Perioperative Management of Traumatic Brain Injury. C. Werner

Transcription

1 Perioperative Management of Traumatic Brain Injury C. Werner

2 Perioperative Management of TBI Pathophysiology Monitoring Oxygenation CPP Fluid Management Glycemic Control Temperature Management Surgical Decompression Neuroprotective Drugs Summary Sedatives

3 Perioperative Management of TBI Pathophysiology Monitoring Oxygenation CPP Fluid Management Glycemic Control Temperature Management Surgical Decompression Neuroprotective Drugs Summary Sedatives

4 Primary and Secondary Injury Hypoxia, Hypotension, Hypercapnia, Hypocapnia, Hyperglycemia, Hyperthermia Vasospasm Thrombus formation ATP-deprivation Anaerobic glycolysis Lactic acidosis Inflammation Autodigestion

5 Perioperative Management of TBI Pathophysiology Monitoring Oxygenation CPP Fluid Management Glycemic Control Temperature Management Surgical Decompression Neuroprotective Drugs Summary Sedatives

6 ICP - Monitoring Duration of Intracranial Hypertension and Response to Treatment vs. Absolute ICP Treggiari M. Neurocrit Care (2007)

7 ICP versus ICE (Imaging and Examination) TBI-Patients with (n=157) vs. without (n=167) ICP Monitoring Chesnut R. NEJM (2012)

8 Impact of ICP-Monitoring Analysis from a Prospective TBI Datapool Patients with (n=1084) vs. without (n=223) ICP-Monitoring Farahvar J Neurosurg (2012)

9 ICP - (and Tissue po 2 ) - Monitoring Treatment Goal: ICP max mmhg (consider monitoring of SvjO 2 or ptio 2 ) Fauci AS. Harrisons s Principles of Internal Medicine (17th Edition)

10 Guideline for ICP - Monitoring comatose patients (GCS 3-8) with pathological CCT comatose patients (GCS 3-8) with normal CCT, but: age > 40 years unilateral or bilateral posturing systolic arterial blood pressure < 90 mmhg Carney N: Neurosurgery (2016)

11 Perioperative Management of TBI Pathophysiology Monitoring Oxygenation CPP Fluid Management Glycemic Control Temperature Management Surgical Decompression Neuroprotective Drugs Summary Sedatives

12 Risk Factors for Early Pneumonia after TBI Bronchard R. Anesthesiology (2004)

13 Competing Treatment Strategies? Lung vs. Brain Lung Brain Ventilation Mode PCV VCV Tidal Volume ~ 600 ml > 600 ml PEEP high low PaCO 2 hypercapnia hypocapnia Positioning evidence venous congestion Volume Management hypovolemia normovolemia

14 Alveolar Recruitment, PEEP Optimization Reduction of Atelectasis and Cyclic Recruitment elevated McGuire G. Crit Care Med (1997)

15 Kinetic Therapy Avoid flexion of the neck Avoid torsion of the neck MaintainSupine MAP 30 constant! left right

16 Mortality with Kinetic Therapy in ARDS Guérin C. N Engl J Med (2013)

17 Supine vs. Prone Position in ARDS ICP, CPP and tipo 2 in Patients with SAH incidence sup pr sup pr sup pr Reinprecht A. Crit Care Med (2003)

18 CBF with Hyperventilation Coles JP: Brit J Anaesth (2007)

19 Management of Hyperventilation Option: transient hyperventilation paco 2 : mmhg during ICP crisis or cerebral protrusion Standard: normoventilation paco 2 : mmhg during tolerable ICP or SvjO 2 < 50% TBI Management Guidelines BTF 4th Ed. (2016); Stocchetti N: Chest (2005)

20 Perioperative Management of TBI Pathophysiology Monitoring Oxygenation CPP Fluid Management Glycemic Control Temperature Management Surgical Decompression Neuroprotective Drugs Summary Sedatives

21 IMAPCT-Studies Pooled Data from 10 Studies and 8172 TBI Patients Maas A. Lancet Neurology (2013)

22 Management of CPP CBF Treatment Goals: ischemia (50) mmhg ICP < mmhg CPP (50) ARDS mmhg CPP TBI Management Guidelines BTF 4th Ed. (2016)

23 Perioperative Management of TBI Pathophysiology Monitoring Oxygenation CPP Fluid Management Glycemic Control Temperature Management Surgical Decompression Neuroprotective Drugs Summary Sedatives

24 Fluid Management Maintain Normovolemia, Avoid Hypoosmolarity adequate: - isotonic cristalloids - isotonic colloids - hypertonic cristalloids / colloids rather adequate: inadequate: - lactated Ringer s solution - glucose, free water

25 Mannitol vs. Hypertonic Saline Retrospective, Dose and Volume to the Effect on ICP Mangat HS. J Neurosurg (2015)

26 Perioperative Management of TBI Pathophysiology Monitoring Oxygenation CPP Fluid Management Glycemic Control Temperature Management Surgical Decompression Neuroprotective Drugs Summary Sedatives

27 ICP, MAP and CPP during Barbiturate Coma Cormio M. J Neurotrauma (1999)

28 Perioperative Management of TBI Pathophysiology Monitoring Oxygenation CPP Fluid Management Glycemic Control Temperature Management Surgical Decompression Neuroprotective Drugs Summary Sedatives

29 Challenges with Tight Glycemic Control Blood Glucose Concentration vs. Mortality Mortality mg/dl Hypoglycemia Hyperglycemia

30 Perioperative Management of TBI Pathophysiology Monitoring Oxygenation CPP Fluid Management Glycemic Control Temperature Management Surgical Decompression Neuroprotective Drugs Summary Sedatives

31 Mild Hypothermia after Pediatric TBI 32.5 o C, 24 h n = 117 n = 108 Hutchinson JS. N Engl J Med (2008)

32 Mild Hypothermia after Pediatric TBI 32.5 o C, 24 h n = 117 n = 108 Hutchinson JS. Dev Neurosci (2010)

33 Mild Hypothermia in Adult TBI 33 o C, 48 h (NABISH-II) n = 108 Clifton GL. Lancet Neurol (2011)

34 Mild Hypothermia in Adult TBI (32-35 o C, 48 h) ICP n = 117 n = 108 CPP Outcome Andrews PJD. N Engl J Med (2015)

35 Hyperthermia Mortality and ICU/Hospital Length of Stay Treat Fever! Diringer MN: Crit Care Med (2004)

36 Perioperative Management of TBI Pathophysiology Monitoring Oxygenation CPP Fluid Management Glycemic Control Temperature Management Surgical Decompression Neuroprotective Drugs Summary Sedatives

37 Surgical Decompression and Stroke A Pooled Analysis of DECIMAL, DESTINY, HAMLET Vahedi K. Lancet Neurol (2007)

38 Decompressive Craniectomy in Diffuse TBI ICP DECRA - Trial No mass lesions Composite Outcome Limited operative technique Long accrual time Differences in study groups RESCUEicp - Trial in progress Cooper DJ. N Engl J Med (2011)

39 Decompressive Craniectomie in Diffuse TBI Rescue - ICP - Trial Hutchinson PJ. N Engl J Med (2016)

40 Perioperative Management of TBI Pathophysiology Monitoring Oxygenation CPP Fluid Management Glycemic Control Temperature Management Surgical Decompression Neuroprotective Drugs Summary Sedatives

41 Neuroprotective Drugs after TBI Steroids: No effect Ca ++ -antagonists: No effect Progesterone: No effect Magnesium: No effect Erythropoietin: No effect NMDA/AMPA antagonists: No effect Etc., etc CRASH trial collaborators. Lancet (2004); Langham J. The Cochrane Library (2003) Skolnick BE. NEJM (2014); Temkin NR. Lancet Neurol (2007); Robertson CS. JAMA (2014)

42 Perioperative Management of TBI Pathophysiology Monitoring Oxygenation CPP Fluid Management Glycemic Control Temperature Management Surgical Decompression Neuroprotective Drugs Summary Sedatives

43 Treatment Goals in TBI Basic Measures ICP < mmhg and CPP (50) mmhg Normovolemia Normotension (CPP=(50) mmhg) Normocapnia (paco 2 =35-38 mmhg) Normoxemia (sao 2 >96 %) Normoglycemia (BS= mg/dl) Normothermia (T=36-37 C)

44 Treatment Goals in TBI ICP < 22 mmhg CPP (50) mmhg basic measures CT-scan ICP-/ptiO 2 -monitoring CSF-drainage mild hyperventilation barbiturate coma osmodiuretics moderate hypothermia profound hyperventilation surgical decompression

45