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Analgo-sedazione nel paziente neurochirurgico

L. LonghiIst Anestesia e RianimazioneUniversita’ Milano

Terapia Intensiva Neuroscienze

Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena

Milano

luca.longhi@unimi.it

Outline

• Principi di fisiopatologia

• Trauma cranico

• ESA

• Postoperatorio

What is proven

Goals of NeuroICU

Diagnosis/treatmentof complications

Prevention/treatment ofsecondary insults

Crit Care Med 2005 Vol. 33, No. 6

What is suggested

Analgesia Sedation

Agitation Pain

↑CMRO2

↑CBF

↑CBV

↑ICP

• head torsion• tube biting

• ↑ PaCO2• cough• fighting ventilator

• hypotension• ↑ CVP

Pathophysiology

Curva volume-pressione

ICP

Volume

A B C D

Langfitt TW et al, J Neurosurg,1964

Perché l’ HICP è dannosa…

Gradienti

ICP, Cerebral Perfusion Pressure

1970 1980 1990 2000

CPP = MAP -ICP

CBF = CPPCVR

Autoregolazione pressoria

CBF

CPPmmHg

50 150

J Neurosurg. Volume 75. November, 1991

J Neurosurg. Volume 75. November, 1991

Why sedation?

CMROCMRO2 2 reductionreduction

ICP

Direct CNS effect Practical goals:

• Relief of agitation, pain, shivering

• Mechanical ventilation

• Blunt stimuli (i.e. suctioning/procedures)

Caveats

• Hypotension• Loss of clinical examination/monitoring• Infections • Longer hospitalization

Ideal sedative/analgesic

Fast onsetEfficacyRapid awakening for extubationEasy to administerFew side effectsNO interactions with other drugsCheap

Neurosurgical milestone: remove masses

Flexion Extension Flexion

Need of sedation balanced against benefits ofclinical observation

Identification of threats

• injury/outcome classification • pre-hospital care• imaging• surgery• critical care • rehabilitation

Neurosurgery 47:546–561, 2000

?

Giusto livello di sedazione nelle varie fasi di un trauma cranico???

Fase acuta

Capire la gravita’ del malato

Scopi della valutazione neurologica

• Quanto depresso è il SNC

• Quale struttura è coinvolta– Corteccia– Tronco

• Evoluzione del danno

Glasgow coma scale

Risp. Verbale

Risp. Motoria

Apertura Occhi Spontaneamente 4Al richiamoAl doloreNo

Frasi confuseParole sconnesseSuoni incomprNullaEsegue gli ordiniLocalizza lo stimoloEvitaFletteEstendeNulla

321

4321654321

Orientata 5

• Mild TBI: 13 – 15

• Moderate TBI: 9 – 12

• Severe TBI: 3 - 8

http://www.braintrauma.org/

Clinical observation - Obstacles

• Sedation• Myorelaxants• Palpebral injuries• Limb fractures

• Neglect• Mess• Fault transmission

JOURNAL OF NEUROTRAUMA Volume 21, Number 9, 2004

• NO surgical intracranial masses

• mGCS < 6

• ICU LOS < 3 days

• mGCS = 6 at discharge

JOURNAL OF NEUROTRAUMA Volume 21, Number 9, 2004

• age < 40• CT scan Diffuse I and II• mGCS ≥ 5• vGCS ≥ 3

Milestones

• Neurological observation• Frequent CT scan• Early mass evacuation• ICP monitoring

Admission CT

After kidney removal

6 hours later

Servadei F, et al. Neurosurgery 46:70-77, 2000 .

Frequency of deterioration in CT appearance from an admission to subsequent scans

Servadei F, et al. Neurosurgery 46:70-77, 2000 .

Frequency of deterioration in CT appearance from an admission to subsequent scans

Servadei F, et al. Neurosurgery 46:70-77, 2000 .

Frequency of deterioration in CT appearance from an admission to subsequent scans

Servadei F, et al. Neurosurgery 46:70-77, 2000 .

Frequency of deterioration in CT appearance from an admission to subsequent scans

La minaccia piu’ importante in un paziente con trauma cranico nelle prime 24-48 ore e’ la comparsa di un ematoma dotato di effetto

massa

time Main goals How to get them

first 48 h

• ICP monitoring• frequent neuro-exam• recognition of threats• ↓ CMRO2

Propofol ± FentanylMyorelaxant

ICP Therapy

Standard

Sedation

CSF with.

Mannitol

PaCO2 30 – 35 mmHg

Reinforced

PaCO2 25 – 29 mmHg

Myorelaxant

Vasopressors

Extremetreatment Barbiturate

Surgicaldecompression

PaCO2 < 25 mmHg

Hypothermia?

ICP

(mm

Hg)

0

20

40

60

10.20.00 10.28.20 10.36.40 10.45.00 10.53.20

Caveats of clinical examination

STOPsedation

resumesedation

Hypnotic drugs

++

+++++

Diazepam

Immune depression

++++

++++

Barbiturate

Infusionsyndrome

Other adverseeffects

+++++Hypotension

+++++Tachyphylaxis

++++Accumulation

MidazolamPropofol

+Fentanyl

Eisenberg 1988 J of neurosurg

Meccanismi di azione del Barbiturico

Metabolismo cerebrale di ossigeno

Flusso ematico cerebrale

Volume ematico cerebrale

Pressione intracranica

CormioCormio M, M, J J NeurotraumaNeurotrauma 19991999

Resistenze vascolari cerebrali1

2

Emodinamico

Metabolico

OguraOgura K,K, NeurosurgeryNeurosurgery 1991.1991.

Barbiturico

• Obiettivo del trattamento è il controllo della ICP – Start con 250 mg in un paio di minuti ripeti fino a carico con 1-

2 gr– Infusione 4-8 gr die

• Attenzione al rebound dell’HICP dopo interruzione del barbiturico– Cominciare con riduzione di ½ gr ogni 24 h – Se ICP stabile continuare con ½ gr ogni 12 h

Barbiturate induction

Barbiturico

• Tp estrema per ipertensione intracranica

– Immunodepressione

– Compromissione emodinamica• Riduzione gettata cardiaca• Riduzione resistenze periferiche

– Decubiti

– Alterazione indici di funzionalita’ epatica e pacreatica

Swan GanzAmine

Letto antidecubito

time Main goals How to get them

first 48 h

• ICP monitoring• frequent neuro-exam• recognition of threats• ↓ CMRO2

Propofol ± FentanylMyorelaxant

• ↓ CMRO2• ICP control

• > 48 h• severity clear

BZD + FentanylMyorelaxantBarbiturate

NATURE CLINICAL PRACTICE NEUROLOGY MAY 2007 VOL 3 NO 5

Problems in SAH

Neurosurgery 60:658–667, 2007

• Age• Hypertension• Diabetes

• WFNS• Size AA

• Vasospasm • Fever

Intensive Care Med. 2007 Sep;33(9):1580-6.

30%

Yin e yan nella diagnosi di vasospasmo

• Sappiamo che esiste

• Sappiamo quando simanifesta

• Sappiamo come si puo’manifestare

• Valutazione clinica“sporca”– Esordio subdolo

– Coma

– Fattori confondenti

Il nostro protocollo

ESA

CTAGFMRI

Deterioramentoneurologico

CTDWI MRIAGF

7 – 10 gg

CTAGF

Prelievo seriato di liquor

• Propofol (± Fentanyl)• Almeno 3 valutazioni “complete”/die

Pain in neurosurgical postop. patients

• Pain

• Hypertension

• Bleeding

• ICP

• Hemostasis

• Side effects of opioids– Sedation– Respiratory depression– Vomitus

Pain inevitable after craniotomy

Limited pain management is sufficient

Anesth Analg 1999;88:335–40

• 90 min postop

• 500 mcg Fentanyl intraop/ 6 ore

• lesioni frontali

J Neurosurg 106:210–216, 2007

• 2/3 dei pazienti: “moderate to severe pain”

• NO FANS

• Paracetamolo in 80% dei casi

• Fentanyl al bisogno

Da approfondire

• Migliore analgesia intraoperatoria?

• Morfina postop. Sicura?

• Quali interventi fanno piu’ male?

Take home messages

• Sedation:– Acute phase: choose a strategy that allows clinical

observation– Thereafter choose a strategy to control ICP

• Analgesia:– Postoperative pain is common after neurosurgery– It requires attention