Advertisement

Current Anesthesiology Reports

, Volume 6, Issue 3, pp 193–201 | Cite as

Perioperative Management of Traumatic Brain Injury

  • Nelson Nicolas Algarra
  • Deepak SharmaEmail author
Neuroanesthesia (M Smith, Section Editor)
Part of the following topical collections:
  1. Neuroanesthesia

Abstract

Purpose of Review

Traumatic brain injury (TBI) is a global public health problem. It is increasingly being recognized as a progressive disease in which intrinsic pathophysiologic processes and systemic secondary insults aggravate the primary brain damage. The perioperative period is crucial in the continuum of the management of TBI. This review summarizes current anesthetic strategies to optimize TBI outcomes.

Recent Findings

Perioperative data on TBI management are limited. However, recent findings indicate that intraoperative secondary insults are common and are associated with worse outcomes after intracranial as well as extracranial surgery in patients with TBI. The choice of anesthetic agents has not been shown to impact that the neurologic outcomes are TBI.

Summary

Perioperative therapeutic goals for patients with TBI include facilitating early cerebral decompression, providing balanced anesthesia for surgery, maintaining adequate cerebral perfusion by optimizing systemic and intracranial hemodynamics, and aggressively avoiding secondary insults. Intensive multimodal monitoring of the brain provides vital information that may be helpful in individualizing therapy; such monitoring should be continued in the perioperative period, particularly during extracranial surgery in TBI patients with polytrauma. While further investigation to characterize the impact of anesthetic agents on the injured brain and their effect on clinical outcomes is awaited, perioperative management should focus on adherence to consensus guidelines.

Keywords

Traumatic brain injury Anesthesia Perioperative Secondary insult 

Notes

Compliance with Ethics Guidelines

Conflict of Interest

Nelson Nicolas Algarra and Deepak Sharma declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Hyder AA, Wunderlich CA, Puvanachandra P, et al. The impact of traumatic brain injuries: a global perspective. NeuroRehabilitation. 2007;22:341–53.PubMedGoogle Scholar
  2. 2.
    Blennow K, Hardy J, Zetterberg H. The neuropathology and neurobiology of traumatic brain injury. Neuron. 2012;76:886–9.CrossRefPubMedGoogle Scholar
  3. 3.
    Cunningham AS, Salvador R, Coles JP, et al. Physiological thresholds for irreversible tissue in contusional regions following brain injury. Brain. 2005;128:1931–42.CrossRefPubMedGoogle Scholar
  4. 4.
    Bouma GJ, Muizelaar JP, Stringer WA, et al. Ultra-early evaluation of regional cerebral blood flow in severe head-injured patients using Xenon-enhanced computerized tomography. J Neurosurg. 1992;77:360–8.CrossRefPubMedGoogle Scholar
  5. 5.
    McHugh G, Engel D, Esteyengerg E, et al. Prognostic value of secondary insults in traumatic brain injury: results from the IMPACT study. J Neurotrauma. 2007;24(2):287–93.CrossRefPubMedGoogle Scholar
  6. 6.
    Chesnut RM, Marshall LF, Klauber MR, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma. 1993;34:216–22.CrossRefPubMedGoogle Scholar
  7. 7.
    Katayama Y, Becker DP, Tamura T, et al. Massive increases in extracelluar potassium and the indiscriminate release of glutamate following contusive brain injury. J Neurosurg. 1990;7:889–900.CrossRefGoogle Scholar
  8. 8.
    Bergsneider MA, Hovda DA, Shalmon E, et al. Cerebral hyperglycolysis following severe human traumatic brain injury: a positron emission tomography study. J Neurosurg. 1997;86:241–51.CrossRefPubMedGoogle Scholar
  9. 9.
    Vespa P, McArthur D, Glenn T, et al. Persistently reduced levels of extracellular glucose early after traumatic brain injury correlate with poor outcome at six months: a microdialysis study. J Cereb Blood Flow Metab. 2003;23:865–77.CrossRefPubMedGoogle Scholar
  10. 10.
    Xiong Y, Gu Q, Peterson PL, et al. Mitochondrial dysfunction and calcium perturbation induced by traumatic brain injury. J Neurotrauma. 1997;14:23–34.CrossRefPubMedGoogle Scholar
  11. 11.
    Coles JP, Fryer TD, Smielewski P, et al. Incidence and mechanism of cerebral ischemia in early clinical head injury. J Cereb Flow Metab. 2004;24:202–11.CrossRefGoogle Scholar
  12. 12.
    Inoye Y, Shiozaki T, Tasaki O, et al. Changes in cerebral blood flow from the acute to the chronic phase of severe head injury. J Neurotrauma. 2005;22:1411–8.CrossRefGoogle Scholar
  13. 13.
    Curry P, Viernes D, Sharma D. Perioperative management of traumatic brain injury. Int J Crit Illn Inj Sci. 2011;1:27–35.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Brain TF. Guidelines for the management of severe traumatic brain injury. J Neurotrauma. 2007;24(Suppl 1):S1–106.Google Scholar
  15. 15.
    •• Gupta D, Sharma D, Kannan N, et al. Guideline adherence and outcomes in severe adult traumatic brain injury for the CHIRAG (Collaborative Head InjuRy and Guidelines) study. World Neurosurg. 2016;89:169–79 [Epub ahead of print] This study demonstrates improved outcomes in severe TBI in India when the rate of adherence to established guidelines are improved. Google Scholar
  16. 16.
    Lee JC, Rittenhouse K, Bupp K, et al. An analysis of Brain Trauma Foundation traumatic brain injury guideline compliance and patient outcome. Injury. 2015;46:854–8.CrossRefPubMedGoogle Scholar
  17. 17.
    Oshima T, Karasawa F, Okazaki Y, et al. Effects of sevoflurane on cerebral blood flow and cerebral metabolic rate of oxygen in human beings: a comparison with isoflurane. Eur J Anaesthesiol. 2003;20:543–7.CrossRefPubMedGoogle Scholar
  18. 18.
    Kaisti KK, Långsjö JW, Aalto S, et al. Effects of sevoflurane, propofol, and adjunct nitrous oxide on regional cerebral blood flow, oxygen consumption, and blood volume in humans. Anesthesiology. 2003;99:603–13.CrossRefPubMedGoogle Scholar
  19. 19.
    Matta BF, Mayberg TS, Lam AM. Direct cerebrovasodilatory effects of halothane, isoflurane, and desflurane during propofol-induced isoelectric electroencephalogram in humans. Anesthesiology. 1995;83:980–5.CrossRefPubMedGoogle Scholar
  20. 20.
    Oshima T, Karasawa F, Satoh T. Effects of propofol on cerebral blood flow and the metabolic rate of oxygen in humans. Acta Anaesthesiol Scand. 2002;46:831–5.CrossRefPubMedGoogle Scholar
  21. 21.
    Petersen KD, Landsfeldt U, Cold GE, et al. Intracranial pressure and cerebral hemodynamic in patients with cerebral tumors: a randomized prospective study of patients subjected to craniotomy in propofol-fentanyl, isoflurane-fentanyl, or sevoflurane-fentanyl anesthesia. Anesthesiology. 2003;98:329–36.CrossRefPubMedGoogle Scholar
  22. 22.
    Pinaud M, Lelausque JN, Chetanneau A, et al. Effects of propofol on cerebral hemodynamics and metabolism in patients with brain trauma. Anesthesiology. 1990;73:404–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Shapiro HM, Galindo A, Wyte SR, et al. Rapid intraoperative reduction of intracranial pressure with thiopentone. 1973. Br J Anaesth. 1998;81:798–803.CrossRefPubMedGoogle Scholar
  24. 24.
    Johnston AJ, Steiner LA, Chatfield DA, et al. Effects of propofol on cerebral oxygenation and metabolism after head injury. Br J Anaesth. 2003;91:781–6.CrossRefPubMedGoogle Scholar
  25. 25.
    Steiner LA, Johnston AJ, Chatfield DA, et al. The effects of large-dose propofol on cerebrovascular pressure autoregulation in head-injured patients. Anesth Analg. 2003;97:572–6.CrossRefPubMedGoogle Scholar
  26. 26.
    Grathwohl KW, Black IH, Spinella PC, et al. Total intravenous anesthesia including ketamine versus volatile gas anesthesia for combat-related operative traumatic brain injury. Anesthesiology. 2008;109:44–53.CrossRefPubMedGoogle Scholar
  27. 27.
    Chesnut RM, Temkin N, Carney N, et al. A trial of intracranial-pressure monitoring in traumatic brain injury. N Engl J Med. 2012;367:2471–81.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Yuan Q, Wu X, Sun Y. Impact of intracranial pressure monitoring on mortality in patients with traumatic brain injury: a systematic review and meta-analysis. J Neurosurg. 2014;5:1–14.Google Scholar
  29. 29.
    Stocchetti N, Picetti E, Berardino M, et al. Clinical applications of intracranial pressure monitoring in traumatic brain injury: report of the Milan consensus conference. Acta Neurochir (Wien). 2014;156:1615–22.CrossRefGoogle Scholar
  30. 30.
    Chesnut R, Videtta W, Vespa P, et al. Intracranial pressure monitoring: fundamental considerations and rationale for monitoring. Neurocrit Care. 2014;21(Suppl 2):S64–84.CrossRefPubMedGoogle Scholar
  31. 31.
    Chan KH, Miller JD, Dearden NM, et al. The effect of changes in cerebral perfusion pressure upon middle cerebral artery blood flow velocity and jugular bulb venous oxygen saturation after severe brain injury. J Neurosurg. 1992;77:55–61.CrossRefPubMedGoogle Scholar
  32. 32.
    Skippen P, Seear M, Poskitt K, et al. Effect of hyperventilation on regional cerebral blood flow in head-injured children. Crit Care Med. 1997;25:1402–9.CrossRefPubMedGoogle Scholar
  33. 33.
    Sharma D, Siriussawakul A, Dooney N, et al. Clinical experience with intraoperative jugular venous oximetry during pediatric intracranial neurosurgery. Paediatr Anaesth. 2013;23:84–90.CrossRefPubMedGoogle Scholar
  34. 34.
    Pérez A, Minces PG, Schnitzler EJ, et al. Jugular venous oxygen saturation or arteriovenous difference of lactate content and outcome in children with severe traumatic brain injury. Pediatr Crit Care Med. 2003;4:33–8.CrossRefPubMedGoogle Scholar
  35. 35.
    De Georgia MA. Brain tissue oxygen monitoring in neurocritical care. J Intensive Care Med. 2015;30:473–83.CrossRefPubMedGoogle Scholar
  36. 36.
    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;111:672–82.CrossRefPubMedGoogle Scholar
  37. 37.
    Bouzat P, Oddo M, Payen JF. Transcranial doppler after traumatic brain injury: is there a role? Curr Opin Crit Care. 2014;20:153–60.CrossRefPubMedGoogle Scholar
  38. 38.
    Kinoshita K, Kushi H, Sakurai A, et al. Risk factors for intraoperative hypotension in traumatic intracranial hematoma. Resuscitation. 2004;60:151–5.CrossRefPubMedGoogle Scholar
  39. 39.
    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;24:178–84.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    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;8:117–22.CrossRefPubMedGoogle Scholar
  41. 41.
    •• Algarra NN, Lele AV, Prathep S, et al. Intraoperative Secondary Insults During Orthopedic Surgery in Traumatic Brain Injury. J Neurosurg Anesthesiol. 2016, Mar 4 [Epub ahead of print] This study is one of the first one to look at the intraoperative period as one of high importance during the hospital treatment of TBI. The types of secondary injuries and the rate of incidence are highlighted as should serve as call to action to all who care for TBI patients in the operating rooms. Google Scholar
  42. 42.
    Schmoker JD, Shackford SR, Wald SL, et al. An analysis of the relationship between fluid and sodium administration and intracranial pressure after head injury. J Trauma. 1992;33:476–81.CrossRefPubMedGoogle Scholar
  43. 43.
    Hartl R, Schurer L, Schmid-Schonbein GW, et al. Experimental antileukocyte interventions in cerebral ischemia. J Cereb Blood Flow Metab. 1996;16:1108–19.CrossRefPubMedGoogle Scholar
  44. 44.
    Hartl R, Medary MB, Ruge M, et al. Hypertonic/hyperoncotic saline attenuates microcirculatory disturbances after traumatic brain injury. J Trauma. 1997;42:S41–7.CrossRefPubMedGoogle Scholar
  45. 45.
    Vassar MJ, Perry CA, Gannaway WL, Holcroft JW. 7.5% sodium chloride/dextran for resuscitation of trauma patients undergoing helicopter transport. Arch Surg. 1991;1(126):1065–72.CrossRefGoogle Scholar
  46. 46.
    Myburgh J, Cooper DJ, Finfer S, et al. Saline or albumin for fluid resuscitation in patients with traumatic brain injury. N Engl J Med. 2007;2007(357):874–84.Google Scholar
  47. 47.
    Van Aken HK, Kampmeier TG, Ertmer C, et al. Fluid resuscitation in patients with traumatic brain injury: what is a SAFE approach? Curr Opin Anesthesiol. 2012;25:563–5.CrossRefGoogle Scholar
  48. 48.
    Sookplung P, Siriussawakul A, Malakouti A, et al. Vasopressor use and effect on blood pressure after severe adult traumatic brain injury. Neurocrit Care. 2011;15:46–54.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Krishnamoorthy V, Prathep S, Sharma D, et al. Association between electrocardiographic findings and cardiac dysfunction in adult isolated traumatic brain injury. Indian J Crit Care Med. 2014;18:570–4.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    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;32:1049–54.CrossRefPubMedGoogle Scholar
  51. 51.
    Steiner LA, Coles JP, Johnston AJ, et al. Assessment of cerebrovascular autoregulation in head-injured patients a validation study. Stroke. 2003;34:2404–9.CrossRefPubMedGoogle Scholar
  52. 52.
    Young B. Relationship between admission hyperglycemia and neurologic outcome of severely brain injured patients. Ann Surg. 1989;210:466–73.CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Lam A. Hyperglycemia and neurological outcome in patients with head injury. J Neurosurg. 1991;75:545–51.CrossRefPubMedGoogle Scholar
  54. 54.
    • Vespa P, McArthur DL, Stein N, et al. Tight glycemic control increases metabolic distress in traumatic brain injury: A randomized controlled within-subjects trial.Crit Care Med. 2012;40:1923–29. This important study adds to the current view that tight glycemic control in the TBI patient is not advisable and could be detrimental as the brain tries to “self-regulate” substrate consumption vs supply. Google Scholar
  55. 55.
    Seo SY, Kim EY, Kim H, et al. Neuroprotective effect of high glucose against NMDA, free radical, and oxygen-glucose deprivation through enhanced mitochondrial potentials. J Neurosci. 1999;19:8849–55.PubMedGoogle Scholar
  56. 56.
    Ginsberg MD, Prado R, Dietrich WD, et al. Hyperglycemia reduces the extent of cerebral infarction in rats. Stroke. 1987;18:570–4.CrossRefPubMedGoogle Scholar
  57. 57.
    Zasslow MA, Pearl RG, Shuer LM, et al. Hyperglycemia decreases acute neuronal ischemic changes after middle cerebral artery occlusion in cats. Stroke. 1989;20:519–23.CrossRefPubMedGoogle Scholar
  58. 58.
    Pecha T, Sharma D, Hoffman NG, et al. Hyperglycemia during craniotomy for adult traumatic brain injury. Anesth Analg. 2011;113:336–42.CrossRefPubMedGoogle Scholar
  59. 59.
    • 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;26:313–9. This study further elucidates the derangements in glucose metabolism associated with TBI. Even in patients without previous metabolic disorders hyperglycemia can be present and exacerbated by medical interventions. Google Scholar
  60. 60.
    Chatzipanteli K, Alonso OF, Kraydieh S, et al. Importance of posttraumatic hypothermia and hyperthermia on the inflammatory response after fluid percussion brain injury: biochemical and immunocytochemical studies. J Cereb Blood Flow Metab. 2000;20:531–42.CrossRefPubMedGoogle Scholar
  61. 61.
    Clifton GL, Jiang JY, Lyeth BG, et al. Marked protection by moderate hypothermia after experimental traumatic brain injury. J Cereb Blood Flow Metab. 1991;11:114–21.CrossRefPubMedGoogle Scholar
  62. 62.
    Sutcliffe IT, Smith HA, Stanimirovic D, et al. Effects of moderate hypothermia on IL-1 beta-induced leukocyte rolling and adhesion in pial microcirculation of mice and on proinflammatory gene expression in human cerebral endothelial cells. J Cereb Blood Flow Metab. 2001;21:1310–9.CrossRefPubMedGoogle Scholar
  63. 63.
    •• Andrews PJ, Sinclair HL, Rodriguez A, et al; Eurotherm3235 Trial collaborators. hypothermia for intracranial hypertension after traumatic brain injury. N Engl J Med. 2015;373:2403–12 This much awaited study did not show any improvement with hypothermia therapy vs standard of care and seems to follow the current Brain Trauma Foundation recommendations as we adapt them to the operating rooms. Google Scholar
  64. 64.
    Velmahos GC, Arroyo H, Ramicone E, et al. Timing of fracture fixation in blunt trauma patients with severe head injuries. Am J Surg. 1998;176:324–9.CrossRefPubMedGoogle Scholar
  65. 65.
    Sviri GE, Aaslid R, Douville CM, et al. Time course for autoregulation recovery following severe traumatic brain injury. J Neurosurg. 2009;111:695–700.CrossRefPubMedGoogle Scholar
  66. 66.
    Razumovsky A, Tigno T, Hochheimer SM, et al. Cerebral hemodynamic changes after wartime traumatic brain injury. Acta Neurochir Suppl. 2013;115:87–90.PubMedGoogle Scholar
  67. 67.
    Fujita Y, Algarra NN, Vavilala MS, Prathep S, Prapruettham S, Sharma D. Intraoperative secondary insults during extracranial surgery in children with traumatic brain injury. Child’s Nervous System. 2014;1(30):1201–8.CrossRefGoogle Scholar
  68. 68.
    Vespa PM, Nuwer MR, Nenov V, Ronne-Engstrom E, Hovda DA, Bergsneider M, Kelly DF, Martin NA, Becker DP. Increased incidence and impact of nonconvulsive and convulsive seizures after traumatic brain injury as detected by continuous electroencephalographic monitoring. J Neurosurg. 1999;91(5):750–60.CrossRefPubMedPubMedCentralGoogle Scholar
  69. 69.

Copyright information

© Springer Science + Business Media New York 2016

Authors and Affiliations

  1. 1.Department of Anesthesiology, College of MedicineUniversity of FloridaGainesvilleUSA
  2. 2.Divison of Neuroanesthesiology & Perioperative Neurosciences, Department of Anesthesiology & Pain Medicine and Neurological SurgeryHarborview Medical CenterSeattleUSA

Personalised recommendations