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Anesthesia for patients with acute traumatic brain injury

Authors
Deepak Sharma, MBBS, MD, DM
Pratik V Patel, MD
Section Editor
Jeffrey J Pasternak, MD
Deputy Editor
Marianna Crowley, MD

INTRODUCTION

Patients with severe traumatic brain injury (TBI) frequently have other traumatic injuries to internal organs, lungs, limbs, or the spinal cord. Thus, the management of the patient with severe TBI is often complex and requires a multidisciplinary approach.

Anesthesiologists are involved in the care of patients with TBI in various situations, including but not limited to: resuscitation and stabilization in the emergency department (ED), sedation and anesthesia for diagnostic imaging, craniotomy or decompressive craniectomy, extracranial surgery, and intensive care management.

Surgery and anesthesia may subject the injured brain to new, secondary injuries as a result of hypotension, hypoxemia, hypo- or hypercarbia, fever, hypo- or hyperglycemia, and/or increased intracranial pressure (ICP) that may adversely impact outcome.

This topic will discuss the intraoperative anesthetic management of patients with acute TBI. Epidemiology and pathophysiology, prehospital management, general concerns for anesthesia for craniotomy, and anesthesia for acute spinal cord injury are discussed separately. (See "Management of acute severe traumatic brain injury" and "Anesthesia for craniotomy" and "Traumatic brain injury: Epidemiology, classification, and pathophysiology" and "Anesthesia for adults with acute spinal cord injury".)

PREOPERATIVE EVALUATION

The goal for preoperative evaluation for patients with traumatic brain injury (TBI) is to minimize secondary brain injury. Patients with TBI may require surgery for other associated injuries (eg, orthopedic, abdominal, or thoracic procedures). Even if such procedures are delayed beyond the immediate postinjury period, the goals for anesthesia should include prevention of secondary brain injury.

                                 

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Literature review current through: Nov 2016. | This topic last updated: Thu Sep 15 00:00:00 GMT+00:00 2016.
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References
Top
  1. Sviri GE, Aaslid R, Douville CM, et al. Time course for autoregulation recovery following severe traumatic brain injury. J Neurosurg 2009; 111:695.
  2. De Georgia MA. Brain Tissue Oxygen Monitoring in Neurocritical Care. J Intensive Care Med 2015; 30:473.
  3. Narotam PK, Morrison JF, Nathoo N. Brain tissue oxygen monitoring in traumatic brain injury and major trauma: outcome analysis of a brain tissue oxygen-directed therapy. J Neurosurg 2009; 111:672.
  4. Demetriades D, Charalambides K, Chahwan S, et al. Nonskeletal cervical spine injuries: epidemiology and diagnostic pitfalls. J Trauma 2000; 48:724.
  5. Lanier WL, Iaizzo PA, Milde JH, Sharbrough FW. The cerebral and systemic effects of movement in response to a noxious stimulus in lightly anesthetized dogs. Possible modulation of cerebral function by muscle afferents. Anesthesiology 1994; 80:392.
  6. Kovarik WD, Mayberg TS, Lam AM, et al. Succinylcholine does not change intracranial pressure, cerebral blood flow velocity, or the electroencephalogram in patients with neurologic injury. Anesth Analg 1994; 78:469.
  7. Brown MM, Parr MJ, Manara AR. The effect of suxamethonium on intracranial pressure and cerebral perfusion pressure in patients with severe head injuries following blunt trauma. Eur J Anaesthesiol 1996; 13:474.
  8. Stirt JA, Grosslight KR, Bedford RF, Vollmer D. "Defasciculation" with metocurine prevents succinylcholine-induced increases in intracranial pressure. Anesthesiology 1987; 67:50.
  9. Enevoldsen EM, Jensen FT. Autoregulation and CO2 responses of cerebral blood flow in patients with acute severe head injury. J Neurosurg 1978; 48:689.
  10. Hauerberg J, Xiaodong M, Willumsen L, et al. The upper limit of cerebral blood flow autoregulation in acute intracranial hypertension. J Neurosurg Anesthesiol 1998; 10:106.
  11. Hlatky R, Furuya Y, Valadka AB, et al. Dynamic autoregulatory response after severe head injury. J Neurosurg 2002; 97:1054.
  12. Jaeger M, Schuhmann MU, Soehle M, Meixensberger J. Continuous assessment of cerebrovascular autoregulation after traumatic brain injury using brain tissue oxygen pressure reactivity. Crit Care Med 2006; 34:1783.
  13. Jünger EC, Newell DW, Grant GA, et al. Cerebral autoregulation following minor head injury. J Neurosurg 1997; 86:425.
  14. Lam JM, Hsiang JN, Poon WS. Monitoring of autoregulation using laser Doppler flowmetry in patients with head injury. J Neurosurg 1997; 86:438.
  15. Lang EW, Czosnyka M, Mehdorn HM. Tissue oxygen reactivity and cerebral autoregulation after severe traumatic brain injury. Crit Care Med 2003; 31:267.
  16. Chaiwat O, Sharma D, Udomphorn Y, et al. Cerebral hemodynamic predictors of poor 6-month Glasgow Outcome Score in severe pediatric traumatic brain injury. J Neurotrauma 2009; 26:657.
  17. Strebel S, Lam AM, Matta BF, Newell DW. Impaired cerebral autoregulation after mild brain injury. Surg Neurol 1997; 47:128.
  18. Andrews PJ, Sleeman DH, Statham PF, et al. Predicting recovery in patients suffering from traumatic brain injury by using admission variables and physiological data: a comparison between decision tree analysis and logistic regression. J Neurosurg 2002; 97:326.
  19. Clifton GL, Miller ER, Choi SC, Levin HS. Fluid thresholds and outcome from severe brain injury. Crit Care Med 2002; 30:739.
  20. Juul N, Morris GF, Marshall SB, Marshall LF. Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury. The Executive Committee of the International Selfotel Trial. J Neurosurg 2000; 92:1.
  21. Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, et al. Guidelines for the management of severe traumatic brain injury. IX. Cerebral perfusion thresholds. J Neurotrauma 2007; 24 Suppl 1:S59.
  22. Elf K, Nilsson P, Ronne-Engström E, et al. Cerebral perfusion pressure between 50 and 60 mm Hg may be beneficial in head-injured patients: a computerized secondary insult monitoring study. Neurosurgery 2005; 56:962.
  23. Jaeger M, Dengl M, Meixensberger J, Schuhmann MU. Effects of cerebrovascular pressure reactivity-guided optimization of cerebral perfusion pressure on brain tissue oxygenation after traumatic brain injury. Crit Care Med 2010; 38:1343.
  24. Grände PO. The "Lund Concept" for the treatment of severe head trauma--physiological principles and clinical application. Intensive Care Med 2006; 32:1475.
  25. Howells T, Elf K, Jones PA, et al. Pressure reactivity as a guide in the treatment of cerebral perfusion pressure in patients with brain trauma. J Neurosurg 2005; 102:311.
  26. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual, 9th ed, American College of Surgeons, Chicago 2012.
  27. Pietropaoli JA, Rogers FB, Shackford SR, et al. The deleterious effects of intraoperative hypotension on outcome in patients with severe head injuries. J Trauma 1992; 33:403.
  28. Sharma D, Brown MJ, Curry P, et al. Prevalence and risk factors for intraoperative hypotension during craniotomy for traumatic brain injury. J Neurosurg Anesthesiol 2012; 24:178.
  29. Kawaguchi M, Sakamoto T, Ohnishi H, et al. Preoperative predictors of reduction in arterial blood pressure following dural opening during surgical evacuation of acute subdural hematoma. J Neurosurg Anesthesiol 1996; 8:117.
  30. Kinoshita K, Kushi H, Sakurai A, et al. Risk factors for intraoperative hypotension in traumatic intracranial hematoma. Resuscitation 2004; 60:151.
  31. Curry P, Viernes D, Sharma D. Perioperative management of traumatic brain injury. Int J Crit Illn Inj Sci 2011; 1:27.
  32. Vavilala MS, Sharma D. Essentials of Pediatric Traumatic Brain Injury: A Practical Approach to Neuroanesthesia, Mongan PD, Soriano SG, Sloan TB (Eds), Lippincott, Williams & Wilkins, Philadelphia 2013.
  33. Sharma D, Vavilala MS. Perioperative management of adult traumatic brain injury. Anesthesiol Clin 2012; 30:333.
  34. SAFE Study Investigators, Australian and New Zealand Intensive Care Society Clinical Trials Group, Australian Red Cross Blood Service, et al. Saline or albumin for fluid resuscitation in patients with traumatic brain injury. N Engl J Med 2007; 357:874.
  35. Salim A, Hadjizacharia P, DuBose J, et al. Role of anemia in traumatic brain injury. J Am Coll Surg 2008; 207:398.
  36. Carlson AP, Schermer CR, Lu SW. Retrospective evaluation of anemia and transfusion in traumatic brain injury. J Trauma 2006; 61:567.
  37. Robertson CS, Hannay HJ, Yamal JM, et al. Effect of erythropoietin and transfusion threshold on neurological recovery after traumatic brain injury: a randomized clinical trial. JAMA 2014; 312:36.
  38. Sookplung P, Siriussawakul A, Malakouti A, et al. Vasopressor use and effect on blood pressure after severe adult traumatic brain injury. Neurocrit Care 2011; 15:46.
  39. Ract C, Vigué B. Comparison of the cerebral effects of dopamine and norepinephrine in severely head-injured patients. Intensive Care Med 2001; 27:101.
  40. Steiner LA, Johnston AJ, Czosnyka M, et al. Direct comparison of cerebrovascular effects of norepinephrine and dopamine in head-injured patients. Crit Care Med 2004; 32:1049.
  41. Schroeder T, Schierbeck J, Howardy P, et al. Effect of labetalol on cerebral blood flow and middle cerebral arterial flow velocity in healthy volunteers. Neurol Res 1991; 13:10.
  42. Alali AS, McCredie VA, Golan E, et al. Beta blockers for acute traumatic brain injury: a systematic review and meta-analysis. Neurocrit Care 2014; 20:514.
  43. Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, et al. Guidelines for the management of severe traumatic brain injury. I. Blood pressure and oxygenation. J Neurotrauma 2007; 24 Suppl 1:S7.
  44. Adelson PD, Bratton SL, Carney NA, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents. Chapter 19. The role of anti-seizure prophylaxis following severe pediatric traumatic brain injury. Pediatr Crit Care Med 2003; 4:S72.
  45. Davis DP, Meade W, Sise MJ, et al. Both hypoxemia and extreme hyperoxemia may be detrimental in patients with severe traumatic brain injury. J Neurotrauma 2009; 26:2217.
  46. Brenner M, Stein D, Hu P, et al. Association between early hyperoxia and worse outcomes after traumatic brain injury. Arch Surg 2012; 147:1042.
  47. Asher SR, Curry P, Sharma D, et al. Survival advantage and PaO2 threshold in severe traumatic brain injury. J Neurosurg Anesthesiol 2013; 25:168.
  48. Rincon F, Kang J, Vibbert M, et al. Significance of arterial hyperoxia and relationship with case fatality in traumatic brain injury: a multicentre cohort study. J Neurol Neurosurg Psychiatry 2014; 85:799.
  49. Rockswold SB, Rockswold GL, Zaun DA, Liu J. A prospective, randomized Phase II clinical trial to evaluate the effect of combined hyperbaric and normobaric hyperoxia on cerebral metabolism, intracranial pressure, oxygen toxicity, and clinical outcome in severe traumatic brain injury. J Neurosurg 2013; 118:1317.
  50. Whitesell R, Asiddao C, Gollman D, Jablonski J. Relationship between arterial and peak expired carbon dioxide pressure during anesthesia and factors influencing the difference. Anesth Analg 1981; 60:508.
  51. Wahba RW, Tessler MJ. Misleading end-tidal CO2 tensions. Can J Anaesth 1996; 43:862.
  52. Coles JP, Fryer TD, Coleman MR, et al. Hyperventilation following head injury: effect on ischemic burden and cerebral oxidative metabolism. Crit Care Med 2007; 35:568.
  53. Imberti R, Bellinzona G, Langer M. Cerebral tissue PO2 and SjvO2 changes during moderate hyperventilation in patients with severe traumatic brain injury. J Neurosurg 2002; 96:97.
  54. Coles JP, Minhas PS, Fryer TD, et al. Effect of hyperventilation on cerebral blood flow in traumatic head injury: clinical relevance and monitoring correlates. Crit Care Med 2002; 30:1950.
  55. Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, et al. Guidelines for the management of severe traumatic brain injury. XIV. Hyperventilation. J Neurotrauma 2007; 24 Suppl 1:S87.
  56. Madden LK, DeVon HA. A Systematic Review of the Effects of Body Temperature on Outcome After Adult Traumatic Brain Injury. J Neurosci Nurs 2015; 47:190.
  57. Pecha T, Sharma D, Hoffman NG, et al. Hyperglycemia during craniotomy for adult traumatic brain injury. Anesth Analg 2011; 113:336.
  58. Bhattacharjee S, Layek A, Maitra S, et al. Perioperative glycemic status of adult traumatic brain injury patients undergoing craniotomy: a prospective observational study. J Neurosurg Anesthesiol 2014; 26:313.
  59. Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, et al. Guidelines for the management of severe traumatic brain injury. XV. Steroids. J Neurotrauma 2007; 24 Suppl 1:S91.
  60. Kochanek PM, Carney N, Adelson PD, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents--second edition. Pediatr Crit Care Med 2012; 13 Suppl 1:S1.
  61. Joseph B, Pandit V, Khalil M, et al. Use of prothrombin complex concentrate as an adjunct to fresh frozen plasma shortens time to craniotomy in traumatic brain injury patients. Neurosurgery 2015; 76:601.
  62. Bachelani AM, Bautz JT, Sperry JL, et al. Assessment of platelet transfusion for reversal of aspirin after traumatic brain injury. Surgery 2011; 150:836.
  63. McMillian WD, Rogers FB. Management of prehospital antiplatelet and anticoagulant therapy in traumatic head injury: a review. J Trauma 2009; 66:942.
  64. Batchelor JS, Grayson A. A meta-analysis to determine the effect on survival of platelet transfusions in patients with either spontaneous or traumatic antiplatelet medication-associated intracranial haemorrhage. BMJ Open 2012; 2:e000588.
  65. Briggs A, Gates JD, Kaufman RM, et al. Platelet dysfunction and platelet transfusion in traumatic brain injury. J Surg Res 2015; 193:802.