1. PERIOPERATIVE MANAGEMENT OF TRAUMATIC BRAIN INJURY OBJECTIVE OBJECTIVE 1.REVIEW IMPORTANCE OF SECONDARY ISCHEMIC BRAIN INJURY AFTER HEAD INJURY 1.REVIEW IMPORTANCE OF SECONDARY ISCHEMIC BRAIN INJURY AFTER HEAD INJURY 2.ANESTHETIC MANAGE OF ACUTE HEAD INJURY 2.ANESTHETIC MANAGE OF ACUTE HEAD INJURY 3.EVIDENCE BASE MEDICINE FOR INTENSIVE CARE OF HEAD INJURY 3.EVIDENCE BASE MEDICINE FOR INTENSIVE CARE OF HEAD INJURY

2. INTRODUCTION PERIOPERATIVE IS GUIDE TO DECREASE BURDEN OF SECONDARY BRAIN INJURY BY 2 STRATEGIES PERIOPERATIVE IS GUIDE TO DECREASE BURDEN OF SECONDARY BRAIN INJURY BY 2 STRATEGIES 1.MAINTAIN CARDIOPULMONARY STABILITY 1.MAINTAIN CARDIOPULMONARY STABILITY 2.MONITOR PHYSIOLOGIC VARIABLE REFLECT SECONDARY BRAIN INJURY 2.MONITOR PHYSIOLOGIC VARIABLE REFLECT SECONDARY BRAIN INJURY SECONDARY BRAIN INJURY ASSOCIATE WITH SECONDARY BRAIN INJURY ASSOCIATE WITH 1.POST INJURY HYPOTENSION[ esp sBP<90] 1.POST INJURY HYPOTENSION[ esp sBP<90]

3. INTRODUCTION 2.HYPOXEMIA 2.HYPOXEMIA 3.INTRACRANIAL HYPERTENSION 3.INTRACRANIAL HYPERTENSION CONTRIBUTING MECHANISM OF SECONDARY TBI CONTRIBUTING MECHANISM OF SECONDARY TBI 1.CEREBRAL VASOCONSTRICTION 1.CEREBRAL VASOCONSTRICTION 2.IMPAIR AUTOREGULATION 2.IMPAIR AUTOREGULATION TO MINIMIZE M&M TO PREVENT HYPOTENSION TO MINIMIZE M&M TO PREVENT HYPOTENSION

4. CEREBRAL CIRCULATION RESPONSES TO ACUTE HEAD INJURY TBI IS CHARACTERIZED BY TBI IS CHARACTERIZED BY 1.DECREASE CBF[ ESP < 18 CC/100G/MIN] 1.DECREASE CBF[ ESP < 18 CC/100G/MIN] 2.IMPAIR AUTOREGULATION 2.IMPAIR AUTOREGULATION 3.INCREASE ICP 3.INCREASE ICP HYPERVENTILATION DECREASE CBF AND DECREASE BRAIN OXYGENATION HYPERVENTILATION DECREASE CBF AND DECREASE BRAIN OXYGENATION 1/3 OF PT AFTER TBI, CBF CHANGEED AS CPP CHANGED 1/3 OF PT AFTER TBI, CBF CHANGEED AS CPP CHANGED THEN TO CONTROL ICP MAINTAIN CPP AND THEN CBF THEN TO CONTROL ICP MAINTAIN CPP AND THEN CBF

5. PREANESTHETIC STABILIZATION AND ASSESSMENT MINIMIZE TIME TO RESUSCITATE AND ASSESSMENT MINIMIZE TIME TO RESUSCITATE AND ASSESSMENT 1.ASSOCIATE INJURY 1.ASSOCIATE INJURY 2.RESUSCITATION DETAIL 2.RESUSCITATION DETAIL 3.GCS [ ESP <=8 IS SEVERE TBI] TELL PROGNOSTIC FACTOR 3.GCS [ ESP <=8 IS SEVERE TBI] TELL PROGNOSTIC FACTOR

6. EMERGENT AIRWAY CONTROL INTUBATION SEQUENCE INTUBATION SEQUENCE 1.PRESERVE OXYGENATION 1.PRESERVE OXYGENATION 2.ELIMINATION CO2 2.ELIMINATION CO2 3.PREVENT ASPIRATION 3.PREVENT ASPIRATION 4.MAINTAIN SYSTEMIC BP 4.MAINTAIN SYSTEMIC BP 5.MINIMIZE INCREASE ICP 5.MINIMIZE INCREASE ICP 6.AVOID AGGRAVATION OF CERVICAL SPINE INJURY[10% OF TBI] BY MANUAL IN LINE AXIAL STABILIZATION 6.AVOID AGGRAVATION OF CERVICAL SPINE INJURY[10% OF TBI] BY MANUAL IN LINE AXIAL STABILIZATION

7. EMERGENT AIRWAY CONTROL 7.BLIND NASAL INTUBATION CAUTION IN 7.BLIND NASAL INTUBATION CAUTION IN 7.1 MAXILLARY FX 7.1 MAXILLARY FX 7.2 BASILAR SKULL FX 7.2 BASILAR SKULL FX DURING INTUBATION CADIOPULMONARY SHOULD STABILITY AVOID COUGHING,STRAINING,HYPERCARBIA,HY POXEMIA DURING INTUBATION CADIOPULMONARY SHOULD STABILITY AVOID COUGHING,STRAINING,HYPERCARBIA,HY POXEMIA THIOPENTHAL AND ETOMIDATE DOSE DEPENDENTLY REDUCE CMRO2, CBF, ICP THIOPENTHAL AND ETOMIDATE DOSE DEPENDENTLY REDUCE CMRO2, CBF, ICP

8. EMERGENT AIRWAY CONTROL SUPPLEMENTATION WITH LIDOCAINE IV WILL BLUNT SYMPATHETIC RESPONSES AND LIMIT ICP SUPPLEMENTATION WITH LIDOCAINE IV WILL BLUNT SYMPATHETIC RESPONSES AND LIMIT ICP MIDAZOLAM DECREASES CBF AND DOES NOT INCREASE ICP MIDAZOLAM DECREASES CBF AND DOES NOT INCREASE ICP PROPOFOL REDUCES ICP AND CBF BUT INDUCED HYPOTENSION PROPOFOL REDUCES ICP AND CBF BUT INDUCED HYPOTENSION AFTER ACUTE TBI, SUCCINYLCHOLINE IS APPROPRIATE DESPITE TIS MAKE TRANSIENT INCREASES IN ICP AFTER ACUTE TBI, SUCCINYLCHOLINE IS APPROPRIATE DESPITE TIS MAKE TRANSIENT INCREASES IN ICP

9. FLUID RESUSCITATION PROMPT RESTORATION OF SYSTOLIC AND MAP AND THEN MAINTAIN CPP [ CPP = MAP-ICP ] PROMPT RESTORATION OF SYSTOLIC AND MAP AND THEN MAINTAIN CPP [ CPP = MAP-ICP ] HYPOTONIC SOLUTION [ LRS ] INCREASE BRAIN WATER CONTENT THAN 0.9 %NSS HYPOTONIC SOLUTION [ LRS ] INCREASE BRAIN WATER CONTENT THAN 0.9 %NSS DRUMMOND ET AL. DEMONSRTATED COLLOID MAINTAINED LOWER BRAIN WATER THAN CRYSTALLOID AND THEN DECREASE ICP DRUMMOND ET AL. DEMONSRTATED COLLOID MAINTAINED LOWER BRAIN WATER THAN CRYSTALLOID AND THEN DECREASE ICP

10. INTRAOPERATIVE MANAGEMENT MONITOR : EKG, A- LINE,O2SAT,FOLAY,CAPNOGRAPHY MONITOR : EKG, A- LINE,O2SAT,FOLAY,CAPNOGRAPHY PULMONARY ARTERIAL CATHETERIZATION USE TO TELL ADEQUACY OF INTRAVASCULAR VOLUMN OR CARDIAC PERFORMANCE PULMONARY ARTERIAL CATHETERIZATION USE TO TELL ADEQUACY OF INTRAVASCULAR VOLUMN OR CARDIAC PERFORMANCE RESTRICTION OF FLUID IS CONTROVERSIAL,NO CLINICAL EVIDENCE SUPPORT RESTRICTION OF FLUID IS CONTROVERSIAL,NO CLINICAL EVIDENCE SUPPORT EARLY NONNEUROLOGIC SURGERY NOT TO WORSEN OUTCOME OF MULTIPLYTRAUMATIZED PATIENTS TBI EARLY NONNEUROLOGIC SURGERY NOT TO WORSEN OUTCOME OF MULTIPLYTRAUMATIZED PATIENTS TBI

11. INTRAOPERATIVE MANAGEMENT IN NONNEUROSURGERY IN TBI,MONITOR ICP IS IMPORTANT BY IN NONNEUROSURGERY IN TBI,MONITOR ICP IS IMPORTANT BY 1.JUGULAR VENOUS BULB CATHETERIZATION TELL MIX CEREBRAL VENOUS BLOOD THAT REFLECT CEREBRAL ISCHEMIA EVEN ONE EPISODE 1.JUGULAR VENOUS BULB CATHETERIZATION TELL MIX CEREBRAL VENOUS BLOOD THAT REFLECT CEREBRAL ISCHEMIA EVEN ONE EPISODE 2.BRAIN TISSUE PO2 IS DIRECT METHOD THAT REFLECT ISCHEMIA AND CHANGED IN CPP AND PaCO2 2.BRAIN TISSUE PO2 IS DIRECT METHOD THAT REFLECT ISCHEMIA AND CHANGED IN CPP AND PaCO2 BOTH METHOD SENSITIVITY 50% DETECT CEREBRAL ISCHEMIA BOTH METHOD SENSITIVITY 50% DETECT CEREBRAL ISCHEMIA

12. INTRAOPERATIVE MANAGEMENT ACUTE INCREASE ICP IMMIDIATE MANAGEMENT BY ACUTE INCREASE ICP IMMIDIATE MANAGEMENT BY 1.HYPERVENTILATION : RAPID EFFECTIVE 1.HYPERVENTILATION : RAPID EFFECTIVE 2.DIURETIC : MANNITOL,FUROSEMIDE 2.DIURETIC : MANNITOL,FUROSEMIDE 3.SURGERY 3.SURGERY MAINTENANCE OF ANESTHESIA VARIABLY INFLUENCE CBF,CBV,CMRO2,AUTOREGULATION,RESP ONSIVENESS TO PaCO2 MAINTENANCE OF ANESTHESIA VARIABLY INFLUENCE CBF,CBV,CMRO2,AUTOREGULATION,RESP ONSIVENESS TO PaCO2

13. INTRAOPERATIVE MANAGEMENT BARBITURATES,BZP,NARCOTIC,HYPOCAPNIA APPEAR TO LIMIT N2O-INDUCED INCREASE CBF AND ICP BARBITURATES,BZP,NARCOTIC,HYPOCAPNIA APPEAR TO LIMIT N2O-INDUCED INCREASE CBF AND ICP N2O AVOID IN PNEUMOCEPHALUS AND PNEUMOTHORAX N2O AVOID IN PNEUMOCEPHALUS AND PNEUMOTHORAX USE LOW CONCENTRATION [< 0.5 MAC] OF ISOFURANE OR SEVOFLURANE USE LOW CONCENTRATION [< 0.5 MAC] OF ISOFURANE OR SEVOFLURANE AVOID SUFENTANIL AND ALFENTANIL BECAUSE INCREASE ICP AVOID SUFENTANIL AND ALFENTANIL BECAUSE INCREASE ICP

14. INTRAOPERATIVE MANAGEMENT IMPORTANCE ADJUVANT DRUGS IMPORTANCE ADJUVANT DRUGS 1.NON-DEPOL NMB [ SHOULD NOT REDUCE BP OR INCREASE CBF AND ICP] : VERCURONIUM,ROCURONIUM IS RECOMMENDED 1.NON-DEPOL NMB [ SHOULD NOT REDUCE BP OR INCREASE CBF AND ICP] : VERCURONIUM,ROCURONIUM IS RECOMMENDED 2.BETA-BLOCKER OR LIDOCAINE DEMINISH HYPERTENSON OR TACHYCARDIA 2.BETA-BLOCKER OR LIDOCAINE DEMINISH HYPERTENSON OR TACHYCARDIA PaO2 SHOULD MAINTAIN AT LEAST >60 mmHg BECAUSE HYPOXIA INCREASE CBF PaO2 SHOULD MAINTAIN AT LEAST >60 mmHg BECAUSE HYPOXIA INCREASE CBF

15. INTRAOPERATIVE MANAGEMENT PaO2 FROM 100-150 mmHg TO 200-250 mmHg IMPROVE CEREBRAL VENOUS OXYGENATION IN PATIENT AFTER TBI PaO2 FROM 100-150 mmHg TO 200-250 mmHg IMPROVE CEREBRAL VENOUS OXYGENATION IN PATIENT AFTER TBI TREATMENT OF SYSTEMIC HYPERTENSION TREATMENT OF SYSTEMIC HYPERTENSION 1.NTP,NTG,HYDRALAZINE : UNACCEPT CEREBRAL VASODILATATION IN WHO HAVE DECREASE INTRACRANIAL COMPLIANCE 1.NTP,NTG,HYDRALAZINE : UNACCEPT CEREBRAL VASODILATATION IN WHO HAVE DECREASE INTRACRANIAL COMPLIANCE 2.BARBITURATE,NARCOTIC,BZP REDUCE MAP WITH LESS RISK 2.BARBITURATE,NARCOTIC,BZP REDUCE MAP WITH LESS RISK

16. INTRAOPERATIVE MANAGEMENT 3.LABETALOL [ALPHA+BETA BLOCKER] REDUCE MAP AND ICP 3.LABETALOL [ALPHA+BETA BLOCKER] REDUCE MAP AND ICP EMERGENT MANAGE HYPOTENSION REQIURE SHORT TERM INFUSE VASOCONSTRICTORS TO MAINTAIN CPP UNTIL HYPOVOLEMIA IS CORRECTED EMERGENT MANAGE HYPOTENSION REQIURE SHORT TERM INFUSE VASOCONSTRICTORS TO MAINTAIN CPP UNTIL HYPOVOLEMIA IS CORRECTED WHEN DURA IS OPENED,HYPERTENSION SHOULD BE CONTROLLED BECAUSE INCREASE CPP MAY INCREASE CBF WHEN DURA IS OPENED,HYPERTENSION SHOULD BE CONTROLLED BECAUSE INCREASE CPP MAY INCREASE CBF

17. INTRAOPERATIVE MANAGEMENT AFTER BRAIN SURGERY,MOST PATIENT ARE NEITHER AWAKED NOR EXTUBATED UNLESS AFTER BRAIN SURGERY,MOST PATIENT ARE NEITHER AWAKED NOR EXTUBATED UNLESS 1.PREOPERATIVE CONSCIUOS NORMAL 1.PREOPERATIVE CONSCIUOS NORMAL 2.PREOPERATIVE CONSCIOUS RAPIDLY DECLINED 2.PREOPERATIVE CONSCIOUS RAPIDLY DECLINED PROFOUND PARALYSIS REDUCED CHANGED ICP WHEN TRANSFER TO ICU PROFOUND PARALYSIS REDUCED CHANGED ICP WHEN TRANSFER TO ICU DURING TRANSPORT SHOULD MONITOR BP,O2sat,CAPNOMETRY [ ICP MONITORING IF AVALIABLE DURING TRANSPORT SHOULD MONITOR BP,O2sat,CAPNOMETRY [ ICP MONITORING IF AVALIABLE

18. INTRAOPERATIVE BRAIN PROTECTION HIGH DOSE PENTOBARBITOL IMPROVE ICP CONTROL AND REDUCTION EXTRACELLULAR LACTATE AND EXCITOTOXIC AMINO ACIDS GLUTAMATE AND ASPARTATE HIGH DOSE PENTOBARBITOL IMPROVE ICP CONTROL AND REDUCTION EXTRACELLULAR LACTATE AND EXCITOTOXIC AMINO ACIDS GLUTAMATE AND ASPARTATE MILD HYPOTHERMIA [ 34 *C] WILL REDUCE CMRO2 AND ICP AND IMPROVED OUTCOME AFTER SEVERE TBI, THUS REWARMING PATIENT SHOULD BE SLOWLY BUT NOW NO EVIDENCE BASE MILD HYPOTHERMIA [ 34 *C] WILL REDUCE CMRO2 AND ICP AND IMPROVED OUTCOME AFTER SEVERE TBI, THUS REWARMING PATIENT SHOULD BE SLOWLY BUT NOW NO EVIDENCE BASE

19. INTRAOPERATIVE BRAIN PROTECTION HOWEVER, HYPERTHERMIA SHOULD BE CORRECTED BECAUSE THERE HAVE EVIDENCE THAT SMALL ELEVATIONS IN TEMPERATURE INCREASE RELEASE OF EXCITOTOXIC AMINOACIDS DURING ISCHEMIC EPISODES HOWEVER, HYPERTHERMIA SHOULD BE CORRECTED BECAUSE THERE HAVE EVIDENCE THAT SMALL ELEVATIONS IN TEMPERATURE INCREASE RELEASE OF EXCITOTOXIC AMINOACIDS DURING ISCHEMIC EPISODES GOAL TO MAINTAIN CPP ABOVE TARGET LEVEL[>70 mmHg] WITH HOPE THAT BETTER CBF WILL BE ASSURED TO IMPROVE OUTCOME AFTER TBI GOAL TO MAINTAIN CPP ABOVE TARGET LEVEL[>70 mmHg] WITH HOPE THAT BETTER CBF WILL BE ASSURED TO IMPROVE OUTCOME AFTER TBI

20. INTRAOPERATIVE BRAIN PROTECTION ROBERTSON ET AL COMPARED CBF- TARGET STRATEGY OF MAINTAIN CPP>70 mmHg WITH ICP TARGET STRATEGY FOUND NO DIFFERENCE IN OUTCOME ROBERTSON ET AL COMPARED CBF- TARGET STRATEGY OF MAINTAIN CPP>70 mmHg WITH ICP TARGET STRATEGY FOUND NO DIFFERENCE IN OUTCOME MONITORING CEREBRAL OXYGENATION AND PROMPT TREATMENT WHEN DESATURATION OR HYPOXEMIA[ TO PREVENT SECONDARY ISCHEMIC INJURY] ARE MORE EFFECTIVE THAN CORRECT SYSTEMIC VARIABLE[ HYPOTENSION] MONITORING CEREBRAL OXYGENATION AND PROMPT TREATMENT WHEN DESATURATION OR HYPOXEMIA[ TO PREVENT SECONDARY ISCHEMIC INJURY] ARE MORE EFFECTIVE THAN CORRECT SYSTEMIC VARIABLE[ HYPOTENSION]

21. TRANSFER OF PATIENTS TO THE INTENSIVE CARE UNIT DURING TRANSFER VENTILATION,OXYGENATION,CPP MUST BE CAREFULLY MAINTAINED. DURING TRANSFER VENTILATION,OXYGENATION,CPP MUST BE CAREFULLY MAINTAINED. MINITOR BP,CAPNOGRAPHY,O2sat,ICP MONITORING MINITOR BP,CAPNOGRAPHY,O2sat,ICP MONITORING DURING EMERGENCE RESULT IN INCREASE IN BP,ICP, ADDITIONALSEDATIVE,NARCOTIC,LABET ALOL MAY BE REQUIRED DURING EMERGENCE RESULT IN INCREASE IN BP,ICP, ADDITIONALSEDATIVE,NARCOTIC,LABET ALOL MAY BE REQUIRED ALVEOLAR VENTILATION MUST BE CAREFULLY SUPPORTED AND MONITORED UNTIL TO ICU ALVEOLAR VENTILATION MUST BE CAREFULLY SUPPORTED AND MONITORED UNTIL TO ICU