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CONFERENCIAS MAGISTRALES Vol. 35. Supl. 1 Abril-Junio 2012 pp S283-S291

El neuroanestesilogo ocasional-siete preguntas que hacerse para tener xito en neuroanestesia

Adrian W. Gelb*
* Professor. Dept Anesthesia & Perioperative Care. University of California San Francisco gelba1@anesthesia.ucsf.edu UCSF. Department of Anesthesia and Perioperative Care

PREGUNTAS QU HACER ANTES DE EMPEZAR QUESTIONS TO ASK BEFORE YOU START Cul es el diagnstico y cul es la ciruga? Whats the diagnosis and what operation? En qu posicin estar el paciente? What position will the patient be in? Cul ser la prdida sangunea? How much blood loss will there be? Cree qu se producir algn tipo de isquemia? Do you anticipate any ischemia? Dispondr de neuromonitorizacin? La presin intracraneal, est elevada? Is the ICP elevated? A qu unidad ir el paciente tras la ciruga? Where will the patient go afterwards? UCSF Department of Anesthesia and Perioperative Care Cul es el diagnstico? Qu intervencin quirrgica se har al paciente? Whats the diagnosis? What operation?

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UCSF Department of Anesthesia and Perioperative Care

Este artculo puede ser consultado en versin completa en http://www.medigraphic.com/rma

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HEMATOMA SUBDURAL AGUDO ACUTE SUBDURAL HEMATOMA Inicio rpido Rapid onset Compresin del cerebro Brain compression Edema cerebral Cerebral edema Viene entubado = Dejar entubado Come intubated = Leave intubated

CUL ES LA CIRUGA? WHAT OPERATION? Gupta & Gelb Essentials of Neuroanesthesia Elsevier 2008

HEMATOMA SUBDURAL CRNICO CHRONIC SUBDURAL HEMATOMA Inicio lento Sin edema Compresin leve Atroa cerebral Slow onset No edema Little compression Brain atrophy

EN QU POSICIN ESTAR EL PACIENTE? WHAT POSITION WILL THE PATIENT BE IN? UCSF Department of Anesthesia and Perioperative Care Gupta & Gelb Essentials of Neuroanesthesia Elsevier 2008

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COLOCACIN DEL PACIENTE POSITIONING Complicaciones: Complications: Cambios ventilatorios y hemodinmicos Ventilatory & Hemodynamic Changes Prdida de las vas respiratorias, monitores, catteres Loss of airway, monitors, catheters Embolismo de aire venoso Venous air embolism Dao a los ojos, nariz, oreja Injury to eyes, nose, ear Lesin neurovascular Injury to neurovascular bundle

Baje el hombro con su mano y luego asegrelo con cinta adhesiva Depress shoulder then apply tape Cojn axilar Axillary roll Demasiada exin/rotacin?

Asegrese que la lengua est dentro de la boca Ensure tongue is in the mouth

Cunta sangre cree que perder el paciente? How much blood loss will there be?

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Dowd C Neurosurg Focus 2003; 15:10 Cree que se producir algn tipo de isquemia? Do you anticipate any ischemia? Meningioma UCSF Department of Anesthesia and Perioperative Care No hay un buen estudio en humanos que demuestre que los anestsicos son protectores cerebrales There are no good human studies showing that anesthetics are cerebral protectants !!!!! UN MENINGIOMA MUY VASCULARIZADO A VERY VASCULAR MENINGIOMA
Database search MEDLINE EMBASE PubMED Central 5,904 1,983 1,914 1,009 998

Irrelevant

5,872

Irrelevant Not RCT Observational study Post-hoc analysis Non pharmacological study Pre and postoperative evaluation not consistent

Included trials Lidocaine S(+) ketamine Nimodipine GM1 Ganglioside Glut/asp Remacemide (NMDA antagonist) Erythropoietin Rivastigmine (cholinergic) 17-estradiol 4 2 2 1 1 1 1

25 2 2 2 1 1 1 1 1

Thiopental Propofol Magnesium sulfate Lexipafant (anti PAF) Xenon Atorvastatin Piracetam (GABA analogue)

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Pergorgotein (anti-ox)

EMBOLIZACIN DE MENINGIOMA MENINGIOMA & EMBOLIZATION

La mayor parte de los estudios son en ciruga cardaca Most studies in cardiac surgery Bilotta F, Gelb AW et al unpublished meta-analysis

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METODOLOGA INCONSISTENTE INCONSISTENT METHODOLOGIES Totales asignados al azar: 3,274 pacientes, de cualquier sexo Total randomized: 3,274 patients, either sex Los pacientes por ensayo: 20 a 350 (8 estudios de menos de 100 sujetos) Patients per trial: 20 to 350 (8 studies < 100 subjects) Edad: 22-86 aos Ages: 22-86 yrs

DISPONDR DE ALGN TIPO DE NEUROMONITORIZACIN? WILL THERE BE ANY NEUROMONITORING? UCSF Department of Anesthesia and Perioperative Care LA MAYORA DE OCASIONES SE EMPLEAN EN CIRUGA DE COLUMNA Y CIRUGA VASCULAR MOST FREQUENTLY USED FOR SPINE SURGERY & VASCULAR SURGERY

Duracin del seguimiento: 5-60 das 11 estudios de ms de 2 meses Duration of follow-up: 5-60 days 11 studies > 2 months Tratamiento de inicio: Antes de la operacin, durante o despus induccin Treatment start: Preoperatively, at or after induction Bilotta F, Gelb AW et al unpublished meta-analysis Resultados & Frmacos protectores en IHAST Outcome & Protective drugs in IHAST
Good outcome 24 hours Temperature Normothermia Hypothermia 3 Month Normothermia Hypothermia Supplemental protective drug Protective drug No protective drug Protective drug No protective drug Protective drug No protective drug Protective drug No protective drug All clip Durations 59% 54% 54% 55% 65% 63% 58% 65%
Carotid tenosis

Hindman BJ Anesthesiology 2010; 112: 86.

UCSF Department of Anesthesia and Perioperative Care Modelos multivariantes (Multivariate models)
Resultados (outcome) Buen resultado (sin deterioro neurolgico a las 24 horas despus de la ciruga) Good outcome (no neurologic deterioration at 24 h after surgery) Las variables p-valor p Value 0.504 0.894 0.016

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Hindman BJ. Anesthesiology 2010; 112: 86

Temperatura (Temperature) (hypothermia vs normothermia) Droga de proteccin suplementaria Supplemental protective drug (drug vs none) Duracin del clip temporal Temporary clip duration ( 20 min, 11-19 min vs 10 min)

UCSF Department of Anesthesia and Perioperative Care

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EFECTO DE LOS ANESTSICOS SOBRE LA PIC ANESTHETIC EFFECTS ON INTRACRANIAL PRESSURE

80 Percent change in ICP 40

Desurane Isourane Sevourane

0 -40 -80 Propofol Barbituates

P Patel

Este documento es elaborado por Medigraphic

AYUDA LA HIPERVENTILACIN EN CRANEOTOMA ELECTIVA? DOES HYPERVENTILATION HELP IN ELECTIVE CRANI? Neuromonitorizacin Electromiografa (EMG) Electroencefalografa (EEG) Potenciales evocados somatosensoriales (PESS) Potenciales evocados motores (PEM) UCSF Department of Anesthesia and Perioperative Care EST LA PIC ELEVADA? IS THE ICP ELEVATED?

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UCSF Department of Anesthesia and Perioperative Care

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265 PATIENTS WITH BRAIN TUMOR UNDERGOING ELECTIVE CRANIOTOMY

Propofol (n = 131)

Isourane (n = 134)

Hyperventilation
Brain bulk assessment = 68 ICP measurement = 62

Normoventilation
Brain bulk assessment = 63 ICP measurement = 56

Hyperventilation
Brain bulk assessment = 66 ICP measurement = 60

Normoventilation
Brain bulk assessment = 68 ICP measurement = 65

Normoventilation
Brain bulk assessment = 68 ICP measurement = 61

Hyperventilation
Brain bulk assessment = 63 ICP measurement = 54

Normoventilation
Brain bulk assessment = 66 ICP measurement = 56

Hyperventilation
Brain bulk assessment = 66 ICP measurement = 56

Gelb AW et al Anesth Analg 2008; 106: 585.

PIC & HIPERVENTILACIN PaCO2 38 PaCO2 28

CIRUJANO EVALA LAS CONDICIONES OPERATORIAS SURGEON ASSESSMENT OF OPERATING CONDITION

Normoventilation

28

20

13

Hyperventilation

14

28

15

11

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0

20

40 60 80 Percentage of patients

100

Excellent/good Poor/needs treatment

Gelb AW et al Anesth Analg 2008; 106: 585.

Gelb AW, Rao U, Dash HH, Chan M et al Anesth Analg 2008; 106: 585

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VOLUMEN DE SANGRE CEREBRAL HIPERVENTILACIN REDUCE EL FSC

CO2 Wrong choice [n] 1.6 1.4 1.2 1 0.8 0.6 0.4

MEMORIA EXPLCITA EXPLICIT MEMORY

CBF

Veins

15%

60%

VOLUMEN DEL CEREBRO ISQUMICO ISCHEMIC BRAIN VOLUME IN TBI OR VOLUME OF ISCHEMIC BRAIN
160 140 120 IBV(mL) 100 80 60 40 20 0 PaCO2(mmHg) n = 18

0.2 0
-3 OP 3 6 9 12 15 18

Normoventilation: PaCO2 38-42 mmHg; n = 10 Hyperventilation: PaCO2 28-32 mmHg; n = 11

Eberspacher E, Gelb AW et al. Anesth Analg 2010; 110: 181.

REA DE CEREBRO LESIONADO

12 10 8 6 4 2 36 29 0
0 2 4 6 8 10 12 Distance from zero-point (mm) Eberspacher E, Gelb AW et al. Anesth Analg 2010; 110: 181.

Coles JP. Crit Care Med 2007; 35: 568.

RESULTADO A LOS 21 DAS DE LA EVALUACIN NEUROCOGNITIVA EN RATAS SOMETIDAS A HIPERVENTILACIN (PaCO2 40 vs 30) DURANTE 4 HORAS DESPUS DE TBI

HIPERVENTILACIN CONCLUSIONES: HYPERVENTILATION CONCLUSIONS: Debera usarse slo bajo indicacin especca Should have specic indication

www.medigraphic.org.mx La respuesta debe ser monitorizada

Response should be monitored Hay que estar pendiente de posibles complicaciones Be aware of potential complications Gelb AW, Lin N. Revista colombiana 2012.

21 day neurocognitive outcome in rats hyperventilated (PaCO2 40 vs 30) for 4 hours after TBI

Eberspacher E, Gelb AW et al. Anesth Analg 2010; 110: 181.

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CMO PODEMOS REDUCIR EL TAMAO DEL CEREBRO? HOW CAN WE SHRINK THE BRAIN?

PIC INCREMENTADA/AUMENTADA DE MANERA AGUDA ICP ACUTELY INCREASED Margen de seguridad Margin of safety Propofol Sevo + Iso + Des + Hal + Evitar N2O Avoid CO2 CO2 CO2 CO2

MEDIDAS DE CONTROL DEL CEREBRO HIPERTENSO Pressures Airway PaO2, PaCO2 Arterial, venous CSF

A QU UNIDAD IR EL PACIENTE DESPUS DE LA CIRUGA? WHERE WILL THE PATIENT GO AFTERWARDS? Extubated to PACU Awake, maintains airway, responds Intubated to ICU ETT secured, transport monitoring, sedation

Position M Mannitol Masses (Blood, air, edema) Metabolism Volatile, N2O Nipride, Ca+ blocker

UCSF Department of Anesthesia and Perioperative Care RECUPERACIN COMPLETA EN 30 MINUTOS FULL RECOVERY WITHIN 30 MINUTES Remifentanyl 57% Fentanyl 36%

Vasodilators

TRATAMIENTO DE LA HIPERTENSIN INTRACRANEAL TREATMENT OF INTRACRANIAL HYPERTENSION Rpido Fast Hyperventilation Thiopental Propofol Drain CSF Muscle relax Intermedio Intermediate Mannitol Furosemide Head up or BP Lento Slow Surgery Hypothermia Fluid Restrict

Full recovery = All recovery assessments, verbal commands and mental clarity p < 0.05 Gelb AW. Canad J Anesth 2003; 50: 946.

MUCHAS GRACIAS

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