Anesthetic approach in pediatric brain injury

Traumatic brain injury (TBI) is defined as an insult to the brain resulting from external force, leading alteration in brain function, permanent or temporary impaired cognition, wide-spread impairments in motor and behavior function. TBI is not only a leading cause of death but it is a significant contributor to disability in pediatric age group. Its sequelae is an important health problem throughout the world. The patients face numerous difficulties to return to a productive life. Improvements in the prognosis continue with its elucidated pathophysiology, technological developments in its monitorization, and sustained scientific research. In 2003, the Society of Critical Care Medicine published the Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolecents and updated the guidelines in 2012 with some significant changes. Pediatric anesthesiologists are frequently faced with the perioperative management of such patients. This article reviews pathophysiology, anesthetic management, hemodynamic support, management of intracranial hypertension of pediatric patients with TBI in the light of current evidence-based medicine. Informing the anesthetists confronting TBI patients in the intensive care unit, during preoperative and peri-operative periods, about important issues related to pathophysiology and treatment of TBI will contribute to the improvements in the prognosis of these patients.

Keywords:

General anesthesia Neuroanesthesia, Pediatric brain injury, Pediatric neurotrauma,

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Albanese, J., Vividand, X., Potie, F., Rey, M., Alliez, B., Martin, C., 1999. Sufentanil, fentanyl, and alfentanil in head trauma patients: A study on cerebral hemodynamics. Crit. Care Med. 27, 407-411.
Annane, D., 2005. Icu physicians should abandon the use of etomidate Intensive Care Med. 31, 325-326.
Bar-Joseph, G., Guilburd, Y., Tamir, A., Guilburd, J.N., 2009. Effectiveness of ketamine in decreasing intracranial pressure in children with intracranial hypertension. J. Neurosurg. Pediatr. 4, 40-46.
Bell, M.J., Kochanek, P.M., 2013. Pediatric traumatic brain injury in 2012: The year with new guidelines and common data elements. Crit. Care Clin. 29, 223-238. doi: 10.1016/j.ccc.2012.11.004.
Bhalla, T., Dewhirst, E., Dewhirst, Sawardekar, A., Dairo, O., Tobias, J. D., 2012. Perioperative management of the pediatric patient with traumatic brain injury. Paediatr Anaesth. 22, 627-640. doi:10.1111/j.1460-9592.2012.03842.x.
Brussel, T., Theissen, J. L., Vigfusson, G., Lunkenheimer, P. P., Van Aken, H., Lawin, P., 1989. Hemodynamic and cardiodynamic effects of propofol and etomidate: Negative inotropic properties of propofol. Anesth. Analg. 69, 35-40.
Chesnut, R.M., Marshall, L.F., Klauber, M.R., Blunt, B.A., Baldwin, N., Eisenberg, H.M., Jane, J.A., Marmarou, A., Foulkes, M.A., 1993. The role of secondary brain injury in determining outcome from severe head injury. J. Trauma 34, 216-222.
Davis, D.P., Koprowicz, K.M., Newgard, C.D., Daya, M., Bulger, E.M., Stiell, I., Nichol, G., Stephens, S., Dreyer, J., Minei, J., Kerby, J.D., 2011. The relationship between out-of-hospital airway management and outcome among trauma patients with glasgow coma scale scores of 8 or Less. Prehosp. Emerg. Care. 15, 184-192. doi: 10.3109/10903127.2010.545473.
Davis, D.P., Peay, J., Sise, M.J., Kennedy, F., Simon, F., Tominaga, G., Steele, J., Coimbra, R., 2010. Prehospital airway and ventilation management: A trauma score and injury severity score-based analysis. J. Trauma. 69, 294-301. doi: 10.1097/TA.0b013e3181dc6c7f.
Dickman, C.A. Rekate, H.L., 1992. Pediatric spinal trauma. In pediatric trauma, Prevention, Acute Care, Rehabilitation, edited by Eichelberger MH. 362-377.
Fisher, B., Thomas, D., Peterson, B., 1992. Hypertonic saline lowers raised intracranial pressure in children after head trauma. J. Neurosurg Anesthesiol. 4, 4-10.
Gausche, M., Lewis, R.J., Stratton, S.J., Haynes, B.E., Gunter, C.S., Goodrich, S.M., Poore, P.D., McCollough, M.D., Henderson, D.P., Pratt, F.D., Seidel, J.S., 2000. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: A controlled clinical trial. JAMA. 283, 783-790.
Greve, M.W., Zink, B.J., 2009. Pathophysiology of traumatic brain injury. Mt. Sinai. J. Med. 76, 97-104.
Hardcastle, N., Benzon, H.A., Vavilala, M.S., 2014. Update on the 2012 guidelines for the management of pediatric traumatic brain injury -information for the anesthesiologist. Pediatric Anesthesia 24, 703-710.
Hulke, D.F., 1998. An overview of anatomical considerations of infants and children in the adult world of automobile safety design. Annu Proc Assoc. Adv. Automot. Med. 42, 93-113.
Myburgh, J., Cooper, D.J., Finfer, S., Bellomo, R., Norton, R., Bishop, N., Kai Lo, S., and S. Vallance Investigators, S. S., Australian, G. New Zealand Intensive Care Society Clinical Trials, S. Australian Red Cross Blood, H. George Institute for International. 2007. Saline or albumin for fluid resuscitation in patients with traumatic brain injury. N. Engl. J. Med. 357, 874-884.
Kasoff, S.S., Lansen, T.A., Holder, D., Filippo, J.S., 1988. Aggressive physiologic monitoring of pediatric head trauma patients with elevated intracranial pressure. Pediatr. Neurosci. 14, 241-249.
Melo, J.R., Di Rocco, F., Blanot, S., Cuttaree, H., Sainte-Rose, C., Olveira-Filho, J., Zerah, M., Meyer, P.G., 2011. Transcranial doppler can predict intracranial hypertension in children with severe traumatic brain injuries. Childs Nerv. Syst. 27, 979-984. doi 10.1007/s00381-010- 1367-8.
Myburgh, J., Cooper, D.J., Finfer, S., Bellomo, R., Norton, R., Bishop, N., Kai Lo, S., and S. Vallance Investigators, S. S., Australian, G. New Zealand Intensive Care Society Clinical Trials, S. Australian Red Cross Blood, H. George institute for international. 2007. Saline or albumin for fluid resuscitation in patients with traumatic brain injury. N. Engl. J. Med. 357, 874-884.
Ng, I., Lim, J., Wong, H.B., 2004. Effects of head posture on cerebral hemodynamics: Its influences on intracranial pressure, cerebral perfusion pressure, and cerebral oxygenation. Neurosurgery. 54, 593-597.
Peterson, B., Khanna, S., Fisher, B., Marshall, L., 2000. Prolonged hypernatremia controls elevated intracranial pressure in head-injured pediatric patients. Crit. Care Med. 28, 1136-1143.
Robinson, N., Clancy, M., 2001. In patients with head injury undergoing rapid sequence intubation, does pretreatment with intravenous lignocaine/lidocaine lead to an improved neurological outcome? A review of the literature. Emerg. Med. J. 18, 453-457.
Rovlias, A., Kotsou, S., 2000. The influence of hyperglycemia on neurological outcome in patients with severe head injury. Neurosurgery 46, 2, 335-342.
Schneier, A.J., Shields, B.J., Hostetler, S.G., Xiang, H., Smith, G.A., 2006. Incidence of pediatric traumatic brain injury and associated hospital resource utilization in the United States. Pediatrics. 118, 483-492.
Segal, S., Gallagher, A.C., Shefler, A.G., Crawford, S., Richards, P., 2001. Survey of the use of intracranial pressure monitoring in children in the United Kingdom. Intensive Care Med. 27, 236-239.
Sharma, D., Jelacic, J., Chennuri, R., Chaiwat, O., Chandler, W., Vavilala, M.S., 2009. Incidence and risk factors for perioperative hyperglycemia in children with traumatic brain injury. Anesth. Analg. 108, 81-89.
Simma, B., Burger, R., Falk, M., Sacher, P., Fanconi, S., 1998. A prospective, randomized, and controlled study of fluid management in children with severe head injury: Lactated Ringer’s solution versus hypertonic saline. Crit. Care Med. 26, 1265-1270.
Smith, R.L., Lin, J.C., Adelson, P.D., Kochanek, P.M., Fink, E.L., Wisniewski, S.R., Bayir, H., Tyler-Kabara, E.C., Clark, R.S., Brown, S.D., Bell, M.J., 2012. Relationship between hyperglycemia and outcome in children with severe traumatic brain injury. Pediatr. Crit. Care Med. 13, 85-91.
Soriano, S.G., Eldredge, E.A., Rockoff, M.A., 2002. Pediatric neuroanesthesia. Anesthesiol Clin. North America. 20, 389-404.
Takeshita, H., Okuda, Y., Sari, A., 1972. The effects of ketamine on cerebral circulation and metabolism in man. Anesthesiology. 36, 69-75.
Tobias, J.D., 1996. Airway management for pediatric emergencies. Pediatr. Ann. 25, 317-320, 323-328.
Tobias, J.D., 2000. Etomidate: Applications in pediatric critical care and pediatric anesthesiology. Pediatr. Crit. Care Med. 1, 100-106.
Tritapepe, L., Voci, P., Marino, P., Cogliati, A.A., Rossi, A., Bottari, B., Di Marco, P., Menichetti, A., 1999. Calcium chloride minimizes the hemodynamic effects of propofol in patients undergoing coronary artery bypass grafting. J. Cardiothorac. Vasc. Anesth. 13, 150-153.
Vavilala Monica, S., Chesnut, R., 2008. Anesthetic considerations for pediatric neurotrauma. In essentials of neuroanesthesia and neurointensive Care, Ed by Arun, K., Gupta and Adrian, W., Gelb. 192-201. United States: Elsevier.
Werner, C., Engelhard, K., 2007. Pathophysiology of traumatic brain injury. Br. J. Anaesth. 99, 4-9.
Williams, E. L., Hildebrand, K.L., McCormick, S.A., Bedel, M.J., 1999. The effect of intravenous lactated ringer’s solution versus 0.9% sodium chloride solution on serum osmolality in human volunteers. Anesth. Analg. 88, 999-1003.
Wing, R., James, C., 2013. Pediatric head injury and concussion. Emerg. Med. Clin. North Am. 31, 653-675. doi: 10.1016/j.emc.2013.05.007.