A 5 year-old female is having a craniectomy for resection of a posterior fossa tumor. Which of the following would be MOST appropriate for intraoperative management of this patient?
a) Temperature controlled to 34-36 degrees Celsius
b) Blood transfused to achieve goal hemoglobin 12 g/dL
c) Flexion of the neck until the chin reaches the chest
d) Continuous arterial blood pressure monitoring
e) Administration of ½ Normal saline during the case
Answer d. In some cases, arterial cannulation may not be indicated (based on patient, provider, and local practice factors); however, in general placement of an arterial catheter is useful during the procedure for continuous blood pressure and intermittent laboratory data assessment. Furthermore, postoperatively in the ICU, an arterial cannula is very helpful in avoiding frequent phlebotomy sticks for laboratory assessment. On the other hand, therapeutic hypothermia (A) and hyponatremia fluids (E) are NOT indicated for this case and may be harmful. There is considerable debate about the optimal hemoglobin level, but few providers would transfuse up to a hemoglobin of 12 g/dL. Finally, extreme flexion of the neck for prone cases such as this one may result in spinal cord ischemia as well as decreased venous drainage from the cerebral vasculature (with associated risk of intracranial hypertension).