management perioperatif pada pasien trauma brain injury

8/13/2019 Management Perioperatif Pada Pasien Trauma Brain Injury

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Int J Crit Illn Inj Sci. 2011 Jan-Jun; 1(1): 2735.

doi: 10.103!222"-5151.7"27"

#$CI%: #$C320"""3

#&rio'&rati& anag&&nt of trauatic *rain injur+#aric,at Curr+1 %arin /i&rn&1 and %&&'a S,ara12

1%&'art&nt of n&t,&iolog+ and #ain $&dicin& ni&rit+ of 4a,ington S&attl& 4 S

2%&'art&nt of &urological Surg&r+ ni&rit+ of 4a,ington S&attl& 4 S

ddr& for corr&'ond&nc&: %r. %&&'a S,ara %&'art&nt of n&t,&iolog+ #ain $&dicin&

and &urological Surg&r+ 6ar*ori& $&dical C&nt&r 325 int, &nu& o8 35"72 S&attl&

4 "910 S. -ail: d,arau.a,ington.&du

Co'+rig,t : < Int&rnational Journal of Critical Illn& and Injur+ Sci&nc&

=,i i an o'&n-acc& articl& ditri*ut&d und&r t,& t&r of t,& Cr&ati& Coon ttri*ution-

onco&rcial-S,ar& li& 3.0 n'ort&d ,ic, '&rit unr&trict&d u& ditri*ution and

r&'roduction in an+ &diu 'roid&d t,& original or i 'ro'&rl+ cit&d.

*tract

=rauatic *rain injur+ (=I) i a ajor 'u*lic ,&alt, 'ro*l& and t,& l&ading cau& of d&at, and

dia*ilit+ orldid&. %&'it& t,& od&rn diagnoi and tr&at&nt t,& 'rognoi for 'ati&nt it,

=I r&ain 'oor. 4,il& &&rit+ of 'riar+ injur+ i t,& ajor factor d&t&rining t,& outco&

t,& &condar+ injur+ cau&d *+ ',+iological inult uc, a ,+'ot&nion ,+'o8&ia

,+'&rcar*ia ,+'ocar*ia ,+'&rgl+c&ia and ,+'ogl+c&ia &tc. t,at d&&lo' o&r ti& aft&r t,&

on&t of t,& initial injur+ cau& furt,&r daag& to *rain tiu& or&ning t,& outco& in =I.

#&rio'&rati& '&riod a+ *& 'articularl+ i'ortant in t,& cour& of =I anag&&nt. 4,il&

urg&r+ and an&t,&ia a+ 'r&di'o& t,& 'ati&nt to n& on&t &condar+ injuri& ,ic, a+contri*ut& ad&r&l+ to outco& t,& '&rio'&rati& '&riod i alo an o''ortunit+ to d&t&ct and

corr&ct t,& undiagno&d 'r&-&8iting &condar+ inult to 'r&&nt againt n& &condar+ inult

and i a 'ot&ntial indo to initiat& int&r&ntion t,at a+ i'ro& outco& of =I. >or t,i

r&i& &8t&ni& #u*&d and $&dlin& &arc, on ariou a'&ct of '&rio'&rati& anag&&nt of

=I a '&rfor&d follo&d *+ r&i& of r&&arc, focuing on intrao'&rati& and '&rio'&rati&

'&riod. 4,il& t,& r&&arc, focuing '&cificall+ on t,& intrao'&rati& and i&diat& '&rio'&rati&

=I anag&&nt i liit&d clinical anag&&nt continu& to *& *a&d larg&l+ on ',+iological

o'tii?ation and r&co&ndation of rain =raua >oundation guid&lin&. =,i r&i& i

focu&d on t,& '&rio'&rati& anag&&nt of =I it, 'articular &',ai on r&c&nt

d&&lo'&nt.

@&+ord: n&t,&ia '&rio'&rati& anag&&nt trauatic *rain injur+

I=AB%C=IB

=rauatic *rain injur+ (=I) i a ajor 'u*lic ,&alt, 'ro*l& and t,& l&ading cau& of d&at, and

dia*ilit+ orldid&.1D ''ro8iat&l+ 1.7 illion '&o'l& utain =I &&r+ +&ar in t,& nit&d

Stat& l&ading to 275000 ,o'itali?ation and 52000 d&at,.1D =I i a contri*uting factor in

a*out 30.5E of all injur+-r&lat&d d&at, in t,& nit&d Stat&.1D =I occur ot oft&n in c,ildr&n

ag&d 0 +&ar adol&c&nt ag&d 151" +&ar and &ld&rl+ ag&d F5 +&ar and or&.1D In all ag&

grou' al& ,a& a ,ig,&r rat& of =I t,an f&al&.1D >all and otor &,icl&-traffic injur+ ar&

t,& l&ading cau& of =I in t,& nit&d Stat&.1D In t,& r&c&nt +&ar 'r&,o'ital and int&ni&car& of 'ati&nt it, =I ,a i'ro&d u*tantiall+ and &id&nc&-*a&d guid&lin& for


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anag&&nt ,a& *&&n d&&lo'&d.213D 6o&&r d&'it& t,& od&rn diagnoi and tr&at&nt

t,& 'rognoi for 'ati&nt it, =I r&ain 'oor &',ai?ing t,& n&&d for furt,&r r&&arc, and

i'ro&&nt in car&. =,i r&i& ill focu on t,& '&rio'&rati& anag&&nt of =I it,

'articular &',ai on r&c&nt d&&lo'&nt and i *a&d on &8t&ni& #u*&d and $&dlin&

&arc, on ariou a'&ct of '&rio'&rati& anag&&nt of =I follo&d *+ r&i& of r&&arc,focuing on intrao'&rati& and '&rio'&rati& '&riod.

#=6B#6GSIBLBHG B> =A$=IC AI IJAG

#at,o',+iolog+ of =I inol& 'riar+ and &condar+ injuri& to t,& *rain. #riar+ injur+ i t,&

daag& cau&d *+ t,& initial traua inoling &c,anical i'act to t,& *rain tiu& and ull du&

to acc&l&rationd&c&l&ration or rotational forc& r&ulting in ull fractur& *rain contuion

&8'anding intracranial ,&atoa or diffu& a8onal injur+.1D =,& 'riar+ injur+ t,&n initiat&

inflaator+ 'roc& &d&a foration and &8citoto8icit+ r&ulting in furt,&r incr&a& in

intracranial 'r&ur& (IC#) and r&duc&d c&r&*ral '&rfuion 'r&ur& (C##).115D S&&rit+ of

'riar+ injur+ i t,& ajor factor d&t&rining t,& outco& of =I 'ati&nt. S&condar+ injur+ i a

con&u&nc& of ',+iological inult t,at d&&lo' o&r ti& aft&r t,& on&t of t,& initial injur+

cauing furt,&r daag& to t,& *rain tiu& and or&ning t,& outco& in =I 'ati&nt.115D =o

ajor factor t,at cau& &condar+ injur+ ar& ,+'ot&nion +tolic *lood 'r&ur& (S#) "0

6gD and ,+'o8&ia (#aB2 F0 6g).1FD

tud+ anal+?ing data fro t,& =rauatic Coa %ata an d&ontrat&d t,at ,+'ot&nion and

,+'o8&ia &r& ind&'&nd&ntl+ aociat&d it, incr&a&d or*idit+ and ortalit+ fro &&r&

=I.17D ingl& &'iod& of ,+'ot&nion a aociat&d it, incr&a&d or*idit+ and ortalit+.

17D &ta-anal+i of 9721 'ati&nt (I$#C= tud+) alo ugg&t&d t,at ,+'ot&nion and

,+'o8ia &r& ignificantl+ aociat&d it, unfaora*l& F-ont, outco&.19D tud+ on t,&

aociation *&t&&n intrao'&rati& ,+'ot&nion and outco& d&ontrat&d t,at 'ati&nt ,o ,adintrao'&rati& ,+'ot&nion ,ad o&r t,r&& ti& incr&a&d ortalit+ t,an norot&ni& 'ati&nt.

1"D $or&o&r t,& duration of intrao'&rati& ,+'ot&nion a alo in&r&l+ aociat&d it,

functional outco&.1"D Bt,&r factor i'licat&d in &condar+ injur+ includ& ,+'ogl+c&ia

,+'&rgl+c&ia ,+'&rcar*ia and ,+'ocar*ia and rai&d IC#.2025D

=6 I$#BA=C B> #AIB#A=I/ #AIB%

Hi&n t,& 'oor outco& of =I and i'act of &condar+ inult curr&nt =I anag&&nt

focu& on 'r&&ntion of 'riar+ injur+ and aoidanc& of &condar+ injuri&. =,u t,&

corn&rton& of od&rn =I anag&&nt ar& fi&ld r&ucitation &8'&ditiou triag& &&rg&nt

urgical &acuation of a l&ion control of IC# and u''ort of C## ultiodal onitoring

and o'tii?ation of ',+iological &niron&nt. #&rio'&rati& '&riod a+ *& 'articularl+

i'ortant in t,& cour& of =I anag&&nt for nu&rou r&aon. >irt d&'it& t,& aggr&i&

int&r&ntion to ra'idl+ corr&ct ,+'o8&ia ,+'ot&nion ,+'o and ,+'&rcar*ia and ,+'o and

,+'&rgl+c&ia in t,& &&rg&nc+ d&'art&nt it i not unuual for on& or or& of t,&&

co'licating factor to '&rit or r&ain und&t&ct&d a t,& 'ati&nt i &&rg&ntl+ tran'ort&d to t,&

o'&rating roo. 6&nc& '&rio'&rati& '&riod a+ 'roid& an o''ortunit+ to &it,&r continu&

ongoing r&ucitation or to corr&ct t,& 'r&-&8iting &condar+ inult. S&condl+ urg&r+ and

an&t,&ia a+ 'r&di'o& t,& 'ati&nt to n& on&t &condar+ injuri& (uc, a intrao'&rati&

,+'ot&nion du& to urgical *lood lo or &ff&ct of an&t,&tic ag&nt n& on&t ,+'&rgl+c&ia du&

to tr& r&'on& &tc.) ,ic, a+ contri*ut& ad&r&l+ to outco&. Sinc& &condar+ injur+ ilarg&l+ 'r&&nta*l&!tr&ata*l& t,& '&rio'&rati& '&riod a+ *& a 'ot&ntial indo to initiat&


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int&r&ntion t,at a+ i'ro& t,& outco& of =I. #&rio'&rati& anag&&nt inol& ra'id

&aluation continuation of r&ucitation (c&r&*ral and +t&ic) &arl+ urgical int&r&ntion

int&ni& onitoring and an&t,&tic 'lanning.

Initial &&nt and Bngoing A&ucitation

=,& initial a&&nt and ta*ili?ation i uuall+ ac,i&&d in t,& &&rg&nc+ d&'art&nt andr&ucitation initiat&d *&for& t,& 'ati&nt i tran'ort&d to Co'ut&d =oogra',+ (C=) cann&r and

t,&n to t,& o'&rating roo. &&rt,&l& it i i'ortant for t,& an&t,&ia t&a to '&rfor

anot,&r ra'id a&&nt a t,& 'ati&nt i r&c&i&d in t,& o'&rating roo. =,& a&&nt ,ould

ala+ *&gin it, aira+ *r&at,ing and circulation follo&d *+ a ra'id a&&nt of

n&urological tatu and aociat&d &8tracranial injuri& and att&ntion to '&cific &condar+ injur+

&c,ani and ongoing tr&at&nt t,&r&of. Inforation a*out ti& and &c,ani of injur+ can

*& alua*l&. ri&f n&urological a&&nt i '&rfor&d *+ uing Hlago Coa Scal& (HCS)2FD

cor& and 'u'illar+ r&'on&. ociat&d t,oracic a*doinal 'inal and long *on& injuri& a+

*& ta*l& or &ol& during t,& '&rio'&rati& '&riod and ut *& conid&r&d in diff&r&ntial

diagnoi of n& on&t ,+'ot&nion an&ia ,&od+naic inta*ilit+ or ,+'o8&ia during

an&t,&ia and urg&r+. t,& 'ati&nt i tran'ort&d to t,& o'&rating roo all r&ucitati&

&aur& ,ould continu&.

ira+ $anag&&nt

#ati&nt it, =I r&uiring urg&r+ ill inaria*l+ r&uir& trac,&al intu*ation. In fact ot

'ati&nt ar& li&l+ to arri& in t,& o'&rating roo alr&ad+ intu*at&d. 6o&&r o& 'ati&nt

'articularl+ t,o& it, &8tradural ,&atoa a+ *& conciou and *r&at,ing 'ontan&oul+. =,&

ind&lling trac,&al tu*& can 'oi*l+ igrat& during tran'ort l&ading to &ndo*ronc,ial

intu*ation or &&n dilodg&&nt and ,&nc& ad&uat& 'oition of t,& tu*& ut ala+ *&

confir&d. In t,& &l&ct 'ati&nt ,o a+ not *& alr&ad+ intu*at&d aira+ anag&&nt ico'licat&d *+ a nu*&r of factor including urg&nc+ of ituation (*&cau& of 'r&-

&8iting!or&ning ,+'o8ia) unc&rtaint+ of c&rical 'in& tatu unc&rtaint+ of aira+ (du& to

'r&&nc& of *lood oitu d&*ri in t,& oral cait+ or du& to lar+ngo-',ar+ng&al injur+ or ull

*a& fractur&) full toac, intracranial ,+'&rt&nion and unc&rtain olu& tatu. ll =I

'ati&nt r&uiring urg&nt urg&r+ ut *& conid&r&d to ,a& full toac, and aira+ anag&&nt

ut account for 'oi*l& und&rl+ing c&rical 'in& injur+. lt,oug, it ,a *&&n r&'ort&d t,at

'ati&nt it, cranioc&r&*ral traua ,ad an incid&nc& of c&rical 'in& injur+ (CSI) iilar to t,at

of t,& g&n&ral traua 'o'ulation27D &&rging &id&nc& ugg&t a ,ig,&r incid&nc& of c&rical

injur+ in 'ati&nt ,o ,a& &8'&ri&nc&d cranioc&r&*ral traua &'&ciall+ aong t,o& it,

incr&aing &&rit+ of cranioc&r&*ral injur+ a d&t&rin&d *+ lo HCS cor& and unconcioun&.

292"D

=,& c,oic& of t&c,niu& for trac,&al intu*ation i d&t&rin&d *+ urg&nc+ indiidual

&8'&rti&!ill and aaila*l& r&ourc& and g&n&rall+ incor'orat& ra'id &u&nc& intu*ation it,

cricoid 'r&ur& and anual in-lin& ta*ili?ation.27D =,& ant&rior 'ortion or c&rical collar a+

*& r&o&d ,&n anual in-lin& ta*ili?ation i &ta*li,&d to allo gr&at&r out, o'&ning and

facilitat& lar+ngoco'+. &&r aira+ d&i& 'articularl+ Hlid&co'& id&olar+ngoco'& ,a&

gain&d 'o'ularit+ in r&c&nt +&ar for u& in traua icti and a+ *& u&ful in difficult aira+

c&nario. 6o&&r t,& intu*ation ti& uing Hlid&co'& a+ *& long&r du& to difficult+ in

'aing t,& trac,&al tu*& t,roug, t,& glotti d&'it& &ai&r iuali?ation.30D aal intu*ation,ould *& aoid&d in 'ati&nt it, *a& of ull fractur& &&r& facial fractur& or *l&&ding


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diat,&i. In an+ ca& it i adia*l& to ,a& a *ac-u' 'lan r&ad+ in ca& of difficult intu*ation

gi&n t,& ignificant ri of intracranial ,+'&rt&nion r&ulting fro incr&a&d c&r&*ral *lood

olu& (C/) *&cau& of ,+'o8&ia and ,+'&rcar*ia.

C,oic& of induction ag&nt and ucl& r&la8ant i i'ortant for ucc&ful unco'licat&d aira+

anag&&nt. Sodiu t,io'&ntal &toidat& and 'ro'ofol ar& coonl+ u&d to induc& an&t,&ia*&for& intu*ation. ll t,&& ag&nt d&cr&a& t,& +t&ic ,&od+naic r&'on& to intu*ation

*lunt incr&a& in IC# and d&cr&a& t,& c&r&*ral &ta*olic rat& for o8+g&n (C$AB2). 6o&&r

'ro'ofol and t,io'&ntal a+ cau& cardioacular d&'r&ion l&ading to ,+'ot&nion &'&ciall+ in

t,& 'r&&nc& of uncorr&ct&d ,+'ool&ia. toidat& a+ *& adantag&ou du& to littl& c,ang& in

*lood 'r&ur& during induction d&'it& r&duction of C$AB2.31D 6o&&r it a+ l&ad to

adr&nal inuffici&nc+ cauing d&la+&d ,+'ot&nion and r&uiring ao'r&or u&.32D @&tain&

,ic, cau& liit&d cardioacular co'roi& ,a *&&n aociat&d it, incr&a&d c&r&*ral

*lood flo (C>) and incr&a&d IC# and a uc, a+ *& r&lati&l+ contraindicat&d for intu*ating

'ati&nt it, ri for or 'r&-&8iting incr&a&d IC#.33D =,& c,oic& of ucl& r&la8ant for ra'id

&u&nc& induction i *&t&&n uccin+lc,olin& and rocuroniu.3D Succin+lc,olin& a+

contri*ut& to incr&a&d IC#353FD ,ic, can *& *lunt&d *+ adinitration of an ad&uat& do& of

an induction ag&nt uc, a t,io'&ntal.37D 4,il& t,& clinical ignificanc& of t,& &ff&ct of

uccin+lc,olin& on IC# i u&tiona*l&3739D incr&a& in IC# &condar+ to ,+'o8ia and

,+'&rcar*ia ar& &ll docu&nt&d and uc, or& li&l+ to *& clinicall+ i'ortant. 6&nc& in

'ati&nt it, =I clinician a+ not aoid uing uccin+lc,olin&.39D

n&t,&tic $anag&&nt

=,& ajor goal of an&t,&tic anag&&nt of =I ar& to

aintain C##;

tr&at incr&a&d IC#;'roid& o'tial urgical condition;

aoid &condar+ inult uc, a ,+'o8&ia ,+'&r and ,+'ocar*ia ,+'o and ,+'&rgl+c&ia; and

'roid& ad&uat& analg&ia and an&ia.

n&t,&tic t&c,niu&

I'ortant ',aracod+naic and ',aracoin&tic diff&r&nc& &8it *&t&&n intra&nou and

olatil& an&t,&tic ag&nt. Intra&nou ag&nt including t,io'&ntal 'ro'ofol and &toidat& cau&

c&r&*ral aocontriction and r&duc& C> C/ C$AB2and IC#.3"D B'ioid ,a& no dir&ct

&ff&ct on c&r&*ral ,&od+naic in t,& 'r&&nc& of controll&d &ntilation.0D ll olatil&

an&t,&tic ag&nt (iofluran& &ofluran& d&fluran&) d&cr&a& C$AB2 and a+ cau& c&r&*ral

aodilation r&ulting in incr&aing C> and IC#. ut at conc&ntration l& t,an 1 iniu

al&olar conc&ntration ($C) t,& c&r&*ral aodilator+ &ff&ct ar& inial and ,&nc& t,&+ a+

*& u&d in lo conc&ntration in 'ati&nt it, =I.1D itrou o8id& can incr&a& C$AB2 and

cau& c&r&*ral aodialation and incr&a&d IC# and ,ould *& aoid&d.2D I'ortantl+ t,& &ff&ct

of an&t,&tic ag&nt (in,alation . total intra&nou an&t,&ia) on outco& of =I ,a& not *&&n

d&ontrat&d. In t,& a*&nc& of conclui& &id&nc& &it,&r an&t,&tic t&c,niu& a+ *& &'lo+&d

judicioul+. 6o&&r or& i'ortantl+ t,& 'rinci'l& of an&t,&tic anag&&nt ,ould ad,&r& to

t,& curr&nt guid&lin& for t,& anag&&nt of &&r& =I =a*l& 1D.213D

/&ntilation

/&ntilation ,ould *& adjut&d to &nur& ad&uat& o8+g&nation and ga &8c,ang&. In'ir&d o8+g&nconc&ntration i adjut&d to aintain #aB2 KF0 6g.2$onitoring art&rial #CB2 i


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r&co&nd&d inc& &nd-tidal CB2 a+ not *& r&lia*l&. 6+'&rcar*ia ,ould *& aoid&d *ut

,+'ocar*ia ut not *& u&d indicriinat&l+.12D 8c&i& ,+'&r&ntilation a+ cau& c&r&*ral

aocontriction l&ading to ic,&ia.12D 6&nc& ,+'&r&ntilation ,ould *& u&d judicioul+ for

,ort-t&r control of IC# and to facilitat& urgical &8'our& during cranioto+. orocar*ia

,ould *& r&tor&d *&for& dural clour& to aoid d&&lo'&nt of t&nion 'n&uoc&',alu.$onitoring c&r&*ral o8+g&nation i r&co&nd&d ,&n utili?ing ,+'&r&ntilation for 'rolong&d

'&riod. In t,& intrao'&rati& '&riod t,i a+ *& acco'li,&d *+ jugular &nou o8i&tr+"3D

and in t,& 'oto'&rati& '&riod *+ *rain tiu& o8+g&nation (#*tB2) or C> onitoring (&.g. uing

=rancranial %o''l&r ultraonogra',+)."D

$onitoring

In additional to tandard &rican Soci&t+ of n&t,&iolog+ (S) onitor art&rial

cat,&t&ri?ation i r&co&nd&d for *&at-to-*&at *lood 'r&ur& onitoring and for *lood ga

anal+i and *lood gluco& onitoring during cranioto+. C&ntral &nou 'r&ur& (C/#) a+ *&

u&ful 'articularl+ for r&ucitation and ,&n ao'r&or ar& adinit&r&d. 6o&&r it i

adia*l& not to d&la+ urgical &acuation of &8'anding intracranial ,&atoa *&cau& of

intitution of inai& onitoring. ccording to t,& curr&nt guid&lin& IC# onitoring i

r&co&nd&d in all alag&a*l& 'ati&nt it, a &&r& =I (HCS ") and an a*noral C= can

(,&atoa contuion &lling ,&rniation or co'r&&d *aal cit&rn) and in 'ati&nt it,

&&r& =I it, a noral C= can if to or or& of t,& folloing f&atur& ar& not&d at t,&

adiion: ag& K 0 +&ar unilat&ral or *ilat&ral otor 'oturing or S# "0 6g.5D =,& u&

of ultiodal onitoring for 'oto'&rati& and int&ni& car& of 'ati&nt it, =I i incr&aing

and onitoring c&r&*ral o8+g&nation (glo*al or focal) or C> and &ta*oli 'ara&t&r a+ *&

,&l'ful in aing i'ortant tr&at&nt d&ciion."D

Intra&nou >luid lood #r&ur& $anag&&nt and /ao'r&or &6+'ot&nion folloing =I can co'roi& c&r&*ral ,&od+naic and cau& c&r&*ral ic,&ia.

=,&r&for& *lood 'r&ur& anag&&nt including c,oic& of fluid and ao'r&or i of

'araount i'ortanc&. rain =raua >oundation guid&lin& for t,& anag&&nt of =I

r&co&nd aoiding ,+'ot&nion (S# "0 6g) and aintaining C## *&t&&n 50 and 70

6g.29D 4ar non-gluco& containing iotonic cr+talloid olution i 'r&f&ra*l& for =I

'ati&nt. =,& rol& of colloid i contro&rial. 'ot-,oc anal+i of t,& Salin& &ru l*uin

>luid aluation (S>) tud+ d&ontrat&d t,at r&ucitation it, al*uin a aociat&d it,

,ig,&r ortalit+ rat& and unfaora*l& n&urological outco& at 2 ont,.D 6+'&rtonic alin&

a+ *& *&n&ficial r&ucitation fluid for =I 'ati&nt *&cau& it incr&a& intraacular fluid and

d&cr&a& IC#. #r&,o'ital ,+'&rtonic alin& r&ucitation ,a *&&n ,on to *& aociat&d it, a

r&duction in &ru *ioar&r l&&l (S100 &uron S'&cific nola& and $&*ran& aic

#rot&in) ,ic, corr&lat&d it, *&tt&r outco&.5D 6o&&r a dou*l&-*lind randoi?&d

controll&d trial co'aring 'r&,o'ital r&ucitation of ,+'ot&ni& =I 'ati&nt it, ,+'&rtonic

alin& it, tandard fluid r&ucitation 'rotocol found no diff&r&nc& in n&urological outco& at F

ont,.FD

/ao'r&or ar& coonl+ adinit&r&d to tr&at ,+'ot&nion or to aug&nt C##. 6o&&r t,&r&

ar& onl+ a f& tudi& co'aring t,& &ff&cti&n& of coonl+ u&d ao'r&or in =I and

r&ult of t,&& tudi& ar& conflicting. 6uan data &8'licitl+ co'aring ao'r&or ar& liit&d

to t,r&& all 'ro'&cti& randoi?&d croo&r trial co'aring &u&ntial &ff&cti&n&*&t&&n nor&'in&',rin& and do'ain&. %&'it& t,&r& *&ing no diff&r&nc& in &an c&r&*ral flo


6/15

&locit+79D and c&r&*ral o8+g&nation or &ta*oli"D *&t&&n t,& to ao'r&or

nor&'in&',rin& ,ad or& 'r&dicta*l& and conit&nt &ff&ct9D ,il& do'ain& u& l&d to ,ig,&r

IC#.7D r&c&nt ingl&-c&nt&r r&tro'&cti& tud+ of 'ati&nt it, &&r& =I ,o r&c&i&d

',&n+l&',rin& nor&'in&',rin& or do'ain& r&'ort&d a8iu incr&a& in $# and C## fro

*a&lin& it, ',&n+'&',rin& u&.50D =,&r& a no diff&r&nc& in IC# *&t&&n t,& tr&at&ntgrou' aft&r initiating t,& ao'r&or alt,oug, it a uncl&ar ,&t,&r i'ro&d $#!C## it,

ao'r&or u& tranlat&d into i'ro&d C> or o8+g&nation.50D Curr&nt &id&nc& do& not

u''ort 'r&f&r&nc& of on& ao'r&or o&r t,& ot,&r.

lood =ranfuion

n&ia i aociat&d it, incr&a&d in-,o'ital ortalit+51D and 'oor outco& in =I.5253D

G&t t,&r& i littl& &id&nc& to u''ort 'ac&d r&d *lood c&ll (#AC) tranfuion 'ractic& tandard

to corr&ct an&ia in =I. 4,il& o& ,a& ugg&t&d t,at 'ati&nt it, =I a+ not *&n&fit fro

a ,ig,&r tranfuion t,r&,old t,an ot,&r criticall+ ill 'ati&nt52D ot,&r ,a& caution&d againt

t,& li*&ral u& of *lood tranfuion in =I.53D #ot&ntial &c,ani of c&r&*ral injur+ du& to

an&ia includ& tiu& ,+'o8ia injur+ cau&d *+ r&acti& o8+g&n '&ci& inflaation diru'tion

of *lood-*rain *arri&r () function acular t,ro*oi and an&ic c&r&*ral ,+'&r&ia.5D

6o&&r a nu*&r of c&r&*ro'rot&cti& ',+iological &c,ani *&co& &ff&cti& it, an&ia

,ic, includ& aortic c,&or&c&'tor actiation incr&a&d +'at,&tic actiit+ l&ading to incr&a&d

,&art rat& tro& olu& and cardiac ind&8 r&duc&d +t&ic acular r&itanc& and &n,anc&d

o8+g&n &8traction. $or&o&r a nu*&r of c&llular &c,ani of c&r&*ral 'rot&ction *&co&

&ff&cti& in acut& an&ia. =,&& includ& 6+'o8ia Induci*l& >actor (6I>) incr&a&d nitric o8id&

+nt,&ta& and nitric o8id& in t,& *rain (nBS!B) &r+t,ro'oi&tin and acular &ndot,&lial

grot, factor (/H>) &diat&d angiog&n&i and acular r&'air.5D lt,oug, incr&a& in C>

during acut& an&ia can i'ro& o8+g&n d&li&r+ ,ig, ,&atocrit aft&r #AC tranfuion a+'ot&ntiall+ d&cr&a& C> and incr&a& t,& ri of c&r&*ral ic,&ia.55D 6o&&r an&ia du& to

,&odilution a+ i'air c&r&*ral autor&gulation.5FD =,& o&rall &ff&ct of an&ia on t,& *rain

ig,t t,&r&for& d&'&nd on t,& r&lati& *alanc& *&t&&n t,&& co'&ting 'rot&cti& and ,arful

factor of an&ia and #AC tranfuion and it i uncl&ar ,&t,&r tranfuion trigg&r in 'ati&nt

it, =I ,ould *& an+ diff&r&nt fro ot,&r criticall+ ill 'ati&nt and ,&t,&r t,& injur&d *rain i

or& uc&'ti*l& to d&l&t&riou &ff&ct of an&ia.

In t,& a*&nc& of d&fin&d o'tial ,&oglo*in (6*) l&&l it ,a *&&n ugg&t&d t,at

n&uro',+iologic crit&ria for AC tranfuion a+ *& or& rational and a+ 'rogr&i&l+

r&'lac& ar*itrar+ 6*-*a&d tranfuion trigg&r in n&urocritical car&.57D AC tranfuion a+

influ&nc& c&r&*ral o8+g&nation t,roug, a nu*&r of 'ot&ntial &c,ani in 'ati&nt it, =I.

&id& incr&aing t,& o8+g&n-carri&r ca'acit+ of *lood AC tranfuion incr&a& t,& circulating

olu& and can incr&a& C> in 'ati&nt it, i'air&d c&r&*ral autor&gulation &condar+ to t,&

=I. =ranfuion alo incr&a& t,& *lood icoit+ to ,ic, t,& circulator+ n&tor r&'ond it,

t,& r&l&a& of nitric o8id& l&ading to aodilatation and incr&aing functional ca'illar+ d&nit+

(,ic, uantifi& ca'illar+ '&rfuion).59D In r&c&nt +&ar t,&r& ,a *&&n groing int&r&t in t,&

&ff&ct of AC tranfuion on *rain tiu& o8+g&nation (#*tB2) in 'ati&nt it, =I and it &&

an int&r&ting 'oi*ilit+ t,at #*tB2 alu& a+ *& d&&lo'&d into 'ot&ntial tranfuion trigg&r.

6o&&r ot tudi& &aluating t,& &ff&ct of tranfuion on #*tB2 in n&urourgical 'ati&nt ar&

liit&d *+ all a'l& i?& and ,a& fail&d to d&ontrat& a conit&nt r&'on& to tranfuion or&lucidat& 'r&dictor of #*tB2 r&'on& to tranfuion.5"F0D =,& 'ot&ntial rol& of *rain tiu&


7/15

o8+g&nation in d&ciding tranfuion t,r&,old ,a *&&n dicu&d &l&,&r&.F1F2D

8iting &id&nc& ugg&t t,at *ot, an&ia and AC tranfuion ar& aociat&d it, 'oor

n&urological outco& in =I.5253D 4,il& an&ia i aociat&d it, incr&a&d in-,o'ital

ortalit+51D and lo&r ,o'ital dic,arg& HCS cor& dic,arg& Hlago outco& cor& and

Aanc,o Lo igo cor&52D AC tranfuion i aociat&d it, acut& lung injur+ long&rint&ni& car& unit and ,o'ital ta+ and ortalit+.F3F5D =,& o'tial 6* l&&l in =I 'ati&nt i

till uncl&ar *ut t,&r& i no *&n&fit of a li*&ral tranfuion trat&g+ (tranfuion ,&n 6* 10 g!dl)

in od&rat& to &&r& =I 'ati&nt and it i not r&co&nd&d.53D

Coagulo'at,+ and >actor /II

Coagulation diord&r i a coon 'ro*l& aft&r =I. Coagulation diord&r could r&ult fro =I

and cau& &condar+ *rain injur+. r&c&nt r&i& r&'ort&d t,at t,& o&rall 'r&al&nc& of

coagulo'at,+ a 32.7E aft&r =I and or& t,an F0E in &&r& =I and t,at t,& 'r&&nc& of

coagulo'at,+ a aociat&d it, an incr&a&d ortalit+ and 'oor outco&.FFD ccording to a

r&c&nt 'ro'&cti& tud+ t,& ind&'&nd&nt ri factor for coagulo'at,+ in =I ar& HCS 9

Injur+ S&&rit+ Scor& (ISS) 1F 'r&&nc& of c&r&*ral &d&a u*arac,noid ,&orr,ag& and

idlin& ,ift.F7D 4,&n *rain i injur&d tiu& factor (=>) i r&l&a&d. Su*&u&ntl+ 'ro-

coagulant factor ar& actiat&d r&ulting in t,ro*in foration and con&rion of fi*rinog&n to

fi*rin. orall+ antit,ro*otic &c,ani ar& alo actiat&d to count&r fi*rin foration.

%i&inat&d intraacular coagulation (%IC) in,i*it t,& antit,ro*otic &c,ani cauing

i*alanc& of coagulation and fi*rinol+i. Curr&ntl+ t,&r& ar& no guid&lin& for anag&&nt of

coagulo'at,+ in =I. 6&otatic drug including antifi*rinol+tic ag&nt uc, a tran&8aic acid

and 'ro-coagulant drug uc, a r&co*inant actiat&d factor /II (r>/IIa) ar& o&ti& u&d in

tr&at&nt of coagulo'at,+ aft&r =I. Coc,ran& r&i& found to randoi?&d controll&d trial

t,at &aluat&d t,& &ff&ct of r>/IIa *ut *ot, t,& trail &r& too all to dra a concluionr&garding t,& &ff&cti&n& of r>/IIa for =I 'ati&nt.F9D =,& Clinical Aandoi?ation of

ntifi*rinol+tic in Significant 6&orr,ag& (CAS6-2) trial a larg& int&rnational 'lac&*o-

controll&d trial &aluating t,& &ff&ct of tran&8aic acid on d&at, acular occluion &&nt and

*lood tranfuion in adult traua 'ati&nt d&ontrat&d t,at tran&8aic acid a aociat&d it,

a r&duction of ortalit+ (AA: 0."1 "5E CI: 0.95-0"7 # 0.0035).F"D =,& ri of d&at, fro

*l&&ding a alo lo&r in tran&8aic acid grou' (AA: 0.95 "5E CI: 0.7F0."F # 0.0077).F"D

6+'&roolar =,&ra'+

$annitol i t,& tandard ag&nt u&d in ,+'&roolar t,&ra'+. =,& r&co&nd&d do& of annitol

i 0.251 g!g *od+ &ig,t. %u& to ootic diur&i ,ic, can r&ult in ,+'ool&ia and

,+'ot&nion annitol i r&co&nd&d onl+ ,&n t,&r& ar& ign of trant&ntorial ,&rniation or

'rogr&i& n&urological d&t&rioration not attri*uta*l& to &8tracranial cau&.3D In 'ati&nt it,

&&r& =I and &l&at&d IC# r&fractor+ to annitol tr&at&nt 7.5E ,+'&rtonic alin&

adinit&r&d a &cond ti&r t,&ra'+ can incr&a& c&r&*ral o8+g&nation and i'ro& c&r&*ral and

+t&ic ,&od+naic.70D

Hl+c&ic Control

6+'&rgl+c&ia aft&r =I i aociat&d it, incr&a&d or*idit+ and ortalit+.7173D It a+

r&fl&ct t,& &8t&nt of injur+ &&rit+7D r&fl&cting a noral r&'on& to tr& du& to a ri& in

circulating count&r-r&gulator+ ,oron& or a+ or&n outco& aft&r =I.775D S&condar+

*rain injur+ fro ,+'&rgl+c&ia can &nu& l&ading to an incr&a& in gl+col+tic rat& a ,on *+incr&a&d lactat&!'+ruat& ratio r&ulting in &ta*olic acidoi it,in *rain 'ar&nc,+a


8/15

o&r'roduction of r&acti& o8+g&n '&ci& and ultiat&l+ n&uronal c&ll d&at,.7 77D In 2001

/an d&n &rg,& &t al. r&'ort&d t,at int&ni& inulin t,&ra'+ (targ&t *lood gluco& 90 110 g!dl)

in criticall+ ill 'ati&nt a aociat&d it, lo&r ortalit+.79D 6o&&r or& r&c&nt tudi& not

onl+ fail&d to d&ontrat& t,& ortalit+ *&n&fit of int&ni& inulin t,&ra'+ *ut alo found an

incr&a&d ri of ,+'ogl+c&ia.7"90D illotta &t al. randoi?&d "7 &&r& =I 'ati&nt toint&ni& inulin t,&ra'+ grou' targ&ting *lood gluco& at 90-120 g!dl or con&ntional inulin

t,&ra'+ grou' targ&ting *lood gluco& *&lo 220 g!dl and found t,at *ot, t,& grou' ,ad iilar

ortalit+ and n&urological outco& at F ont,.90D lt,oug, t,& int&ni& inulin t,&ra'+ grou'

,ad ,ort&r IC ta+ inf&ction rat& &r& iilar *&t&&n *ot, t,& grou' and &'iod& of

,+'ogl+c&ia (gluco& 90 g!dl) &r& ignificantl+ ,ig,&r in t,& int&ni& inulin t,&ra'+

grou'.90D

6&nc& tig,t gluco& control it, int&ni& inulin t,&ra'+ r&ain contro&rial. 4,il& a nu*&r

of tudi& ,a& in&tigat&d ,+'&rgl+c&ia in adult =I in diff&r&nt cont&8t (adiion . IC

trani&nt . '&rit&nt &arl+ . lat& &tc.) non& ,a '&cificall+ addr&&d t,& intrao'&rati&

'&riod and t,& 'r&al&nc& of intrao'&rati& ,+'&rgl+c&ia and it r&lation to 'r&o'&rati&

gl+c&ic 'att&rn in adult =I i not non. Sinc& ,+'&rgl+c&ia i attri*ut&d to a tr& r&'on&

fro t,& initial injur+775D and *lood gluco& l&&l ar& non to incr&a& und&r an&t,&ia

&&n in non-dia*&tic 'ati&nt91D it i 'oi*l& t,at add&d tr& during g&n&ral an&t,&ia and

urg&r+ a+ or&n ,+'&rgl+c&ia and contri*ut& to 'oor outco&. $or&o&r indiidual

an&t,&tic ag&nt ,a& *&&n ,on to ,a& diff&r&ntial &ff&ct on *lood and *rain gluco& l&&l.

9293D =,& onl+ '&rio'&rati& tud+ in c,ildr&n it, =I d&ontrat&d t,at intrao'&rati&

,+'&rgl+c&ia i coon ,+'ogl+c&ia in t,& a*&nc& of inulin tr&at&nt i not rar& and =I

&&rit+ and t,& 'r&&nc& of u*dural ,&atoa (S%6) 'r&dict intrao'&rati& ,+'&rgl+c&ia.73D

In t,& aut,orM &8'&ri&nc& in adult 'ati&nt und&rgoing cranioto+ for =I intrao'&rati&,+'&rgl+c&ia (gluco& K 200 g!dl) a coon (15E) and ,+'ogl+c&ia (gluco& F0

g!dl) a not o*&r&d (un'u*li,&d data). 4& alo found t,at t,& ind&'&nd&nt ri factor for

intrao'&rati& ,+'&rgl+c&ia &r& &&r& =I S%6 'r&o'&rati& ,+'&rgl+c&ia and ag& F5

+&ar and t,& in-,o'ital ortalit+ a ,ig,&r in 'ati&nt it, intrao'&rati& ,+'&rgl+c&ia.

Hi&n t,& curr&nt &id&nc& for gluco& control for =I in '&rio'&rati& '&riod a targ&t gluco&

rang& of 90190 g!dl && r&aona*l&.

=,&ra'&utic 6+'ot,&ria and St&roid

6+'ot,&ria r&duc& c&r&*ral &ta*oli during tr& r&duc& &8citator+ n&urotranitt&r

r&l&a& att&nuat& '&r&a*ilit+ and ,a *&&n u&d for *rain 'rot&ction in =I 'ati&nt for

d&cad&. 6o&&r clinical &id&nc& in t&r of ortalit+ and functional outco& i till

inconclui&. r&c&nt &ta-anal+i r&'ort&d tatiticall+ inignificant r&duction in ortalit+ and

incr&a&d faora*l& n&urological outco& it, ,+'ot,&ria in =I.9D =,& *&n&fit of

,+'ot,&ria &r& gr&at&r ,&n cooling a aintain&d for or& t,an 9 ,our *ut t,& 'ot&ntial

*&n&fit of ,+'ot,&ria a+ li&l+ *& off&t *+ a ignificant incr&a& in t,& ri of 'n&uonia.

9D =,&& o*&ration u''ort 'r&iou finding t,at ,+'ot,&ric t,&ra'+ contitut& a

*&n&ficial tr&at&nt of =I in '&cific circutanc&. ccordingl+ t,& =>!S guid&lin&

ta forc& ,a iu&d a L&&l III r&co&ndation for o'tional and cautiou u& of ,+'ot,&ria for

adult it, =I.D

St&roid ,a& not *&&n ,on to i'ro& outco& or lo&r IC# in =I.13D In fact findingfro a randoi?&d ultic&nt&r tud+ on t,& &ff&ct of corticot&roid ($AC CAS6 trail) ,o&d


9/15

t,at adinitration of &t,+l'r&dniolon& it,in 9 ,our of =I a aociat&d it, ,ig,&r ri

of d&at, and t,& ri of d&at, or &&r& dia*ilit+ a or& co'ar&d to 'lac&*o.95D =,&r&for&

t,& u& of ,ig,-do& &t,+l'r&dniolon& i contraindicat&d in 'ati&nt it, od&rat& or &&r&

=I.13D

S$$AG#&rio'&rati& '&riod a+ *& i'ortant in =I anag&&nt. 4,il& it a+ 'r&di'o& t,& 'ati&nt to

n& on&t &condar+ injuri& ,ic, a+ contri*ut& ad&r&l+ to outco& it i alo an

o''ortunit+ to d&t&ct and corr&ct t,& undiagno&d 'r&-&8iting &condar+ inult. It a+ alo *& a

'ot&ntial indo to initiat& int&r&ntion t,at a+ i'ro& t,& outco& of =I. 4,il& r&&arc,

focu&d '&cificall+ on t,& intrao'&rati& and '&rio'&rati& =I anag&&nt i aait&d clinical

anag&&nt ill continu& to *& *a&d on ',+iological o'tii?ation.

L&&l I r&co&ndation ar& *a&d on t,& trong&t &id&nc& for &ff&cti&n& and r&'r&&nt

'rinci'l& of 'ati&nt anag&&nt t,at r&fl&ct ,ig, d&gr&& of clinical c&rtaint+. L&&l II

r&co&ndation r&fl&ct a od&rat& d&gr&& of clinical c&rtaint+. >or l&&l III r&co&ndation

t,& d&gr&& of clinical c&rtaint+ i not &ta*li,&d.

>ootnot&

Sourc& of Su''ort: il

Conflict of Int&r&t: on& d&clar&d.

A>ACS

1. >aul $ Nu L 4ald $$ Coronado /H. =rauatic *rain injur+ in t,& nit&d Stat&:

&rg&nc+ d&'art&nt iit ,o'itali?ation and d&at,. tlanta (H): C&nt&r for %i&a&

Control and #r&&ntion ational C&nt&r for Injur+ #r&&ntion and Control; 2010.

2. ratton SL C,&tnut A$ H,ajar J $cConn&ll 6aond >> 6arri B 6artl& A &t al. rain

=raua >oundation; &rican ociation of &urological Surg&on; Congr& of &urologicalSurg&on; Joint S&ction on &urotraua and Critical Car& S!CS. Huid&lin& for t,&

anag&&nt of &&r& trauatic *rain injur+ lood 'r&ur& and o8+g&nation. J &urotraua.

2007;2:S713. #u*$&d: 175115"D

3. ratton SL C,&tnut A$ H,ajar J $cConn&ll 6aond >> 6arri B 6artl& A &t al. rain

=raua >oundation; &rican ociation of &urological Surg&on; Congr& of &urological

Surg&on; Joint S&ction on &urotraua and Critical Car& S!CS. Huid&lin& for t,&

anag&&nt of &&r& trauatic *rain injur+ II. 6+'&roolar t,&ra'+. J &urotraua.

2007;2:S120. #u*$&d: 1751153"D

. ratton SL C,&tnut A$ H,ajar J $cConn&ll 6aond >> 6arri B 6artl A &t al. rain



anag&&nt of &&r& trauatic *rain injur+ III #ro',+lactic ,+'ot,&ria. J &urotraua.

2007;2:S215. #u*$&d: 1751150D

5. ratton SL C,&tnut A$ H,ajar J $cConn&ll 6aond >> 6arri B 6artl A &t al. rain



anag&&nt of &&r& trauatic *rain injur+. /I. Indication for intracranial 'r&ur& onitoring.

J &urotraua. 2007;2:S37. #u*$&d: 175115D

F. ratton SL C,&tnut A$ H,ajar J $cConn&ll 6aond >> 6arri B 6artl A &t al. rain=raua >oundation; &rican ociation of &urological Surg&on; Congr& of &urological


10/15


anag&&nt of &&r& trauatic *rain injur+. /II. Intracranial 'r&ur& onitoring t&c,nolog+. J

&urotraua. 2007;2:S55. #u*$&d: 1751155D


=raua >oundation; &rican ociation of &urological Surg&on; Congr& of &urologicalSurg&on; Joint S&ction on &urotraua and Critical Car& S!CS. Huid&lin& for t,&

anag&&nt of &&r& trauatic *rain injur+. /III. Intracranial 'r&ur& t,r&,old. J

&urotraua. 2007;2:S559. #u*$&d: 175115FD




anag&&nt of &&r& trauatic *rain injur+. IN. C&r&*ral '&rfuion t,r&,old. J &urotraua.

2007;2:S5"F. #u*$&d: 1751157D

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anag&&nt of &&r& trauatic *rain injur+. N. rain o8+g&n onitoring and t,r&,old. J

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2007;2:S93F. #u*$&d: 17511552D




anag&&nt of &&r& trauatic *rain injur+. NI/. 6+'&r&ntilation. J &urotraua.

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1. Hr&& $4 Oin J. #at,o',+iolog+ of trauatic *rain injur+. $t Sinai J $&d. 200";7F:"7

10. #u*$&d: 1"30F37"D

15. 4&rn&r C ng&l,ard @. #at,o',+iolog+ of trauatic *rain injur+. r J na&t,. 2007;"":".

#u*$&d: 175733"2D

1F. C,&nut A$ $ar,all L> @lau*&r $A lunt aldin i&n*&rg 6$ &t al. =,& rol&of &condar+ *rain injur+ in d&t&rining outco& fro &&r& ,&ad injur+. J =raua.


11/15

1""3;3:21F22. #u*$&d: 95"59D

17. $ar,all L> &c&r %# o&r S Ca+ard C i&n*&rg 6 Hro CA &t al. =,& ational

=rauatic Coa %ata an. #art 1: %&ign 'ur'o& goal and r&ult. J &urourg.

1"93;5":27F9. #u*$&d: F35729D

19. $c6ug, HS ng&l %C utc,&r I St&+&r*&rg 4 Lu J $u,udiani &t al. #rognoticalu& of &condar+ inult in trauatic *rain injur+: A&ult fro t,& I$#C= tud+. J

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management perioperatif pada pasien trauma brain injury

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