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A nesthesia for Non-neurosurgical Surgery in Head Injury

Dr Surinder Singh. A nesthesia for Non-neurosurgical Surgery in Head Injury. What is the concern?. Head Injury (HI) rarely occurs alone 21% require life saving surgery for control of bleeding laprotomies and thoracotomies Only 2.5% patients undergo craniotomies

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A nesthesia for Non-neurosurgical Surgery in Head Injury

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  1. Dr Surinder Singh Anesthesia for Non-neurosurgical Surgery in Head Injury

  2. What is the concern? • Head Injury (HI) rarely occurs alone • 21% require life saving surgery for control of bleeding laprotomiesand thoracotomies • Only 2.5% patients undergo craniotomies • More severe HI; More Non-NS operations • Severe HI patients invariably admitted in ICU • Risk of further Neurological deterioration

  3. Literature Resources… Recent Advances in anesthesia & Analgesia 20 1998 Brain Trauma Foundation Guidelines 3rd Ed 2007 Millers 7th Edition 2010 Traumatic Coma Data Bank TCBD Pub med Evidence level: Grade-III and very limited Grade II Implications: The concepts apply to adult patients Advisory and subject to change with time Clinical judgment in each case is MOSTimportant All cases MLC documentation is utmost important

  4. Classification of brain damage • Primary brain damage, which is damage that is complete at the time of impact, may include: • Skull fractures • Contusions • Hematomas/blood clots • Lacerations • Diffuse axonal injury: damage to nerve cells in the brain's connecting nerve fibers

  5. Classification...... • Secondary brain damage: Further neurological deterioration of primary injury • Evolves over time spanning hour to days or weeks Causes include: • Brain swelling (Edema) • Raised intracranial pressure (ICP) • Epilepsy • Intracranial infection

  6. Classification of Head injury • Grade Incidence GCS • Severe 10% <8 • Moderate 10% 8 – 12 • Mild 80% 13 – 15 • Mild to moderate injury most recover well • Some deteriorate due to ICH/ brain edema • Diagnosis may be delayed/ masked

  7. Problems due to Non NS surgery Interruption of: • Resuscitaion • Monitoring • Clinical care • Delay in the diagnosis of worsening of brain damage • Delay in institution of treatment • Non NS surgery and anesthesia → Worsening

  8. What are the issues? More severe the HI; more nonNS trauma More trauma: more operations (Multispeciality) What is urgent ? Brain or non NS trauma Life saving surgery for controlling major bleeding is more important than brain Brain is more important in non-vital trauma What is the priority of surgery? Life saving vascular, laparotomy, thoracotomyfirst Stabilization of the patient next CT scan/ neuroradiological imaging next Orthopedic, facio-maxillary and plastic last

  9. How to manage in between? The transfer, imaging or waiting for surgery • Resuscitation • Monitoring • Stabilization • Prevention of secondary brain injury

  10. Resuscitation A: Tracheal Intubation: Airway 45%have obstruction • Loss of airway reflexes • Significant bleeding into the airway • Hypoxia - PaO2 < 98mmHg on oxygen • Hypercarbia - PaCO2 > 45mmHg • Spont. Hyperventilation PaCO2 < 30mmHg • Inadequate/Irregular/Abnormal breathing • GCS < 8 • Seizures • Neurological deterioration (↓ of ≥ 1 points in M component of GCS • Before Inter-facility or Inter-hospital patient transfer • Bilateral fractured mandible

  11. Resuscitation..... B. Breathing Hypoxia: SpO2 ≤ 90% Incidence≈25% Air ambulance study SpO2 Mortality Disability ≤ 60% 50% 100% ≥90% 14.3% 4-8% Hypoxia of 11 – 20 min duration significant C. Circulation: Hypotension • Systolic blood pressure < 90mmHg • ↑Mortality rate • Independent risk factor • Multiple episodes more harmful than single • Duration ∞ Mortality and disability

  12. Resuscitation.... • Hypotension ↓ CPP • More damaging in the presence of ↑ICP • TCDB:Early hypotension seen in 14% • In adults not due to head lacerations BUT • Due to abdominal/ thoracic bleeding • Late hypotension in 32% (over hours) • Due to fractures/ non-visceral trauma Pediatric patients: • Scalp bleeding alone may cause hypotension

  13. Resuscitation..... • Impact of Hypotension: • The only insult in 24% cases Vegetative survival or Death Hypotension Mortality None 17% Early 47% Late 66% Early and late 77%

  14. Resuscitation..... Comprises of: • Prevention of Hypoxemia • Prevention of Hypotension • Prevention/ control of bleeding All before CT head/ Neuro-radiological imaging Diagnosis: • Abdominal/ Thoracic CT Scan& USG time consuming • Diagnostic limitations& require expertise DPL: Diagnostic peritoneal lavage • Quick, reliable, bedside • ≥ 10 ml blood or ≥500 WBCs • Or ≥1,00,000 RBC/cumm • or fecal/ enetric/vegetable material is diagnostic

  15. Anesthetic Management: General anesthesia: Pre operative Management: Severe HI may already be intubated: Manage oxgenation and ventilation Investigations: Blood biochem, Gp/ CM and ABG X-ray chest & Neck should be obtained Monitoring: ECG, NIBP, SpO2EtCO2 and Temperature 2 large bore iv lines In severe HI/ unstable patients CVP: Antecubital or femoral vein Arterial pressure

  16. Anesthetic Management... General anesthesia: Check hemodynamic status Be prepared for difficult intubation Assume C Spine Injury – Inline intubation Fiberoptic intubation Cricothyroidotmy/ Tracheostomy RSI is the best: Anesthetic Agents& Doses: based on hemodynamics Too much anesthetic – Hypotension and ↓CPP Too little anesthetic – ↑ICP → ↓CPP Inappropriate use of ketamine – ↑ICP → ↓CPP Unconscious patients to require A&A, NM Blockade

  17. AnestheticManagement... General Anesthesia • Suxa or Rocuronium no difference if adequate depth • Prefer suxa if difficult intubation • Control hemodynamic response • Safe: lignocaine, esmolol, metoprolol • Unsafe: NTG, Sod Nitroprusside↑ CBF, ↑ICP, ↓MAP → ↓CPP Cushing’s Triad in raised ICP may mask: (HTN,Brady, irregular breath) • Hypovolaemia& severe dehydration • e.g. an patient with apparently normal SBP 120-130, HR 70-80 might collapse with thiopentone or propofol • Check input/ output and the doses of diuretics

  18. Anesthetic Management... • General Anesthesia…. • Maintenance: IAA Isoflurane at 1MAC is best • N2O ↑ CBF but analgesia ↓sympathetic response • TIVA : EVIDENCE IS LACKING however may be • Useful if intra or inter-hospital transfer is planned • Generous doses of NMBA • Too little relaxation ↑ICP • Pancuronium or atracurium may ↑CBF ↑ ICP • Vecuronium may be better • Avoid and prevent hypotension at all stages

  19. Anesthetic Management... Positioning for surgery: Slight head-up table top with head neutral relative to the body Do not use very tight tapes for securing tracheal tubes Ensure un-impeded venous drainage from the brain Reversal or ICU: Severe head injury→ NeuroICU/ ICU Mild to moderate HI→ Assess and reverse Prevent extubation response Monitor and observe in Recovery/ ICU/HDU Prevent hypoxia, hypoventilation

  20. Anesthetic Management... Ventilation: • Normocapnea or PaCO2 of 34 – 38mmHg • Brief hyperventilation to control ICP >30 • PaCO2 ≤ 26mmHg ) ↓↓CBF, ↑es No. and Intensity of oligemic areas • ↓esSjVO 2 ≤ 56% usually due to ↓ perfusion due to VC, Hypotension and Hypoxia • Is associated with Poor Outcome Dsaturation Mortality/ Vegetative state No episode 55% • 01 episode 74% • Multiple episodes 90% • ↑ SjVO2 ≥ 75% also assoc. with Poor Outcome (Hyperperfusion or Infarction) • Arterial to jugular vein O2 difference (ADJO2)or • Cerebral Oxygen Extraction and has better co-relation

  21. Anesthetic Management... Fluid Therapy: Objectives • Optimal blood pressure • Plasma electrolyte homeostasis • Normoglycemia • Plasma osmolality • Crystalloids: • Hypotonic: Avoid RL, D5, N/2 saline, Isolyte P • NS recommended • Hyperglycemia to be avoided • Colloids: • Hydroxyehtyl starch Not Used • Gelatins& albumin have been found safe

  22. Brain Decongestion Therapy: Hypertonic Fluids • Mannitol 20% • Saline 3% and 7.5% • Evidence strongly favours use of Mannitol • Not so convincing for Saline Diuretics: • Not really justified in severe HI with polytrauma Monitor volume status& electrolytes with all above Steroids: • Onset of action in HI 72-96 hrs • CRASH trial 1008 patients: 3% ↑in Mortality rate • ↓ Immunity, • ↑ Risk of GI Bleed • Best used in tumor/ infective pathology like TBM

  23. Temperature control • Prevent hyperthermia at all costs • 34-32oC has shown better results in ICU • Interferes with reversal, bleeding and assessment • Not recommended below 32oC • Post-op shivering↑oxygen demand, ↑ICP, ↓Oxygen availability

  24. Neurological Monitoring: During General Anesthesia: Signs of ↑ ICP • Hypertension and bradycardia remains intact • Pupillary signs: Remain intact • Size > 4mm significant • Asymmetry >3mm significant • Less than 50% have hematoma • Less than two thirds only have ipsilateral ICH Blind Burr holes can’t be justified

  25. Ac deterioration/Herniation • Mannitol 0.25g/kg, hyperventilation • To buy time for investigate and intervene Bilateral fixed pupils: • 25% evntually survive with moderate disability • Younger patients • Extradural hematoma • Evacuation of ICH in < 3hours of dilatation

  26. Extent and Duration of surgery • Absolute minimum • Repair major vascular injuries to control bleeding • Orthopedic surgery may not be urgent • Non-urgent surgery not allowed with Thoracotomy/laprotomy • Splinting for stabilization of #s to be permitted

  27. Further management Monitoring, sedation& ventilation to continue: During • CT Scan for HI and neurosurgical interventions • Transfer to Neuro-ICU/ ICU/ HDU. • Inter-specialitytransfer • Inter-hospital transfer After sustained stabilization decide future course: • Whether ICU care and weaning • Or non-neurosurgical interventions

  28. Mild to Moderate Head Injury: GCS 8- 15 Immediate Priority for life saving surgery • laprotomy/ thoracotomy/ Bleeding control surgery: Orthopedic, faciomaxillary or plastic procedures: • Usually to be done in first 72 hours • Does surgery and anesthesia impose additional risk? • Do the anesthesia techniques differ in hazards? Majority of patients make good recovery

  29. Mild to Moderate Head Injury Small minority deteriorates to develop • ICH, brain edema or both Risk Factors: A review of 183 deteriorated patients: • Altered conscious state • Headache • Vomiting • Focal deficit • Skull fracture Deterioration reported even after 5 weeks post injury

  30. Minor to Moderate HI... • CT Scan 20% have some abnormalities • 75% have failed auto-regulation of CBF for > 10 days* • Normal CT Scan: Unlikely to deteriorate but with DUE PRECAUTIONS • Prevention of hypo& hypertension • Prevention of Hypoxia • Prevention of hypo& hypercarbia • Anesthetic likely to be implicated for deterioration * This study was conducted at 10 days post injury

  31. Anesthesia for mild& moderate HI General Anesthesia: • Same as discussed for Severe Head Injury Epidural anesthesia: • 5 – 10ml of epidural NS ↑ ICP even after 1wk • Compression of dural sac is implicated • Proved in animal model • Extremely slow injection with smallest volume

  32. Regional anesthesia... Spinal anesthesia: Concern for raised ICP • Std teaching risk of tentorialherniation • But diagnostic lumbar punctures in meningitis& SAH • Lumbar CSF drainage for ICP control in pediatrics • The patient with normal CT Scan is unlikely to be at risk • Do not presume safe without a CT scan • The fine needles and small LA volumes offer advantage

  33. Regional anesthesia.... IVRA: • Period just after the release of tourniquette is critical • Lower limbs have more profound impact • Several reports of ICP worsening on deflation • Quite often complicated by hypotension • Profound bleeding may further worsen hypotension

  34. Regional anestheisa.... Nerve Blocks: • Seemingly safer than ESA • Toxic doses of LA worsen neurological status • Anxiety, pain and vasoconstrictors ↑BP ↑ICP • Advantage of post operative analgesia

  35. Post-operative Analgesia: NSAIDs: May aggravate bleeding/hematoma Paracetamol: May be safer option Systemic opioids:→ Respiratory depression PCA: → ?? Cognitive state Nerve blocks: Useful but limited duration, limited sites Limited thoracic epidural: Upper abdomen, rib fractures Rib fracutres: Ventilation, epidural, paravertebral, intercostal catheter

  36. Therapeutic Targets: ICU • PaO2> 13kPa (98 – 150mmHg ) • PaCO2 of 4.5 – 5.0kPa (34- 38mmHg) • A lower PaCO2 (30mmHg) for↑ ICT) • SBP > 90mmHg • MAP " 80 mmHg (in the absence of ICP monitoring) • Glucose 4 – 8 mmol/l • Temperature < 37°C

  37. Therapeutic Targets: ICU • ICP < 20mmHg (Actionable ICP limits 20 – 25 mmHg) • CPP 50 – 70mmHg • SJvO2/ SJO2 55- 75% • PBtO2/ PBr O2/PBO2 > 10-15mmhg • Microdialysis for BS, Glutamate • Full calorie replacement within 7 days • NG tube, Jejunal tub/ jeunostomy • Or TPN

  38. Thanks for patient listening . . . .

  39. ICP and other Concepts 40 – 50 mmHg survived wuth disability 5 had 75mmHg died of herniation Optimal CPP not defined 45- 60mmHg 73 mmHg was associated with abnormal markers Lund concept: Normovaemia, Hct, PP,Glucose,po2,pco2 Hyperglycemia>15mmol

  40. Age: • Classification: Class III Study • Conclusions: GOS • Age 1 • 0-20 (N=62) 32% • 21-40 (N=62) 48 • 41-60 (N=53) 59 • ≥ 60 (N=27) 78

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