Parameter/modality | Recommendation/comment | Anesthetic consideration |
Treatment phase | ||
Hyperosmolar therapy |
| Hyperosmolar agents are often required preoperatively and intraoperatively. When using mannitol, the anesthetist must be aware of fluid shifts; hypovolemia in a patient with concurrent hemorrhagic shock can be exacerbated. |
Cerebrospinal fluid drainage |
| Continuous monitoring requires constant intraoperative vigilance; excessive drainage can lead to brain herniation. |
Ventilation therapies |
| The target PaCO2 is 35 to 45 mmHg; PaCO2 is a powerful determinant of CBF. Low PaCO2 levels result in low CBF and cerebral ischemia whereas high PaCO2 levels can result in cerebral hyperemia and high ICP. |
Anesthetics, analgesics, sedatives |
| Patients with ICP elevation refractory to standard medical treatment may present to the operating room on a barbiturate infusion. High dose propofol should be avoided. |
Steroids |
| Steroids are contraindicated and should not be administered in the OR. |
Infection prophylaxis |
| Antibiotics before intubation are not required (a change from the previous 3rd edition guidelines). |
Seizure prophylaxis |
| Seizure prophylaxis with phenytoin is often initiated in the operating room. Intravenous fosphenytoin or levetiracetam should be considered instead of phenytoin due to risks associated with extravasation of phenytoin. Active seizures should be treated according to the standard of care (ie, midazolam or lorazepam). |
Prophylactic hypothermia |
| Temperature monitoring for TBI patients is mandatory; normothermia should be maintained. |
Monitoring phase | ||
Intracranial pressure monitoring |
| Although not supported by evidence meeting current standards, ICP should be measured in TBI patients with a GCS of 3 to 8 and an abnormal CT scan (ie, a scan that reveals hematomas, contusions, swelling, herniation, or compressed basal cisterns). ICP monitoring may also be indicated in severe TBI patients with a normal CT scan who are older than 40 years of age, have hypotension (SBP <90 mmHg), or exhibit unilateral or bilateral motor posturing. |
Cerebral perfusion pressure monitoring |
| CPP is proportional to the gradient between MAP and mean ICP; MAP can be modulated directly by the anesthetist (ie, with vasopressors, fluids) and requires close monitoring (ie, with arterial catheter) and treatment in the operating room. |
Advanced cerebral monitoring |
| Anesthetists should be aware of the presence of jugular bulb monitors, and how to correctly interpret the information provided by these devices. |
Thresholds | ||
Blood pressure |
| Monitoring blood pressure (ie, arterial catheter) and avoiding hypotension in patients with severe TBI is a major perioperative goal. |
Intracranial pressure |
| In practice, a combination of ICP values, clinical exam, and brain CT findings are required to make management decisions. |
Cerebral perfusion pressure |
| The exact threshold for CPP is unclear, and depends on the patient's autoregulatory status. |
Advanced monitoring |
| Anesthetists should be aware of the presence of jugular bulb monitors, and how to correctly interpret the information provided by these devices. |
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