3. Anesthetic Management of Neurosurgical Emergencies
Transcription
3. Anesthetic Management of Neurosurgical Emergencies
5/8/2013 Anesthetic Management of Neurosurgical Emergencies Robert From Associate Professor Division of Neuroanesthesia Assistant Director Main Operating Rooms Department of Anesthesia Saturday, May 4, 2013 9:35 ‐ 10:15 Outline • Definition of emergency • Analysis at the University of Iowa • Review of neurophysiology • Relevant cases • Review strategies for brain protection 1 5/8/2013 Procedures by Service Jan 1 ‐ Dec 31, 2012 Cardiothoracic 0% 6% Dentistry 6% 4% Gynecology 6% Neurosurgery 28% Ophthalmology 12% Surgery Neuro 2,244 Orthopaedics Otolaryngology 5% Radiology Oto Orthopaedics 1% Surgery 11% 21% 18,970 Total Urology Miscellaneous 2 5/8/2013 Emergency Surgical Classification at UIHC Class Medical Condition Time A Emergent: life & limb threatening 1 hr B Emergent: life & limb threatening 4 hr C Urgent: severe complications 8 hr D Urgent: severe complications 24 hr Neurosurgical Emergencies: “A’s & B’s” 498 cases: Jan 1 – Dec 31, 2012 8% 9% 9% 30% 30% NIR Craniectomy/ Craniotomy 10% 10% CRANIECTOMY / CRANIOTOMY VENTRICULOSTOMY VP Shunt MISCELLANEOUS VP SHUNT 15% Ventriculostomy 28% 28% NEURO INTERVENTIONAL RADIOLOGY (NIR) BURR HOLES 30 + 28 +10 + 9 = 77% 3 5/8/2013 Pathology of Emergencies A B Craniectomy Craniotomy 30% Ventriculostomy 28% D C VP Shunt 10 % Neuro Interventional 9% Therapies are not mutually exclusive Neurophysiology ‐ Review • CMRO2 (ml/100gm/min) • CBV/CBF (ml/100gm/min) COUPLED • CPP (mm Hg) • ICP • Skull is rigid box with limited room for expansion • Brain tissue (80%) • CSF (150 ml in adults) (10%) • Blood (10%) 4 5/8/2013 Neurophysiology ‐ Review • Any increase in components (blood, brain, CSF) will increase pressure • Compensatory mechanisms • Displace blood (hyperventilation, MAP) • Displace CSF (osmols, ventric, shunt) • Increase CSF reabsorption • ICP rises rapidly after these are exhausted • “Herniation pressure” Above 20‐25 mmHg Bratton SL: J Neurotrauma 2007:24 What You Can Do • Avoidable factors contributing to death after neuro compromise • 26% had airway obstruction • 22% had hypotension (MAP < 80 mmHg, SBP < 90 mmHg) • 17% had poorly controlled seizure Rose, J: BMJ 1977; 2:615‐8 • • • • • • • Rapid access to the operating room Hyperventilate?? Blood pressure?? Inhalation agents Succinylcholine Cooling Osmotic therapy: mannitol or saline 5 5/8/2013 Hyperventilation • CBF varies directly with PaCO2 • Curve is steep within physiologic range (35 to 45 mmHg) • Response is attenuated below 25 mm Hg • Reduction in CBF is greatest when CBF is high – like with volatile anesthetics • Avoid high airway pressure (~35‐45 cm H2O) Hyperventilate when symptoms of herniation are present Blood Pressure CBV / CBF (mL/100 g/mln) CBV Effect of Autoregulation ICP 6 5/8/2013 Plateau Wave BP 120/70/ 140/80 CBV ICP ICP 0 Cerebral Edema • Vasogenic Cerebral Edema (leaky BBB) Tumors Trauma Hematomas Infection Stroke Malignant Hypertension 7 5/8/2013 Decrease Metabolic Requirements Intravenous Agents Inhalation Agents Patel PM and Drummond JC. Cerebral physiology and the effects of anesthetic drugs. In: Miller RD, ed. Anesthesia. 7th ed. Philadelphia, Penn: Churchill Livingstone, 2009: 313-317 Paralysis • Succinylcholine Modest increase in ICP from arousal Little hazard if C02, BP, and depth of anesthesia is controlled NPO period may be unknown • Non‐depolarizing relaxants Potential to ↑ or ↓ ICP – histamine release or tachycardia Anti‐seizure medication induce hepatic induction 8 5/8/2013 Hypothermia • 7% decrease in CMRO2 for each ° C • 36.5° C to 34.5° C = 14% decrease Head trauma, stroke, and cardiac arrest Hypothermia may be successful if maintained for > 48 hours Brain Trauma Foundation: www.braintrauma.org No improvement after craniotomy with aneurysmal subarachnoid hemorrhage Todd MM: Mild Intraoperative Hypothermia during Surgery for Intracranial Aneurysm. N Engl J Med 2005; 352(2): 135‐145 Mannitol • Osmotic Effect 1 mOsm ∆ = 19 mm Hg osmotic pressure 0.5 g/kg Mannitol over 10 min. Change from 295 mOsm to 305 mOsm Results in a rise in 10 mOsm Or 190 mm Hg osmotic pressure sucking fluid out of brain Editorial by MMT: ANESTHESIOLOGY 2013;118:777 • Diuretic Effect Water is drawn from tissue, including RBC • Hemodynamic Effect/Rheological Effect Plasma expanding effect Reduced cerebrovascular resistance 9 5/8/2013 Hypertonic Saline • Intracranial Pressure Reduction Concentrations range from 1.7% to 30 %; 250 ml Majority: 7.5% bolus 100 ml to 250 ml 3% infusion • Na+ to 145 – 155 mEq/L; Osmolality to 300 – 320 mOsm/L Craniectomy/Craniotomy: Principals Apply to all Emergencies (Remember therapies are not mutually exclusive) Bob Woodruff critically wounded by a roadside bomb in Iraq After his crainiectomy and before his bone flap was replaced …and how he looks today. 10 5/8/2013 Ventriculostomy Management of Acute Shunt Malfunction Chorid Plexus Arachnoid Villi 11 5/8/2013 Management of Acute Shunt Malfunction • Adult CSF volume 150 ml • 400 ml produced daily • Complete turnover about 3 times/day Management of Acute Shunt Malfunction • Failure rates may be 40% in first year • Symptoms nausea vomiting seizure visual changes sleepy coma stupor bradycardia respiratory arrest 12 5/8/2013 “Shunt Series” New shunt Old Shunt 17 y/o girl who had a shunt placed 13 years ago Stroke • 85% are ischemic Brain tissue surrounding a severely damaged area may remain viable • 15% are hemorrhagic 13 5/8/2013 Intervention for Acute Ischemic Stroke • Tissue plasminogen activator (tPA) • Use within 3 hours of symptoms onset • Endovascular therapy for greater than 3 hours Intra‐arterial thrombolysis within 6 hours ‐ not an FDA approved therapy Mechanical thrombectomy within 8 hours Becker K: Current Treatment Options in Neurology 2007, 9: 463‐469 Intervention for Acute Ischemic Stroke Thrombectomy Devices A Trevo B Solitaire 14 5/8/2013 Anesthetic Management for Acute Ischemic Stroke • • Blood pressure less than 220/120 should not be treated unless: Aortic dissection Myocardial ischemia Pulmonary edema Hypertensive encephalopathy Consider phenylephrine to push BP above 160 mm Hg systolic Schneck MJ, et al. Intervention for Acute Ischemic Stroke. In Neurosurgical Emergencies, Loftus CM (Ed.), Thieme Medical Publishers Inc., New York, NY, 2008, pp. 105‐114 Adams HP: Stroke 2003, 34:1056‐1083 Strategies for Brain Protection • Keep patient on bed/cart (usually for ventriculostomy) • Hyperventilation • CPP 70 mm Hg (i.e. MAP of at least 80 mm Hg) – higher for stroke • Volatile agents increase CBV – used without apparent morbidity • Paralysis • Hypothermia – works global, not local • Osmotic therapy 15 5/8/2013 bob‐[email protected] If you had no kidneys would mannitol work? Yes or No 16 5/8/2013 Do you have a goal for cerebral perfusion pressure in patients with traumatic brain injury? 17 5/8/2013 Do you use hyperventilation therapy to decrease ICP in the absence of herniation? Yes or No 18 5/8/2013 Head Position Raise the Head • 30° to 45° to lower ICP • ICP is higher when patient is horizontal • ICP reduced, but CPP maintained • Onset of action is immediate • Avoid jugular vein compression (cervical collar) • Avoid high airway pressures (~ how high is high?) Management of Acute Shunt Malfunction • • Proximal obstruction – most common Debris or chorid plexus Shunt tap won’t work CSF builds up faster – it has nowhere to go Distal obstruction • Shunt tap produces CSF Disconnection, fracture, migration 19