İntrakraniyal Acillerde Anestezi Yönetimi
Özet
İntrakraniyal acil durumlarda, özellikle travmatik beyin hasarında (TBH) anestezi yönetimi, primer hasarın ardından gelişebilecek sekonder nörolojik hasarları önlemeyi hedefler. Preoperatif değerlendirmede Glasgow Koma Skalası ve Pupil skorlaması ile hastanın durumu hızlıca belirlenmelidir. Havayolu yönetiminde servikal omurga yaralanması olasılığına karşı dikkatli olunmalı, intrakraniyal basınç (İKB) artışından ve hipoksemiden kaçınılmalıdır. Anestezi indüksiyonunda serebral perfüzyonu koruyan tiyopental, propofol veya etomidat gibi ajanlar tercih edilirken; ketamin ve süksinilkolin kullanımı İKB üzerindeki etkileri nedeniyle dikkatle değerlendirilmelidir. İdame aşamasında hemodinamik stabilite ve hızlı uyanma ön plandadır. İKB yönetimi için hiperventilasyon, hiperozmolar tedavi (mannitol), BOS drenajı ve başın 30° elevasyonu uygulanabilir. Hemodinamik yönetimde sistolik kan basıncının belirli limitlerin üzerinde tutulması ve izotonik sıvıların kullanımı esastır. Ayrıca hiperglisemi, hipertermi ve nöbet profilaksisi gibi sistemik kontroller prognoz açısından kritiktir. Kortikosteroid kullanımı ise TBH'de kontrendikedir.
Anesthesia management in intracranial emergencies, particularly traumatic brain injury (TBI), aims to prevent secondary neurological damage following primary injury. In preoperative assessment, the patient's status should be rapidly determined using the Glasgow Coma Scale and Pupil scoring. Airway management requires caution regarding potential cervical spine injury, avoiding increases in intracranial pressure (ICP) and hypoxemia. For induction, agents like thiopental, propofol, or etomidate that preserve cerebral perfusion are preferred, while the use of ketamine and succinylcholine must be carefully evaluated due to their effects on ICP. Hemodynamic stability and rapid emergence are prioritized during maintenance. For ICP management, hyperventilation, hyperosmolar therapy (mannitol), CSF drainage, and 30° head elevation can be applied. Hemodynamic management focuses on maintaining systolic blood pressure above specific limits and using isotonic fluids. Additionally, systemic controls such as managing hyperglycemia, hyperthermia, and seizure prophylaxis are critical for prognosis. The use of corticosteroids is contraindicated in TBI.
Referanslar
Lam AM. Anesthesia for Neurosurgical Emergencies. Anesthesiology Clinics of North America. 1996;14(3):543-60.
Pearn ML, Niesman IR, Egawa J, Sawada A, Almenar-Queralt A, Shah SB, et al. Pathophysiology Associated with Traumatic Brain Injury: Current Treatments and Potential Novel Therapeutics. Cell Mol Neurobiol. 2017;37(4):571-85.
Kutteruf R, Rozet I, Domino K. Care of the acutely unstable patient. Cottrell and Patel’s Neuroanesthesia E-Book. 2016.
Phan R, Bendo A. Perioperative management of adult patients with severe head injury. Cottrell and Patel’s Neuroanesthesia 6th Edition Elsevier. 2017:326-36.
Sharma D, Vavilala MS. Perioperative management of adult traumatic brain injury. Anesthesiol Clin. 2012;30(2):333-46.
Örken D. Scales Used In Neurointensive Care Unit. Turkiye Klinikleri J Int Med Sci. 2006;2(22):1-3.
Balestreri M, Czosnyka M, Chatfield D, Steiner L, Schmidt E, Smielewski P, et al. Predictive value of Glasgow Coma Scale after brain trauma: change in trend over the past ten years. Journal of Neurology, Neurosurgery & Psychiatry. 2004;75(1):161-2.
Brennan PM, Murray GD, Teasdale GM. Simplifying the use of prognostic information in traumatic brain injury. Part 1: The GCS-Pupils score: an extended index of clinical severity. Journal of neurosurgery. 2018;128(6):1612-20.
Carney N, Totten AM, O'Reilly C, Ullman JS, Hawryluk GW, Bell MJ, et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2017;80(1):6-15.
Wendling AL, Tighe PJ, Conrad BP, Baslanti TO, Horodyski M, Rechtine GR. A comparison of 4 airway devices on cervical spine alignment in cadaver models of global ligamentous instability at c1-2. Anesth Analg. 2013;117(1):126-32.
Upchurch CP, Grijalva CG, Russ S, Collins SP, Semler MW, Rice TW, et al. Comparison of Etomidate and Ketamine for Induction During Rapid Sequence Intubation of Adult Trauma Patients. Ann Emerg Med. 2017;69(1):24-33.e2.
Banh KV, James S, Hendey GW, Snowden B, Kaups K. Single-dose etomidate for intubation in the trauma patient. The Journal of emergency medicine. 2012;43(5):e277-e82.
Bruder EA, Ball IM, Ridi S, Pickett W, Hohl C. Single induction dose of etomidate versus other induction agents for endotracheal intubation in critically ill patients. Cochrane Database Syst Rev. 2015;1(1):Cd010225.
Cohan P, Wang C, McArthur DL, Cook SW, Dusick JR, Armin B, et al. Acute secondary adrenal insufficiency after traumatic brain injury: a prospective study. Crit Care Med. 2005;33(10):2358-66.
Filanovsky Y, Miller P, Kao J. Myth: Ketamine should not be used as an induction agent for intubation in patients with head injury. Cjem. 2010;12(2):154-7.
Cohen L, Athaide V, Wickham ME, Doyle-Waters MM, Rose NG, Hohl CM. The effect of ketamine on intracranial and cerebral perfusion pressure and health outcomes: a systematic review. Ann Emerg Med. 2015;65(1):43-51.e2.
Sanfilippo F, Santonocito C, Veenith T, Astuto M, Maybauer MO. The role of neuromuscular blockade in patients with traumatic brain injury: a systematic review. Neurocrit Care. 2015;22(2):325-34.
Stirt JA, Grosslight KR, Bedford RF, Vollmer D. "Defasciculation" with metocurine prevents succinylcholine-induced increases in intracranial pressure. Anesthesiology. 1987;67(1):50-3.
Minton MD, Grosslight K, Stirt JA, Bedford RF. Increases in intracranial pressure from succinylcholine: prevention by prior nondepolarizing blockade. Anesthesiology. 1986;65(2):165-9.
Clancy M, Halford S, Walls R, Murphy M. In patients with head injuries who undergo rapid sequence intubation using succinylcholine, does pretreatment with a competitive neuromuscular blocking agent improve outcome? A literature review. Emerg Med J. 2001;18(5):373-5.
Kovarik WD, Mayberg TS, Lam AM, Mathisen TL, Winn HR. Succinylcholine does not change intracranial pressure, cerebral blood flow velocity, or the electroencephalogram in patients with neurologic injury. Anesthesia and analgesia. 1994;78(3):469-73.
White PF, Schlobohm RM, Pitts LH, Lindauer JM. A randomized study of drugs for preventing increases in intracranial pressure during endotracheal suctioning. Anesthesiology. 1982;57(3):242-4.
Chui J, Mariappan R, Mehta J, Manninen P, Venkatraghavan L. Comparison of propofol and volatile agents for maintenance of anesthesia during elective craniotomy procedures: systematic review and meta-analysis. Can J Anaesth. 2014;61(4):347-56.
Matsumoto M ST. Effects of anesthetic agents and other drugs on cerebral blood flow, metabolism and intracranial pressure In: James Cottrell PP, editor. Cottrell and Patel's Neuroanesthesia. 6 ed. New York: Elsevier; 2016.
Prabhakar H, Singh GP, Mahajan C, Kapoor I, Kalaivani M, Anand V. Intravenous versus inhalational techniques for rapid emergence from anaesthesia in patients undergoing brain tumour surgery. Cochrane Database Syst Rev. 2016;9(9):Cd010467.
Winkler SR, Munoz-Ruiz L. Mechanism of action of mannitol. Surg Neurol. 1995;43(1):59.
Komotar RJ, Mocco J, Ransom ER, Mack WJ, Zacharia BE, Wilson DA, et al. Herniation secondary to critical postcraniotomy cerebrospinal fluid hypovolemia. Neurosurgery. 2005;57(2):286-92.
Sharma D, Brown MJ, Curry P, Noda S, Chesnut RM, Vavilala MS. Prevalence and risk factors for intraoperative hypotension during craniotomy for traumatic brain injury. Journal of neurosurgical anesthesiology. 2012;24(3):178.
Kawaguchi M, Sakamoto T, Ohnishi H, Karasawa J, Furuya H. Preoperative predictors of reduction in arterial blood pressure following dural opening during surgical evacuation of acute subdural hematoma. J Neurosurg Anesthesiol. 1996;8(2):117-22.
Ract C, Vigué B. Comparison of the cerebral effects of dopamine and norepinephrine in severely head-injured patients. Intensive Care Med. 2001;27(1):101-6.
Steiner LA, Johnston AJ, Czosnyka M, Chatfield DA, Salvador R, Coles JP, et al. Direct comparison of cerebrovascular effects of norepinephrine and dopamine in head-injured patients. Crit Care Med. 2004;32(4):1049-54.
Johnston AJ, Steiner LA, Chatfield DA, Coles JP, Hutchinson PJ, Al-Rawi PG, et al. Effect of cerebral perfusion pressure augmentation with dopamine and norepinephrine on global and focal brain oxygenation after traumatic brain injury. Intensive care medicine. 2004;30(5):791-7.
Sookplung P, Siriussawakul A, Malakouti A, Sharma D, Wang J, Souter MJ, et al. Vasopressor use and effect on blood pressure after severe adult traumatic brain injury. Neurocrit Care. 2011;15(1):46-54.
Myburgh J, Cooper D, Finfer S. Saline or albumin for fluid resuscitation in traumatic brain injury (author reply). The New England Journal of Medicine. 2007;357(25):2635-6.
Cooper DJ, Myburgh J, Heritier S, Finfer S, Bellomo R, Billot L, et al. Albumin resuscitation for traumatic brain injury: is intracranial hypertension the cause of increased mortality? J Neurotrauma. 2013;30(7):512-8.
Bulger EM, May S, Kerby JD, Emerson S, Stiell IG, Schreiber MA, et al. Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock: a randomized, placebo controlled trial. Ann Surg. 2011;253(3):431-41.
Cooper DJ, Myles PS, McDermott FT, Murray LJ, Laidlaw J, Cooper G, et al. Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury: a randomized controlled trial. Jama. 2004;291(11):1350-7.
Sekhon MS, McLean N, Henderson WR, Chittock DR, Griesdale DE. Association of hemoglobin concentration and mortality in critically ill patients with severe traumatic brain injury. Crit Care. 2012;16(4):R128.
Pendem S, Rana S, Manno EM, Gajic O. A review of red cell transfusion in the neurological intensive care unit. Neurocritical Care. 2006;4(1):63-7.
Robertson CS, Hannay HJ, Yamal JM, Gopinath S, Goodman JC, Tilley BC, et al. Effect of erythropoietin and transfusion threshold on neurological recovery after traumatic brain injury: a randomized clinical trial. Jama. 2014;312(1):36-47.
Salim A, Hadjizacharia P, DuBose J, Brown C, Inaba K, Chan L, et al. Role of anemia in traumatic brain injury. J Am Coll Surg. 2008;207(3):398-406.
Warner MA, O'Keeffe T, Bhavsar P, Shringer R, Moore C, Harper C, et al. Transfusions and long-term functional outcomes in traumatic brain injury. J Neurosurg. 2010;113(3):539-46.
Lelubre C, Bouzat P, Crippa IA, Taccone FS. Anemia management after acute brain injury. Crit Care. 2016;20(1):152.
Griesdale DE, Tremblay MH, McEwen J, Chittock DR. Glucose control and mortality in patients with severe traumatic brain injury. Neurocrit Care. 2009;11(3):311-6.
Kramer AH, Roberts DJ, Zygun DA. Optimal glycemic control in neurocritical care patients: a systematic review and meta-analysis. Crit Care. 2012;16(5):R203.
Liu-DeRyke X, Collingridge DS, Orme J, Roller D, Zurasky J, Rhoney DH. Clinical impact of early hyperglycemia during acute phase of traumatic brain injury. Neurocrit Care. 2009;11(2):151-7.
Perman SM, Goyal M, Neumar RW, Topjian AA, Gaieski DF. Clinical applications of targeted temperature management. Chest. 2014;145(2):386-93.
Lewis SR, Evans DJ, Butler AR, Schofield-Robinson OJ, Alderson P. Hypothermia for traumatic brain injury. Cochrane Database Syst Rev. 2017;9(9):Cd001048.
Ahmed AI, Bullock MR, Dietrich WD. Hypothermia in Traumatic Brain Injury. Neurosurg Clin N Am. 2016;27(4):489-97.
Rincon F, Hunter K, Schorr C, Dellinger RP, Zanotti-Cavazzoni S. The epidemiology of spontaneous fever and hypothermia on admission of brain injury patients to intensive care units: a multicenter cohort study. J Neurosurg. 2014;121(4):950-60.
Roberts I, Yates D, Sandercock P, Farrell B, Wasserberg J, Lomas G, et al. Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet. 2004;364(9442):1321-8.
Edwards P, Arango M, Balica L, Cottingham R, El-Sayed H, Farrell B, et al. Final results of MRC CRASH, a randomised placebo-controlled trial of intravenous corticosteroid in adults with head injury-outcomes at 6 months. Lancet. 2005;365(9475):1957-9.
Alderson P, Roberts I. Corticosteroids for acute traumatic brain injury. Cochrane Database Syst Rev. 2005;2005(1):Cd000196.
Vespa PM, Nuwer MR, Nenov V, Ronne-Engstrom E, Hovda DA, Bergsneider M, et al. Increased incidence and impact of nonconvulsive and convulsive seizures after traumatic brain injury as detected by continuous electroencephalographic monitoring. J Neurosurg. 1999;91(5):750-60.
Claassen J, Mayer SA, Kowalski RG, Emerson RG, Hirsch LJ. Detection of electrographic seizures with continuous EEG monitoring in critically ill patients. Neurology. 2004;62(10):1743-8.
Temkin NR, Dikmen SS, Wilensky AJ, Keihm J, Chabal S, Winn HR. A randomized, double-blind study of phenytoin for the prevention of post-traumatic seizures. N Engl J Med. 1990;323(8):497-502.
Thompson K, Pohlmann-Eden B, Campbell LA, Abel H. Pharmacological treatments for preventing epilepsy following traumatic head injury. Cochrane Database Syst Rev. 2015(8):Cd009900.
Inaba K, Menaker J, Branco BC, Gooch J, Okoye OT, Herrold J, et al. A prospective multicenter comparison of levetiracetam versus phenytoin for early posttraumatic seizure prophylaxis. J Trauma Acute Care Surg. 2013;74(3):766-71; discussion 71-3.
Jones KE, Puccio AM, Harshman KJ, Falcione B, Benedict N, Jankowitz BT, et al. Levetiracetam versus phenytoin for seizure prophylaxis in severe traumatic brain injury. Neurosurg Focus. 2008;25(4):E3.
Hernández-Palazón J, Tortosa JA, Martínez-Lage JF, Pérez-Ayala M. Rocuronium-induced neuromuscular blockade is affected by chronic phenytoin therapy. J Neurosurg Anesthesiol. 2001;13(2):79-82.
Heiderich S, Jürgens J, Rudolf D, Dennhardt N, Echtermeyer F, Leffler A, et al. Compatibility of common drugs with acetate-containing balanced electrolyte solutions in pediatric anesthesia. Paediatr Anaesth. 2016;26(6):590-8.
Zafar SN, Khan AA, Ghauri AA, Shamim MS. Phenytoin versus Leviteracetam for seizure prophylaxis after brain injury - a meta analysis. BMC Neurol. 2012;12:30.
