The Anesthetized Brain is less Vulnerable to ischemic injury than the awake brain.
EEG changes suggestive of severe ischemia are present.
Basic Methode Brain Protection are “ Corner Stone “
CPP, CBF, CBV maintained in “Normal Range”, MAP may increased up to 10 – 20 %.
Anesthetics Drugs may have Brain Protectection effect.
Volatile anesthetics do provide some Transient Protection (< 1,5 MAC)
Barbiturates, although long considered to be the gold standard.
Hypothermic methode are controversial, Hyperthermia should be avoided.
Insulin is Administered if glucose values exceed 180 mg/dl.
Close monitoring of BSL to ensure that Hypoglycemia does not develop
a better understanding of sleep and coma may lead to new approaches to general anesthesia based on new ways to alter consciousness,29,97,98 provide analgesia,99,100 induce amnesia, and provide muscle relaxation.66
This presentation describes the concept of temporal plus syndrome, pseudotemporal epilepsy and paradoxical temporal lobe epilepsy and how to differentiate them from temporal lobe epilepsy.
a better understanding of sleep and coma may lead to new approaches to general anesthesia based on new ways to alter consciousness,29,97,98 provide analgesia,99,100 induce amnesia, and provide muscle relaxation.66
This presentation describes the concept of temporal plus syndrome, pseudotemporal epilepsy and paradoxical temporal lobe epilepsy and how to differentiate them from temporal lobe epilepsy.
'Headache Research in Cumbria' - Dr Jitka Vanderpol (Consultant Neurologist for Cumbria Partnership NHS Foundation Trust) from the Cumbria Neuroscience Conference
This presentation looks at generalised periodic epileptiform discharges and the various disorders like Creutzfeldt Jacob disease (CJD), SSPE and metabolic encephalopathies in which it is seen. SIRPID is also discussed. Triphasic waves are described. Radermacker complexes in SSPE are described.
HEAD INJURY- AN OVERVIEW
Dear viewers,
Greetings from “Surgical Educator”
Today I have uploaded a video on Head injury- an important topic in trauma because 50% of trauma deaths are due to head injuries. I haven’t talked elaborately but have included the essential minimum an undergraduate medical student should know. I have talked about pathophysiology, clinical approach, symptoms, signs, investigations, different individual types of head injuries and management of all the varieties of head injuries. My aim is after watching this video all of you should be able to arrive at a correct working diagnosis of the type of head injury and should also be able to institute immediate lifesaving treatment to the patients if there is a need. You can watch the video in the following links:
Surgicaleducator.blogspot.com
Youtube.com/c/surgicaleducator
Thank you for watching the video.
'Headache Research in Cumbria' - Dr Jitka Vanderpol (Consultant Neurologist for Cumbria Partnership NHS Foundation Trust) from the Cumbria Neuroscience Conference
This presentation looks at generalised periodic epileptiform discharges and the various disorders like Creutzfeldt Jacob disease (CJD), SSPE and metabolic encephalopathies in which it is seen. SIRPID is also discussed. Triphasic waves are described. Radermacker complexes in SSPE are described.
HEAD INJURY- AN OVERVIEW
Dear viewers,
Greetings from “Surgical Educator”
Today I have uploaded a video on Head injury- an important topic in trauma because 50% of trauma deaths are due to head injuries. I haven’t talked elaborately but have included the essential minimum an undergraduate medical student should know. I have talked about pathophysiology, clinical approach, symptoms, signs, investigations, different individual types of head injuries and management of all the varieties of head injuries. My aim is after watching this video all of you should be able to arrive at a correct working diagnosis of the type of head injury and should also be able to institute immediate lifesaving treatment to the patients if there is a need. You can watch the video in the following links:
Surgicaleducator.blogspot.com
Youtube.com/c/surgicaleducator
Thank you for watching the video.
SUMMARY:
- Neurophysiologic monitoring not universally adopted but in many centers has become routine monitor for some surgical procedures
- Ideal neurophysiologic monitoring in the neurosurgical procedure should be: non-invasive (v.s invasive), high sensitivity & specificity, cost effective, easy to use, simple instrumentation, and real time or continous monitoring.
What is Alzheimer's disease? pathophysiology of disease, treatment of disease. If there is any update regarding the information provided, your comments are welcomed
HISTORY OF 3-STEP LADDER WHO
1980 – WHO establishes Cancer Control Programme
Cancer prevention
Early diagnosis with curative treatment
Pain relief and palliative care
1986 – ” Cancer Pain Relief “ published by WHO
Step Ladder WHO
Updated on 1996
Worldwide acceptance protocol
Today, worldwide consensus favouring its used for management of all pain associated with serious illness
INADEQUATE PAIN TREATMENT STILL A FACT IN INDONESIA HEALTH SERVICES
PAIN AS A COMPLEX PROBLEM NEED MULTIDISCIPLINARY APPROACH FOR BETTER RESULT BASED INDIVIDUALLY PATIENT NEEDED
THERE IS A BIG ROLE OF PHYSICIAN AND HOSPITAL FOR BETTER PAIN MANAGEMENT
CHANGE PARADIGM TO MULTIDISCIPLINARY PAIN TREATMENT IS AN OBLIGATE FOR ALL PHYSICIAN
Pain is a common yet complex biopsychosocial phenomenon that affects every aspect of a patient’s life
Optimal management often requires good assessment, formulation of the problem in the patient, and combining pharmacological and non-pharmacological (psychological and social) interventions
Through palliative care, we change the role of a patient into a whole human being.
Through palliative care, we transform the stages leading to death into times filled with life
Pain is the production (out put ) of the brain.
Pain is invisible disease, we can’t see it like other disease, such as struma, fracture or blind.
What you have to do is to believe what ever the patient says.
Pain is what ever the patient says it is
Pain is invisible diseases, but is real for patient.
NUTRITIONAL THERAPY IN CRITICAL ILL PATIENTS
However, significant barriers can impede the enteral administration of nutrients, including gastroduodenal dysfunction reflected by high gastric residual volumes, and diarrhoea and constipation.
Possible solutions are suggested. In case of contraindication or failure of enteral nutrition, parenteral nutrition is indicated -----as a replacement or a supplement to failing enteral feeding.
The perfect timing of supplemental parenteral nutrition (early or late) remains uncertain, and parenteral nutrition should be carefully monitored
Solution of inadequate postoperative pain relief lies in developing Acute Pain Service.
APS has been shown to reduced morbidity and
mortality, increased out put and out come of
postoperative pain patients
Increased stisfaction of the patients
Shorten LOS in ICU and Hopital low cost
Nyeri adalah penggabungan perasaan sensorik dan emosional yang dipengaruhi oleh berbagai faktor.
Nyeri memiliki dua dimensi yg jelas, dimensi inderawi dan emosional
Peran dimensi emosional lebih dominan dibanding inderawi utamanya pada nyeri kronik.
History taking
Adequate time
Listen carefully
Empathetic
Trust building
Do not intervere
Pschosocioeconomic & spiritual codition
- quantity: VAS
- quality: nociceptive
- mode of onset and location
- duration & chronicity
- provocating & relieving factors
- special character
- timing of pain
- relation with posture
- associated complaints
Take home message
Acute pain is a symptom, tell us that there is something wrong in our body.
Chronic pain is a disease entity and that must be treated differently to acute pain.
Since chronic pain is biopsychosocial phenomenon it must be treated by multidisciplinary team with multidisiplinary approach.
Clossing
By 3 step ladder WHO cancer pain management, 90 % of cancer pain can be relief.
Since cancer patients cannot be cured, our main task is to let them die free of pain with Iman
Ideal pain clinic
Promoting multidisciplinary team approach
Coordinating all specialist effort
Measuring the outcome of treatment offered
Promoting palliative model rather than curative models of pain treatments
Identifying complications of IPM and promoting safe and base-evidence intervention
PiCCO tidak hanya memberikan informasi tentang curah jantung (CO) tapi bisa memberi pengukuran untuk menilai preload, kontraktilitas, afterload, dan air paru ekstravaskular (ELWI)
Role of the thalamus in propofol-induced unconsciousness relates primarily to the functional connections of nonspecific nuclei to the cortex (i.e., mediating multimodal integration of information)
Anesthesiologists should concern about the risk of POCD by making prevention and attentive to the potential risk factors.
It should be remembered that research in animal models which represent the specific characteristics of POCD in human remains unclear.
With many factors still unknown, there is still a chance for sinchronized preclinical and clinical research on POCD.
Sekecil apapun operasi di dalam otak, tetap dapat membahayakan
Keselamatan tindakan anestesi untuk bedah saraf tergantung neuroanestesiologisnya
Tim Khusus: Dengan dedikasi ada kualitas, dengan komitmen ada keunggulan dan dengan jumlah ada pengalaman
• Memahami struktur kimia dasar
anestetik lokal
• Memahami mekanisme kerja anestetik
lokal
• Memahami pengaruh sifat kimia
anestetik lokal dan aplikasi klinisnya
• Memahami toksisitas anestetik lokal
dan cara mengatasinya
More from Department of Anesthesiology, Faculty of Medicine Hasanuddin University (20)
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
2. INTRODUCTION
Most Feared Complications in Intraoperative Anesthesia and Surgery :
CEREBRAL ISCHEMIA and NEURONAL INJURY.
Althought, The incidence quite low,
BUT certain procedure the risk can be high
The Majority of these complications occur during :
INTRAOPERATIVE PERIOD.
NOT ONLY Evaluating, BUT ALSO : Identifying
Decrease the Brain’s Vulnerability to Ischemia
3. INTRODUCTION
Normal Brain : Glial cell Maintain Imunological Integrity & Protection the Brain
Cerebtal Ischemic : Migration peripherial Imune Cell Infiltrate to the Brain
Exacerbate Neuro Degeneration, Anoxic Depolarization, Failure Glutamate up take.
Neuronal Injury
4. THE BRAIN THAT WOULDN’T DIE ?
May result from many Pathological Causes :
Understanding of Neuronal Death is Essential :
Designing Therapies, Prevent Neuronal death
Intraoperative Brain Protection was focused on
Balance of Supply - Demand Concept.
Rationale by reducing Brain’s ATP requirement.
7. NEUROANESTHESIA PRINCIPLE
A = Airway : Clear
B = Breathing : Normo or Slight Hypocapnia
C = Circulation. Avoid : High Increase or High Decrease of BP.
Avoid : Increase I C P. ( More 20 mmHg Tx)
Fluid tx: Normo ( T, vol, Glycemia, Isoosmoler ).
Correction:Acidosis, Electrolyte, plas. Glucose.
D = Drugs ( Avoid drugs & Anes. Technique will increase ICP ).
Give drugs have B r a i n Protection E f f e c t.
E = Environment (temperature control, mild hypothermia avoid
hyperthermia)
8. INTRAOPERATIVE BRAIN PROTECTION
Basic Methode are “Corner Stone“ Intra Operative Brain Protection
Ensure DO2, Manipulation of PaCO2 = Normocapni/35-40mmHg.
PCO2 is a potent effect to CBF & CBV.
Hypocapnia Reduce CBF, CBV and ICP. to produce Brain Relaxation.
CBF Reduction enhance injury in Ischemic or Traumatic CNS injury
Prophylactic Hyperventilation has not any benefit in ischemic Injury.
BTF; Prophylactic hyperventilation avoided during early stages TBI.
It should be applied with an understanding of its complications.
“
9. CBF is Normally Autoregulated over a MAP Range of 50 to 150 mmHg.
Maintenance of CBF with a CPP in excess of 60 mmHg.
Adequate CPP is to Maintain Perfusion in a Brain Ischemic Injury.
TBI: Higher than normal CPP (>70 mmHg) to maintain normal CBF.
Patients who have Sustained an Ischemic cerebral injury may benefit from :
Induced Hypertension; Increase MAP > 20% baseline, Augmentation CBF
Hypotension to be Deleterious to ischemic or traumatic injured brain.
10. Targets Blood Sugar Levels between 100-180 mg/dl.
• Anaerobic Glucose metabolism product Lactic Acid and ATP.
• The Lactic Acid contributes to the Tissues Acidosis.
Brain Does Not have Glucose Stores : If During Hyperglycemia.
• Increased Neuronal Glucose, Increase Lactic Acid.
• Promote tissue Acidosis, contributes Neuronal Death.
During Hypoglycemia is also associated with Cerebral Injury.
• 40 mg/dl, Shift or Changes EEG Wave .
• 20 mg/dl, Suppression of the EEG (flat).
• Persistence of this level: Seizure and Neuronal Death.
glucose glucose 6-phosphate
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ADP
ATP
H2O Oxygen
lactate
glucose glucose 6-phosphate
ATP
ADP
pyruvateCO2
ATP
ADP
ATP
H2O
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XOxygen
lactate
11. INFLUENCE OF ANESTHETICS
ON THE ISCHEMIC BRAIN
BARBITURAT
Produce isoelectricity EEG extensively, (Gold Standard C. Protectants)
Have been efficacious in the treatment of Focal ischemia
Reduce of cerebral injury produced by M C A Occlusion.
Would not be to provide much benefit in Global ischemia.
Warner et. al;
Approximately a third of the dose required to achieve EEG
suppression, can a reduction in injury that is of similar
achieved with much larger doses.
12. INFLUENCE OF ANESTHETICS
ON THE ISCHEMIC BRAIN
PROPOFOL : ( Shares a number of properties with Barbiturates ).
In Particular :
Produce burst suppression of the EEG, reducing CMRO2 > 50%.
In Focal Ischemia, Reduced the E x t e n t of Cerebral Infarction.
Gelb’s Group Study Suggest :
Propofol NP Is not sustained beyond a period of One Week.
Provided that the severity of injury is Very Mild.
Efficacy of propofol is Similar to Volatile agents.
13. INFLUENCE OF ANESTHETICS
ON THE ISCHEMIC BRAIN
ETOMIDATE :
Reduce CMRO2 by up to 50% by producing EEG Burst Suppression.
Cleared rapidly, does not cause myocardial depression or hypotension.
In Global Ischemia :
Reduce Ischemic Injury. (hippocampus).
Reduce nitric oxide levels by inhibiting NOS or directly scavenging NO
In Focal Ischemia :
Actually Increased the volume brain infarction.
14. INFLUENCE OF ANESTHETICS
ON THE ISCHEMIC BRAIN
VOLATIL AGENT :
Isoflurane, Sevoflurane and Desflurane can EEG burst-suppression in
<1.5 MAC.
Isoflurane : to be neuroprotective in models of hemispheric, focal and
near complete ischemia.
Similarly, both sevoflurane and desflurane can reduce ischemic
cerebral injury.
There does not substantial difference among the volatile agents with
regard to neuroprotective efficacy.
15. INFLUENCE OF ANESTHETICS
ON THE ISCHEMIC BRAIN
VOLATIL AGENT :
Produce Neuroprotection after : S h o r t Recovery Periods.
Produce Long Term N P in the severity of injury is Very Mild.
Efficacy was not sustained when was : Extended to 2 weeks.
Volatile anesthetics Delay but do not prevent neuronal death.
Delaying Neuronal, Increase Duration Therapeutic Window.
For the administration of other agents that have N P Efficacy.
16. INFLUENCE HYPOTHERMIA
ON THE ISCHEMIC BRAIN
Hypothermia :
Hypothermia Protective Effect Greater in Restored After Ischemia.
Temperature (34 - 35°C) reduce the brain’s vulnerability to Ischemic Injury.
Induction Mild Hypothermia did not reduce Incidence New Cerebral Injury.
Mild Hypothermia inTBI: Reduced ICP and Improved Neurologic Outcome.
Hyperthermia :
Increases Brain Temperature During and After Ischemia : Aggravate Injury.
An Increase of 1° C can dramatically increase injury
18. INFLUENCE OF SEIZURE
ON THE ISCHEMIC BRAIN
Seizures :
Intracranial Pathology : (Increased neuronal activity, Increased CBF and
CBV (consequently increased ICP) and Cerebral acidosis).
Untreated Seizures produce neuronal necrosis even with normal CPP.
Prevention and Rapid Treatment of seizures is an Important Goal.
Can be Rapidly Treated : BZD, Barbiturates, Etomidate and Propofol.
Antiepileptic : Phenytoin, Pentobarbital are often use.
19. SUMMARY
The Anesthetized Brain is less Vulnerable to ischemic injury than the awake brain.
EEG changes suggestive of severe ischemia are present.
Basic Methode Brain Protection are “ Corner Stone “
CPP, CBF, CBV maintained in “Normal Range”, MAP may increased up to 10 – 20 %.
Anesthetics Drugs may have Brain Protectection effect.
Volatile anesthetics do provide some Transient Protection (< 1,5 MAC)
Barbiturates, although long considered to be the gold standard.
Hypothermic methode are controversial, Hyperthermia should be avoided.
Insulin is Administered if glucose values exceed 180 mg/dl.
Close monitoring of BSL to ensure that Hypoglycemia does not develop
20. REFERENCE
1. Vincent AM1, McLean LL, Backus C, Feldman EL; FASEB J. 2005. “, Short-term
hyperglycemia produces oxidative damage and apoptosis in neurons.
Apr;19(6):638-40. Epub 2005 Jan 27
2. Malone JI, Hanna S, Saporta S, Mervis RF, Park CR, Chong L, Diamond DM;
Pediatr Diabetes. 2008 Dec;9(6):531-9. doi: 10.1111/j.1399-5448.2008.00431.x.
“Hyperglycemia not hypoglycemia alters neuronal dendrites and impairs
spatial memory.”
3. Sharma R, Buras E, Terashima T, Serrano F, Massaad CA, Hu L, et al. (2010)
Hyperglycemia Induces Oxidative Stress and Impairs Axonal Transport Rates
in Mice. PLoS ONE 5(10): e13463. doi:10.1371/journal.pone.0013463
4. Sang Won Suh et al; The Journal of Neuroscience, 19 November 2003, 23(33):
10681-10690;Hypoglycemic Neuronal Death and Cognitive Impairment Are
Prevented by Poly(ADP-Ribose) Polymerase Inhibitors Administered after
Hypoglycemia.
Editor's Notes
Good morning for; Committe, Moderator, All participant. (CMA)
In this morning we will present with a Title “ Applied Neuropharmacology Intraoperative Brain Protection “
One of the most Feared Complications in Intraoperative periode is : CI and N Injury. Although, the incidence quite low, BUT certain procedures the risk can be high.
The majority of these complications OCCUR DURING THE INTRAOPERATIVE PERIOD
The Objective of the sesion are not only Evaluating, Prevent CI BUT ALSO identifying anesthetic agents that might decrease the Brain’s Vulnerability to ischemia
Back to Basic : Normal Brain : Glial Cells maintain the IMMUNOLOGICAL INTEGRITY and Protection the Brain from the any injury.
During C I : Peripheral immune cells acutely infiltrate the brain and may exacerbate Neurodgeneration, Anoxic Depolarization, failure Glutamate
up take and finaly Neuronal injury.
The Brain Can be die, Neuronal Cell Death : may result from Many Pathological Causes. In other cases, cell death is controlled (programmed cell death/apoptosis) and necrotic cell death. Understanding the CD is essential for Designing therapies which will prevent or limit inappropriate cell death in the nervous system.
The approach of CI was INITIALLY FOCUSED on Balance of Supply - Demand Concept by Optimalizing Energy Production and Reducing Brain Energy requirement.
The rationale was that by reducing ATP requirements,
The response of the BRAIN TO DECREASE CBF, are CHARACTERIZED. When CBF about 20 ml/100 gm/ min, EEG ISOELECTRICITY, If CBF Below a flow of 10 ml/100 gm/min, ATP levels decline rapidly (within 5 minutes) and the neuron is unable to maintain ionic homeostasis. At this point, the neuron undergoes depolarization (anoxic depolarization) and neuronal terminals release massive quantities of neurotransmitters.
These neurotransmitters (such as glutamate) activate post-synaptic receptors which results in the neuron being flooded with calcium. By activating several biochemical cascades in a haphazard manner, calcium ultimately leads to neuronal death.
So IO BP can be done with Inhibit the Cacscade
Ensure the energy production by maintain Balance Supply – Demand Concept
Using ROS, Glutamate, Calcium antagonist
NMDA stimulate
The brain is metabolically very active and its oxygen consumption is about 3.5 - 4.0 ml/100 gm/min. Electrical activity of neurons (transient depolarization and repolarization with their attendant ionic shifts) consumes about 50% of the total energy production of neurons. Thus, energy consumption can be reduced significantly by agents that can render the EEG isoelectric (e.g., barbiturates). The remaining 50% is used to maintain basal cellular homeostasis. Although this portion of the total energy consumption is not amenable to reduction by anesthetic agents, hypothermia can reduce it substantially.
Below a flow of 10 ml/100 gm/min, ATP LEVELS DECLINE RAPIDLY (WITHIN 5 MINUTES) AND THE NEURON IS UNABLE TO MAINTAIN IONIC HOMEOSTASIS. At this point, the neuron undergoes depolarization (anoxic depolarization) and neuronal terminals release massive quantities of neurotransmitters(5). These neurotransmitters (such as glutamate) activate post-synaptic receptors which results in the neuron being flooded with calcium. By activating several biochemical cascades in a haphazard manner, CALCIUM ULTIMATELY LEADS TO NEURONAL DEATH.
Cerebral Protection during Operative with using NEURO ANESTHESIA PRINCIPLE : the principle of Maintain adequate ventilation and oxygenation, Maintain of systemic hemodynamics , Maintain of Cerebral perfusion. Temperature Control and Physical Manipulation
Basic Methode Brain Protection are Corner Stone in Intraoperative Brain Protection:
1) Control Ventilation : To Ensure DO2 and maintain PaCO2 normocapnia between 35-40 mmHg, ICP reduced by 30% per 10mmHg reduction in CO2 • Avoid hypoxia – cytotoxic cerebral oedema • For how long? 24-48H only • After 48H, acute changes in hyperventilation return to normal value owing to normalize CSF pH and compensatory to CSF volume • Can be repeated if needed : interval of 12-24 H in between cerebral resuscitation
2) Hypothermia • Each 1°C reduction can reduce CMRO2 by 7% • Aim for mild (33-34°C) to moderate (26-31°C) hypothermia • Avoid shivering- increase CMRO2 & CBF, may require muscle relaxant
2. Hypertension : Aim: To limit ischemia by increasing regional CBF : To overcome regional vasospasm, Done usually with drugs - vasopressors • During ischemia Autoregulation is impaired CBF is pressure dependent • Maintain CPP 70-80 mmHg
3. Hypothermia • Each 1°C reduction can reduce CMRO2 by 7% • Aim for mild (33-34°C) to moderate (26-31°C) hypothermia • Avoid shivering- increase CMRO2 & CBF, may require muscle relaxant
D. Pharmacological• Sedation and neuromuscular blockade • IV anaesthetic agent decreased cerebral metabolism and reduce CBF • Propofol more potent than benzodiazepine • Opioid min effect on cerebral metabolism and CBF• Routine use NMB should be avoided • Prevent raise ICP during straining and coughing • Impossible to recognized the seizure • Long term polyneuropathy and myopathy, Anticonvulsant • Severe TBI – 20% seizures • Highest in depressed skull fractures, IC hematoma and contusion • Efficient in reducing of early post traumatic seizure • First line therapy – phenytoin ( a week duration)
Fluid management and glycaemic control• Aim fluid management provide adequate hydration• Hypotonic fluid (dextrose) may exacerbate brain edema• High plasma levels of glucose associated with poor outcome from TBI
62. Osmotherapy• Mannitol • Increase plasma osmolality – withdrawal of brain across bbb • Reduction ICP after 20-30mins • Need to monitor plasma osmolality, not > 320 mosmol/ml• Hypertonic saline (5or 7.5%) • Reduces brain water by establish osmotic gradient across bbb • Hypernatremia, <155 mmol/L • Cause tissue necrosis and thrombophlebitis
63. Barbiturate coma• Barbiturates decreases ICP – reduce CMRO2 and CBF• Can lower ICP refractory to other measures• Dose titrated to burst suppression on EEG
64. Physical manipulation1) Patient position Important for both prevention and treatment of elevated ICP Aim : Allow proper cerebral venous drainage (venous return) Maintain the head and neck elevated 30° Maintain neutral position Avoid obstruction to jugular vein i.e; ETT anchoring, cervical collar Avoid increase in intrathoracic & intraabdominal pressure
65. Avoid ; Excessive stimulation e.g suctioning, only do it when necessary Sudden movement to head Rough handling of patient Painful stimulation Hyperthermia >38°C
66. Surgical intervention1) Ventriculostomy / CSF drainage Eg; EVD, VP shunt1) Decompressive surgery Decompressive craniectomy part of skull is removed Decompressive lobectomy brain parenchymal is resected either from non dominant temporal or frontal lobe Cerebral ischemia is broadly classified into two categories: global ischemia and focal ischemia. Global ischemia is characterized by a complete cessation of CBF (e.g., cardiac
arrest). In this situation, neuronal depolarization occurs with in 5 minutes. Selectively vulnerable neurons within the hippocampus and cerebral cortex are the first to die. The window of opportunity for the restoration of flow is very small because death of neurons is rapid. Focal ischemia is characterized by a region of dense ischemia (the so called “core”) that is surrounded by a larger variable zone that is less ischemic (the penumbra). Within the core, flow reduction is severe enough to result in relatively rapid neuronal death. Flow reduction in the penumbra is sufficient to render the EEG isoelectric but not severe enough to kill neurons rapidly. If, however, the flow is not restored, death and infarction will also occur in the penumbra albeit at a much slower rate. Because of this slow rate of neuronal death, the window of opportunity for therapeutic intervention that is designed to salvage neurons is considerably longer in the setting of focal ischemia. Most episodes of ischemia in the operating room are focal in nature
Basic Methode Brain Protection are Corner Stone in Intraoperative Brain Protection:
1. Control Ventilation : a + b
2. Hypertension : Aim: To limit ischemia by increasing regional CBF : To overcome regional vasospasm, Done usually with drugs - vasopressors • During ischemia Autoregulation is impaired CBF is pressure dependent • Maintain CPP 70-80 mmHg
3. Hypothermia • Each 1°C reduction can reduce CMRO2 by 7% • Aim for mild (33-34°C) to moderate (26-31°C) hypothermia • Avoid shivering- increase CMRO2 & CBF, may require muscle relaxant
4. Pharmacological : Sedation and neuromuscular blockade • IV anaesthetic agent decreased cerebral metabolism and reduce CBF • Propofol more potent than benzodiazepine • Opioid min effect on cerebral metabolism and CBF• Routine use NMB should be avoided • Prevent raise ICP during straining and coughing • Impossible to recognized the seizure • Long term polyneuropathy and myopathy, Anticonvulsant • Severe TBI – 20% seizures • Highest in depressed skull fractures, IC hematoma and contusion • Efficient in reducing of early post traumatic seizure • First line therapy – phenytoin ( a week duration)
Fluid management and glycaemic control• Aim fluid management provide adequate hydration• Hypotonic fluid (dextrose) may exacerbate brain edema• High plasma levels of glucose associated with poor outcome from TBI
62. Osmotherapy• Mannitol • Increase plasma osmolality – withdrawal of brain across bbb • Reduction ICP after 20-30mins • Need to monitor plasma osmolality, not > 320 mosmol/ml• Hypertonic saline (5or 7.5%) • Reduces brain water by establish osmotic gradient across bbb • Hypernatremia, <155 mmol/L • Cause tissue necrosis and thrombophlebitis
63. Barbiturate coma• Barbiturates decreases ICP – reduce CMRO2 and CBF• Can lower ICP refractory to other measures• Dose titrated to burst suppression on EEG
64. Physical manipulation1) Patient position Important for both prevention and treatment of elevated ICP Aim : Allow proper cerebral venous drainage (venous return) Maintain the head and neck elevated 30° Maintain neutral position Avoid obstruction to jugular vein i.e; ETT anchoring, cervical collar Avoid increase in intrathoracic & intraabdominal pressure
65. Avoid ; Excessive stimulation e.g suctioning, only do it when necessary Sudden movement to head Rough handling of patient Painful stimulation Hyperthermia >38°C
66. Surgical intervention1) Ventriculostomy / CSF drainage Eg; EVD, VP shunt1) Decompressive surgery Decompressive craniectomy part of skull is removed Decompressive lobectomy brain parenchymal is resected either from non dominant temporal or frontal lobe Cerebral ischemia is broadly classified into two categories: global ischemia and focal ischemia. Global ischemia is characterized by a complete cessation of CBF (e.g., cardiac
arrest). In this situation, neuronal depolarization occurs with in 5 minutes. Selectively vulnerable neurons within the hippocampus and cerebral cortex are the first to die. The window of opportunity for the restoration of flow is very small because death of neurons is rapid. Focal ischemia is characterized by a region of dense ischemia (the so called “core”) that is surrounded by a larger variable zone that is less ischemic (the penumbra). Within the core, flow reduction is severe enough to result in relatively rapid neuronal death. Flow reduction in the penumbra is sufficient to render the EEG isoelectric but not severe enough to kill neurons rapidly. If, however, the flow is not restored, death and infarction will also occur in the penumbra albeit at a much slower rate. Because of this slow rate of neuronal death, the window of opportunity for therapeutic intervention that is designed to salvage neurons is considerably longer in the setting of focal ischemia. Most episodes of ischemia in the operating room are focal in nature
Basic Methode Brain Protection are Corner Stone in Intraoperative Brain Protection:
1) Control Ventilation , 2) BP Control :
3. Fluid management and Glycaemic Control• Aim fluid management provide adequate hydration• Hypotonic fluid (dextrose) may exacerbate brain edema•
High plasma levels of glucose associated with poor outcome from TBI
Osmotherapy• Mannitol • Increase plasma osmolality – withdrawal of brain across bbb • Reduction ICP after 20-30mins • Need to monitor plasma osmolality, not > 320 mosmol/ml• Hypertonic saline (5or 7.5%) • Reduces brain water by establish osmotic gradient across bbb • Hypernatremia, <155 mmol/L • Cause tissue necrosis and thrombophlebitis
B. Pharmacological : Sedation and neuromuscular blockade • IV anaesthetic agent decreased cerebral metabolism and reduce CBF • Propofol more potent than benzodiazepine • Opioid min effect on cerebral metabolism and CBF• Routine use NMB should be avoided • Prevent raise ICP during straining and coughing • Impossible to recognized the seizure • Long term polyneuropathy and myopathy, Anticonvulsant • Severe TBI – 20% seizures • Highest in depressed skull fractures, IC hematoma and contusion • Efficient in reducing of early post traumatic seizure • First line therapy – phenytoin ( a week duration)
Barbiturate coma• Barbiturates decreases ICP – reduce CMRO2 and CBF• Can lower ICP refractory to other measures• Dose titrated to burst suppression on EEG
B. Pharmacological• Sedation and neuromuscular blockade • IV anaesthetic agent decreased cerebral metabolism and reduce CBF • Propofol more potent than benzodiazepine • Opioid min effect on cerebral metabolism and CBF• Routine use NMB should be avoided • Prevent raise ICP during straining and coughing • Impossible to recognized the seizure • Long term polyneuropathy and myopathy, Anticonvulsant • Severe TBI – 20% seizures • Highest in depressed skull fractures, IC hematoma and contusion • Efficient in reducing of early post traumatic seizure • First line therapy – phenytoin ( a week duration)
Barbiturate coma• Barbiturates decreases ICP – reduce CMRO2 and CBF• Can lower ICP refractory to other measures• Dose titrated to burst suppression on EEG
The approach to the problem of cerebral ischemia was initially focused on Reducing the brain’s requirement for energy. The rationale was that by reducing ATP requirements, the brain would be able to tolerate ischemia for a longer time. Such a supply - demand concept had already been proven to be relevant in the case of cardiac ischemia. Therefore, the agents investigated first were those that could render the EEG isoelectric (such agents would
The approach to the problem of cerebral ischemia was initially focused on Reducing the brain’s requirement for energy. The rationale was that by reducing ATP requirements, the brain would be able to tolerate ischemia for a longer time. Such a supply - demand concept had already been proven to be relevant in the case of cardiac ischemia. Therefore, the agents investigated first were those that could render the EEG isoelectric (such agents would
The approach to the problem of cerebral ischemia was initially focused on Reducing the brain’s requirement for energy. The rationale was that by reducing ATP requirements, the brain would be able to tolerate ischemia for a longer time. Such a supply - demand concept had already been proven to be relevant in the case of cardiac ischemia. Therefore, the agents investigated first were those that could render the EEG isoelectric (such agents would
For example, while the Normothermic brain undergoes injury after 5 min of ischemia, the brain made hypothermic to a temperature of 16° C can tolerate ischemia for up to 30 minutes
Hypothermia • Each 1°C reduction can reduce CMRO2 by 7% • Aim for mild (33-34°C) to moderate (26-31°C) hypothermia • Avoid shivering- increase CMRO2 & CBF, may require muscle relaxant
The approach to the problem of cerebral ischemia was initially focused on Reducing the brain’s requirement for energy. The rationale was that by reducing ATP requirements, the brain would be able to tolerate ischemia for a longer time. Such a supply - demand concept had already been proven to be relevant in the case of cardiac ischemia. Therefore, the agents investigated first were those that could render the EEG isoelectric (such agents would