ICPNT Brain Monitoring Workshop Bootcamp: Reflections from Two Neuroanesthesia Fellows
Heather Brosnan, MD
Department of Anesthesia and Perioperative Care
University of California, San Francisco, CA, USA
Jean Beresian, MD, FASE
Clinical Fellow in Neuroanesthesiology
Department of General Anesthesiology
Anesthesiology Institute, Cleveland Clinic, OH, USA
The ICPNT Brain Monitoring Workshop Bootcamp was an afternoon dedicated to teaching attendees five methods of brain monitoring: jugular venous oximetry, pupillometry, cerebral oximetry, transcranial doppler (TCD), and intracranial pressure (ICP) monitoring. We moved from station to station in small groups, listened to two world-renowned experts speak briefly on each topic, and then learned how to use each team’s devices. As fellows, we learned the nuances of brain monitoring and enjoyed testing the devices. The following are our reflections on the boot camp:
Heather: My group started at the jugular venous oximetry station. Placing a catheter in the jugular venous bulb allows you to monitor venous oxygen content from the blood leaving the brain, which provides valuable information about cerebral oxygen supply and demand. Having never used jugular venous bulb monitoring, I especially enjoyed the clinical scenarios presented at this station because they got me thinking (possibly lowering my own SjvO2…). For example, what changes would you expect in a patient undergoing surgery for an AVM?
Next, we traveled to the pupillometry station. Having driven myself mad manually checking the pupils on neuro ICU patients, I am quite fond of pupillometers. As anesthesiologists, we all know the value of checking for conjugate pupils in an emerging patient, but how many of us have thought to use pupillometers to monitor levels of consciousness or analgesia in ICU patients? This station certainly opened my eyes to new ways we can use pupillometry.
The cerebral oximetry station was up next. I have a personal interest in how preoperative autoregulatory disturbances lead to postoperative complications, so I was excited when the discussion drifted into the use of intraoperative cerebral oximetry to monitor changes in cerebral blood flow. Naturally, there was some cross-over in the discussion from the jugular venous oximetry station. Still, as clinicians who are often tasked with decreasing cerebral blood flow, we must also keep in mind the importance of maintaining cerebral oxygenation.
I will admit that the next station was my favorite – TCD. As a trainee, I have repeatedly read about the utility of TCD but have never had a chance to use it. After a brief review of the direction of blood flow through the circle of Willis and its branches, I could easily identify the MCA versus ACA with the small doppler probe. I was thrilled to have a chance to use TCD finally.
The final station for my group was ICP monitoring. I am always excited when a patient comes to the OR with an EVD because I enjoy watching the ICP changes as I adjust my anesthetics and vent settings (and yes, my excitement about such things is why I’m doing a neuroanesthesia fellowship). I appreciated formally going through the different pieces of an EVD and how to safely care for a patient with an EVD. For those interested, there is a safety checklist for transporting patients with EVDs on the SNACC website.
Jean: I would like to thank ICPNT/SNACC for organizing the ICPNT Brain Monitoring Workshop Bootcamp at the SNACC 50th annual meeting in Seattle. This has been my first live SNACC meeting, and it has been a remarkable experience.
The five neuromonitoring stations were very well developed, and I had the opportunity to learn the theoretical concepts and then experience the practical aspects of each segment. Actual devices have been provided and we had the chance to even do TCD on normal subjects. How cool is it to put a probe on the skull to find and analyze the MCA, ACA, and PCA flow velocities?
I had limited knowledge regarding jugular venous oximetry and pupillometry. After the workshop, I developed a more comprehensive understanding of the two subjects. First, we had a detailed explanation of how to insert the jugular venous bulb catheter and how to withdraw blood slowly for jugular venous oximetry. Then several case scenarios reiterated its benefits and explained supply versus demand abnormalities. During the ICP monitoring, the presenters handed us different EVD devices and went through them in depth. The safety aspect of EVD during patient transport was critical.
Overall, we both found the boot camp informative and fun. The format was interactive, with a good balance between instruction, discussion, and hands-on training. To future neuroanesthesia fellows, we recommend attending these boot camps. In addition to learning new skills, they are a great opportunity to meet friends, mentors, and future colleagues.