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Kim H. Anesthetic management of the traumatic brain injury patients undergoing non-neurosurgery. Anesth Pain Med (Seoul) 2023; 18:104-113. [PMID: 37183278 PMCID: PMC10183618 DOI: 10.17085/apm.23017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 03/15/2023] [Indexed: 05/16/2023] Open
Abstract
This article describes the anesthetic management of patients with traumatic brain injury (TBI) undergoing non-neurosurgery, primarily targeting intraoperative management for multiple-trauma surgery. The aim of this review is to promote the best clinical practice for patients with TBI in order to prevent secondary brain injury. Based on the current clinical guidelines and evidence, anesthetic selection and administration; maintenance of optimal cerebral perfusion pressure, oxygenation and ventilation; coagulation monitoring; glucose control; and temperature management are addressed. Neurological recovery, which is critical for improving the patient's quality of life, is most important; therefore, future research needs to be focused on this aspect.
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Affiliation(s)
- Hyunjee Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
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Davis JA, Grau JW. Protecting the injured central nervous system: Do anesthesia or hypothermia ameliorate secondary injury? Exp Neurol 2023; 363:114349. [PMID: 36775099 DOI: 10.1016/j.expneurol.2023.114349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/13/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023]
Abstract
Traumatic injury to the central nervous system (CNS) and stroke initiate a cascade of processes that expand the area of tissue loss. The current review considers recent studies demonstrating that the induction of an anesthetic state or cooling the affected tissue (hypothermia) soon after injury can have a therapeutic effect. We first provide an overview of the neurobiological processes that fuel tissue loss after traumatic brain injury (TBI), spinal cord injury (SCI) and stroke. We then examine the rehabilitative effectiveness of therapeutic anesthesia across a variety of drug categories through a systematic review of papers in the PubMed database. We also review the therapeutic benefits hypothermia, another treatment that quells neural activity. We conclude by considering factors related to the safety, efficacy and timing of treatment, as well as the mechanisms of action. Clinical implications are also discussed.
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Affiliation(s)
- Jacob A Davis
- Cellular and Behavioral Neuroscience, Department of Psychology, Texas A&M University, College Station, TX 77843, USA.
| | - James W Grau
- Cellular and Behavioral Neuroscience, Department of Psychology, Texas A&M University, College Station, TX 77843, USA
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Abstract
We experienced a case posted for bilateral lower limb surgery in a patient having mild traumatic brain injury (TBI), where administration of graded epidural anesthesia led to agitation, probably resulting from the transient elevation of intracranial pressure (ICP). Due to the wide range of benefits provided by regional anesthesia, an anesthetist should be aware of the possible options for perioperative management to best handle such polytrauma cases. In this case, agitation was managed with a bolus of benzodiazepine and maintenance infusion of dexmedetomidine while the six-hour-long surgery continued with epidural anesthesia. This patient was a smoker who had bronchospasm and underlying pneumonia precluding a high risk for postoperative ventilatory support if only general anesthesia was administered. Post-surgery the patient was conscious, oriented, and pain-free leading to early mobilization and discharge from the hospital. The patient did not report any neurological deterioration in a follow-up period of one month.
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Affiliation(s)
- Ankita Kabi
- Anesthesiology, All India Institute of Medical Sciences, Rishikesh, IND
- Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, IND
| | - Shipra Tandon
- Anesthesiology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Priya T Kandy
- Anesthesiology, All India Institute of Medical Sciences, Rishikesh, IND
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Froese L, Dian J, Batson C, Gomez A, Unger B, Zeiler FA. Cerebrovascular Response to Propofol, Fentanyl, and Midazolam in Moderate/Severe Traumatic Brain Injury: A Scoping Systematic Review of the Human and Animal Literature. Neurotrauma Rep 2020; 1:100-112. [PMID: 33251530 PMCID: PMC7685293 DOI: 10.1089/neur.2020.0040] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Intravenous propofol, fentanyl, and midazolam are utilized commonly in critical care for metabolic suppression and anesthesia. The impact of propofol, fentanyl, and midazolam on cerebrovasculature and cerebral blood flow (CBF) is unclear in traumatic brain injury (TBI) and may carry important implications, as care is shifting to focus on cerebrovascular reactivity monitoring/directed therapies. The aim of this study was to perform a scoping review of the literature on the cerebrovascular/CBF effects of propofol, fentanyl, and midazolam in human patients with moderate/severe TBI and animal models with TBI. A search of MEDLINE, BIOSIS, EMBASE, Global Health, SCOPUS, and the Cochrane Library from inception to May 2020 was performed. All articles were included pertaining to the administration of propofol, fentanyl, and midazolam, in which the impact on CBF/cerebral vasculature was recorded. We identified 14 studies: 8 that evaluated propofol, 5 that evaluated fentanyl, and 2 that evaluated midazolam. All studies suffered from significant limitations, including: small sample size, and heterogeneous design and measurement techniques. In general, there was no significant change seen in CBF/cerebrovascular response to administration of propofol, fentanyl, or midazolam during experiments where PCO2 and mean arterial pressure (MAP) were controlled. This review highlights the current knowledge gap surrounding the impact of commonly utilized sedative drugs in TBI care. This work supports the need for dedicated studies, both experimental and human-based, evaluating the impact of these drugs on CBF and cerebrovascular reactivity/response in TBI.
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Affiliation(s)
- Logan Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Joshua Dian
- Section of Neurosurgery, Department of Surgery, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Carleen Batson
- Department of Anatomy and Cell Science, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Anatomy and Cell Science, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Bertram Unger
- Section of Critical Care, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Frederick A Zeiler
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada.,Section of Neurosurgery, Department of Surgery, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Anatomy and Cell Science, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada.,Division of Anesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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