High Dose Fentanyl-Oxygen Anesthesia for Intracranial Mycotic Aneurysm Surgery

Abstract

Although this paper recounts a technique of anesthesia that obviously served this patient well, it might be important to highlight some of the steps and indicate their potential results. First, the administration of 12 mg. of pancuronium for tracheal intubation, although it undoubtedly provided good conditions nonetheless committed the patient to muscle relaxant action for well over 1 hour, if not 2. Had there been any need to restore normal breathing, it would have been impossible to do so. The use of large doses of fentanyl made the administration of naloxone necessary at the end of the procedure and during the postoperative period. The commentator has an inherent distrust of techniques of anesthesia that depend heavily on the reversal of drugs acting on the brain by antidotes. It is clear from the author's account of what happened that no problem arose in this particular instance. Although it is a matter primarily for the surgeon, the commentator would have been a little concerned at lumbar drainage. Cerebrospinal fluid was being drained in a patient in whom there was some kind of early space-occupying lesion within the brain substance, where angiography had revealed the presence of a right frontal mass. The commentator would have preferred a left anterior horn ventricular tap as a means of reducing the brain bulk, and possibly the use of mannitol, for both these methods of lowering intracranial pressure are, in theory at least, less likely to result in a medullary pressure cone. Again, however, it must be emphasized that no serious problem did arise from this cause, and the authors are to be congratulated on obtaining so good a result in so difficult a case.