Is TIVA better than Is TIVA better than inhalation agents for inhalation agents for elective brain surgery? elective brain surgery? Siti Chasnak Saleh Dept. Anesthesiology Airlangga Univ/ Dr. Soetomo Hosp. Surabaya 06/23/22 1
Jun 19, 2015
Is TIVA better than Is TIVA better than inhalation agents for inhalation agents for
elective brain surgery?elective brain surgery?
Siti Chasnak SalehDept. Anesthesiology Airlangga
Univ/ Dr. Soetomo Hosp. Surabaya
04/13/23 1
TIVA vs INHALATION
Propofol (+opioid: fentanyl/remifenta
nil)
Sefovlurane (+ opioid:
fentanyl/remifentanil)
04/13/23 2
Goals of Anesthetic Management for Brain Surgery
Hemodynamic stability Minimize changes in intracranial pressure Maintain cerebral perfusion pressure Neuroprotection Provide optimal condition for surgery Smooth emergence Rapid awakening
04/13/23 3
Ideal Anesthetic Agent
Maintain CBF without affecting autoregulation Preserve hemodynamic stability (especially CPP) Minimize detrimental changes in ICP Preserve reactivity of cerebral arterioles to PaCO2 changes Decrease CMRO2 with cerebral protection effects Devoid of seizure activity Devoid of arrhythmogenic effect
04/13/23 4
Pharmacodynamic •Wide therapeutic ratio •Minimal cardiorespiratory & motor side-effects •Rapid, predictable, smooth onset •Painless & non-irritant •Stable at room temperature•Rapid recovery (no rebound or emergence effects) •No adrenal or immune suppression •Low potential for anaphylaxis
Ideal IV anesthetic drug
04/13/23 5
Pharmacokinetic
• Rapid redistribution & biotransformation • Inactive metabolites • Clearance independent of duration of administration • Duration of action unaffected by reduced renal or hepatic function • Rapid recovery
04/13/23 6
Estimated changes in (CBF) and the (CMRO2) caused by volatile anesthetics
04/13/23 7
Changes in (CBF) and the (CMRO2 ) caused by I V agents
04/13/23 8
Effects of Anesthetic Agents
04/13/23 9
TIVA vs Inhalation for Neurosurgery
The differences were of minimal relevance in elective patients.The specific choice of anesthetic agents may not be the most crucial aspect of successful neuroanesthetic practice
04/13/23 10
Sevoflurane
Cerebral pressure autoregulation was preserved during 0.2 and 1.5 MAC of sevoflurane anesthesia in human.
Favouring its use in neuroanesthetic practice.
Gupta et al. BJA 1997; 79:469-472
04/13/23 11
Propofol : reduced rCBF and rCMRO2 comparably at BIS value of 40
Sevoflurane: reduced rCBF less than propofol reduced fCMRO2 to an extent
similar to propofol; does not increase ICP
Anesthesiology 2003; 99:603-613
04/13/23 12
TIVA TIVA vs vs InhalationInhalation
Kaisti et al. Anesthesiology 2003; 99:603–1304/13/23 13
04/13/23 14
PROPOFOLPROPOFOL
In patients without intracranial pathology, cerebral pressure autoregulation and CO2 reactivity are intact during propofol-induced EEG silence
Is this true for patients with intracranial pathology?
Matta,et al. BJA 1995;74:159-163
04/13/23 15
PROPOFOL and BRAIN TRAUMA
Propofol reduced ICP in patients with severe brain trauma. Propofol may decrease CPP (its effect on MAP ) Propofol exerts no consistent effect on CVR Propofol does not alter cerebral arteriovenous oxygen content difference
Anesthesiology 1990; 73:404-409
04/13/23 16
CAROTID CLAMPING
The most importance during carotid clamping is cerebral
blood flow, not arterial pressure. Sevoflurane is
the preferred agent.
Anesthesiology 2007; 106:56-64
1st Interpretation
04/13/23 17
2nd Interpretation
If the increased flow with sevoflurane is interpreted
as luxury perfusion, it could be argued that
propofol is the preferred agent.
Anesthesiology 2007; 106:56-64
04/13/23 18
Anesthesiology 2001;95:616-626
Volatile anesth agents (iso/sevo)
Propofol
Volatile anesth
(iso/sevo)
Propofol
CO2 reactivity + (maintain) -
ICP ↑ ↓
CMRO2 ↓ ↓
CBF & CBV ↑ ↓
PONV < iso/sevo
04/13/23 19
04/13/23 20
COST BENEFIT?
04/13/23 21
CONCLUSIONCONCLUSION-1-1
For all agents, the ultimate condition of the patient will be deternined by the sum of the effects of the chosen agent on CBF, CMRO2, CO2 reactivity, MAP, and CBV.
The ultimate effects of volatile agents on ICP/CPP are less predictable
The effect of propofol on intracranial dynamics are more predictable than volatile agents
04/13/23 22
CONCLUSIONCONCLUSION-2-2
Propofol reduces intracranial pressure in patients with severe brain trauma and ICP to or less that 15 mmHg TIVA is preverable , at least until the dura is opened.
The CO2 reactivity during anethesia with volatile anesthetic agents is significantly higher inhalation anesthesia is preverable in brain tumor surgery.
04/13/23 23