CONCLUSION: - 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

1. IIss TTIIVVAA bbeetttteerr tthhaann
iinnhhaallaattiioonn aaggeennttss ffoorr
eelleeccttiivvee bbrraaiinn ssuurrggeerryy??
Siti Chasnak Saleh
Dept. Anesthesiology Airlangga
Univ/ Dr. Soetomo Hosp.
Surabaya
10/30/14 1

2. TIVA vs
INHALATION
Propofol (+opioid:
fentanyl/remifenta
nil)
Sefovlurane
(+ opioid:
fentanyl/remifenta
nil)
10/30/14 2

3. 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
10/30/14 3

4. 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
10/30/14 4

5. Ideal IV anesthetic drug
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
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6. Pharmacokinetic
• Rapid redistribution & biotransformation
• Inactive metabolites
• Clearance independent of duration of administration
• Duration of action unaffected by reduced renal or
hepatic function
• Rapid recovery
10/30/14 6

7. Estimated changes in (CBF) and the
(CMRO2) caused by volatile anesthetics
10/30/14 7

8. Changes in (CBF) and the (CMRO2 )
caused by I V agents
10/30/14 8

9. Effects of Anesthetic
Agents
10/30/14 9

10. 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
10/30/14 10

11. 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
10/30/14 11

12. TTIIVVAA vvss IInnhhaallaattiioonn
 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
10/30/14 12

13. Kaisti et al. Anesthesiology 2003; 99:603–13
10/30/14 13

14. PPRROOPPOOFFOOLL
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
10/30/14 14

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
10/30/14 15

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
10/30/14 16
1st Interpretation

17. 10/30/14 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

18. Anesthesiology 2001;95:616-626
10/30/14 18

19. Volatile
anesth
(iso/sevo)
Volatile anesth
agents (iso/sevo)
Propofol
Propofol
CO2 reactivity + (maintain) -
ICP ↑ ↓
CMRO2 ↓ ↓
CBF & CBV ↑ ↓
PONV < iso/sevo
10/30/14 19

20. 10/30/14 20
COST
BENEFIT?

21. CCOONNCCLLUUSSIIOONN--11
 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
10/30/14 21

22. CCOONNCCLLUUSSIIOONN--22
 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.
10/30/14 22

23. 10/30/14 23