Pre-op Verbal Preparation - Since the patient is awake and able to communicate with the OR team during the procedure, you should prepare them for the experience. Pre-operative scalp block, surgical pinning, OR noise, remaining still, and how to properly communicate discomfort/pain should all be discussed. Pre-Induction Pharmaceutical Preparation - Just before induction, most patients will receive a loading dose of Keppra for seizure prophylaxis. A common loading dose is 500 mg IV. Drips - The patient will be awake and able to speak (for neuro exams) all the way through the procedure. The propofol and remi drips are titrated basically just enough to manage pain and anxiety. Some suggest starting Remifentanil at .3-.5mcg/kg/min and Propofol at 100mcg/kg/min titrated to keeping the patient conscious. Lines - Have two at least two large-bore IV's. An arterial line will be placed either before the case in preop, or in the OR shortly after the patient arrives. It may be advisable/kind to have local anesthetic ready for that placement. Airway Preparation - it is common to use a nasal cannula with ETCO2 monitor. However, have a nasal airway, supraglottic airway, and ETT ready in case of airway complications (eg. seizures). 5-ALA - this is a compound (swallowed by the patient before the surgery, in a liquid solution) that causes malignant glioma cells to fluoresce. If it's used during the case, the OR lights will be turned off. Organize Your Lines - Neurological assessments are conducted periodically during the case, so ensure that lines are positioned and secured in a manner that prevents them from malfunctioning or shifting due to patient movement. Soft Bite Block - Make a soft bite block for the patient to absorb some of the vibration from the drill. A common method to create one: Roll up 4x4s and wrap with silk tape. Scalp Block - use 0.0375% Bupivicaine, epinephrine, and sodium bicarbonate. The scalp block will be done in small (usually 10cc) doses around the areas that will be pinned or operated on. Watch carefully during pinning and incision to assess effectiveness of block or need for more local. Intraoperative Drugs - Fosphenytoin is a drug that surgeons may ask for if they anticipate a lot of stimulation during the case. The use of this is highly variable and surgeon preference, so have it available. IV ondansetron and acetaminophen are also good to give before the end of case. Sedation Cessation - Do not turn off sedation fully until the patient is out of the surgical pins.
