Anesthesia and Intensive Care chair nr.

1 “Valeriu Ghereg”
Coordinator of Anesthesia and Intensive Care programs CUSIM
Svetlana Plamadeala, MD, PhD, associate professor

sveta_plam@yahoo.com
 OUR story…

…..Years ago……………………………………………
AM.
 COMA
BRAIN DEATH
 Primary survey

ABCDE approach:
A –airway and C-spine imobilisation
B – breathing
C – circulation
D – disability
E – exposure
A oropharyngeal tube in place
C-spine imobilisation
a lot of blood in the mouth

B RR- 27/min,
superficial ,
SpO2 88% room air

C BP 80/65 mmHg
HR 118 mmHg
CRT >3 sec

D GCS 6 p (O-1, V -1, P - 4)

OD>OS
Reflex S<D

E Multiple excoriotions on the chest

T=35.4° C
 ?
• Oxygen (high flow)
• Airway securisation (ET tube)
A oropharyngeal tube in place
C-spine imobilisation
a lot of blood in the mouth

B RR- 27/min,
superficial ,
SpO2 88% room air

C BP 80/65 mmHg
HR 118 mmHg
CRT >3 sec

D GCS 6 p (O-1, V -1, P - 4)

OD>OS
Reflex S<D

E Multiple excoriotions on the chest

T=35.4° C
• Volume replacement
• Cristaloid solutions
• NaCl 0.9% - the BEST
A oropharyngeal tube in place
C-spine imobilisation
a lot of blood in the mouth

B RR- 27/min,
superficial ,
SpO2 88% room air

C BP 80/65 mmHg
HR 118 mmHg
CRT >3 sec

D GCS 6 p (O-1, V -1, P - 4)

OD>OS
Reflex S<D

E Multiple excoriotions on the chest

T=35.4° C
 GLASGOW COMA SCALE
Eye opening
Spontaneous 4
To speech 3
To pain 2
None 1
Verbal response
Orientated 5
Confused conversation 4
Words (inappropriate) 3
Sounds (incomprehensible) 2
None 1
Motor response
Obey commands 6
Localize pain 5
Flexion normal 4
Flexion abnormal 3
Extend 2

None 1
 Causes

Organic Metabolic

• Head trauma • hypoxia

• Cerebral abscess • fluid and electrolyte disorders
• Cerebral tumors • endocrine abnormalities
• Cerebro-vascular diseases • endogenous toxins
• exogenous toxins
?
 Causes

Organic Metabolic

• Head trauma • hypoxia

• Cerebral abscess • fluid and electrolyte disorders
• Cerebral tumors • endocrine abnormalities
• Cerebro-vascular diseases • endogenous toxins
• exogenous toxins
A oropharyngeal tube in place
C-spine imobilisation
a lot of blood in the mouth

B RR- 27/min,
superficial ,
SpO2 88% room air

C BP 80/65 mmHg
HR 118 mmHg
CRT >3 sec

D GCS 6 p (O-1, V -1, P - 4)

OD>OS
Reflex S<D

E Multiple excoriotions on the chest

T=35.4° C
Pupillary size and reactivity
 OD>OS

• unilateral dilated pupil

• inferolateral eye deviation

• ptosis
 • subfalcine herniation

• lateral transtentorial herniation

• central transtentorial herniation

• cerebellar tonsillar herniation

• herniation into the burr hole

Reflex S<D
Cranial compliance
 Monroe-Kellie law

Skull = Brain substance + Blood + CSF

1200-1600 ml 100-150 ml
100-150 ml
 Monroe-Kellie law

Skull = Brain substance + Blood + CSF

 Cerebral edema

increases in brain of water content

• Vazogenic edema

• Cytotoxic edema
 Vazogenic edema

• Blood-brain barrier
incompetence

• Migration of protein-rich
exudate

• White & green matter

 Vazogenic edema

• Cerebral tumors

• Abscess

• Head trauma

• Meningitis

• Cerebral stroke (ischemic, hemorrhagic)

NB. Corticosteroids demonstrate effectiveness

Cytotoxic edema

• Swelling of neurons, glia, and

endothelial cells

• Unimpaired blood-brain barrier

• Energy depletion
Cytotoxic edema

K 140 mmol/l K 4 mmol/l

Na 15 mmol/l Na 143 mmol/l
 Cytotoxic edema

Hypoperfusion - the first cause

NB. Effective – osmotic agents

 Monroe-Kellie law

Skull = Brain substance + Blood + CSF

 CBF & BP

Skull= Brain+ Blood+ CSF

 CBF & CO2

Skull= Brain+ Blood+ CSF

 SBF & O2

Skull= Brain+ Blood+ CSF

 Monroe-Kellie law

Skull = Brain substance + Blood + CSF

Cerebral hypoperfusion=CPP< 50mmHg
CPP
CPP = MAP - ICP
A oropharyngeal tube in place
C-spine imobilisation
a lot of blood in the mouth

B RR- 27/min,
superficial ,
SpO2 88% room air

C BP 80/65 mmHg
HR 118 mmHg
CRT >3 sec

D GCS 6 p (O-1, V -1, P - 4)

OD>OS
Reflex S<D

E Multiple excoriotions on the chest

T=35.4° C
 ABG CPP
• pH7.3 • MAP 70 mmHg
• PaO2 57 mmHg • ICP ≈20 mmHg
• PaCO2 28 mmHg • CPP 50mmHg
• Blood sugare – 7 mmol/l

Secondary brain injury

• SpO2 <90% - 50% mortality rate

• Tas <90 mmHg rises morbidity and doubles mortality

After primary survey

A Intubated patient
C-spine imobilisatied

B Mechanical y ventilated
RR- 12/min,
SpO2 98% , FiO2 50%

C BP 110/70 mmHg
HR 86 mmHg
CRT ≈ 2 sec

D GCS ? (sedated patient)

OD>OS
Reflex ??? (sedated patient)

E Covered patient, warming

T=35.9° C
 Paraclinical examination

• CT scan

• MRI

• Lumbar puncture

• EEG

• Evoked potentials
Principles of neuro-intensive care

Skull= Brain + Blood + CSF

Control of cerebral metabolism

 Skull= Brain + Blood + CSF

Osmotic therapy

• Manitol

• 3% NaCl
 Skull= Brain + Blood + CSF

• Patient position

• Temperature control

• Control of Blood Pressure

• Sedation/analgezia/ventilation

• Control of (PEEP)
Skull= Brain + Blood + CSF

Drenage of CSF
 Ventricular catheter

• Invasive method
• Gold standard of ICP
monitoring
• Risk of infection (ventriculitis,
meningoencephalitis)

• With possibility to • Risk of intracranial bleeding

drain SCF as needed
• Risk of seizures
 Loop diuretic

• Potentiates osmotic effect

• Reduces ICP by means of the flowing effects:

• Increasing of osmotic gradient
• Reducing of CSF production
• Reducing of the cerebral water compartment

Skull= Brain + Blood + CSF

 Control of cerebral metabolism

• Control of seizure activity

• Barbituric coma

• Hipothermia
Uncontrolled ICP
 Brain death

Brain injury with unreversible

cessation of the brain and brain stem

functions
 Brain death

The medical and legal definitions of death:

brain death & cardiac death

are the same.

Summary

• Cerebral injury primary/secondary

• Secondary cerebral injuries – preventable

• Skull= Brain + Blood + CSF

• CPP > 60 mmHg