Anesthesia Considerations 

Traumatic Brain Injury

 

 

 

Considerations

 

• Trauma/ATLS approach

• Possible C-spine injury

• Monitoring & managing ↑ ICP:

  • Risk of cerebral ischemia & brain herniation

• Prevention of secondary brain injury:

  • Avoid hypoxia, hypercarbia

  • Maintain adequate CPP (60-70)

  • Avoid hyperglycemia, hyperthermia

• Multisystem complications:

  • CNS: herniation, seizures

  • CVS: myocardial dysfunction and ST changes, arrhythmias

  • Pulmonary: neurogenic pulmonary edema

  • DIC (disseminated intravascular coagulopathy) 

  • DI (diabetes insipidus), SIADH (syndrome of inappropriate ADH), CSW (cerebral salt wasting)

 

 

Neurosurgical Considerations

 

• Limited airway access

• Optimization of surgical exposure

• Invasive monitoring

• Complications:

  • Venous air embolism

  • Hemorrhage

  • Arrhythmias and hemodynamic instability

 

 

Goals

 

• Assess severity of TBI

• Prevent secondary brain injury:

  • Hypoxia (PaO2 > 60 mmHg)

  • Hypercarbia (PaCO2 35mmHg)

  • Hypotension, maintain CPP ~ 60 mmHg (MAP ~ 80)

• Avoid abrupt ↑ in BP & ICP (< 20-25mmHg)

• Avoid hyperthermia & hyperglycemia

• C-spine precautions

• Hct > 30

 

 

Conflicts

 

• Full stomach vs. ↑ ICP

• Hemorrhage/hypovolemia vs. ↑ ICP

• Difficult airway vs. ↑ ICP 

 

 

Treatment of ↑ ICP

 

• Elevate HOB

• Loosen collars, ETT ties to promote venous drainage

• Decrease intrathoracic pressures (change ventilator settings, decrease PEEP)

• Hyperventilation to PaCO2 30 for a brief period only of ~30 min  

• Sedate

• Analgesia

• Paralysis

• Barbiturate coma (1-5 mg/kg sodium thiopental then 1-3 mg/kg/hr)

• Hypothermia (or at least normothermia)

• Mannitol (0.5-1 g/kg)

• Furosemide (0.25-0.5 mg/kg)

• Hypertonic saline 6-8 ml/kg of 3% saline

• Correct sodium and osmolality

• CSF drainage

• Surgical decompression (head, abdomen)