With the improvement of medical level and the arrival of population aging, the number of elderly (over 60 years old) brain tumor patients has increased, and the perioperative complications and mortality rate of elderly brain tumor patients are higher than that of young adults, so how to reduce the perioperative safety of elderly brain tumors and reduce the complications are doubly concerned by neurosurgeons. The author conducted a retrospective study on the clinical data of 140 cases of elderly brain tumor patients who underwent surgical treatment in the Brain Department of the Affiliated Hospital of the Armed Police Medical College from August 2005 to July 2009, and reported as follows. 1.Clinical data General data: 140 cases in this group, 72 males and 68 females, age 60-88 years old, average (69±6.1) years old. Tumor site: 98 cases of supratentorial tumors, accounting for 70.0%, 42 cases of infratentorial tumors, accounting for 30.0%. Tumor nature: 37 cases of benign tumors, accounting for 26.4%; 103 cases of malignant tumors, accounting for 73.6%. Preoperative co-morbidities: hypertension 29 cases (20.7%), coronary heart disease 28 cases (20.0%), chronic bronchitis, emphysema 23 cases (16.4%), diabetes mellitus 18 cases (12.8%), malnutrition 19 cases (13.5%), malignant tumors in other parts of the body 15 cases (10.7%), cerebral infarction 10 cases (7.1 percent), cerebral infarction 10 times (accounting for 7.1 percent), renal insufficiency 6 times (accounting for 4.3 percent), a total of 148 cases, of which: 32 cases combined with 1 kind of disease, 18 cases combined with 2 kinds of disease, 16 cases combined with 3 kinds of disease, and 8 cases combined with 4 kinds of disease. 2.Results Surgical situation: general anesthesia was used in all cases, and surgical resection was performed under the Leica microscope. Among the 37 cases of benign tumors, 35 cases were completely resected and 2 cases were mostly resected; among the 103 cases of malignant tumors, 85 cases were completely resected and 18 cases were mostly resected, among which 7 cases were decompressed by debridement flap. Postoperative complications: 15 cases of pulmonary infection (10.7%); 8 cases of stress ulcer bleeding (5.7%); 6 cases of intracranial hematoma (4.2%); 5 cases of epilepsy (3.6%); 4 cases of cerebral infarction (2.8%); 4 cases of dysphagia and choking (2.8%); 3 cases of intracranial infection (2.1%); 2 cases of incision infection (1.4%); 2 cases of deep-septal infection (2%); 2 cases of deep-septal infection (1.4%). (1.4%); and deep vein thrombosis in 1 case (0.7%). Complications totaled 25 cases, 48 times. Morbidity and mortality: 4 cases died within 1 month after surgery (including 2 cases died of intracranial hematoma, 1 case died of large cerebral infarction, and 1 case died of intracranial infection), with a mortality rate of 2.85%. 3, Discussion Brain tumors can occur at any age, and are more common in adults, with less incidence in the elderly, generally accounting for 3% to 8.9% of all intracranial tumors [1], the incidence of perioperative complications in the elderly is significantly higher than that in young adults, and the elderly patients with brain tumors are higher than the others. With the development of neurosurgery, the surgical mortality rate has decreased to 0~5%, but surgical complications are still inevitable and the incidence of poor prognosis after surgery is still high [2]. Elderly brain tumor patients have reduced cardiopulmonary compensatory function, often accompanied by a variety of comorbidities, coupled with the impact of general anesthesia craniotomy on the function of various organs of the patient, the postoperative period is prone to cause a variety of complications. How to reduce the postoperative complications of elderly brain tumors has attracted the attention of neurosurgeons. Correct preoperative evaluation of elderly brain tumor patients, selection of appropriate operative modality, and timely postoperative management of possible complications are the keys to perioperative management. Summarizing our clinical experience in the surgical treatment of 140 elderly (over 60 years old) brain tumor patients over the past 4 years, we believe that we should pay attention to the following aspects. 1, correct preoperative assessment, active treatment of comorbidities Physiological and psychological preparation: postoperative bedridden patients should practice urination and defecation in bed before surgery; for surgery that may affect the posterior cranial nerves, patients should be trained to cough, sputum, and swallow correctly; postoperative patients who need a special position or retention of drainage should be accounted for preoperatively, and patients should be cooperated with the operation. Understand the family’s expectations of the surgical results, explain the condition to the patient and the family, adjust the patient’s psychological state, so that the patient’s and the family’s psychological state is prepared and adjusted [3]. Gastrointestinal preparation : Elective general anesthesia surgery patients should be fed with fluids the night before surgery, fasted for 8 h before surgery, and water fasted for 6 h before surgery, to ensure gastric emptying, and to prevent gastric reflux during anesthesia resulting in aspiration. Nutritional support :Since postoperative feeding is poor, and tissue repair also needs to replenish energy, preoperative nutritional support should be strengthened, including calories, proteins and vitamins, in order to facilitate postoperative healing, enhance the body’s resistance, and defend against infections. Adjusting comorbidities and grasping the timing of surgery: Elderly patients with brain tumors are often accompanied by comorbidities, which should be corrected before surgery for patients suffering from malnutrition, diabetes mellitus, malignant tumors, undergoing radiation therapy or chemotherapy, and taking immunosuppressant for a long time to improve the resistance of patients. For example: hypertension, diabetic patients to adjust blood pressure, blood sugar to a relatively stable level; malnutrition patients to strengthen the oral energy intake, if necessary, intravenous supplementation; anemia patients blood transfusion; patients with hypoproteinemia transfusion of human albumin or plasma; patients with low white blood cells, the application of white blood cells, etc.; electrolyte disorders as far as possible to adjust to normal. However, the preoperative preparation time should not be too long, so as not to miss the best time for surgery. Perfect examination: understand the health condition and comorbidity of elderly brain tumor patients, perfect head imaging examination (such as: cranial CT, cranial magnetic resonance imaging (MRI), cranial magnetic resonance imaging (MRI), and some patients need to perfect special examination (such as: preoperative pure tone audiometry and auditory evoked potentials of acoustic neuroma; pituitary tumor visual acuity, visual field, and visual evoked potentials; and endocrinological examination of pituitary tumor and craniopharyngioma before surgery). Pituitary tumor: visual acuity, visual field and visual evoked potentials; pituitary tumor, craniopharyngioma: preoperative endocrinologic examination, etc.) Preoperative localization: Read the film carefully before operation, identify the anatomical markings, make localization images (e.g. electrode sheet for CT, cod liver oil pill for MRI) if necessary, make preparations for measurements, design the most reasonable approach, plan the boundary of the bone window, and strive to see the tumor after opening the bone window, shorten the operation time, and strive to achieve the best therapeutic effect with the minimum trauma. Surgical access and position: The choice of surgical access and position mainly depends on the site of the tumor, and also takes into account the microscope and possible problems during surgery. A suitable position can provide the operator with more reasonable exposure and easier operation during surgery. Avoid brain swelling caused by excessive twisting of the neck which may affect venous return and increase the difficulty of surgery. Skin preparation :Haircut can be done in advance, for folliculitis and other skin infection foci can be given iodine povidone externally in advance, shaving the head is best done in the morning of the day of surgery to prevent accidental injury to the scalp to form an infection, which can lead to surgical infection. Chloramphenicol ophthalmic drops were placed in the nasal cavity bilaterally for 3 d prior to the nasobutterfly approach surgery, and nasal hairs were clipped and rinsed 1 day prior to the surgery. Blood preparation :Routine blood type and cross-matching test, routine blood preparation 1 d before surgery, should be based on the condition of the decision of the amount of blood preparation, for the craniotomy range is large, the venous sinus may be damaged, blood rich tumor, preoperative blood preparation should be adequate. For large craniotomy area, the venous sinus may be damaged, and blood-rich tumors, the blood should be prepared sufficiently before surgery. Sign the informed consent for surgery: The possible accidents during the surgery and the potential complications after the surgery should be clearly considered and explained to the family members, and sign the informed consent for the surgery. Others :Sedative should be given to ensure good sleep the night before surgery, urine should be emptied before surgery, and urinary catheter should be left in place if long surgery time is expected. Remove the denture. What kind of special surgical equipment is needed. If the intracranial pressure of the subcuratorial tumor is significantly increased, extraventricular puncture drainage or ventriculoperitoneal shunt should be performed first. Preoperative ligation or interventional embolization of meningioma can reduce intraoperative bleeding and complications. 2, intraoperative precautions Surgery time should not be too long :Elderly people have poor physical condition, too long anesthesia time and too much medicine may lead to resuscitation difficulties; in addition, long surgery time and increased bleeding will also increase the risk of surgery. Pay attention to aseptic operation :Older people have low resistance, once infected, the operation fails. Avoid the flow of people after the beginning of surgery, limit the number of visitors, change gloves before opening the dura, and operate strictly aseptically during the operation. Intraoperative protection of the functional zone: different surgical styles are used according to the nature and location of the tumor, such as frontal pole resection, temporal pole resection, intracapsular segmental resection of the tumor, and so on. Identify the anatomical markers carefully during surgery to avoid pulling on the functional area. If the patient is located in or invades the functional area, partial resection or preservation can be performed according to the situation, weighing the pros and cons. Communicate well with the anesthesiologist: lower the blood pressure if there is much bleeding during craniotomy, raise the blood pressure appropriately before cranial closure, and observe the patient for 5 minutes to see that there is no active bleeding before cranial closure, so as to reduce the chances of postoperative rebleeding. If the dural tension is high during cranial closure, hyperventilation can be given appropriately, and the anesthesiologist should be notified in advance when the surgery is expected to be over soon to reduce the medication, so as to strive for the end of the surgery and wake up the patient. 3.Potential complications after surgery and preventive measures Whether to pull the tracheal tube after surgery: general anesthesia with tube patients awake with the tube is prone to choking reaction, breath holding, obvious blood pressure, heart rate increase, resulting in cerebral hemorrhage, so it is very critical to pull the tracheal tube at the right time. Whether to pull the tracheal tube depends on the patient’s degree of wakefulness, if the postoperative patients can open their eyes, follow the instructions to shake hands, you can pull the tracheal tube; if the postoperative anesthesia is deeper, hazy consciousness, there is a heavy choking reaction, can be properly sedated; no choking reaction (good tolerance for tracheal intubation), in the recovery of spontaneous respiration, arterial oxygen saturation (SPO2) is normal, with the tracheal tube back to intensive care unit (ICU) or ward (it is generally accepted that SPO2 should not be lower than 94%; elderly patients with comorbid COPD who are chronically tolerant to hypoxia will have an even lower SPO2), and try not to use an improvised ventilator on the way. Prevent postoperative rebleeding: common causes of postoperative rebleeding of brain tumor hematoma formation: 1. intracranial pressure (ICP) plummeted; 2. intraoperative hemostasis difficulty or incomplete; intraoperative operative injuries; reperfusion injuries; inappropriate intraoperative position; low ICP before the closure of the skull; cranial nailing through the skull; drainage is not smooth, platelet oozing; hypertension, vitamin K1 deficiency, platelet low [etc.], and so on. deficiency, low platelets, etc [4]. For elderly brain tumor patients, blood pressure should be lowered to a stable state before operation, and small-dose glucocorticoids should be applied appropriately to improve the stress capacity of the organism and tolerance to surgery; patients with high ICP should be treated with dehydration in advance, and external ventricular drainage or ventriculo-peritoneal shunt should be carried out before operation if necessary, so as to avoid a sudden drop in ICP during operation, and to reasonably use dehydrating agents and hyperventilate, and to appropriately elevate the blood pressure by ascending before the cranial closure. Rebleeding is easy to occur within 8 hours after surgery, and the chance of bleeding is significantly reduced after 8 hours. During this period, vital signs should be closely observed, blood pressure should be controlled below the basal level, external stimuli should be avoided as much as possible to avoid blood pressure fluctuation, hemostatic drugs can be applied appropriately, and vasodilators should not be used as much as possible within 8 hours. Preventing postoperative grand mal seizures: The reasons for prone to seizures after craniotomy are: 1. damage to the central anterior and posterior gyrus and the nearby cortex; 2. damage caused by intraoperative stretching, electrocautery, and exposure of the cerebral cortex; 3. postoperative cerebral edema, cerebral hemorrhage; and 4. metabolic disorders of the neuronal cells in the postoperative period [5]. Patients with supratentorial brain tumors are routinely checked for electroencephalo- graph (EEG) before surgery, and for patients with preoperative seizures or EEG abnormalities or given antiepileptic treatment. Those who had preoperative seizures were more likely to have seizures after surgery. Grand mal seizures in patients just after craniotomy can be fatal. Sodium valproate injection can be applied intravenously before awakening from general anesthesia and maintained for about 24 hours after the operation, and Valium can be applied to patients with severe convulsions to maintain the IV drip for 8~10 h. For patients with preoperative partial seizures, it is routine to take oral medication of carbamazepine tablets before the operation. “Carbamazepine tablets or oxcarbazepine tablets are routinely given orally before surgery, and sodium valproate extended-release tablets are given to patients with grand mal seizures, and the oral medication is maintained after surgery. The blood concentration of antiepileptic drugs should be checked regularly. Control of intracranial pressure (ICP): ICP is the core concern after brain tumor surgery, try to control the ICP in the perioperative period in the normal range, so as to make the patients pass through the cerebral edema period smoothly. The basic method is to elevate the head of the bed by 20°, with the intravenous application of dehydration drugs, according to the patient’s ICP to adjust the number and type of dehydration drugs (mannitol, tachycardia, albumin, etc.), and hormones can be added if necessary. Attention should be paid to the indirect evidence of ICP, such as: when coughing, infusion fast headache has worsened? Does the headache decrease with dehydration? How long does the relief last? How many times can the headache be controlled with dehydration? Reasonable application of antibiotics: Pre-operative prophylactic application of antibiotics can be used in the following cases: 1. transnasal, mastoid, oral surgery; 2. foreign body placement surgery; 3. secondary surgery; 4. patients with low immunity, malnutrition and so on. Intraoperative antibiotics are given 30 minutes before surgery, and giving a single dose of antibiotics ensures that the antibiotics reach an effective therapeutic concentration at the time of craniotomy, and additional sub-doses can be given if the surgery takes more than 4 hours and the concentration of the drug decreases. When stopping antibiotics after surgery, comprehensive consideration should be given to the patient’s temperature, blood count, head incision and the presence of comorbidities. Prevention of infection: 1, respiratory infection: elderly brain tumor patients with chronic bronchitis is more, due to general anesthesia intubation, vomiting and aspiration, postoperative bedridden and other factors, prone to respiratory infections, so postoperative turning, knocking the back, the use of oscillating sputum expectorator, nebulization, sputum suction, the first application of broad-spectrum antibiotics, sputum culture in a timely manner, according to the results of the culture of the adjustment of antibiotic use. Give “sodium bicarbonate injection” gargle, pay attention to the prevention of fungal infections; postoperative choking patients should be thickened with lotus root powder in the drinking water, and if necessary, give nasal feeding to avoid aspiration, resulting in aspiration pneumonia; 2, the prevention of urinary tract infections: daily perineal scrubbing, bladder irrigation, awake patients urinary catheter as far as possible to remove the catheter, and can be given as appropriate. “Tamsulosin hydrochloride tablets can be given orally as appropriate. 3, incision infection: postoperative incision on time to change the medication, change the medication, pay attention to the incision with or without redness, swelling, oozing, fluctuating sensation, subcutaneous accumulation of fluid need to be puncture suction and pressure bandage under aseptic conditions, the puncture fluid should be routinely sent to the bacterial culture. 4, central venous puncture infection: central venous puncture point should be changed once a day, if the puncture is detected, the central venous puncture point should be changed once a day. If the puncture point is found to be red and oozing, the central venous catheter should be removed immediately, and bacterial culture should be done at the head end of the central vein. Stress ulcer bleeding: Stress ulcer is acute gastric mucosal erosion and ulcer caused by severe trauma, burn, surgery and other major diseases, often combined with upper gastrointestinal bleeding, which can be life-threatening. Large amounts of catecholamines are released in the body under stress, serum gastrin levels increase, gastric acid increases, while gastric mucosal blood flow decreases, causing extensive bleeding of the gastrointestinal mucosa, which further causes necrotic ulceration of the mucosa, leading to upper gastrointestinal bleeding [6]. Stress ulcers of the gastrointestinal tract can easily occur after surgery for brainstem and tetralogy of Fallot lesions. Acid inhibition such as “omeprazole sodium” should be applied prophylactically after surgery. If there is gastrointestinal bleeding, gastrointestinal decompression should be given immediately, and thrombin or Yunnan Baiyao should be injected into the gastric tube at regular intervals, and the pH value of the gastric juice should be monitored at the same time as the acid-suppressing treatment of omeprazole sodium. At the same time, the PH value of gastric fluid should be monitored, so that the PH value is more than 4 [7]. Strengthen basic care: 1. Diet: the energy consumption during the recovery period is large, so it is necessary to consume enough calories and nutrient-rich food. Follow the principle of small amount and multiple meals in a gradual manner. If the swallowing function is poor, nasal feeding can be used, and the amount of nasal feeding should be increased gradually with the recovery of digestive function, and if the digestive function is poor, intravenous high-nutrition can be added. 2, sleep: patients should try to ensure that they can sleep as much as possible after the operation, and can be given drugs such as “Shuluoanding” and other drugs for proper sedation. 3, to ensure that the stool is evacuated once a day or two, and the application of “Ma Ren Soft Capsules” can be used. The patient can apply laxatives such as “Ma Ren Soft Capsules” and Keselu if necessary to keep the stools unobstructed and avoid accidents caused by increased intracranial pressure due to straining to defecate.4. Functional training of limbs: the amount of postoperative activities will be gradually increased and gradual, firstly, the head of the bed will be raised, the patient will be sitting up, and gradually, the patient will be sitting or standing by the side of the bed, and then finally, the patient will leave the bed under the assistance of family members, and the patient who can not get down from the ground will be elevated in the lower limbs. Those who can’t get off the ground should elevate their lower limbs and give extracorporeal rebound to prevent venous thrombosis of the lower limbs. In conclusion, meticulous preoperative preparation and evaluation, active treatment of concomitant diseases, strengthening the observation of complications and giving early anticipatory measures can significantly reduce postoperative complications and improve the prognosis.