Trends in Neuroanesthesia Christopher M Wike BSN RN

Trends in Neuroanesthesia Christopher M. Wike, BSN, RN, CCRN, SRNA David J. Krasucki, BSN, RN, CCRN, SRNA Villanova University/Crozer-Chester Medical Center School of Nurse Anesthesia Class of 2016

Objectives • Describe pharmacology/physiology related to neuroanesthesia • Identify the foundations for selection of anesthetic techniques • Identify outcomes related to pharmacologic and nonpharmacologic techniques • Identify emerging neuroanesthetic pharmacology and techniques • Understand the need for future studies in outcomes related to neuroanesthetic care

Part I - Neurophysiology David J. Krasucki, BSN, RN, CCRN Villanova University/Crozer- Chester Medical Center School of Nurse Anesthesia Class of 2016

CPP = MAP – ICP CBF, ICP, & MAP

MAP and CPP

Hyperventilation Increase MAP CPP = MAP - ICP

Monro-Kellie Hypothesis Cerebrospinal Fluid 150 ml (10%) Ventricles 20% = 30 ml Cerebral Parenchyma 1400 ml (80%) SA Space 80% = 120 ml Spinal SA Space ~50% = ~75 ml Cerebral SA Space ~30% = ~45 ml Cerebral Blood Volume 150 ml (10%) Venous Arterial 20% = 20 -30 ml 80% = 80 – 120 ml

• c. VIH – Venogenic intracranial hypertension Space occupying lesion IICP Obstruction of venous blood (level of outflow cuff segments) Increased Intracranial volume Blood stasis

Space Occupying Lesion Decreased CBF Increased ICP Auto. Regulation Increase in CBVa+v Stability Boundary Increase in CBF (CBVa) Decreased Venous Drainage Increased ICP CSF shift into Spinal SA Decreased ICP Increased CPP Venous Drainage

What does this all mean?

Part II - Neuropharmacology Christopher M. Wike, BSN, RN, CCRN, SRNA Villanova University/Crozer- Chester Medical Center School of Nurse Anesthesia Class of 2016

Evidence Based Practice Short-term Outcomes • • • ICP CPP Brain Swelling Emergence Extubation Long-term Outcomes • • Mortality Rate Cognitive Ability Occupational Ability Recreational Ability

History

Dexmedetomidine

Neuroprotection Dexmedetomidine Glutamate Excitotoxicty Cell Survival

Neuroprotection Dexmedetomidine Bcl-2 Glutamine Mdm-2 Glutamate Mitochondrial Permeability p 53 Inhibition Excitotoxicty Cell Survival

Dexmedetomidine • Intraoperative – Hemodynamic perturbation – Awake procedures – Evoked potentials • Additional Points – Hypothermia – P 450 induction

Ketamine

Ketamine then • Gardner, Olson, & Lichtiger, 1971 – All 11 patients had increased ICP • Gibbs, 1972 – Only 6 out of 20 patients had increased ICP • Shapiro, Wyte, & Harris, 1972 – 5 out of 7 had increased ICP • Wyte, 1972 – 2 patients…

Cortical Spread Depolarization

Excess Glutamate Ketamine Extrasynaptic NMDAr Activation Calcium Influx Calpain Activation Na+/Ca 2+ Disabled Excess Calcium Influx Cellular destruction

Ketamine now • Cohen and colleagues, 2014 – 10 studies, 953 patients – 6 studies include TBI (GCS <8) – “No evidence…”

“WE HAVE ALWAYS DONE IT THIS WAY”

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