ANESTHESIOLOGY

CLINICAL NEUROANESTHESIA
Anna Lea L. Enriquez, M.D., DBPA, FPSA
First Loop | August 18, 2020

TABLE OF CONTENTS
■ Reflects how much the cerebral
I. Review of Basics blood vessels can vasoconstrict or
A. Cerebral Metabolic Rate for O2
B. Cerebral Metabolic Rate for glucose vasodilate
C. Cerebral Blood Flow
D. Monroe Kellie Hypothesis ○ Among these 3 concepts, CPP is more
E. Regulation of cerebral blood flow important since it’s the one which will be able
to deliver a molecule of oxygen and glucose
Review of the basics into a neuron.
● Cerebral Perfusion Pressure = MAP - ICP
● Brain is highly dependent on 2 substrates
○ Oxygen ○ NV: 60 - 80 mmHg
○ Glucose ○ Mean arterial pressure
● The brain cannot manufacture and store large amounts ■ The sum of the ⅓ of systolic and ⅔
of these 2 substance of diastolic pressure
○ Intracranial pressure
○ Have to be constantly delivered in large
amounts ■ The pressure inside the cranium
■ NV: 10 - 15 mmHg
○ An increase in intracranial pressure, the CPP
Cerebral Metabolic Rate for O2 (CMRO2)
suffers → will increase blood pressure to try
● How much oxygen the brain demands is reflected as
to maintain a good CPP
CMRO2
○ Cushing’s Triad of ICP
● Awake young adults
■ Hypertension
○ 3.5 ml O2/100g/min
■ Bradycardia
○ 20% of O2 of the body at rest
■ Abnormal patterns of respiration
● Children
● Secondary to the
○ 5.2 ml O2/100g/min
compression of brainstem
○ This is because the child’s brain is still
in the posterior fossa
developing and needs additional oxygen
during the process of anatomic and
Monro-Kellie Hypothesis
physiologic development
● Brain: 80%, 1400 ml
○ Cerebral hypoxia happens earlier/faster than
that of an adult ● Blood: 10%, 150 ml
■ Do not hesitate to oxygenate a child ● CSF: 10%, 150 ml
● The skull is a rigid structure
who goes into hypoxia because you
are thinking of the cerebral ● When there is an abnormal increase in one of the
protection of your patient. components, there is a compensatory accommodation
from the other two
● There will come a time when no further compensation
Cerebral Metabolic Rate for glucose (CMRglu)
will happen → manifest signs of increased ICP
● The brain’s glucose requirement is reflected as
● Important to maintain normal ICP
CRMglu
● Among the 3, blood is the component we can initial
● 5.5 mg glucose/100g/min
regulate to control the increasing ICP
● 25% of glucose consumption at rest
Regulation of Cerebral Blood Flow
Cerebral Blood Flow
● Adults: 45 - 50 ml/100g/min
1. Autoregulation
● Children: 95 ml/100g/min
○ Reflects that children have a higher oxygen ● Process by which the cerebral blood flow is maintained
and glucose demand relatively constant to ensure consistent delivery of
oxygen and glucose

● Comparison of the different organ systems and their

blood flow
● Relative to its mass, the brain receives a lot of blood
flow. ● MAP of 50 - 150
● Cerebral Blood Flow = CPP/CVR ○ Depicts that your brain will receive 50 ml of
○ Cerebral Perfusion Pressure blood flow/100g/min
■ Net pressure gradient that drives
oxygen and glucose delivery to the
brain tissue
○ Cerebral Vascular Resistance

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ANESTHESIOLOGY
● In chronically HTN patients → shift to the right
○ Used to higher perfusion pressures
○ Do not bring down to normotensive levels →
They will manifest signs of poor cerebral
perfusion
Irreversible Brain Damage
● Focal Ischemia: 30 - 60 mins
○ Eg: Stroke
○ Need to bring to hospital within the golden
hour to establish the diagnosis and institute
proper treatment.
○ If not → poorer outcomes and irreversible
brain damage
● Global ischemia: 4 - 6 mins
○ Eg: Cardiac arrest
○ Important to immediately institute high quality
chest compressions
○ If not → revived the heart and got normal
sinus rhythm but the brain has been damaged
and the patient is in a vegetative state for life
● During a focal ischemic event, 3 regions in the brain
have been identified
○ Core
■ Central, infarcted area
■ No longer receives any blood flow
○ Penumbra
■ Ischemic area
■ Can be still receiving collateral blood
flow
■ Target of management in stroke
patients.
■ Salvageable neurons that can still be
brought back to their normal function
- Neuroresuscitation
○ Normal brain tissue
■ Prevent ischemia or infarct in these
normal areas - Neuroprotection
2. Flow - Metabolism Coupling
● Decrease in metabolism → Decrease in blood flow
○ Eg: Sleep states, under general anesthesia
● Increase in metabolism → Increase in blood flow
○ Eg: Awake state, seizures
3. Oxygen
● Normal and Hyperoxia
○ Minimal CBF changes
● PaO2 <50 mmHg
○ Increased CBF in the hope of delivering more
oxygen
○ Initially good, but later on too much blood flow
to the brain → cerebral edema and
concomitant increase in ICP
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CLINICAL NEUROANESTHESIA
4. Carbon Dioxide
● Hypercapnia causes cerebral vasodilation which will
increase CBF → cerebral edema and increased ICP
● Excessive hyperventilation (blowing off of CO2) causes
vasoconstriction which will decrease CBF → infarct
● For every increase or decrease in PaCO2 by 1mmHg,
there is a corresponding increase or decrease in CBF
by 2 - 4%
○ PaCO2 is arterial CO2 level
● Normocapnia: 35 - 45 mmHg
● Mild hypocapnia: 30 - 35 mmHg
○ Can be instituted to manage increased ICP
○ Below 30 → cerebral infarct
○ CO2 is also the drive to breathe
5. Rheology
● Hemodilution → Increased blood flow
● Hemoconcentration → Decreased blood flow
● Hct of 47% is associated with a significantly reduced
cerebral blood flow
○ Lowering the hct to physiologic range by
volume expansion increases cerebral blood
flow (hemodilution)
6. Temperature
● Hypothermia → decreased basal metabolism →
decreased O2 demand
○ Basis for the utilization of hypothermia during
neuroprotection
● Core temperature
○ Normothermia: 36.5 - 38.5C
○ Mild hypothermia: 33 - 36C
■ Recommended core temperature for
cerebral protection
○ Moderate hypothermia: 28 - 32C
○ Deep hypothermia: 16 - 27C
○ Profound hypothermia: 5 - 15C
○ Ultraprofound hypothermia: <5C
● Complications of hypothermia
○ CV depression - hypotension
○ Arrhythmias - tachy/brady arrhythmias
○ Immunosuppression - infection
○ Coagulopathy - bleeding problems
○ Prolonged drug clearance results to delayed
awakening from anesthesia
○ Shivering - increases O2 demand by 400 -
500%
● Hyperthermia
○ Increase in temperature → increased
metabolism → increased cerebral blood flow
→ increased intracranial pressure
● Recommendation: Maintain euthermia and
aggressively cool a core temperature that rises higher
than 37 degrees celsius
● Brain temperature measurements not routinely done:
○ Brain Tissue
○ Intraventricular areas
○ Epidural areas
● Brain temperature measurements that are usually
done because of their anatomic proximity to the brain:
○ Tympanic membrane
○ Nasopharyngeal
7. Neurogenic Factors
● Catecholamines have various roles like
vasoconstriction and vasodilation
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ANESTHESIOLOGY CLINICAL NEUROANESTHESIA

● Systemic catecholamines have little direct effect in ● Elevate the patient’s head by 30 degrees to allow
cerebral metabolism provided that the blood brain venous drainage without compromising the cerebral
barrier is intact perfusion
● Keep head in the midline
Blood Glucose ● Avoid circumferential neck tapes of the endotracheal
● Hypoglycemia causes seizures leading to neuronal tube to prevent compression of the jugular veins
injury
● Hyperglycemia causes lactic acidosis leading to Ideal Anesthetic Agent
cerebral edema ● Should not be a drug that causes an increase in
○ Can also cause a decrease in adenosine cerebral blood flow
levels and an increase in excitatory amino ○ Will only lead to cerebral edema and further
acids increase in intracranial pressure
○ The ideal IV fluid for patients with cerebral ● Should not increase demand for oxygen or cerebral
edema or increased ICP are non-dextrose metabolic rate for oxygen (CMRO2)
containing IV fluids ● Should not increase ICP
○ Blood sugar levels should be strictly ● Should preserve autoregulation
monitored Should preserve carbon dioxide reactivity
■ Non-Diabetic: 80-150 mg/dL
■ Diabetic: 150-200 mg/dL Commonly Used IV Agents in Anesthesia
● All may be safely used in patients with increased ICP
Serum Osmolarity except Ketamine
● Important when managing cerebral edema and ○ Increases CBF → increased demand for
increased ICP oxygen → increased ICP
● Water and hypotonic solutions are not advocated in ○ Triggers seizure attacks in susceptible
these patients patients
○ Decrease serum osmolarity leading to further ● Thiopental Sodium
cerebral edema ○ Ultrashort acting barbiturate
○ Choose a fluid closest to the normal serum ○ Indications:
osmolarity to prevent fluid shift to the brain: ■ IV induction of a patient about to
■ Plain 0.9 NaCl with an osmolarity undergo general anesthesia
of 308 mOsm/L ■ Provide state of general anesthesia
■ Normal serum osmolarity: 285-290 for short procedures
mOsm/L ■ ICU sedation in patients struggling
● Lactated Ringers Solution (LRS) against the ventilator
○ Quite close to the normal serum osmolarity, ■ Management of seizures (ani-
however, it becomes slightly hypotonic inside convulsant)
the body ■ State of barbiturate comatose for
■ Calculated osmolarity: 275 mOsm/L cerebral protection
■ Measures osmolarity inside the ● Propofol
body: 254 mOsm/L ○ Newer sedative hypnotic
● Use this fluid at a limited ○ Same indications as Thiopental
amount ○ Drug-induced comatose for cerebral
● First choice would still be protection
isotonic solutions or ● Midazolam
plain normal saline ○ Benzodiazepine
○ Ideal choice for preoperative medication to
Mannitol alleviate anxiety or fear of patients about to
● Gold standard pharmacologic treatment for patients undergo surgery
with cerebral edema or increased intracranial pressure ○ Provides anterograde amnesia
● Classified as an osmotic diuretic and is a hypertonic ○ Anticonvulsant
solution
○ Draws water from the brain to be diuresed
from the patient
● Decrease edema, decreases ICP, improves cerebral
perfusion pressure (CPP), scavenges free radicals and
decreases infarct size

Goals of Neuroanesthesiologists
● Prevent hypoxemia
○ Oxygen is a major substrate that is needed by
the brain
● Maintain normocapnia at 35-45 mmHg
● Keep patients euthermic
● Maintain appropriate blood glucose levels
● Provide adequate cerebral perfusion
● Maintain isovolemia, isotonicity, and isooncoticity

What can one additionally do?

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ANESTHESIOLOGY CLINICAL NEUROANESTHESIA

Opioid Analgesics
● May be safely used with caution
● Side effects:
○ Respiratory depression → hypoxemia and
CO2 retention

Neuromuscular Blockers
● Non-depolarizing muscle relaxants are the better
choice because they have no significant effects on
cerebral dynamics
● Succinylcholine
○ Causes minimal and transient increase in
ICP

Inhalational Anesthetics
● All inhalational anesthetics cause cerebral vasodilation
→ increase in cerebral blood flow → increased ICP
○ There is a limit to the minimum alveolar
concentration (MAC) we are allowed to
deliver
● CMRO2 decreases due to the induced sleep state
● Autoregulation is impaired and CO2 reactivity is
preserved
● Sevoflurane is the safest

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Sleep peacefully~

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