a bunch of labetalol and esmolol. Hard to drop BP of a crying anxious patient. Wanted to give hydralazine but we dont have it in our rooms
 
We used to do a lot at my old place (5-6/week sometimes) normally under sedation without an a-line. Our surgeons were a little bit more lax with blood pressure control; they pretty much wanted it somewhere under 150. As a neuroanesthesiologist/intensivist I can honestly say I don't worry about short periods where the BP might be slightly above some arbitrary goal set by the neurosurgeon. Just try and prevent extreme and sustained hypertension and for this I agree with the use of nicardipine if the typical bolus antihypertensives (hydralazine/labetalol) fail. We rarely use nitroglycerine for blood pressure control in Neuro as it causes cerebral venous dilation to a greater degree than nicardipine and thus increased ICPs (Monroe-Kellie Doctrine).

Why does ICP matter in a DBS implantation? Nitroglycerin is a fine drug to lower SBP in these cases. I trained at probably one of the busiest neurosurgical centers in the country and we used to use it frequently.

Also the goal that is set isn't all that arbitrary -- look at the review article I had posted above. Though it may not be based on trials and whatnot, experts in the field agree that keeping the SBP < 140 mmHg is desirable due to the increased incidence of hemorrhage in hypertensive patients. I agree that having a couple periods here and there where the pressure is up shouldn't worry you too much, but in general you should aim to control it a little more tightly than you would in other cases.
 
As a resident, I have never put in an A-line, or had a patient that was particularly upset during the awake portion. Neurosurgeons always ask for "normotension", no specific number. Patient selection is a major factor, most are well-educated and affluent, highly motivated and more than willing to go along with the awake portion. Usually when the neurologist is testing the lead position with the patient fully awake, the mood in the room is lighthearted. No patient melt-downs so far. I have been using propofol and alfentanil for sedation and analgesia, surgeons give healthy dose of local. Interesting to hear how practices vary from place to place.
 
As a resident, I have never put in an A-line, or had a patient that was particularly upset during the awake portion. Neurosurgeons always ask for "normotension", no specific number. Patient selection is a major factor, most are well-educated and affluent, highly motivated and more than willing to go along with the awake portion. Usually when the neurologist is testing the lead position with the patient fully awake, the mood in the room is lighthearted. No patient melt-downs so far. I have been using propofol and alfentanil for sedation and analgesia, surgeons give healthy dose of local. Interesting to hear how practices vary from place to place.

Alfentanil infysion?
 
Why does ICP matter in a DBS implantation? Nitroglycerin is a fine drug to lower SBP in these cases. I trained at probably one of the busiest neurosurgical centers in the country and we used to use it frequently.

My experience has been that ntg can give patients a wicked headache, especially when pushed. Much rather prefer pushing cardene during dbs.
 
Remi infusion? 0.15mcg/kg/min is usually golden
 
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My experience has been that ntg can give patients a wicked headache, especially when pushed. Much rather prefer pushing cardene during dbs.

Not sure, I do these cases fairly frequently and I have never had a patient complain about headache during it. Admittedly I rarely push it though, usually just start an infusion.
 
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