Neuroanesthesia

Some of the more interesting cases I've done are craniotomies for brain cancer, often intense all-day cases. Simply the preparation and anesthesia for these surgeries take a significant amount of time. After intubating the patient, we place extra IVs, an arterial line for moment-to-moment blood pressure monitoring, and a central line for access. Positioning the patient takes time as well; the surgeon often will place pins in the head to keep it in place, allowing him to use stereotactic imaging to precisely locate the cancer. The surgeries are often done with neurologic monitoring; a specialized technician places electrodes in various muscle groups, and throughout the operation, stimulates these to make sure that the brain surgery hasn't damaged any of the motor pathways to those muscle groups. This provides an anesthetic challenge as well because inhaled agents will interfere with neuromonitoring. Each institution has a specialized cocktail, and at Valley, it's an interesting combination of remifentanil, propofol, and low dose sevoflurane. Most of the time, the surgeries proceed pretty smoothly. The  neurosurgeons at Valley are outstanding and we rarely run into complications. I often enjoy watching the surgeries themselves; seeing someone operating on the brain is really quite amazing.

Image of brain surgery shown under GNU Free Documentation License, from Wikipedia.