Anestesia en neurocríticos

1. Estrategias de Relajación
Cerebral en pacientes
neurocríticos
Cristhian Camilo Bastidas
Neuroanestesiología
Instituto Nacional de Neurología
y Neurocirugía
Universidad Nacional Autónoma
de México

2. Declaro no tener conflictos de interés

3. TABLA DE CONTENIDO
Neuromonitoreo aplicado
INTERVENCIÓN
04
Farmacológica y no
Farmacológica
FACTORES DE
RIESGO
DEFINICIÓN Y
CONCEPTOS
ACTUALES
01
02
Bases fisiológicas
Diagnóstico y Clasificación.
¿SE PUEDE
MEDIR LA BR ?
03
CONCLUSION
ES
05

4. Relación equilibrada que existe entre
el volumen cerebral y la capacidad
craneal una vez que se ha realizado
la craniectomía.
Implicaciones anestésicas,
quirúrgicas, fisiológicas y pronosticas
RELAJACIÓN
CEREBRAL
J. Li1, A. W. Gelb2, A. M. Flexman3, Et al, Definition, evaluation, and management of brain relaxation during craniotomy , British Journal of Anaesthesia, 116 (6): 759–69 (2016)

5. RELAJACIÓN CEREBRAL
• Volumen del contenido
intracraneal es igual o
menor a la capacidad
del espacio
intracraneal.
J. Li1, A. W. Gelb2, A. M. Flexman3, Et al, Definition, evaluation, and management of brain relaxation during craniotomy , British Journal of Anaesthesia, 116 (6): 759–69 (2016)

6. RELAJACIÓN CEREBRAL vs ICP
J. Li1, A. W. Gelb2, A. M. Flexman3, Et al, Definition, evaluation, and management of brain relaxation during craniotomy , British Journal of Anaesthesia, 116 (6): 759–69 (2016)

7. RELAJACIÓN CEREBRAL vs ICP
J. Li1, A. W. Gelb2, A. M. Flexman3, Et al, Definition, evaluation, and management of brain relaxation during craniotomy , British Journal of Anaesthesia, 116 (6): 759–69 (2016)

8. RELAJACIÓN CEREBRAL
J. Li1, A. W. Gelb2, A. M. Flexman3, Et al, Definition, evaluation, and management of brain relaxation during craniotomy , British Journal of Anaesthesia, 116 (6): 759–69 (20

9. RELAJACIÓN CEREBRAL
Niels A. Lassen, Cerebral Blood Flow and Oxygen Consumption in Man, Physiological Reviews, The American Physiological Society, April 1959

10. Pérez de Arriba N, Antuña Ramos A, Martin Fernandez V, et al. (May 31, 2022) Risk Factors Associated With Inadequate Brain Relaxation in Craniotomy for Surgery of Supratentorial Tumors.
Cureus 14(5): e25544. DOI 10.7759/cureus.25544

11. Factores de riesgo
Pérez de Arriba N, Antuña Ramos A, Martin Fernandez V, et al. (May 31, 2022) Risk Factors Associated With Inadequate Brain Relaxation in Craniotomy for Surgery of Supratentorial Tumors.
Cureus 14(5): e25544. DOI 10.7759/cureus.25544
• Estudio prospectivo
observacional single center.
• Sept 2017 – Dic 2020
• 325 pacientes contemplados
• 273 excluidos
• 52 pacientes
Dexametasona 12 mg antes de incisión en
piel,
Propofol TCI Schnider Ce 2 ug/ml BIS 40 -
60
Remifentanil Minto Ce 2 - 3 ng/ml
Rocuronio 0.6 a 1.2 mg/kg TOF 1
Línea arterial con Zero en foramen de
Monro
Sonda vesical, Termómetro esofágico
Manitol al 20% y líquidos con Plasmalite

12. Factores de riesgo
Pérez de Arriba N, Antuña Ramos A, Martin Fernandez V, et al. (May 31, 2022) Risk Factors Associated With Inadequate Brain Relaxation in Craniotomy for Surgery of Supratentorial Tumors.
Cureus 14(5): e25544. DOI 10.7759/cureus.25544

13. Pérez de Arriba N, Antuña Ramos A, Martin Fernandez V, et al. (May 31, 2022) Risk Factors Associated With Inadequate Brain Relaxation in Craniotomy for Surgery of Supratentorial Tumors.
Cureus 14(5): e25544. DOI 10.7759/cureus.25544
Factores de riesgo

14. Pérez de Arriba N, Antuña Ramos A, Martin Fernandez V, et al. (May 31, 2022) Risk Factors Associated With Inadequate Brain Relaxation in Craniotomy for Surgery of Supratentorial Tumors.
Cureus 14(5): e25544. DOI 10.7759/cureus.25544
M 0.25 y 0.5 g/ kg
no concluyente
Factores de riesgo

15. MADS RASMUSSEN, M.D., PH.D., Et al. Craniotomy for supratentorial brain tumors: risk factors for brain swelling after opening the dura mater J Neurosurg 101:621–626, 2004
Factores de riesgo

16. MADS RASMUSSEN, M.D., PH.D., Et al. Craniotomy for supratentorial brain tumors: risk factors for brain swelling after opening the dura mater J Neurosurg 101:621–626, 2004
• Estudio prospectivo observacional single
center.
• Marzo 1994 - Enero 2003
• 975 pacientes contemplados
• 692 pacientes.
• Dx Histopatológico, Radiología, Anestesia,
Medición de la ICP por catéter subdural.
Esquemas Anestésicos:
Isofluorane/ Fentanil 1.5 MAC
(tiopental, atracurio, Fentanil 2-3
ug/Kg/hr. Lidocaina)
Sevofluorane/ Fentanil 1.5 MAC
(Propofol, lidocaína, atracurio,
Fentanil 2-3 ug/Kg/hr)
Propofol/ Fentanil 6 -10 mg/kg/hr
propofol, Fentanil 2-3 ug/Kg/hr
Propofol/ Remifentanil Propofol
4-8 mg/kg/hr, Remi 0.2 – 0.5
ug/kg/min
Factores de riesgo

17. MADS RASMUSSEN, M.D., PH.D., Et al. Craniotomy for supratentorial brain tumors: risk factors for brain swelling after opening the dura mater J Neurosurg 101:621–626, 2004

18. MADS RASMUSSEN, M.D., PH.D., Et al. Craniotomy for supratentorial brain tumors: risk factors for brain swelling after opening the dura mater J Neurosurg 101:621–626, 2004

20. INTERVENCIONES
•NO FARMACOLÓGICA
1. Posicionamiento de la cabeza
2. Ventilación
a)Hiperoxemia?
b)Hipocapnia?
3. Drenaje de LCR.
FARMACOLÓGICA
Terapia Hiperosmolar
Manitol
SH
Anestésicos
Volátiles
Propofol
Diuréticos
Esteroides

21. •Posicionamiento
cefalico
•Permeabilidad Yugular.
•10° mejora el retorno
venoso.
•Favorecer la
hemodinamia.

22. Sarhan KA, Emad R, Mahmoud D, Hasanin A, Hosny O, Al-Sonbaty M, Abo El-Ela A, Othman S. The effect of hyperventilation versus normoventilation on cerebral
oxygenation using near infrared spectroscopy in children undergoing posterior fossa tumor resection: A randomized controlled cross-over trial. Anaesth Crit Care
Pain Med. 2023 Jun;42(3):101190. doi: 10.1016/j.accpm.2022.101190. Epub 2022 Dec 21. PMID: 36565745.

23. Sarhan KA, Emad R, Mahmoud D, Hasanin A, Hosny O, Al-Sonbaty M, Abo El-Ela A, Othman S. The effect of hyperventilation versus normoventilation on cerebral
oxygenation using near infrared spectroscopy in children undergoing posterior fossa tumor resection: A randomized controlled cross-over trial. Anaesth Crit Care
Pain Med. 2023 Jun;42(3):101190. doi: 10.1016/j.accpm.2022.101190. Epub 2022 Dec 21. PMID: 36565745.

24. Sarhan KA, Emad R, Mahmoud D, Hasanin A, Hosny O, Al-Sonbaty M, Abo El-Ela A, Othman S. The effect of hyperventilation versus normoventilation on cerebral
oxygenation using near infrared spectroscopy in children undergoing posterior fossa tumor resection: A randomized controlled cross-over trial. Anaesth Crit Care
El análisis de regresión lineal
reveló que cada disminución
de 1 mmHg en ETCO2
disminuiría los valores NIRS
izquierdos en un 1,4 % [0,66–
2,2] y los valores NIRS
derechos en un 1,38 % [0,45–
2,3].
No se encontró correlación
entre la PaCO2 al final de la
fase 1 y la puntuación de
relajación cerebral (r = 0,06,
p = 0,66).

25. Lane BC, Scranton R, Cohen-Gadol AA. Risk of Brain Herniation After Craniotomy With Preoperative Lumbar Spinal Drainage: A Single-Surgeon Experience of 365
Patients Among 3000 Major Cranial Cases. Oper Neurosurg (Hagerstown). 2021 Jan 13;20(2):E77-E82. doi: 10.1093/ons/opaa262. PMID: 32823289.

26. Lane BC, Scranton R, Cohen-Gadol AA. Risk of Brain Herniation After Craniotomy With Preoperative Lumbar Spinal Drainage: A Single-Surgeon Experience of 365
Patients Among 3000 Major Cranial Cases. Oper Neurosurg (Hagerstown). 2021 Jan 13;20(2):E77-E82. doi: 10.1093/ons/opaa262. PMID: 32823289.

27. Drenaje entre 40 a 60 ml al momento
de apertura de la duramadre.
Seguimiento a 30 días.
No se demostró fistula del LCR
mRankin favorable
Descompresión temprana
Rápido acceso a la base del cráneo
Herniación?
Lane BC, Scranton R, Cohen-Gadol AA. Risk of Brain Herniation After Craniotomy With Preoperative Lumbar Spinal Drainage: A Single-Surgeon Experience of 365
Patients Among 3000 Major Cranial Cases. Oper Neurosurg (Hagerstown). 2021 Jan 13;20(2):E77-E82. doi: 10.1093/ons/opaa262. PMID: 32823289.

28. •Hernández-Palazón J, et al. Comparison of 20% mannitol and 3% hypertonic saline for intra- operative brain relaxation during
supratentorial brain tumour craniotomy in patients with a midline shift. Neurocirugia. 2023.
https://doi.org/10.1016/j.neucie.2022.10.003

29. •Hernández-Palazón J, et al. Comparison of 20% mannitol and 3% hypertonic saline for intra- operative brain relaxation during supratentorial brain tumour craniotomy in patients with a midline
shift. Neurocirugia. 2023. https://doi.org/10.1016/j.neucie.2022.10.003

30. No hubo diferencias
estadísticas
No hubo diferencias
estadísticas
Manitol 1 g/kg vs SH 3%
Prospectivo, aleatorizado doble ciego
60 Pcts entre Enero y Octubre 2020
Hemodinamia
BRS
No hubo diferencias
estadísticas
*** uresis.
Complicaciones y
estancia hospitalaria
Hernández-Palazón J, et al. Comparison of 20% mannitol and 3% hypertonic saline for intra- operative brain relaxation during supratentorial brain tumour craniotomy in patients with a midline shift. Neurocirugia. 202
https://doi.org/10.1016/j.neucie.2022.10.0

31. • Joaquín Hernández-Palazón, Et al. (2016) A comparison of equivolume, equiosmolar solutions of hypertonic saline and mannitol for brain relaxation during elective supratentorial craniotomy, British Journal of
Neurosurgery, 30:1, 70-75, DOI: 10.3109/02688697.2015.1109061

32. • Joaquín Hernández-Palazón, Et al. (2016) A comparison of equivolume, equiosmolar solutions of hypertonic saline and mannitol for brain relaxation during elective supratentorial craniotomy, British Journal of
Neurosurgery, 30:1, 70-75, DOI: 10.3109/02688697.2015.1109061

33. • Joaquín Hernández-Palazón, Diego Fuentes-García, Paloma Doménech- Asensi, Sebastián Burguillos-López, Joaquín García-Ferreira, Luis Falcón-Araña & Claudio Piqueras-Pérez (2018)
A dose-response relationship study of hypertonic saline on brain relaxation during supratentorial brain tumour craniotomy, British Journal of Neurosurgery, 32:6, 619-627, DOI:
10.1080/02688697.2018.1508640

34. Joaquín Hernández-Palazón, Diego Fuentes-García, Paloma Doménech- Asensi, Sebastián Burguillos-López, Joaquín García-Ferreira, Luis Falcón-Araña & Claudio Piqueras-Pérez (2018) A
dose-response relationship study of hypertonic saline on brain relaxation during supratentorial brain tumour craniotomy, British Journal of Neurosurgery, 32:6, 619-627, DOI:

35. • Ze Jiang†, Youxuan Wu†, Fa Liang, Minyu Jian, Haiyang Liu, Hongxun Mei and Ruquan Han*, Brain relaxation using desflurane anesthesia and total intravenous anesthesia in patients undergoing craniotomy
for supratentorial tumors: a randomized controlled study 2023, https://doi.org/10.1186/s12871-023-01970-z

36. Ze Jiang†, Youxuan Wu†, Fa Liang, Minyu Jian, Haiyang Liu, Hongxun Mei and Ruquan Han*, Brain relaxation using desflurane anesthesia and total intravenous anesthesia in patients undergoing craniotomy for
supratentorial tumors: a randomized controlled study 2023, https://doi.org/10.1186/s12871-023-01970-z

37. Curr Opin Anaesthesiol. 2015 October ; 28(5): 532–536. doi:10.1097/ACO.0000000000000232.
• Dosis de Remifentanil
• Uso de Sulfato de
magnesio perioperatorio
• Terapia endovascular
Técnica anestésica
• Brote de supresión en
Cirugía vascular HSA.

38. Brian L. Hoh, MD, MBA, FAHA, Chair; Nerissa U. Ko, MD, MAS, Vice Chair; Sepideh AminHanjani, MD, FAHA*; 2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American
Heart Association/ American Stroke Association Stroke. 2023;54:e00–e00. DOI: 10.1161/STR.0000000000000436

39. Brian L. Hoh, MD, MBA, FAHA, Chair; Nerissa U. Ko, MD, MAS, Vice Chair; Sepideh AminHanjani, MD, FAHA*; 2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart
Association/ American Stroke Association Stroke. 2023;54:e00–e00. DOI: 10.1161/STR.0000000000000436

40. Hagihira S (2017) Brain Mechanisms during Course of Anesthesia: What We Know from EEG Changes during Induction and Recovery. Front. Syst. Neurosci. 11:39. doi: 10.3389/fnsys.2017.00039
MONITORIZACIÓN
Protección neuronal y sueño
fisiológico.

41. Li, R.; Yang, D.; Fang, F.; Hong, K.-S.; Reiss, A.L.; Zhang, Y. Concurrent fNIRS and EEG for Brain Function Investigation: A Systematic, Methodology-Focused Review. Sensors2022,22,5865. https://
doi.org/10.3390/s22155865
MONITORIZACIÓN

42. Li, R.; Yang, D.; Fang, F.; Hong, K.-S.; Reiss, A.L.; Zhang, Y. Concurrent fNIRS and EEG for Brain Function Investigation: A Systematic, Methodology-Focused Review. Sensors2022,22,5865. https:// doi.org/10.3390/s22155865
MONITORIZACIÓN

43. Couture, E.J., Deschamps, A. & Denault, A.Y. Patient management algorithm combining processed electroencephalographic monitoring with cerebral and somatic near-infrared spectroscopy: a case
series. Can J Anesth/J Can Anesth 66, 532–539 (2019). https://doi.org/10.1007/s12630-019-01305-y
MONITORIZACIÓN

44. World Neurosurg. (2021) 151:23-28. https://doi.org/10.1016/j.wneu.2021.04.054
MONITORIZACIÓN

45. CONCLUSIONES
1. La relajación cerebral se debe alcanzar en todos los
escenarios de paciente neurocrítico: Tumoración
cerebral, HSA, Stroke, Traumatismo craneal severo.
2. El manejo anestésico no solo se limita a la correcta
elección del agente a utilizar.
3. Es imperativo mantener y preservar los parámetros
fisiológicos durante el trans anestésico.
4. El monitoreo neurológico puede ser una estimación
del grado de relajación cerebral.
5. El brote de supresión temporal esta teniendo mayor
interés en la cirugía vascular neurológica.

46. Gracias
• cbastidasbastidas@innn.edu.mx
• cristhian.bastidasb@Hotmail.com