Transcript PERIOPERATIVE MANAGEMENT OF TRAUMATIC BRAIN INJURY

PERIOPERATIVE MANAGEMENT
OF TRAUMATIC BRAIN INJURY
• OBJECTIVE
• 1.REVIEW IMPORTANCE OF SECONDARY
ISCHEMIC BRAIN INJURY AFTER HEAD
INJURY
• 2.ANESTHETIC MANAGE OF ACUTE HEAD
INJURY
• 3.EVIDENCE BASE MEDICINE FOR
INTENSIVE CARE OF HEAD INJURY
INTRODUCTION
• PERIOPERATIVE IS GUIDE TO DECREASE
BURDEN OF SECONDARY BRAIN INJURY
BY 2 STRATEGIES
• 1.MAINTAIN CARDIOPULMONARY
STABILITY
• 2.MONITOR PHYSIOLOGIC VARIABLE
REFLECT SECONDARY BRAIN INJURY
• SECONDARY BRAIN INJURY ASSOCIATE
WITH
• 1.POST INJURY HYPOTENSION[ esp
sBP<90]
INTRODUCTION
• 2.HYPOXEMIA
• 3.INTRACRANIAL HYPERTENSION
• CONTRIBUTING MECHANISM OF
SECONDARY TBI
• 1.CEREBRAL VASOCONSTRICTION
• 2.IMPAIR AUTOREGULATION
• TO MINIMIZE M&M TO PREVENT
HYPOTENSION
CEREBRAL CIRCULATION
RESPONSES TO ACUTE HEAD
INJURY
• TBI IS CHARACTERIZED BY
• 1.DECREASE CBF[ ESP < 18
CC/100G/MIN]
• 2.IMPAIR AUTOREGULATION
• 3.INCREASE ICP
• HYPERVENTILATION DECREASE CBF AND
DECREASE BRAIN OXYGENATION
• 1/3 OF PT AFTER TBI, CBF CHANGEED AS
CPP CHANGED
PREANESTHETIC
STABILIZATION AND
ASSESSMENT
• MINIMIZE TIME TO RESUSCITATE AND
ASSESSMENT
• 1.ASSOCIATE INJURY
• 2.RESUSCITATION DETAIL
• 3.GCS [ ESP <=8 IS SEVERE TBI] TELL
PROGNOSTIC FACTOR
EMERGENT AIRWAY CONTROL
• INTUBATION SEQUENCE
• 1.PRESERVE OXYGENATION
• 2.ELIMINATION CO2
• 3.PREVENT ASPIRATION
• 4.MAINTAIN SYSTEMIC BP
• 5.MINIMIZE INCREASE ICP
• 6.AVOID AGGRAVATION OF CERVICAL
SPINE INJURY[10% OF TBI] BY MANUAL
IN LINE AXIAL STABILIZATION
EMERGENT AIRWAY CONTROL
• 7.BLIND NASAL INTUBATION CAUTION IN
• 7.1 MAXILLARY FX
• 7.2 BASILAR SKULL FX
• DURING INTUBATION CADIOPULMONARY
SHOULD STABILITY AVOID
COUGHING,STRAINING,HYPERCARBIA,HY
POXEMIA
• THIOPENTHAL AND ETOMIDATE DOSE
DEPENDENTLY REDUCE CMRO2, CBF, ICP
EMERGENT AIRWAY CONTROL
• SUPPLEMENTATION WITH LIDOCAINE IV
WILL BLUNT SYMPATHETIC RESPONSES
AND LIMIT ICP
• MIDAZOLAM DECREASES CBF AND DOES
NOT INCREASE ICP
• PROPOFOL REDUCES ICP AND CBF BUT
INDUCED HYPOTENSION
• AFTER ACUTE TBI, SUCCINYLCHOLINE IS
APPROPRIATE DESPITE TIS MAKE
TRANSIENT INCREASES IN ICP
FLUID RESUSCITATION
• PROMPT RESTORATION OF SYSTOLIC
AND MAP AND THEN MAINTAIN CPP [ CPP
= MAP-ICP ]
• HYPOTONIC SOLUTION [ LRS ]
INCREASE BRAIN WATER CONTENT THAN
0.9 %NSS
• DRUMMOND ET AL. DEMONSRTATED
COLLOID MAINTAINED LOWER BRAIN
WATER THAN CRYSTALLOID AND THEN
INTRAOPERATIVE MANAGEMENT
• MONITOR : EKG, A-
LINE,O2SAT,FOLAY,CAPNOGRAPHY
• PULMONARY ARTERIAL
CATHETERIZATION USE TO TELL
ADEQUACY OF INTRAVASCULAR VOLUMN
OR CARDIAC PERFORMANCE
• RESTRICTION OF FLUID IS
CONTROVERSIAL,NO CLINICAL EVIDENCE
SUPPORT
• EARLY NONNEUROLOGIC SURGERY NOT
TO WORSEN OUTCOME OF
MULTIPLYTRAUMATIZED PATIENTS TBI
INTRAOPERATIVE MANAGEMENT
• IN NONNEUROSURGERY IN TBI
,MONITOR ICP IS IMPORTANT BY
• 1.JUGULAR VENOUS BULB
CATHETERIZATION TELL MIX CEREBRAL
VENOUS BLOOD THAT REFLECT
CEREBRAL ISCHEMIA EVEN ONE EPISODE
• 2.BRAIN TISSUE PO2 IS DIRECT METHOD
THAT REFLECT ISCHEMIA AND CHANGED
IN CPP AND PaCO2
• BOTH METHOD SENSITIVITY 50%
DETECT CEREBRAL ISCHEMIA
INTRAOPERATIVE MANAGEMENT
• ACUTE INCREASE ICP IMMIDIATE
MANAGEMENT BY
• 1.HYPERVENTILATION : RAPID
EFFECTIVE
• 2.DIURETIC : MANNITOL ,FUROSEMIDE
• 3.SURGERY
• MAINTENANCE OF ANESTHESIA VARIABLY
INFLUENCE
CBF,CBV,CMRO2,AUTOREGULATION,RESP
ONSIVENESS TO PaCO2
INTRAOPERATIVE MANAGEMENT
• BARBITURATES
,BZP,NARCOTIC,HYPOCAPNIA APPEAR TO
LIMIT N2O-INDUCED INCREASE CBF AND
ICP
• N2O AVOID IN PNEUMOCEPHALUS AND
PNEUMOTHORAX
• USE LOW CONCENTRATION [< 0.5 MAC]
OF ISOFURANE OR SEVOFLURANE
• AVOID SUFENTANIL AND ALFENTANIL
BECAUSE INCREASE ICP
INTRAOPERATIVE MANAGEMENT
• IMPORTANCE ADJUVANT DRUGS
• 1.NON-DEPOL NMB [ SHOULD NOT
REDUCE BP OR INCREASE CBF AND ICP] :
VERCURONIUM,ROCURONIUM IS
RECOMMENDED
• 2.BETA-BLOCKER OR LIDOCAINE
DEMINISH HYPERTENSON OR
TACHYCARDIA
• PaO2 SHOULD MAINTAIN AT LEAST >60
mmHg BECAUSE HYPOXIA INCREASE CBF
INTRAOPERATIVE MANAGEMENT
• PaO2 FROM 100-150 mmHg TO 200-250
mmHg IMPROVE CEREBRAL VENOUS
OXYGENATION IN PATIENT AFTER TBI
• TREATMENT OF SYSTEMIC
HYPERTENSION
• 1.NTP,NTG,HYDRALAZINE : UNACCEPT
CEREBRAL VASODILATATION IN WHO
HAVE DECREASE INTRACRANIAL
COMPLIANCE
• 2.BARBITURATE,NARCOTIC,BZP REDUCE
MAP WITH LESS RISK
INTRAOPERATIVE
MANAGEMENT
• 3.LABETALOL [ALPHA+BETA BLOCKER]
REDUCE MAP AND ICP
• EMERGENT MANAGE HYPOTENSION
REQIURE SHORT TERM INFUSE
VASOCONSTRICTORS TO MAINTAIN CPP
UNTIL HYPOVOLEMIA IS CORRECTED
• WHEN DURA IS OPENED ,HYPERTENSION
SHOULD BE CONTROLLED BECAUSE
INCREASE CPP MAY INCREASE CBF
INTRAOPERATIVE MANAGEMENT
• AFTER BRAIN SURGERY,MOST PATIENT
ARE NEITHER AWAKED NOR EXTUBATED
UNLESS
• 1.PREOPERATIVE CONSCIUOS NORMAL
• 2.PREOPERATIVE CONSCIOUS RAPIDLY
DECLINED
• PROFOUND PARALYSIS REDUCED
CHANGED ICP WHEN TRANSFER TO ICU
• DURING TRANSPORT SHOULD MONITOR
BP,O2sat,CAPNOMETRY [ ICP
MONITORING IF AVALIABLE
INTRAOPERATIVE BRAIN
PROTECTION
• HIGH DOSE PENTOBARBITOL IMPROVE
ICP CONTROL AND REDUCTION
EXTRACELLULAR LACTATE AND
EXCITOTOXIC AMINO ACIDS GLUTAMATE
AND ASPARTATE
• MILD HYPOTHERMIA [ 34 *C] WILL
REDUCE CMRO2 AND ICP AND IMPROVED
OUTCOME AFTER SEVERE TBI, THUS
REWARMING PATIENT SHOULD BE
SLOWLY BUT NOW NO EVIDENCE BASE
INTRAOPERATIVE BRAIN
PROTECTION
• HOWEVER, HYPERTHERMIA SHOULD BE
CORRECTED BECAUSE THERE HAVE
EVIDENCE THAT SMALL ELEVATIONS IN
TEMPERATURE INCREASE RELEASE OF
EXCITOTOXIC AMINOACIDS DURING
ISCHEMIC EPISODES
• GOAL TO MAINTAIN CPP ABOVE TARGET
LEVEL[>70 mmHg] WITH HOPE THAT
BETTER CBF WILL BE ASSURED TO
IMPROVE OUTCOME AFTER TBI
INTRAOPERATIVE BRAIN
PROTECTION
• ROBERTSON ET AL COMPARED CBF-
TARGET STRATEGY OF MAINTAIN CPP>70
mmHg WITH ICP TARGET STRATEGY
FOUND NO DIFFERENCE IN OUTCOME
• MONITORING CEREBRAL OXYGENATION
AND PROMPT TREATMENT WHEN
DESATURATION OR HYPOXEMIA[ TO
PREVENT SECONDARY ISCHEMIC
INJURY] ARE MORE EFFECTIVE THAN
CORRECT SYSTEMIC VARIABLE[
HYPOTENSION]
TRANSFER OF PATIENTS TO
THE INTENSIVE CARE UNIT
• DURING TRANSFER
VENTILATION,OXYGENATION,CPP MUST
BE CAREFULLY MAINTAINED.
• MINITOR BP,CAPNOGRAPHY,O2sat,ICP
MONITORING
• DURING EMERGENCE RESULT IN
INCREASE IN BP,ICP,
ADDITIONALSEDATIVE,NARCOTIC,LABETA
LOL MAY BE REQUIRED
• ALVEOLAR VENTILATION MUST BE
CAREFULLY SUPPORTED AND