Muh Ramli Ahmad Muh Ramli Ahmad Department
Department of Anesthesof Anesthesilogy Facuilogy Faculty of Mlty of Medicine edicine Hasanuddin Hasanuddin University University MakassarMakassar RINGKASAN
RINGKASAN
Di Amerika Serikat kejadian
Di Amerika Serikat kejadian trauma kepala setiap tahunnya diperkirakan mencapai 500.000trauma kepala setiap tahunnya diperkirakan mencapai 500.000 kasus, Dari jumlah tersebut 10% meninggal sebelum tiba di rumah sakit.Pengelolaan cedera kasus, Dari jumlah tersebut 10% meninggal sebelum tiba di rumah sakit.Pengelolaan cedera kepala harus dimulai dari tempat kejadian ( prehospital ) untuk menghindari kerusakan otak kepala harus dimulai dari tempat kejadian ( prehospital ) untuk menghindari kerusakan otak sekunder. Kerusakan otak sekunder dapat terjadi karena kelainan sistemik
sekunder. Kerusakan otak sekunder dapat terjadi karena kelainan sistemik maupun intrakranial,maupun intrakranial, Penyebab sistemik adalah hipoksemia, hiperkapnia, hipotensi, anemia, hipovo;emik,
Penyebab sistemik adalah hipoksemia, hiperkapnia, hipotensi, anemia, hipovo;emik, hiponatremia, hipertermi, sepsis, koagulopati.
hiponatremia, hipertermi, sepsis, koagulopati. Sedangkan penyebab intrakranial adalahSedangkan penyebab intrakranial adalah epidural/subdur
epidural/subdural hemotoma, al hemotoma, kontusio serebri, perdarahan intraserebral, infeksi, kontusio serebri, perdarahan intraserebral, infeksi, epilepsi postepilepsi post trauma. Evaluasi preoperatif meliputi Anamnesis riwayat
trauma. Evaluasi preoperatif meliputi Anamnesis riwayat kecelakaan perlu diketahui,kecelakaan perlu diketahui, Mekanisme injuri akan menolong dalam
Mekanisme injuri akan menolong dalam menentukan prognosis, Tanda-tanda vital harus segeramenentukan prognosis, Tanda-tanda vital harus segera diperiksa, Hipotensi mungkin disebabkan adanya injuri ditempat lain, Hipertensi terutama bila diperiksa, Hipotensi mungkin disebabkan adanya injuri ditempat lain, Hipertensi terutama bila disertai bradikardi menunjukkan adanya kenaikan ICP akibat lesi
disertai bradikardi menunjukkan adanya kenaikan ICP akibat lesi massa yang memerlukanmassa yang memerlukan pembedahan. Pengelolaan anestesi pada trauma secara prinsip meliputi
pembedahan. Pengelolaan anestesi pada trauma secara prinsip meliputi : Mengoptimalkan: Mengoptimalkan perfusi serebri, menghindari iskemia sekunder serta obat/tehnik yang dapat
perfusi serebri, menghindari iskemia sekunder serta obat/tehnik yang dapat meningkatkanmeningkatkan tekanan intra kranial. Premedikasi pada trauma
tekanan intra kranial. Premedikasi pada trauma kepala biasanya tidak diperlukan.Bila generalkepala biasanya tidak diperlukan.Bila general anestesi sebagai alternatif maka diperlukan induksi yag ideal adalah menghindari hipotensi , anestesi sebagai alternatif maka diperlukan induksi yag ideal adalah menghindari hipotensi , kenaikan tekana darah,dan TIK. Pentotal merupakan obat induksi pilihan bila tidak ada
kenaikan tekana darah,dan TIK. Pentotal merupakan obat induksi pilihan bila tidak ada kontraindikasi karena menurunkan CBF dan ICP, bila
kontraindikasi karena menurunkan CBF dan ICP, bila ada kontraindikasi maka propofolada kontraindikasi maka propofol merupakan alternatif. Pemeliharaan anestesi digunakan obat yang kurang mempengaruhi merupakan alternatif. Pemeliharaan anestesi digunakan obat yang kurang mempengaruhi CBF,CBV,CMRO2 dan Autoregulasi, biasanya
CBF,CBV,CMRO2 dan Autoregulasi, biasanya menggunakan berbagai kombinasi barbiturat,menggunakan berbagai kombinasi barbiturat, narkotik, N2O ,obat anestesi inhalasi dengani MAC rendah dan relaksasi otot. (J
narkotik, N2O ,obat anestesi inhalasi dengani MAC rendah dan relaksasi otot. (J Med Nus.Med Nus. 2004; 25:50-54)
2004; 25:50-54) SUMMARY SUMMARY
The incidences of head injury in the
The incidences of head injury in the United State reached 500.000 cases yearly. Ten percentsUnited State reached 500.000 cases yearly. Ten percents or them died before reach the hospital.
or them died before reach the hospital. Management of head injury has to be Management of head injury has to be started on the spotstarted on the spot of the accident (prehospital) in order to avoid secondary brain damage. The secondary brain of the accident (prehospital) in order to avoid secondary brain damage. The secondary brain damage might be caused either by systemic disorder or intracranial. The systemic disorders are damage might be caused either by systemic disorder or intracranial. The systemic disorders are hypoxemia, hypercapnia, hypotension, anemia, hypovolemia, hyponatremia, hyperthermia, hypoxemia, hypercapnia, hypotension, anemia, hypovolemia, hyponatremia, hyperthermia, sepsis, and coagulopathies. Intracranial factors are epidural/
sepsis, and coagulopathies. Intracranial factors are epidural/ subdural hematoma, cerebralsubdural hematoma, cerebral contusion, intracerebral infection, and post-trauma epilepsy. Preoperative evaluations are contusion, intracerebral infection, and post-trauma epilepsy. Preoperative evaluations are included: Anamnesis the history of accident and the mechanism of
included: Anamnesis the history of accident and the mechanism of injury, which can help toinjury, which can help to determine the prognosis. The vital signs have to be
determine the prognosis. The vital signs have to be examine, hypotension could be caused byexamine, hypotension could be caused by injury in others place.
injury in others place. Hypertension especially accompanied by bradycardia showed elevated ofHypertension especially accompanied by bradycardia showed elevated of intracranial pressure by mass lesion that
intracranial pressure by mass lesion that needs surgical procedure. The principal managementneeds surgical procedure. The principal management of head injury are optimize of
of head injury are optimize of cerebral perfusion, avoid secondary ischemia and administrationcerebral perfusion, avoid secondary ischemia and administration of drugs/ techniques which can caused elevation of intracranial pressure. Premedication in head of drugs/ techniques which can caused elevation of intracranial pressure. Premedication in head injury usually is unnecessary. However, if general anesthesia is the alternative for ideal
injury usually is unnecessary. However, if general anesthesia is the alternative for ideal induction require maneuver to avoid hypotension, elevation of both blood pressure or induction require maneuver to avoid hypotension, elevation of both blood pressure or intracranial pressure
intracranial pressure. Penthotal is an . Penthotal is an ideal induction agent if there no ideal induction agent if there no contraindications where itcontraindications where it can reduce the cerebral blood flow (CBF) and intracranial pressure (ICP); while if there any can reduce the cerebral blood flow (CBF) and intracranial pressure (ICP); while if there any contraindication pro
contraindication propofol is the choice. The maintenapofol is the choice. The maintenance nce of anesthesia used druof anesthesia used drugs, which lessgs, which less affected to the CBF,
affected to the CBF, CBV, CMRO2 and auto regulation, usually using the CBV, CMRO2 and auto regulation, usually using the combination ofcombination of barbiturate, narcotic, N2O, volatile anesthetic with, low MAC
barbiturate, narcotic, N2O, volatile anesthetic with, low MAC and muscle relaxant.(J Med Nus.and muscle relaxant.(J Med Nus. 2004; 25:50-54)
{mospagebreak} {mospagebreak}
INTRODUCTION INTRODUCTION
The incidences of head injury in the
The incidences of head injury in the United State reached 500.000 cases yearly. Ten percentsUnited State reached 500.000 cases yearly. Ten percents or them died before reach the hospital.
or them died before reach the hospital. The victims who reached the hospital 80% are classifiedThe victims who reached the hospital 80% are classified as mild head injury, 10%
as mild head injury, 10% moderate head injury amoderate head injury and 10% severe hnd 10% severe head injury1. ead injury1. The managementThe management of head injury has to
of head injury has to be started at the place be started at the place of accident (prehospital) to prevent secondary brainof accident (prehospital) to prevent secondary brain damage (secondary injury).1,2
damage (secondary injury).1,2
The results of head injury, primary injury is
The results of head injury, primary injury is caused by direct damage both of the caused by direct damage both of the neurons orneurons or blood vessels by collision. Secondary injury taking place for several minutes, hours even days blood vessels by collision. Secondary injury taking place for several minutes, hours even days after primary injury and
after primary injury and resulting further neurons damage.resulting further neurons damage. The secondary injury can be
The secondary injury can be caused by systemic disorder or intracranial. The caused by systemic disorder or intracranial. The systemicsystemic disorders are hypoxemia, hypercapnia, arterial hypotension, anemia, hypovolemia, and disorders are hypoxemia, hypercapnia, arterial hypotension, anemia, hypovolemia, and hyponatremia imbalance of osmotic pressure, hyperthermia, sepsis, coagulopathies, and hyponatremia imbalance of osmotic pressure, hyperthermia, sepsis, coagulopathies, and
hypertension. While intracranial caused by epidural/ subdural hematomes, contusion cerebral, hypertension. While intracranial caused by epidural/ subdural hematomes, contusion cerebral, intracranial infection and post t
intracranial infection and post trauma epilepsy.2-4rauma epilepsy.2-4
Secondary injury can be considered as a complication from early injury. Several substances like Secondary injury can be considered as a complication from early injury. Several substances like enzyme proteolytics, biogenic amine (serotonin and histamine),
enzyme proteolytics, biogenic amine (serotonin and histamine), neurotransmitter (glutamate)neurotransmitter (glutamate),, unsaturated lipids (aracidonic acid and its metabolic), free radical and kalikrein-kinin, showed as unsaturated lipids (aracidonic acid and its metabolic), free radical and kalikrein-kinin, showed as reversible and irreversible physiology mediator of secondary injury. This
reversible and irreversible physiology mediator of secondary injury. This mechanism includingmechanism including vasogenic edema caused by the
vasogenic edema caused by the circulation disorder, cytotoxic edema and cells circulation disorder, cytotoxic edema and cells nectrosis.2,4nectrosis.2,4 The important of secondary injury to the outcome has
The important of secondary injury to the outcome has been showed in patients while right afterbeen showed in patients while right after a trauma or a few
a trauma or a few moments after trauma still conscious and talking, them moments after trauma still conscious and talking, them getting worse andgetting worse and died. At these patients the
died. At these patients the death can be mentioned by effect death can be mentioned by effect of secondary injury.4,5of secondary injury.4,5
Because of secondary injury might developed during patient therapy in the hospital, require Because of secondary injury might developed during patient therapy in the hospital, require active intervention in the management of the
active intervention in the management of the patient. The important contribution in secondarypatient. The important contribution in secondary injury is hypoxemia and hypovolemia with hypotension, which have to be
injury is hypoxemia and hypovolemia with hypotension, which have to be actively found andactively found and corrected immediately.4
corrected immediately.4 In order to deal with
In order to deal with head injury patients, there are several considerations according tohead injury patients, there are several considerations according to physiology disorders after injury. The goal of these considerations is to administered physiology disorders after injury. The goal of these considerations is to administered
anesthesia, which do not disturb cerebral perfusion pressure (CPP). It has been known that anesthesia, which do not disturb cerebral perfusion pressure (CPP). It has been known that brain function and cell neuron depend on adequacy of brain blood vessels. The
brain function and cell neuron depend on adequacy of brain blood vessels. The brain bloodbrain blood vessels affect the brain perfusion pressure. In normal individual, the auto
vessels affect the brain perfusion pressure. In normal individual, the auto regulation willregulation will maintain constant blood flow at certain pressure (MAP 50- 150 mmHg).
maintain constant blood flow at certain pressure (MAP 50- 150 mmHg). Head injury causesHead injury causes defect in auto regulation. The increase of
defect in auto regulation. The increase of ICP by head injury or decrease of MAP ICP by head injury or decrease of MAP caused bycaused by bleeding in other place can risked the brain perfusion.3,4,6
bleeding in other place can risked the brain perfusion.3,4,6 {mospagebreak} {mospagebreak} PREOPERATIVE EVALUATION PREOPERATIVE EVALUATION History History
The history of accident has to
The history of accident has to be known, The mechanism of injury will be known, The mechanism of injury will help to determine thehelp to determine the prognosis. For example, pasient with falling accident, has for
prognosis. For example, pasient with falling accident, has for times greater possibility for intratimes greater possibility for intra cerebral hematoma than vehicle accident. The condition of patient immediately after i
cerebral hematoma than vehicle accident. The condition of patient immediately after injury is anjury is a base for reevalua
base for reevaluation especially regardtion especially regarding level of consciousneing level of consciousness, Also patients ss, Also patients conditioncondition before injury can help to evaluate the
before injury can help to evaluate the patient.patient. Physical Examination
Physical Examination
Vital signs evaluated immediately for hypotension, which caused by injuries in
Vital signs evaluated immediately for hypotension, which caused by injuries in other place.other place. Hypertension especially accompanied by bradycardia showed elevation of ICP,
by mass lesion (Cushing’s Syndrome) that
by mass lesion (Cushing’s Syndrome) that need the surgery.need the surgery.
The evaluation is primary and secondery.. Primary evaluation correlated with patient’s life The evaluation is primary and secondery.. Primary evaluation correlated with patient’s life saving are:
saving are:
a. Airway control with C-spine protection a. Airway control with C-spine protection b. Breathing
b. Breathing c. Circulation &
c. Circulation & HemorrhageHemorrhage d. Disability/ disorder of CNS d. Disability/ disorder of CNS e. Exposure the whole body e. Exposure the whole body
Secondary evaluation is physical examination from head
Secondary evaluation is physical examination from head to toe to toe and diagnostic proceduresand diagnostic procedures (X-ray, CT-scan, MRI, ect.).7,8
(X-ray, CT-scan, MRI, ect.).7,8
Several uncooperative patients for CT-scan have to be intubated to control the ventilation. Several uncooperative patients for CT-scan have to be intubated to control the ventilation. InIn trauma capitis patient sedation must be given carefully for
trauma capitis patient sedation must be given carefully for CT-scan evaluation because ofCT-scan evaluation because of hypoventilation can occurred. Study estimated approximately 5-17% incidence of
hypoventilation can occurred. Study estimated approximately 5-17% incidence of cervicalcervical fracture in trauma capitis. If spine
fracture in trauma capitis. If spine radiography includes C7 cannot be done properly, better beradiography includes C7 cannot be done properly, better be assumed there is cervical fracture, cause a simple lateral radiography can not excluded for assumed there is cervical fracture, cause a simple lateral radiography can not excluded for cervical fracture and serial cervical radiography are needed.
cervical fracture and serial cervical radiography are needed. If there are indications for intubation have
If there are indications for intubation have used standard fast induction with thiopental,used standard fast induction with thiopental, succinylcholine and cricoid pressur
succinylcholine and cricoid pressure. Collar can be removed if e. Collar can be removed if disturb the intubation and put itdisturb the intubation and put it back after intubation. To avoid the
back after intubation. To avoid the sliding of posterior cervical when cricoid pressure applied,sliding of posterior cervical when cricoid pressure applied, one of the helper has to
one of the helper has to put both palms beside the put both palms beside the neck (remember inline C position).1,5neck (remember inline C position).1,5 Laboratory evaluations have to be done prior to surgery like Hgb, Hct,
Laboratory evaluations have to be done prior to surgery like Hgb, Hct, chemical blood, arterialchemical blood, arterial blood gas, thrombocyte, bleeding time and clothing time.7,9 Hgb < 10 g% is one of the
blood gas, thrombocyte, bleeding time and clothing time.7,9 Hgb < 10 g% is one of the important factor for worsen condition of head injury’s patient. Several trials
important factor for worsen condition of head injury’s patient. Several trials showed thatshowed that hematocryte of 30% still optimal to
hematocryte of 30% still optimal to deliver oxygen in cerebral ischemic, however hematocrytedeliver oxygen in cerebral ischemic, however hematocryte less than 30% worsen the condition, consider to give blood
less than 30% worsen the condition, consider to give blood earlier in multiple trauma to earlier in multiple trauma to preventprevent worse condition. 3,8
worse condition. 3,8
Many head injury patients accompany with multi system trauma and signs
Many head injury patients accompany with multi system trauma and signs of hypovolemic.of hypovolemic. Maintain adequate intravascular circulation to avoid hypotension and maintain CPP volume is Maintain adequate intravascular circulation to avoid hypotension and maintain CPP volume is very important. Intravascular volume has to be maintained and replaced with free glucose very important. Intravascular volume has to be maintained and replaced with free glucose isotonic crystalloid solution (Saline Normal
isotonic crystalloid solution (Saline Normal 0.9%), albumin (5%) or blood 0.9%), albumin (5%) or blood product.5,8,9product.5,8,9 Adult patient hematocryte concentration has to be maintained around 30% to optimize
Adult patient hematocryte concentration has to be maintained around 30% to optimize oxygenoxygen transport. Fluid restriction to
transport. Fluid restriction to decrease cerebral fluid volume and prevent cerebral edemadecrease cerebral fluid volume and prevent cerebral edema assumed have not applicable anymore.4,6,7 Then,
assumed have not applicable anymore.4,6,7 Then, the inotropic and vasopressor might neededthe inotropic and vasopressor might needed to increase blood pressure.6,7.
to increase blood pressure.6,7. Colloid vs Crystalloid: Shifting of f
Colloid vs Crystalloid: Shifting of fluid and solution from intravascular space to interstitial andluid and solution from intravascular space to interstitial and intracellular affected by hydrostatic pressure, osmotic pressure and oncotic
intracellular affected by hydrostatic pressure, osmotic pressure and oncotic pressure. Cerebralpressure. Cerebral capillary endothels are bound tightly, except if Blood Brain
capillary endothels are bound tightly, except if Blood Brain Barrier (BBB) damaged, electrolyteBarrier (BBB) damaged, electrolyte cannot enter extra cellular brain. Although colloid (Albumin and Hetastarch) have higher oncotic cannot enter extra cellular brain. Although colloid (Albumin and Hetastarch) have higher oncotic pressure and theoretically can reduce edema cerebral, oncotic pressure, as
pressure and theoretically can reduce edema cerebral, oncotic pressure, as pusher energy ispusher energy is smaller than osmotic. Therefore the experimental studies in reducing osmolalitas without smaller than osmotic. Therefore the experimental studies in reducing osmolalitas without reducing osmotic always accompanied by edema cerebral, while
reducing osmotic always accompanied by edema cerebral, while reducing oncotic pressurereducing oncotic pressure without changing osmotic pressure do not have affect to
without changing osmotic pressure do not have affect to ICP and cerebral fluid volume.ICP and cerebral fluid volume. Therefore maintain osmotic pressure is more
Therefore maintain osmotic pressure is more important than maintaining oncotic important than maintaining oncotic pressure.sopressure.so that, the usage of
that, the usage of colloid versus crystalloid in head injury still controversial, even though thecolloid versus crystalloid in head injury still controversial, even though the usage of crystalloid still acceptable practice.
usage of crystalloid still acceptable practice. {mospagebreak}
A
ANNEESSTTHHEESSIIA A MMAANNAAGGEEMMEENNTT
Anesthesia management of head injury, principally same with others patient with
Anesthesia management of head injury, principally same with others patient with increase ofincrease of ICP.,5,6,7,9
ICP.,5,6,7,9
1. Optimize cerebral perfusion 1. Optimize cerebral perfusion 2. Avoid cerebral ischemia 2. Avoid cerebral ischemia 3. Avoid the usage of
3. Avoid the usage of drugs/ technique that caused increase intracranial pressuredrugs/ technique that caused increase intracranial pressure.. Premedication
Premedication
In head injury premedication is unnecessary for sedation. The effect of
In head injury premedication is unnecessary for sedation. The effect of increase PaO2 isincrease PaO2 is undesirable and the requirement of
undesirable and the requirement of control ventilation when respiratory depressant drugs havecontrol ventilation when respiratory depressant drugs have been given. It is
been given. It is enough to give anti cholinergic to prevent hyper salivation, glycopyrolate is drugenough to give anti cholinergic to prevent hyper salivation, glycopyrolate is drug of choice for anti secretion by its lesser effect to the heart.7 But if there are medulla spinalis of choice for anti secretion by its lesser effect to the heart.7 But if there are medulla spinalis injury with tendency to bradycardia, administration of sulfas atropine is recommended 0.02 injury with tendency to bradycardia, administration of sulfas atropine is recommended 0.02 mg/kg body weight, IV when heart rate
mg/kg body weight, IV when heart rate is below 70. Metoclopropamide (10 mg, IV) is below 70. Metoclopropamide (10 mg, IV) reducereduce gastrointestinal motility.
gastrointestinal motility.
Generally narcotic drug, barbiturate, tranquilizer are not
Generally narcotic drug, barbiturate, tranquilizer are not recommended can bother neurologicrecommended can bother neurologic evaluation and depress the ventilation.
evaluation and depress the ventilation. Induction
Induction
Once general anesthesia chosen, an ideal induction are to avoid hypotension, increase either Once general anesthesia chosen, an ideal induction are to avoid hypotension, increase either blood pressure or ICP. Therefore has to determine weather blood volume is enough and stabile, blood pressure or ICP. Therefore has to determine weather blood volume is enough and stabile, when CVP is not attached can be done a simple test (tilt test).7,8,9
when CVP is not attached can be done a simple test (tilt test).7,8,9
Although blood pressure is already normal do not mean the circulation volume is
Although blood pressure is already normal do not mean the circulation volume is enoughenough
because induction in hypovolemia caused immediately shock. Avoid condition that can caused because induction in hypovolemia caused immediately shock. Avoid condition that can caused pain which can increase blood pressure and ICP like application infuse, suction of
pain which can increase blood pressure and ICP like application infuse, suction of secretion,secretion, manipulation at trauma area, ect.9
manipulation at trauma area, ect.9 Not all authors agree, but majority are
Not all authors agree, but majority are indicated that head elevation 15- 30 degree will indicated that head elevation 15- 30 degree will reducereduce increase of ICP without influencing CPP or
increase of ICP without influencing CPP or cerebral oxygenation. Elevation >30 degree earncerebral oxygenation. Elevation >30 degree earn influence increase ICP in some patients through auto regulation process by vasodilatation, influence increase ICP in some patients through auto regulation process by vasodilatation, better head elevation 20 degree can prevent neck vein obstruction in supine position. When better head elevation 20 degree can prevent neck vein obstruction in supine position. When patient has to be in
patient has to be in lateral or prone position, chest and abdomen have to lateral or prone position, chest and abdomen have to be freed frombe freed from pressure.8,9,
pressure.8,9,
When larygoscopy and intubation prevent cough and strain which can caused increase of blood When larygoscopy and intubation prevent cough and strain which can caused increase of blood pressure, ICP, edema, and brain herniation. This can be reached by usage of
pressure, ICP, edema, and brain herniation. This can be reached by usage of fentanyl 50-100 g,fentanyl 50-100 g, IV prior to induction, both
IV prior to induction, both Sufentanyl and Alfentanyl caused increase ICP.6Sufentanyl and Alfentanyl caused increase ICP.6 Penthotal is an ideal induction agent
Penthotal is an ideal induction agent when there are no contra indication because its ability when there are no contra indication because its ability toto reduce CBF and ICP. When penthotal is contra indication,
reduce CBF and ICP. When penthotal is contra indication, propofol is an alternative because itspropofol is an alternative because its effect to
effect to reduce CBF and intra reduce CBF and intra cerebral pressure without disturbing cerebral perfusioncerebral pressure without disturbing cerebral perfusion pressure.6,7
pressure.6,7
Norcuron is a choice for relaxant because its
Norcuron is a choice for relaxant because its cardiovascular stability and effect to ICP iscardiovascular stability and effect to ICP is minimal. Succinylcholine caused increase CBF and ICP, possibility of hyperkalemia, minimal. Succinylcholine caused increase CBF and ICP, possibility of hyperkalemia, Roccuronium 0.6 mg/kg body weight is an alternative with
Roccuronium 0.6 mg/kg body weight is an alternative with 60 seconds intubations can be done60 seconds intubations can be done with duration of action for
with duration of action for 30- 40 minutes.6,730- 40 minutes.6,7
Pancuronium is not recommended because its effect of hypertension and increase CBF & ICP Pancuronium is not recommended because its effect of hypertension and increase CBF & ICP where in head injury patient auto regulation disorder has occurred. Atracurium has to be
where in head injury patient auto regulation disorder has occurred. Atracurium has to be avoided as mush as possible according to its histamine release effect
avoided as mush as possible according to its histamine release effect and metaboliteand metabolite laudanosin, which caused seizure in animal.8,9
laudanosin, which caused seizure in animal.8,9 Maintenance of Anesthesia
The usage of drugs for maintaining of
The usage of drugs for maintaining of anesthesia can effected CBF, CBV, CMRO2, autoanesthesia can effected CBF, CBV, CMRO2, auto regulation pressure and response to PaCO2. Anesthesiologist usually uses
regulation pressure and response to PaCO2. Anesthesiologist usually uses combination ofcombination of barbiturate, benzodiazep
barbiturate, benzodiazepine, narcotic, N2O and low ine, narcotic, N2O and low MAC of volatile agent. The MAC of volatile agent. The usage ofusage of Isoflurane and Sevoflurane are based on a good auto regulation up to
Isoflurane and Sevoflurane are based on a good auto regulation up to 1.5 MAC and its1.5 MAC and its response to CO2 up to 2.8
response to CO2 up to 2.8 MAC. The reducing of CMRO2 up MAC. The reducing of CMRO2 up to 50% therefore has cerebralto 50% therefore has cerebral protection. The increase of ICP by Isoflurane 1% is
protection. The increase of ICP by Isoflurane 1% is easily against with hypocapnea andeasily against with hypocapnea and barbiturate.
barbiturate. {mospagebreak} {mospagebreak}
The usage of Halothane in head injury must
The usage of Halothane in head injury must be carefully in order to myocardium sensitization tobe carefully in order to myocardium sensitization to arrhythmias in acute head injury,
arrhythmias in acute head injury, catecholamine concentration elevated. Halothane can be usedcatecholamine concentration elevated. Halothane can be used with caution by hyperventilation and using < 0.5
with caution by hyperventilation and using < 0.5 MAC because cerebral auto regulationMAC because cerebral auto regulation diminished at ³ 1
diminished at ³ 1 MAC Halothane and permanently up to postoperative period.2,3,5MAC Halothane and permanently up to postoperative period.2,3,5 Enflurane is not recommended because it’s abolished auto regulation at 1 MAC
Enflurane is not recommended because it’s abolished auto regulation at 1 MAC and causedand caused seizure EEG at moderate dose (1.5 – 2)
seizure EEG at moderate dose (1.5 – 2) MAC where CMRO2 will increase several percent andMAC where CMRO2 will increase several percent and increase CBF and ICP for 3
increase CBF and ICP for 3 hours after the drug is discontinued.7,8hours after the drug is discontinued.7,8
N2O 60% concentration cause an increase of CBF ± 100% and CMRO2 ±
N2O 60% concentration cause an increase of CBF ± 100% and CMRO2 ± 20% and avoid its20% and avoid its usage if there any aerocel or risk of
usage if there any aerocel or risk of air emboli especially accompany by damage of sinusair emboli especially accompany by damage of sinus nervosa or sinus bone contact with air, or t
nervosa or sinus bone contact with air, or there are pneumothorax, abdominal distended as anhere are pneumothorax, abdominal distended as an analgesic alternative fentanyl can be used.
analgesic alternative fentanyl can be used.
The usage of muscle relaxant continuously is better than intermittent
The usage of muscle relaxant continuously is better than intermittent to prevent patient’sto prevent patient’s sudden movement during the operation which can caused increase ICP dramatically can be sudden movement during the operation which can caused increase ICP dramatically can be used veccuronium 0.1 mg/kg BW/hour.7,9
used veccuronium 0.1 mg/kg BW/hour.7,9
Mild hypertension do not need correction, except if MAP
Mild hypertension do not need correction, except if MAP > 130 mmHg, low dose of > 130 mmHg, low dose of IsofluraneIsoflurane can be tried when still
can be tried when still unresponsive esmolol, propanounresponsive esmolol, propanolol or labetolol. Nitroglycerine orlol or labetolol. Nitroglycerine or nitroprusside are not recommended because their cerebral vasodilator effect can
nitroprusside are not recommended because their cerebral vasodilator effect can increase ICP.increase ICP. The incidence of
The incidence of intraoperative arrhythmias especially through central hyperadrenergic,intraoperative arrhythmias especially through central hyperadrenergic, lidocaine bolus (1-1.5) mg/ kgBW IV, and titrated
lidocaine bolus (1-1.5) mg/ kgBW IV, and titrated (1-4) mg/ minute, might neutralize it. (1-4) mg/ minute, might neutralize it. HoweverHowever every correction of hypertension and arrhythmia, hypoxia and
every correction of hypertension and arrhythmia, hypoxia and hypercarbia must behypercarbia must be considered.5,9
considered.5,9
Intraoperative hypotension must be treated immediately
Intraoperative hypotension must be treated immediately with fluid twith fluid therapy, when unresponsiveherapy, when unresponsive then vasopressor given. The principle of administering fluid is to
then vasopressor given. The principle of administering fluid is to prevent hypotension,prevent hypotension, hypervolume, hypoosmo
hypervolume, hypoosmolar and hyperglycemia. NaCl 0.9% is the chosen fluid lar and hyperglycemia. NaCl 0.9% is the chosen fluid where itswhere its osmolarity is 300 mOsm/L; while Ringer Lactate is
osmolarity is 300 mOsm/L; while Ringer Lactate is hypoosmolar (273 mOsm/L) therefore itshypoosmolar (273 mOsm/L) therefore its usage must be limited to
usage must be limited to prevent cerebral edema. To maintain intravascular colloid is the choiceprevent cerebral edema. To maintain intravascular colloid is the choice because its ability to absorb water and i
because its ability to absorb water and intravascular volume expansntravascular volume expansion.5,7 Likely heastart ision.5,7 Likely heastart is good enough, relatively cheaper, one liter is able to
good enough, relatively cheaper, one liter is able to expand 750 cc intravascular volume,expand 750 cc intravascular volume, however must be limited at 20
however must be limited at 20 ml/ kg BW/ day tml/ kg BW/ day to avoid coagulation disorder through Factor VIIIo avoid coagulation disorder through Factor VIII function.7,10
function.7,10
Manitol is very effective in
Manitol is very effective in order to decrease ICP, through its oncotic pressure hence reduceorder to decrease ICP, through its oncotic pressure hence reduce cerebral edema and cause secondary vasoconstriction to decrease the viscosity.
cerebral edema and cause secondary vasoconstriction to decrease the viscosity. Its effectIts effect started at 10 minutes and reached the peak
started at 10 minutes and reached the peak at 60 minutes. Because the tendency to at 60 minutes. Because the tendency to repair CBFrepair CBF to prevent cerebral ischemia and has minimal side effects, i
to prevent cerebral ischemia and has minimal side effects, in unconsciousness patient manitoln unconsciousness patient manitol advisable to be given immediately at 1.5
advisable to be given immediately at 1.5 gr/ kg BW. Even though generally is gr/ kg BW. Even though generally is said that manitolsaid that manitol given too fast can cause hypotension and it
given too fast can cause hypotension and it has to be given slowly for has to be given slowly for 20 minutes. The other20 minutes. The other effect from manitol given too
effect from manitol given too fast is transient hypokalemia (decrease up to 2 mmol/L).6fast is transient hypokalemia (decrease up to 2 mmol/L).6 POST OPERATIVE
When patient is
When patient is conscious and adequate spontaneous breathing, can be extubated. conscious and adequate spontaneous breathing, can be extubated. SuctioningSuctioning of secretion and extubation itself can cause patient
of secretion and extubation itself can cause patient cough, straining which potentially increasecough, straining which potentially increase ICP which worsen the cerebral edema. Giving Lidocaine 1- 1.5 mg/kg
ICP which worsen the cerebral edema. Giving Lidocaine 1- 1.5 mg/kg BW IV three minutes priorBW IV three minutes prior extubation. can reduce this event
extubation. can reduce this event If GCS < 8
If GCS < 8 or there are facial fractures, neck trauma and the or there are facial fractures, neck trauma and the chest intubation is advisablechest intubation is advisable maintained for ventilation at ICU
maintained for ventilation at ICU & protection of the airway. As & protection of the airway. As long as transferring the patientlong as transferring the patient from operating room to ICU ventilation, oxygen saturation and CPP
from operating room to ICU ventilation, oxygen saturation and CPP must be observed carefully.must be observed carefully. Monitoring of blood pressure, capnograph and pulse oxymetry must be used. If possible
Monitoring of blood pressure, capnograph and pulse oxymetry must be used. If possible monitoring of intra cranial pressure and cerebral circulation are attached during transport to monitoring of intra cranial pressure and cerebral circulation are attached during transport to ICU.2,3,7 The need of sedation or
ICU.2,3,7 The need of sedation or low dose of narcotic to reduce irritation of low dose of narcotic to reduce irritation of endotracheal tubeendotracheal tube irritation in the airway. Once emergency condition is happened like immediately increase blood irritation in the airway. Once emergency condition is happened like immediately increase blood pressure and intra cranial pressure, additional dose of sedative, narcotic and labetolol must be pressure and intra cranial pressure, additional dose of sedative, narcotic and labetolol must be given.7,8,9, Trendelenberg position, hyper flexion of the head, hyperextension or rotation can given.7,8,9, Trendelenberg position, hyper flexion of the head, hyperextension or rotation can obstruct large vein in the neck which cause increase ICP.
obstruct large vein in the neck which cause increase ICP.
Hyperventilation suggested as a priority in management of increases ICP, however now on it’s Hyperventilation suggested as a priority in management of increases ICP, however now on it’s still controversial, because hyperventilation causes cerebral ischemia even though not
still controversial, because hyperventilation causes cerebral ischemia even though not reducereduce CO2 pressure below 20 mmHg (level of cerebral ischemia in normal individual). Other
CO2 pressure below 20 mmHg (level of cerebral ischemia in normal individual). Other problemsproblems are its effect only for short term, because CBF will return to the lowest/ basal in 24 hours.6
are its effect only for short term, because CBF will return to the lowest/ basal in 24 hours.6 When blood pressure elevated (MAP > 130 mmHg) has to be corrected, because its disturbed When blood pressure elevated (MAP > 130 mmHg) has to be corrected, because its disturbed Blood Brain Barrier, interstitial edema, increase ICP. Avoid any conditions, which caused
Blood Brain Barrier, interstitial edema, increase ICP. Avoid any conditions, which caused increase in blood pressure like
increase in blood pressure like hypoxia, hypercarbia, hypothermia and fluid overload then hypoxia, hypercarbia, hypothermia and fluid overload then givinggiving of anti hypertension. The principle of fluid
of anti hypertension. The principle of fluid administration must be maintained a little administration must be maintained a little restriction torestriction to prevent exacerbation of cerebral edema, but when inadequate CPP having risk to extent
prevent exacerbation of cerebral edema, but when inadequate CPP having risk to extent cerebral damage itself, therefore do not hesitate to
cerebral damage itself, therefore do not hesitate to give fluids as long as give fluids as long as not overhydration.7,8not overhydration.7,8 {mospagebreak}
{mospagebreak}
Many researchers obser
Many researchers observed the effect of ved the effect of crystalloid on cerebral using Ringer Lactate orcrystalloid on cerebral using Ringer Lactate or Hartman solution as crystalloid solution and said that t
Hartman solution as crystalloid solution and said that this solution is isotonic. Hartman solutionhis solution is isotonic. Hartman solution contains 280 mmol soluble ions but incomplete in
contains 280 mmol soluble ions but incomplete in particles dissociation, the value is not 280particles dissociation, the value is not 280 mmol/ L soluble particle ions. It
mmol/ L soluble particle ions. Its osmolality only 265 osmol/ kg s osmolality only 265 osmol/ kg (normal plasma osmolality 285),(normal plasma osmolality 285), means is hypotonic. Normal Salt Solution contains 308 mmol/ L ion with osmolality of 285 and means is hypotonic. Normal Salt Solution contains 308 mmol/ L ion with osmolality of 285 and isotonic. Blood glucose concentration maintains below 150 mg% while more than 200 mg% isotonic. Blood glucose concentration maintains below 150 mg% while more than 200 mg% must be treated with insulin.
must be treated with insulin. Hyperglycemia will increase brain acidosis, which cause brain cellsHyperglycemia will increase brain acidosis, which cause brain cells damage where lactate concentration elevated. Glucose only
damage where lactate concentration elevated. Glucose only given when hypoglycemiagiven when hypoglycemia occurs.8,9
occurs.8,9
Administration of anticonvulsant should be
Administration of anticonvulsant should be considered because 10% severe head injury patientsconsidered because 10% severe head injury patients who do not give anticonvulsant develop seizure at the
who do not give anticonvulsant develop seizure at the first weeks ICU care. Consequences offirst weeks ICU care. Consequences of seizure itself are severe increase in CMR, CBF and CBV,
seizure itself are severe increase in CMR, CBF and CBV, which generate significant increase ofwhich generate significant increase of ICP that harmful. Administration of phenytoin loading dose
ICP that harmful. Administration of phenytoin loading dose 15 mg/ kg BW slowly 15 mg/ kg BW slowly to preventto prevent hypotension.
hypotension.
Avoid hyperthermia where any increase of
Avoid hyperthermia where any increase of temperature will lead increase oxygen consumption.temperature will lead increase oxygen consumption. Hypothermia is advisable to reduce oxygen demand and brain protection but only up to
Hypothermia is advisable to reduce oxygen demand and brain protection but only up to 35 °C35 °C by regulating room temperature regarding the complications of
by regulating room temperature regarding the complications of shivering, electrolyte disorder,shivering, electrolyte disorder, cardiovascular change
cardiovascular changes and renal s and renal function. Shivering will function. Shivering will increase oxygen consumption byincrease oxygen consumption by 400%.7
400%.7
Bronchial toilet should be done in sedated condition to
Bronchial toilet should be done in sedated condition to reduce airway stimulation, which leadreduce airway stimulation, which lead increase intra cranial pressure. Controlling of
benzodiazepin, barbitura
benzodiazepin, barbiturate or lidocaine. This is te or lidocaine. This is important to be done in important to be done in order with increase intraorder with increase intra cranial pressure, hypertension even cerebral bleeding, and hypoxia and brain
cranial pressure, hypertension even cerebral bleeding, and hypoxia and brain cellscells damage.2,5,6
damage.2,5,6
Cerebral protection is conducted by maintain oxygen supply, hemodynamic stability, low Cerebral protection is conducted by maintain oxygen supply, hemodynamic stability, low intracranial pressure, high O2, normalize chemical blood
intracranial pressure, high O2, normalize chemical blood results. Lower the temperature, alsoresults. Lower the temperature, also administration of drugs that
administration of drugs that reduce CMRO2 like barbiturate8,9, can reduce reduce CMRO2 like barbiturate8,9, can reduce oxygen demand.oxygen demand. CONCLUSIONS
CONCLUSIONS
The management of head injury is to
The management of head injury is to be able to prevent secondary brain damage (secondarybe able to prevent secondary brain damage (secondary injury). Etiology of secondary injury can be systemic and intracranial. Systemic are hypoxia, injury). Etiology of secondary injury can be systemic and intracranial. Systemic are hypoxia, hypercarbia, arterial hypotension, anemia, hypovolemia,
hypercarbia, arterial hypotension, anemia, hypovolemia, hyponatremia, osmotic imbalance,hyponatremia, osmotic imbalance, hyperthermia, sepsis and coagulopathies. Intracranial are epidural/ subdural hematoma, hyperthermia, sepsis and coagulopathies. Intracranial are epidural/ subdural hematoma, intracerabral contusion, and intracranial infection, post trauma
intracerabral contusion, and intracranial infection, post trauma epilepsy. Anesthesiaepilepsy. Anesthesia management of head injury, basically same with any patients
management of head injury, basically same with any patients with elevation of ICP: with elevation of ICP: OptimizeOptimize cerebral perfusion, Avoid cerebral ischemia, Avoid drugs/ techniques that
cerebral perfusion, Avoid cerebral ischemia, Avoid drugs/ techniques that cause increase incause increase in intracranial pressure.
intracranial pressure. REFERENCES
REFERENCES
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