Non Opioid Crainiotomy

Recently, during my neuro-surgery rotation at a major medical center here in Los Angeles, I had the privilege to work with Robert Naruse, M.D. My time with him was fabulous and so totally entertaining. Now maybe that is not what a high stress rotation should sound like – after all this is brain surgery – but it was so much fun working with him. Dr. Naruse is a terrific advocate for nurse anesthesia practice and his knowledge of anesthesia is profound. Working with him for a month has been the best experience of my short career as a student nurse anesthetist.

What I learned from working with him is not in any text books or journal articles. Believe me I looked long and hard. Prior to coming into this rotation for neuro-surgery I had been using quite a bit of opioids during induction and emergence. After all patients have pain from the surgery – that seems plain enough. Patients need opioids, need lots of opioids especially the indigent person who is enzyme induced and the ortho-surgical patient with large fractures. At least this is what I have been taught and seems reasonable.

In the course of a month during this neuro-surgical rotation we provided anesthesia care for over 20 large craniotomies and 25 or so spine cases. The total amount of opioid that I used during the entire month was…….let me calculate this up…….hydromorphone 2 milligrams. What you say only 2 milligrams of hydromorphone during an entire month of surgery? Yes and that was to only one patient who had chronic pain and was taking opioids regularly at home. For the ordinary patient without a habituated need, no opioids were given. You can read my case report of a very difficult craniotomy case in the clinical document section to evaluate my anesthetic plan. (Here is the link to the case study).

This issue of pain in an anesthetized patient is complex and currently there is not a consensus of opinion on the matter. This is a complicated issue and I do not have the acumen or wisdom to expound on it in depth at this moment but I have developed some opinions based on my clinical experience. What I do know is that I had been giving a lot of opioids prior to this rotation and now am giving far less. Currently my patients are waking up very nicely without pain and are really comfortable under my current regimen. For the neurosurgical patient especially the clinical picture during wake up is critical. Any agent clouding a patient’s mentation is to be used with the greatest care in these cases. This seems prudent at least for this patient population.

The experience of working with Bob has profoundly changed the way I do my anesthetic and so far my patients have been very happy for it. No one wants to see a patient in pain but giving opioids before a demonstrable need for me now seems to be imprudent. After you read the case report I would appreciate any feed back.