EDUCATION CORNER

A Reflection On My Neuroanesthesiology Rotation Experience

Ji Yoon Baek, MD
CA-2 Resident
Department of Anesthesiology
SUNY Upstate Medical University
Syracuse, NY

Eugenia Ayrian, MD
Ji Yoon Baek, MD

During the first week of neuroanesthesiology month in my CA-1 year, I had my very first case of cerebral aneurysm clipping procedure. I approached the case with some anxiety and nervousness, particularly for the fear of potential intraoperative rupture of the aneurysm. To prepare for it, I read about the anesthetic management of intraoperative aneurysm rupture the night before the operation and discussed this potential with my attending. On the morning of surgery, my attending came into the OR with a printout of an algorithm for the management of intra op aneurysm rupture and taped it on the anesthesia machine. I called the blood bank for the availability of blood products and made sure that all the potentially necessary medications were readily available.

Although prepared for the dreaded event, I held my breath and watched anxiously as the screen showed the neurosurgeon carefully placing the clip. Things appeared to be going smoothly until all of the sudden, the aneurysm ruptured and the whole screen turned red instantly. Because my attending and I were prepared, we were able to effectively provide the conditions in which the surgeon could identify the location of, and control the bleeding, while keeping the patient’s condition stable. 

I look back to my neuroanesthesiology rotation with particular fondness, not only because it was my very first subspecialty rotation and I encountered a wealth of interesting pathologies during the rotation, but also because it forced me to grow and adopt a particular mindset whenever I provide anesthesia to my patients. Just to list a few, the following are what I learned and experienced during my rotation in neuroanesthesiology that fueled my growth as a starting anesthesiology resident. 

First, I learned the importance of the way I talk to each patient preoperatively. Although I had just a few minutes on average to meet each patient and speak to them, I realized that the tone of my voice and the way I talked to them matter in shaping the patient’s expectation for the surgery. For example, when talking to a patient who will likely do well with a surgical resection of a simple pituitary tumor, it may be alright to speak in a promising and reassuring tone that will place the patient at ease for the anticipated surgery. However, I quickly learned that it may not be okay to speak in the same tone to a patient who comes in for a biopsy of an intracranial tumor that appeared aggressive on imaging. 

Second, I learned to pay close attention to each step of the procedure and to remain vigilant to what the surgeon is doing. As mentioned above, watching closely at the critical moment of the aneurysm clipping was crucial in detecting the rupture instantly and acting in a timely manner to facilitate control of the bleeding. Also, one of the first things I learned to do during my neuro month was to anticipate the changes in the vital signs and the ICP and thus medicate the patient prior to the Mayfield head clamp placement.  

Third, neurosurgical patients pose unique anesthetic challenges. I recall a particularly nervous patient who came in for a DBS procedure. The challenge was to provide just enough anesthesia to get the patient through the preoperative MRI and Burr hole placement and facilitate a quick transition to a completely awake state in anticipation of the target localization and electrode insertion step of the surgery. Then, the patient had to be induced into general anesthesia for the subcutaneous tunneling for battery placement, the last step of the procedure. It was a delightful challenge to learn each surgical step of this procedure and to master how to provide various depths of anesthesia for each step. Smooth emergence and rapid wake-up from anesthesia to avoid or minimize postoperative intracranial bleeding and encouraging the patient to participate in a post-op neurological exam were also important challenges.

Though I encountered pathologies and various anesthetic considerations unique to neuroanesthesiology, all the above things I learned from my neuro rotation are relevant and vital to incorporate into all surgical procedures that require anesthesia. For that reason, I am glad that I had neuro rotation early in my CA -1 and, as a result, learned all these valuable things early on. As a result of the experience I had during my neuro rotation, I adopted a particular mindset that I believe is essential in practicing anesthesiology – to remain vigilant in each step of the surgery, to embrace the anesthetic challenges unique to each surgery, and to display sensitivity to the patient’s unique condition regardless of how short the conversation you have with them. With this mindset, I look forward to the privileges of providing anesthesia for my patients whom I have yet to meet in the future.

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