G. E. Cold N. Juul (Eds.) Monitoring of Cerebral and Spinal Haemodynamics During Neurosurgery

Transcription

1 G. E. Cold N. Juul (Eds.) Monitoring of Cerebral and Spinal Haemodynamics During Neurosurgery

2 Georg E. Cold Niels Juul (Eds.) Monitoring of Cerebral and Spinal Haemodynamics During Neurosurgery With collaboration of Mads Rasmussen, Alp Tankisi, Helle Bundgaard, Lise Schlünzen, Birgitte Duch, Etienne Karatasi, Lisbeth Krogh, Jens-Aage Kølsen-Petersen, Karsten Skovgaard Olsen, Claus Mosdal and Bent Lob Dahl 123

3 Georg E. Cold Hojkolvej Aarhus V Niels Juul Norrebrogade 44 ISBN e-isbn DOI / Library of Congress Control Number: Springer-Verlag Berlin Heidelberg This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer Verlag. Violations are liable to prosecution under the German Copyright Law. The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Cover design: Frido Steinen-Broo, estudio, Calamar, Spain Typesetting and Production: le-tex publishing services ohg, Leipzig, Germany Printed on acid-free paper springer.com

4 Preface Make the best of it (Samuel Pepys) Everyone interested in neuroanaesthesia talks about intracranial pressure (ICP), but in daily clinical practice nobody measures it during craniotomy. This was our view ten years ago, when Dr. Cold was asked by an international congress to make a speech with the title: Is hyperventilation mandatory during craniotomy? Panic triggered our intellectual resources and, thanks to our good friends the neurosurgeons, we soon performed the first measurement of subdural ICP. Very soon we were convinced that perioperative subdural ICP measurement not only gave important information concerning the occurrence of brain swelling after opening of dura, but also it was possible to follow the effects of ICP-reducing procedures such as hyperventilation, indomethacin, mannitol treatment and surgical decompression by drainage of ventricular fluid or cystic tumours. Moreover, we were convinced that perioperative ICP measurement combined with gas analysis from arterial and jugular venous blood would provide us with important neurophysiological information, instead of the prevailing feeling that the intracranial content is a black box until the exposure of dura. As a consequence, we introduced subdural ICP measurement and insertion of a jugular bulb catheter as routine procedures, provided resources were available, and we soon found that a database containing relevant information for interpretation of ICP data was needed. Our database contains information from about 1,830 predominantly elective patients undergoing craniotomy. Our first publication concerning the method was published in the British Journal of Neurosurgery (1996), and was followed by other publications. Data from these publications are presented in this book and we acknowledge the editors for giving permission to extract data from these publications. The studies presented in this book are prospectively collected and 8 studies were designed as controlled studies, but the majority of the comparative studies were based on data from the database. In total 16 published and 27 unpublished studies are included in this book. We are well aware that uncontrolled studies, based on collection from a database, can be criticized. Nevertheless, we argue that results from uncontrolled studies may give a hint, and stimulate the repetition of such studies in a controlled design.

5 VI Preface As the methods of monitoring, measurement of subdural ICP and data concerning cerebral haemodynamics, and anaesthetic practice are the same, we have chosen to collect these data in a separate chapter (Chapter 2). Moreover, we have preferred the old fashioned way of presenting references in the text by name and year of publication, and consequently the reference lists are alphabetical. Georg E. Cold Niels Juul Published papers concerning subdural ICP include the following: Bundgaard H, Cold GE (2000) Studies of regional subdural pressure gradients during craniotomy. Br J Neurosurg 14: Bundgaard H, Jensen K, Cold GE et al (1996) Effects of perioperative indomethacin in intracranial pressure, cerebral blood flow, and cerebral metabolism in patients subjected to craniotomy for cerebral tumors. J Neurosurg Anesthesiol 8: Bundgaard H, Landsfeldt U, Cold GE (1997) Subdural monitoring of ICP during craniotomy: thresholds of cerebral swelling/herniation. Acta Neurochir Suppl 71: Bundgaard H, von Oettingen G, Larsen KM et al (1998) Effects of sevoflurane on intracranial pressure, cerebral blood flow and cerebral metabolism. Acta Anaesthesiol Scand 42: Bundgaard H, von Oettingen G, Jørgensen H et al (2001) Effects of dihydroergotamine on intracranial pressure, cerebral blood flow, and cerebral metabolism in patients undergoing craniotomy for brain tumors. J Neurosurg Anesthesiol 3: Cold GE, Tange M, Jensen TM et al (1996) Subdural pressure measurement during craniotomy. Correlation with tactile estimation of dural tension and brain herniation after opening of dura. Br J Neurosurg 10: Cold GE, Bundgaard H, von Oettingen G et al (1998) ICP during anaesthesia with sevoflurane: a dose-response study. Effect of hypocapnia. Acta Neurochir Suppl 71: Haure P, Cold GE, Hansen TM et al (2003) The ICP-lowering effect of 10 reverse Trendelenburg position during craniotomy is stable during a 10-minute period. J Neurosurg Anesthesiol 15: Jørgensen HA, Bundgaard H, Cold GE (1999) Subdural pressure measurement during posterior fossa surgery. Correlation studies of brain swelling/herniation after dural incision with measurement of subdural pressure and tactile estimation of dural tension. Br J Neurosurg 13: Olsen KS, Juul N, Cold GE (2005) Effect of alfentanil on intracranial pressure during propofol-fentanyl anesthesia for craniotomy. A randomized prospective dose-response study. Acta Anaesthesiol Scand 49: Petersen KD, Landsfeldt U, Cold GE et al (2003) Intracranial pressure and cerebral hemodynamic in patients with cerebral tumors. Anesthesiology 98: Rasmussen M, Tankisi A, Cold GE (2004) The effects of indomethacin on intracranial pressure and cerebral haemodynamics in patients undergoing craniotomy: a randomized prospective study. Anaesthesia 59:1 8 Rasmussen M, Bundgaard H, Cold GE (2004) Craniotomy for supratentorial brain tumors: risk factors for brain swelling after opening of dura mater. J Neurosurg 101:

6 Preface VII Rolighed Larsen JK, Haure P, Cold GE (2002) Reverse Trendelenburg position reduces intracranial pressure during craniotomy. J Neurosurg Anesthesiol 14:16 21 Stilling M, Karatasi E, Rasmussen M et al (2005) Subdural intracranial pressure, cerebral perfusion pressure, and degree of cerebral swelling in supra- and infratentorial spaceoccupying lesions in children. Acta Neurochir Suppl 95: Tankisi A, Cold GE (2007) Optimal reverse Trendelenburg position in patients undergoing craniotomy for cerebral tumors. J Neurosurg 106: Tankisi A, Rolighed Larsen J, Rasmussen M et al (2002) The effects of 10 degrees reverse Trendelenburg position on ICP and CPP in prone positioned patients subjected to craniotomy for occipital or cerebellar tumours. Acta Neurochir (Wien) 144: Tankisi A, Rasmussen M, Juul N et al (2006) The effects of 10 reverse Trendelenburg position (rtp) on subdural intracranial pressure and cerebral perfusion pressure in patients subjected to craniotomy for cerebral aneurysm. J Neurosurg Anesthsiol 18:11 17

7 Content 1 Monitoring of Intracranial Pressure (ICP): A Review Normal Intracranial Pressure Values Regional Differences in Intracranial Pressure Animal Studies Human Studies Pressure/Volume Relationship Pressure Waves Critical Levels of Intracranial Pressure Experimental Studies Human Studies Intracranial Pressure: Impact on Mortality Intracranial Pressure After Intracranial Surgery Approaches to Control of Intracranial Hypertension Control of Cerebral Blood Volume and Intracranial Pressure Head Elevation Reverse Trendelenburg Position Head Flexion, Rotation and Tilting Central Venous Pressure, Intraabdominal Pressure and Body Position Endotracheal Suction and Tracheotomy Positive End-Expiratory Pressure and Continuous Positive Airway Pressure Dihydroergotamine (DHE) The Lund Model Hyperventilation (HV) Cerebral Blood Flow, Cerebral Blood Volume and Intracranial Pressure Steal and Inverse Steal Phenomenon Bohr Effect Risk of Ischaemia Adaptation to Prolonged Hyperventilation Hyperventilation in Premature, Neonates and Paediatric Patients Hyperventilation as a Lifesaving Procedure... 19

8 X Content Guidelines Indomethacin Experimental Studies Human Studies Metabolic Control of Cerebral Blood Flow Hypothermia Experimental Studies Clinical Studies Guidelines Hypnotic Agents Vasodilatation Cerebral Metabolic Rate of Oxygen Sedation Intracranial Hypertension Guidelines Analgesics Spontaneous Ventilation Controlled Ventilation Sufentanil, Alfentanil Muscular Relaxation Osmotic-Acting Drugs, Plasma Expanders and Diuretics Electrolytes and Proteins and the Blood-Brain Barrier (BBB) Hydroxyethyl Starch and Hyperosmolar/ Hyperoncotic Solutions Mannitol Osmotic Gradient Experimental Studies Human Studies Mannitol in Acute Head Injury Mannitol in Cerebral Infarct Mannitol and the Blood-Brain Barrier Rebound Phenomenon Guidelines Glycerol Hypertonic Saline Experimental Studies; Central Haemodynamics Intracranial Pressure, Cerebral Blood Flow and Blood-Brain Barrier Comparative Studies Between Hypertonic Saline and Mannitol Human Studies Furosemide Corticosteroids References Material Included in the Database Diagnosis of Tumour, Localization of Cerebral Aneurysm and Hunt and Hess Gradation Anaesthesia... 61

9 Content XI 2.3 Intracranial Pressure-Reducing Procedures Discussion References Method Neuroradiological Examination in Patients with Cerebral Tumours Localization of Aneurysm and Hunt and Hess Gradation Anaesthesia and Monitoring Group 1: Propofol-Fentanyl Group 2: Isoflurane-Fentanyl Group 3: Sevoflurane-Fentanyl Group 4: Propofol-Remifentanil Fluid Administration and Regulation of Blood Pressure Subdural Intracranial Pressure and Cerebral Perfusion Pressure Catheterization of the Internal Jugular Vein and Blood Gas Analyses Measurement of Cerebral Blood Flow and Cerebral Metabolic Rate of Oxygen Measurement of Flow Velocity Effect of Hyperventilation and Indomethacin Estimation of Dural Tension and Cerebral Swelling Measurement of Intracranial Pressure During Tilting of the Operating Table Comparative Studies of Intracranial Pressure-Reducing Methods Hyperventilation Ten Degrees Reverse Trendelenburg Position Mannitol Treatment Indomethacin Surgical Decompression Studies of the Effect of Central Analgetics in Patients with Cerebral Tumours Studies of Propofol Bolus Dose Patients Subjected to Controlled Studies Statistical Analysis References Comparative Studies of Intracranial Pressure in Patients With and Without Space-Occupying Lesions Study Outline Discussion References Studies of Regional Subdural Pressure Gradients During Craniotomy Study 1: Studies of Pressure Gradients Between Subdural Intracranial Pressure and Pressures Within the Neuroaxis, Including Intraventricular Pressure and Lumbar Spinal Pressure... 91

10 XII Content Study 2: Subdural Intracranial Pressure Gradients Within the Supratentorial Surgical Field Study 3: Subdural Intracranial Pressure Gradients Within the Surgical Field in Infratentorial Surgery Study 4: Changes in Subdural Intracranial Pressure During Opening of Dura Discussion References Subdural Intracranial Pressure and Degree of Swelling After Opening of Dura in Patients with Supratentorial Tumours Study 1: Subdural Monitoring of ICP During Craniotomy: Thresholds of Cerebral Swelling/Herniation Study 2: Craniotomy for Supratentorial Brain Tumours: Risk Factors for Brain Swelling After Opening of Dura Mater Discussion References Subdural Intracranial Pressure, Cerebral Haemodynamics, Dural Tension and Degree of Swelling After Opening of Dura in Patients with Infratentorial Tumours Study 1: The Relationship Between Intracranial Pressure and the Degree of Brain Swelling in Patients Subjected to Infratentorial Surgery Study 2: Patients Subjected to Craniotomy for Occipital Tumours with Special Reference to Position Discussion References Subdural Intracranial Pressure During General Anaesthesia for Craniotomy in Patients with Supratentorial Cerebral Tumours Study 1: Subdural Intracranial Pressure and Cerebral Haemodynamics in Patients with Supratentorial Cerebral Tumours Randomized to Either Propofol-Fentanyl, Isoflurane-Fentanyl or Sevoflurane-Fentanyl Anaesthesia Study 2: Subdural Intracranial Pressure and Cerebral Haemodynamics in Patients Operated on in the Supine Position for Supratentorial Glioblastoma, Meningioma and Metastasis Study 3: Studies of Subdural Intracranial Pressure and Jugular Bulb Pressure in Patients with Supratentorial Tumours Anaesthetized with Propofol-Fentanyl or Propofol-Remifentanil Discussion References

11 Content XIII 9 Effect of Sevoflurane on Subdural Intracranial Pressure and Cerebral Haemodynamics During Craniotomy Effect of Sevoflurane on Intracranial Pressure, Cerebral Blood Flow and Cerebral Metabolism Discussion References Effect of Hyperventilation on Subdural Intracranial Pressure Study 1: Comparative Study of the Effect of Hyperventilation During Propofol-Fentanyl, Isoflurane-Fentanyl and Sevoflurane- Fentanyl Anaesthesia on Cerebral Haemodynamics Study 2: Comparative Study of the Effect of Hyperventilation During Propofol-Fentanyl and Propofol-Remifentanil Anaesthesia on Cerebral Haemodynamics Study 3: Is It Possible to Reduce Subdural Intracranial Pressure Below 10 mmhg by Hyperventilation Eventually Supplemented with Mannitol Treatment? Discussion References Effect of Indomethacin on Subdural Intracranial Pressure and Cerebral Haemodynamics Study 1: Effect of Perioperative Indomethacin on Intracranial Pressure, Cerebral Blood Flow and Cerebral Metabolism in Patients Subjected to Craniotomy for Cerebral Tumours Study 2: Effect of Indomethacin on Intracranial Pressure and Cerebral Haemodynamics in Patients Undergoing Craniotomy: A Randomized Prospective Study Discussion References Effect of Dihydroergotamine on Subdural Intracranial Pressure and Cerebral Haemodynamics Effect of Dihydroergotamine on Intracranial Pressure, Cerebral Blood Flow and Cerebral Metabolism in Patients Undergoing Craniotomy for Brain Tumours Discussion References Effect of a Bolus Dose of an Analgetic on Subdural Intracranial Pressure and Cerebral Haemodynamics During General Anaesthesia for Craniotomy in Patients with Supratentorial Cerebral Tumours Study 1: Effect of Alfentanil on Subdural Intracranial Pressure, Cerebral Haemodynamics and CO2 Reactivity During Propofol-Fentanyl Anaesthesia in Patients Subjected to Craniotomy for Supratentorial Cerebral Tumours

12 XIV Content Study 2: Effect of a Bolus Dose of Remifentanil on Cerebral Haemodynamics During Propofol-Remifentanil Anaesthesia in Patients Subjected to Craniotomy for Supratentorial Cerebral Tumours Study 3: Effect of a Bolus Dose of Fentanyl on Cerebral Haemodynamics During Propofol-Fentanyl Anaesthesia in Patients Subjected to Craniotomy for Supratentorial Cerebral Tumours Discussion References Effect of a Propofol Bolus Dose on Subdural Intracranial Pressure and Cerebral Haemodynamics During General Anaesthesia for Craniotomy in Patients with Supratentorial Cerebral Tumours Study 1: Effect of a Propofol Bolus Dose on Subdural Intracranial Pressure and Cerebral Haemodynamics in Patients Subjected to Craniotomy for Supratentorial Cerebral Tumours in Propofol-Remifentanil Anaesthesia Study 2: Effect of a Propofol Bolus Dose on Subdural Intracranial Pressure and Cerebral Haemodynamics in Patients Subjected to Craniotomy for Supratentorial Cerebral Tumours in Propofol-Fentanyl Anaesthesia Discussion References Effect of Reverse Trendelenburg Position on Subdural Intracranial Pressure and Cerebral Haemodynamics During General Anaesthesia for Craniotomy in Patients with Supratentorial Cerebral Tumours Study 1: The Intracranial Pressure-Lowering Effect of 10 Degrees Reverse Trendelenburg Position During Craniotomy is Stable During a 10-Minute Period Study 2: Effect of 10 Degrees Reverse Trendelenburg Position on Intracranial Pressure and Cerebral Perfusion Pressure in Prone-Positioned Patients Subjected to Craniotomy for Occipital or Cerebellar Tumours Study 3: Optimal Reverse Trendelenburg Position in Patients Undergoing Craniotomy for Cerebral Tumours Study 4: Effect of Reverse Trendelenburg Position on Intracranial Pressure and Cerebral Perfusion Pressure in Patients with Cerebral Tumours. A Comparative Study of Propofol-Fentanyl and Propofol-Remifentanil Anaesthesia Discussion References

13 Content XV 16 Effect of Evacuation of Cerebral Cysts on Subdural Intracranial Pressure and Cerebral Perfusion Pressure Study Outline Discussion References Comparative Studies of Therapeutic Measures to Reduce Subdural Intracranial Pressure During Craniotomy Study 1: A Comparative Study of the Intracranial Pressure-Reducing Effect of Hyperventilation, 10 Degrees Reverse Trendelenburg Position, Mannitol Treatment, Indomethacin or Surgical Decompression in Patients with Intracranial Hypertension Subjected to Craniotomy for Supratentorial Cerebral Tumours in Propofol-Fentanyl Anaesthesia Study 2: A Comparative Clinical Study of the Intracranial Pressure-Reducing Effect of 10 Degrees Reverse Trendelenburg Position and Hyperventilation in Patients Subjected to Supratentorial Craniotomy for Cerebral Tumours in Propofol-Remifentanil Anaesthesia Study 3: A Comparative Study of the Intracranial Pressure- Reducing Effect of 10 Degrees Reverse Trendelenburg Position, Hyperventilation, Indomethacin and Surgical Drainage in Patients Undergoing Fossa Posterior Surgery in the Prone Position Discussion References Effect of Positive End-Expiratory Pressure on Subdural Intracranial Pressure in Patients Undergoing Supratentorial Craniotomy Study 1: Effect of 5 cmh2o Positive End-Expiratory Pressure on Subdural Intracranial Pressure, Cerebral Perfusion Pressure and Jugular Bulb Pressure Study 2: Effect of 10 cmh2o Positive End-Expiratory Pressure on Subdural Intracranial Pressure, Cerebral Perfusion Pressure and Jugular Bulb Pressure Discussion References Subdural Intracranial Pressure and Cerebral Haemodynamics During General Anaesthesia for Craniotomy in Patients with Cerebral Aneurysm Study 1: Comparative Study of Subdural Intracranial Pressure and Cerebral Perfusion Pressure in Patients with Cerebral Aneurysm Anaesthetized with Either Propofol-Fentanyl or Isoflurane-Fentanyl

14 XVI Content Study 2: Effect of 10 Degrees Reverse Trendelenburg Position on Subdural Intracranial Pressure and Cerebral Perfusion Pressure in Patients Subjected to Craniotomy for Cerebral Aneurysm Discussion References Subdural Intracranial Pressure in Children Study 1: Subdural Intracranial Pressure, Cerebral Perfusion Pressure and Degree of Cerebral Swelling in Supraand Infratentorial Space-Occupying Lesions in Children Study 2: Effect of Reverse Trendelenburg Position on Subdural Intracranial Pressure in Children During Craniotomy Discussion References Subdural Spinal Pressure During Surgery for Intradural Tumours and Surgery for Tethered Cord Study Outline Discussion References Studies of Jugular Pressure Study 1: Neck Compression and Jugular Bulb Pressure in Patients Subjected to Craniotomy Study 2: Studies of Jugular Bulb Pressure During Craniectomy in the Sitting Position Discussion References Differences in PCO2, ph, Lactate, K + and Na + Between Arterial Blood and Jugular Bulb Blood in Patients Subjected to Craniotomy in Either Propofol-Fentanyl or Propofol-Remifentanil Anaesthesia Study Outline Discussion References Limitations and Complications Connected with Monitoring of Subdural Intracranial Pressure and Insertion of Jugular Catheter Study Outline Discussion References Subject Index

15 List of Contributors Helle Bundgaard Georg E. Cold Hojkolvej Aarhus V Bent Lob Dahl Birgitte Duch Niels Juul Norrebrogade 44 Etienne Karatasi Jens Aage Kolsen-Petersen Lisbeth Krogh Claus Mosdal Department of Neurosurgery Mads Rasmussen

16 XVIII List of Contributors Lise Schlünzen Alp Tankisi Karsten Skovgaard Olsen Department of Anesthesia and Intensive Care Glostrup University Hospital University of Copenhagen 2600 Glostrup

17 Abbreviations ARDS AVD AVDO 2 BIS BMI CBF CBV CI CMRO 2 CPAP CPP CSF CT CVP CVR DHE DPG DWI EC 50 EEG FiO 2 GCS GOS HES ICP IVP JBP JP MABP MAC MCAO MRI NIBP Acute respiratory distress syndrome Arteriovenous difference Arteriovenous oxygen difference Bispectral index Body mass index Cerebral blood flow Cerebral blood volume Confidence interval Cerebral metabolic rate of oxygen Continuous positive airway pressure Cerebral perfusion pressure Cerebrospinal fluid Computed tomography Central venous pressure Cerebrovascular resistance Dihydroergotamine 2,3-Dephosphoglycerate Diffusion-weighted magnetic resonance imaging Half maximal effective concentration Electroencephalogram Fraction of inspired oxygen Glasgow Coma Scale Glasgow Outcome Scale Hydroxyethyl starch Intracranial pressure Intraventricular pressure Jugular bulb pressure Jugular pressure Mean arterial blood pressure Minimal alveolar concentration Middle cerebral artery occlusion Magnetic resonance imaging Non-invasive blood pressure

18 XX Abbreviations O 2 Ct OR PaCO 2 PaO 2 PbrO 2 PEEP PET PtiO 2 PVI PvO 2 PVR r rcbf rcbv rtp SAH SATv SBF SD SE SjO 2 SPP SSP TBI Venous oxygen content Odds ratio Partial pressure of carbon dioxide Partial pressure of oxygen Brain tissue oxygen tension Positive end-expiratory pressure Positron emission tomography Partial tissue oxygen tension Pressure/volume index Jugular venous oxygen tension Peripheral vascular resistance Correlation coefficient Regional cerebral blood flow Regional cerebral blood volume Reverse Trendelenburg position Subarachnoid haemorrhage Jugular venous saturation Spinal cord blood flow Standard deviation Standard error of mean Jugular venous/bulb oxygen saturation Spinal perfusion pressure Spinal subdural pressure Traumatic brain injury