Perioperative Management of Traumatic Brain Injury

C. Werner

Perioperative Management of TBI

• Pathophysiology

• Monitoring

• Oxygenation

• CPP

• Fluid Management

• Sedatives

• Glycemic Control

• Temperature Management

• Surgical Decompression

• „Neuroprotective“ Drugs

• Summary

• Pathophysiology

• Monitoring

• Oxygenation

• CPP

• Fluid Management

• Sedatives

• Glycemic Control

• Temperature Management

• Surgical Decompression

• „Neuroprotective“ Drugs

• Summary

Perioperative Management of TBI

Primary and Secondary InjuryHypoxia, Hypotension, Hypercapnia,

Hypocapnia, Hyperglycemia, HyperthermiaVasospasm

Thrombus formation

ATP-deprivation

Anaerobic glycolysis

Lactic acidosis

Inflammation

Autodigestion

• Pathophysiology

• Monitoring

• Oxygenation

• CPP

• Fluid Management

• Sedatives

• Glycemic Control

• Temperature Management

• Surgical Decompression

• „Neuroprotective“ Drugs

• Summary

Perioperative Management of TBI

ICP - MonitoringDuration of Intracranial Hypertension and Response to

Treatment vs. Absolute ICP

Treggiari M. Neurocrit Care (2007)

Chesnut R. NEJM (2012)

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

Farahvar J Neurosurg (2012)

Impact of ICP-MonitoringAnalysis from a Prospective TBI Datapool

Patients with (n=1084) vs. without (n=223) ICP-Monitoring

ICP - (and Tissue pO2) - Monitoring

Fauci AS. Harrisons´s Principles of Internal Medicine (17th Edition)

Treatment Goal:

ICP max. 20-22 mmHg(consider monitoring of SvjO2 or ptiO2)

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)

• Pathophysiology

• Monitoring

• Oxygenation

• CPP

• Fluid Management

• Sedatives

• Glycemic Control

• Temperature Management

• Surgical Decompression

• „Neuroprotective“ Drugs

• Summary

Perioperative Management of TBI

Risk Factors for Early Pneumonia after TBI

Bronchard R. Anesthesiology (2004)

Lung Brain

Ventilation Mode PCV VCV

Tidal Volume ~ 600 ml > 600 ml

PEEP high low

PaCO2 hypercapnia hypocapnia

Positioning evidence venous congestion

Volume Management hypovolemia normovolemia

Competing Treatment Strategies ?Lung vs. Brain

Alveolar Recruitment, PEEP OptimizationReduction of Atelectasis and Cyclic Recruitment

McGuire G. Crit Care Med (1997)

elevated

Kinetic Therapy

rightleft

Supine 30°

• Avoid flexion of the neck

• Avoid torsion of the neck

Maintain MAP constant!

Mortality with Kinetic Therapy in ARDS

Guérin C. N Engl J Med (2013)

Reinprecht A. Crit Care Med (2003)

Supine vs. Prone Position in ARDSICP, CPP and tipO2 in Patients with SAH

sup pr sup pr sup pr

inci

denc

e

CBF with Hyperventilation

Coles JP: Brit J Anaesth (2007)

Management of Hyperventilation

Option: transient hyperventilation

• paCO2: 30-34 mmHg during ICP crisis or cerebral protrusion

Standard: normoventilation

• paCO2: 35-38 mmHg during tolerable ICP or SvjO2 < 50%

TBI Management Guidelines BTF 4th Ed. (2016); Stocchetti N: Chest (2005)

• Pathophysiology

• Monitoring

• Oxygenation

• CPP

• Fluid Management

• Sedatives

• Glycemic Control

• Temperature Management

• Surgical Decompression

• „Neuroprotective“ Drugs

• Summary

Perioperative Management of TBI

IMAPCT-StudiesPooled Data from 10 Studies and 8172 TBI Patients

Maas A. Lancet Neurology (2013)

ischemia

ARDS

(50) 60-70 mmHg

CPP

CB

F

Management of CPP

TBI Management Guidelines BTF 4th Ed. (2016)

Treatment Goals:

ICP < 20-22 mmHg

CPP (50) 60-70 mmHg

• Pathophysiology

• Monitoring

• Oxygenation

• CPP

• Fluid Management

• Sedatives

• Glycemic Control

• Temperature Management

• Surgical Decompression

• „Neuroprotective“ Drugs

• Summary

Perioperative Management of TBI

Fluid Management

Maintain Normovolemia, Avoid Hypoosmolarity

adequate: - isotonic cristalloids

- isotonic colloids

- hypertonic cristalloids / colloids

rather adequate: - lactated Ringer´s solution

inadequate: - glucose, free water

Mannitol vs. Hypertonic SalineRetrospective, Dose and Volume to the Effect on ICP

Mangat HS. J Neurosurg (2015)

• Pathophysiology

• Monitoring

• Oxygenation

• CPP

• Fluid Management

• Sedatives

• Glycemic Control

• Temperature Management

• Surgical Decompression

• „Neuroprotective“ Drugs

• Summary

Perioperative Management of TBI

ICP, MAP and CPP during Barbiturate Coma

Cormio M. J Neurotrauma (1999)

• Pathophysiology

• Monitoring

• Oxygenation

• CPP

• Fluid Management

• Sedatives

• Glycemic Control

• Temperature Management

• Surgical Decompression

• „Neuroprotective“ Drugs

• Summary

Perioperative Management of TBI

110-150 mg/dl

Challenges with „Tight Glycemic Control“Blood Glucose Concentration vs. Mortality

Mor

talit

y

HyperglycemiaHypoglycemia

• Pathophysiology

• Monitoring

• Oxygenation

• CPP

• Fluid Management

• Sedatives

• Glycemic Control

• Temperature Management

• Surgical Decompression

• „Neuroprotective“ Drugs

• Summary

Perioperative Management of TBI

Mild Hypothermia after Pediatric TBI32.5 oC, 24 h

n = 117

n = 108

Hutchinson JS. N Engl J Med (2008)

Hutchinson JS. Dev Neurosci (2010)

n = 117

n = 108

Mild Hypothermia after Pediatric TBI32.5 oC, 24 h

Mild Hypothermia in Adult TBI33oC, 48 h (NABISH-II)

Clifton GL. Lancet Neurol (2011)

n = 108

Andrews PJD. N Engl J Med (2015)

n = 117

n = 108

ICP

CPP

Outcome

Mild Hypothermia in Adult TBI (32-35oC, 48 h)

HyperthermiaMortality and ICU/Hospital Length of Stay

Diringer MN: Crit Care Med (2004)

Treat Fever !

• Pathophysiology

• Monitoring

• Oxygenation

• CPP

• Fluid Management

• Sedatives

• Glycemic Control

• Temperature Management

• Surgical Decompression

• „Neuroprotective“ Drugs

• Summary

Perioperative Management of TBI

Surgical Decompression and StrokeA Pooled Analysis of DECIMAL, DESTINY, HAMLET

Vahedi K. Lancet Neurol (2007)

Decompressive Craniectomy in Diffuse TBIDECRA - Trial

Cooper DJ. N Engl J Med (2011)

ICP Composite OutcomeNo mass lesions

Limited operative technique

Long accrual time

Differences in study groups

RESCUEicp - Trial in progress

Decompressive Craniectomie in Diffuse TBIRescue - ICP - Trial

Hutchinson PJ. N Engl J Med (2016)

• Pathophysiology

• Monitoring

• Oxygenation

• CPP

• Fluid Management

• Sedatives

• Glycemic Control

• Temperature Management

• Surgical Decompression

• „Neuroprotective“ Drugs

• Summary

Perioperative Management of TBI

„Neuroprotective“ Drugs after TBI

CRASH trial collaborators. Lancet (2004); Langham J. The Cochrane Library (2003)

Skolnick BE. NEJM (2014); Temkin NR. Lancet Neurol (2007); Robertson CS. JAMA (2014)

• Steroids: No effect

• Ca++-antagonists: No effect

• Progesterone: No effect

• Magnesium: No effect

• Erythropoietin: No effect

• NMDA/AMPA antagonists: No effect

• Etc., etc………

• Pathophysiology

• Monitoring

• Oxygenation

• CPP

• Fluid Management

• Sedatives

• Glycemic Control

• Temperature Management

• Surgical Decompression

• „Neuroprotective“ Drugs

• Summary

Perioperative Management of TBI

• Normovolemia

• Normotension (CPP=(50) 60-70 mmHg)

• Normocapnia (paCO2=35-38 mmHg)

• Normoxemia (saO2>96 %)

• Normoglycemia (BS=110-150 mg/dl)

• Normothermia (T=36-37 °C)

Treatment Goals in TBIBasic Measures

ICP < 20-25 mmHg and CPP (50) 60-70 mmHg

Treatment Goals in TBI

CSF-drainagemild hyperventilation osmodiuretics

barbiturate coma

moderate hypothermia

profound hyperventilationsurgical decompression

ICP < 22 mmHg CPP (50) 60-70 mmHgbasic measures

CT-scan ICP-/ptiO2-monitoring