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การให้ยาระงับความรู้สึกในผู้ป่วย ที่ได้รับบาดเจ็บที่ศีรษะ

การให้ยาระงับความรู้สึกในผู้ป่วย ที่ได้รับบาดเจ็บที่ศีรษะ. พญ. วรินี เล็กประเสริฐ ภาควิชาวิสัญญีวิทยา โรงพยาบาลรามาธิบดี 11/3/53. Goals. To prevent secondary brain injury To optimize conditions for brain recovery & improved outcome. Primary brain injury.

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การให้ยาระงับความรู้สึกในผู้ป่วย ที่ได้รับบาดเจ็บที่ศีรษะ

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  1. การให้ยาระงับความรู้สึกในผู้ป่วยที่ได้รับบาดเจ็บที่ศีรษะการให้ยาระงับความรู้สึกในผู้ป่วยที่ได้รับบาดเจ็บที่ศีรษะ พญ. วรินี เล็กประเสริฐ ภาควิชาวิสัญญีวิทยา โรงพยาบาลรามาธิบดี 11/3/53

  2. Goals • To prevent secondary brain injury • To optimize conditions for brain recovery & improved outcome

  3. Primary brain injury • Primary damage that occurs at the moment of impact or injury

  4. Secondary brain injury • The production of vascular & hematologic events that cause reduction and alteration in CBF leading to hypoxia & ischemia • biochemical cascade Cell death

  5. Systemic factors contributing to secondary brain injury • Hypoxia • hypotension • Hypercapnia / hypocapnia • Hyperthermia • Intracranial hypertension

  6. Time course of neuronal death after cerebral ischemiaEssentials of Neuroanesthesia and Neurointensive care. Gupta & Gelb, eds 2008 pp 36-42 Excitotoxicity Impact Inflammation Apoptosis Minutes Hours Days

  7. Case scenario • A 4 yr-old girl is brought into the ER by a passer after being hit by a car. On arrival she is placed in a neck collar on a spinal board • HR 160, BP 64/30, RR 32, tympanic temp 35.5 C • Arousable to stimulation, open eyes to pain, lethargic, age-appropriate GCS is 7 • Right pupil dilated & NRTL • Distended abdomen

  8. Key questions • Initial management priorities in a patient with severe TBI • Goals for ventilation, cerebral perfusion, glucose • IV access & blood products needs • Effective treatment in lowering ICP • Postoperative care

  9. Neurotrauma Risk factors • Advancing age • Cardiothoracic injury • Alcohol abuse • Shock • Delay in transfer Child abuseIatrogenic Delay in operation Management errors Technical mistakes

  10. Developmental considerationsin Pediatric Neurotrauma • Lower autoregulatory reserve • (<2 yrs) • Larger percentage of CO directed to the brain; risk of unstable hemodynamics • Larger head-to-torso ratio, acceleration-deceleration injuries caused more diffuse brain injury • Open fontanels & cranial sutures ;more compliant intracranial space • Mass effect of a slow growing tumor & insidious hemorrhage is masked ! • Soriano SG. Update on CNS injury: Mx of the pediatric patient,ASA RCL 2008

  11. Developmental considerationsin Pediatric Neurotrauma (II) • Infants & toddlers are more vulnerable to cervical spine injury • SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) in up to 70% of children • with C-spine injury

  12. Initial management • Priorities in trauma care • Primary survey • “ Basic evaluation to recognize & manage life-threatening injuries “

  13. ABCDE algorithm • Immediate management • 100% oxygen administration • Standard monitoring: EKG, NIBP,SpO2 , EtCO2 • Rapid sequence intubation, using in-line stabilization • Mild hyperventilation

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  15. Attempted suicide with a nail gun Presented by Dr.Nguyen from Albany Medical Center, at the 2006 PGA

  16. After immediate stabilization, what next? • Secondary survey (head to toe examination) • Establish definite IV access & • A-line, + CVP line

  17. CT scan: Left temporal extradural hematoma • The neurosurgeon requested to evacuate hematoma • What is your anesthetic plan? • How many IV lines? • What is your choice of IV fluid?

  18. Traumatic brain injury • Consider associated injury in a multiple trauma patient • Cerebral autoregulation is variably impaired • Brain parenchyma is a rich source of tissue factor; DIC may be induced

  19. Preanesthetic assessment of TBI • Airway (C-spine) • Breathing • Circulation • Associated injuries • Neurological status (GCS) • Preexisting chronic illness • Circumstances of the injury: • - time of injury • - duration of unconsciousness • - associated alcohol /drug use

  20. การดูแลระบบไหลเวียนเลือดการดูแลระบบไหลเวียนเลือด • Cerebral hemodynamics CPP = MAP - ICP

  21. Cerebral perfusion pressure 50 150

  22. Effects of intraoperative hypotension on outcome in patients with severe head injury • Pietropaoli, et al. J of Trauma 1992;33;403-7

  23. Hypovolemia • Blood loss • Diuresis • Decreased intake Hypotension & Cerebral ischemia

  24. Clinical goals • Maintain normovolemia & hemodynamic stability • Maintain adequate plasma colloid osmotic pressure • Enhance microvascular blood flow • Guarantee adequate tissue oxygen transport Target Hb 8-9 g/dl must be modified in the context of significant comorbidities !!

  25. ScScanning electron micrographs of RBCs isolated from stored blood on days 1, 21, and 35

  26. Transfusion in neuroanesthesia • The best scenario: coming to the OR with normal Hb level & losing little blood • Minimizing unnecessary loss • Maximizing brain oxygen supply & demand prior to transfusion • Good monitorings !!

  27. Blood glucose control • Target between 140-180 mg% on the basis of the lack of proof of the efficacy of tight control levels in patients with CNS injury & on the real risk of hypoglycemic injury • Intraoperative brain protection; physiologic management . Patel PM. ASA RCL 2009

  28. Where do I keep the PaCo2? • No straight answer • Recent evidence for the effects of hyperventilation from PET • “ Reducing PaCO2 from 35-40 mmHg to 30 mmHg caused a 2.5 fold increase in the volume of brain having flow ≺ 10 ml/100 gm/min “Crit Care Med 2002;30:1950-9

  29. From IHAST database; use of nitrous oxide was associated with an increased risk for the development of DIND (OR 1.78, 95% CI 1.08-2.95; p=0.025). However, there was no evidence of detriment to long-term outcome (3 mths after sx). Anesthesiology 2009;110,56-73 Effects of anesthetic agents : May not be the crucial aspect !!

  30. Effectes of inhalation agents 30

  31. Intracranial hypertension therapy • Head up position & avoid venous drainage obstruction • Adequate ventilation • Diuretics • Reduction of systemic hypertension • Drainage of CSF • Release of hematoma

  32. Temperature control • Hypothermia treatment for TBI : a systematic review and meta-analysis. J Neurotrauma 2008;25:62-71 • Favorable neurological outcome ( RR 1.91; 95% CI 1.28, 2.85) BUT ...... • Increases risk of pneumonia ( RR 2.37;95% CI 1.37-4.10)

  33. Postoperative care • Stabilize cardiovascular abnormalites • Avoid hypoxia • Avoid hyperthermia • Seizure control • Pain control • Maintain a good perfusion pressure at all times, preferably ≻ 65 mmHg • Target glucose 140-180 mg% with frequent monitoring • Normoventilation with judicious use of hyperventilation (if at all)

  34. Thank you for your attention !! 34

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