Management of Traumatic Brain Injury (and other neurosurgical emergencies)
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1 Management of Traumatic Brain Injury (and other neurosurgical emergencies) Laurel Moore, M.D. University of Michigan 22 nd Annual Review February 7, 2019
2 Greetings from Michigan!
3 Objectives for Today s Discussion How to manage refractory intracranial hypertension in the OR Intraoperative aneurysm rupture Major hemorrhage in spine surgery Risks of new minimally invasive spine procedures I have no financial disclosures
4 This is what it s all about A Few Definitions: Intracranial pressure = ICP Mean arterial pressure = MAP Cerebral perfusion pressure = CPP = MAP-ICP TBI = traumatic brain injury
5 There are many reasons for intraoperative intracranial hypertension
6 Neurosurgery 2017; 80:6-15
7 Monro-Kellie Doctrine Intracranial Contents Brain CSF Blood
8 The Intracranial Pressure-Volume Curve Miller s Anesthesia 2015
9 Determinants of cerebral blood flow under normal conditions Miller s Anesthesia 2015 Cottrell and Young s Neuroanesthesia 2010
10 When should we treat intracranial hypertension? It is the burden of intracranial hypertension that affects outcome ICP should be monitored in unconscious (or sedated) patients with abnormal head CT BTF would suggest treat for ICP 22 mmhg ICP monitoring and CPP management have unclear effect on long-term outcomes This speaks to the need to individualize therapy
11 Stepwise approach to ICP management in the OR
12 OR checklist and first line therapies for intracranial hypertension Is cerebral venous drainage optimized? Are respiratory parameters okay? Normocapnia Normoxia Ventilatory pressures Adapted from Drummond, Patel & Lemkuil Miller s Anesthesia 2015
13 OR checklist and first line therapies for intracranial hypertension Is the patient s blood pressure adequate? Rhoney Crit Care Clinics 2006 Miller s Anesthesia 2015
14 OR checklist and first line therapies for intracranial hypertension Are there cerebral vasodilators that can be eliminated? Are metabolic requirements increased for unrecognized reasons? Can anesthetic be altered to increase metabolic suppression? Is there intracranial pathology that is not visible? Hematoma CSF Venous obstruction or infarction
15 When first line measures fail to help Osmotic diuresis Mannitol (2ml/kg of 20% solution or gm/kg) Hypertonic saline (HTS 2ml/kg of 3% solution) Hyperventilation CSF drainage (AV Lele, J Neurosurg Anesthesiol 2017) Optimization of blood pressure
16 Hypertonic saline (HTS) and Mannitol: Establish osmotic gradient across intact blood brain barrier Both initially produce increase in cardiac output and improved laminar flow in microcirculation Both may have anti-inflammatory effects Very similar osmolarity (M = 1098, HTS = 1026 mosm/l)
17 Advantages of each osmotic agent: Mannitol Easily accessed Easily administered Rapid onset Familiarity Hypertonic saline Probably more effective than mannitol daily and cumulative ICP burden Supports intravascular volume Rapid onset and sustained effect May be effective when other rx have failed Possibly more effective at CPP and brain oxygenation
18 Disadvantages of each osmotic agent: Mannitol May crystallize Potential for rebound in ICP Intravascular volume depletion Hypertonic saline May require central access Less familiarity with drug Caution with abnormal Na values 3, 7.5, 23.4% available 1.8% for peripheral administration
19 HTS provides improved ICP control compared to mannitol A Ali, JNA ml/kg 20% mannitol vs. 3% HTS
20 Effects of 3 ml/kg 20% Mannitol and 3% HTS Hernandez-Pelazon Br J Neurosurgery 2016
21 Third line measures for refractory intracranial hypertension: Hypothermia Metabolic suppression Decompressive hemicraniectomy (DC)
22 Decompressive Hemicraniectomy (DC): Not currently recommended by Brain Trauma Foundation* Is effective at reducing ICP and time in ICU If DC planned flap 12 x 15 cm recommended Does improve survival and functional status for malignant stroke in patients 60 years Courtesy of Dr. Aditya Pandey University of Michigan Neurosurg Clin N Am 28 (2017)
23 Intraoperative aneurysm rupture
24 In advance of high risk aneurysm clipping consider: Type and cross 2 u PRBC Large bore IV access (in addition to arterial line) Pacing pads on chest and attached to defibrillator/pacer Adenosine mg/kg available in OR CMRO 2 depressant agents available (propofol) Pressors at hand Physiologic monitoring including EEG very helpful
25 In case of rupture: Call for help Discuss options with surgeons including adenosine or hypotension with CMRO 2 depressing agent until temporary clip placed Once clip placed consider volume replacement and/or induced hypertension Anesth Pain Med 2012; 7: 55-58
26 Major bleeding during spine surgery
27 PMTSS: The Prediction Model of Transfusion in Spine Surgery Anesthesiology 2009;110:
28 Strategies for major bleeding during spine surgery Adequate venous access Appropriate positioning on bolsters Role of colloid? Tranexamic acid (TXA) mg/kg bolus followed by 1-10 mg/kg/hr. Consider baseline thromboelastometry (TEG or ROTEM) PRBC:FFP = 1:1, follow platelets closely Transfusion trigger depends on rate of blood loss Goal hematocrit vs. transfusion trigger
29 Iliac bifurcation at L3-4 (Images from Synthes Spine Technique Module)
30 Interbody fusion approaches Journal of Spine Surgery 2015 Anterior, Lateral, Oblique (retroperitoneal, Anterior To Psoas), Transforaminal and Posterior Lumbar Interbody Fusion
31 OLIF ALIF LLIF
32 In Conclusion: Management of ICP should follow logical physiologic principles in stepwise fashion Neurosurgical procedures are becoming increasingly complex on increasingly sick patients Some technical advances including endovascular and minimally invasive spine procedures are helpful given our aging patient population
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