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CC BY-NC-ND 4.0 · J Neuroanaesth Crit Care 2020; 7(01): 27-33
DOI: 10.1055/s-0039-1693525
Brief Report

Inhalational Isoflurane Sedation in Patients with Decompressive Craniectomy Suffering from Severe Subarachnoid Hemorrhage: A Case Series

Felix Lehmann
1   Department of Anesthesiology and Intensive Care Medicine, Rheinische Friedrich-Wilhelms University of Bonn, Bonn, Germany
,
Marcus Müller
2   Department of Neurology, Rheinische Friedrich-Wilhelms University of Bonn, Bonn, Germany
,
Julian Zimmermann
2   Department of Neurology, Rheinische Friedrich-Wilhelms University of Bonn, Bonn, Germany
,
Ági Güresir
3   Department of Neurosurgery, Rheinische Friedrich-Wilhelms University of Bonn, Bonn, Germany
,
Victoria Lehmann
1   Department of Anesthesiology and Intensive Care Medicine, Rheinische Friedrich-Wilhelms University of Bonn, Bonn, Germany
,
Christian Putensen
1   Department of Anesthesiology and Intensive Care Medicine, Rheinische Friedrich-Wilhelms University of Bonn, Bonn, Germany
,
Hartmut Vatter
3   Department of Neurosurgery, Rheinische Friedrich-Wilhelms University of Bonn, Bonn, Germany
,
Erdem Güresir
3   Department of Neurosurgery, Rheinische Friedrich-Wilhelms University of Bonn, Bonn, Germany
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Abstract

Background Severe aneurysmal subarachnoid hemorrhage (SAH) may lead to the necessity of decompressive craniectomy (DC) to treat refractory elevated intracranial pressure (ICP). In some patients, adequate deep sedation, as one part of conservative treatment, cannot be achieved. Recent investigations suggest that inhalative sedation might not be as detrimental as considered before, and therefore a treatment option.

Materials and Methods A retrospective analysis of seven patients was performed who suffered from aneurysmal SAH (Hunt-Hess grade 3–5, Fisher's score 3) and underwent DC due to a critically elevated ICP. In these patients, the target sedation level could not be achieved even with high doses of intravenous sedatives. Thus, the sedative regimen was switched to inhaled anesthesia with isoflurane. Mean arterial pressure (MAP), ICP, cerebral perfusion pressure (CPP), levels of vasopressors, and respiratory parameters were analyzed.

Results Deep sedation (Richmond Agitation-Sedation Scale [RASS] −5, mean–fractional end-expiratory gas concentration [mean-Fet] 0.78%) was rapidly achieved in all patients after commencing general anesthesia with isoflurane. ICP remained stable when comparing 1 hour before the onset of isoflurane sedation (1) with 6 (2), and 12 hours (3) after commencing isoflurane anesthesia (mean ICP [1] 13.83 mm Hg; [2] 12.57 mm Hg; [3] 11.14 mm Hg). The mean duration of application was 9 (± 4) days. CPP could be maintained above 70 mm Hg without the need for extended vasopressor usage.

Conclusion In a setting of severe SAH and critically elevated ICP with the need for aggressive multimodal therapy, isoflurane was safely applied in those patients. Our sedation goal was rapidly achieved and critical rise in ICP was not observed. Further investigations are required to demonstrate that inhaled anesthesia with isoflurane can be a promising alternative option, as this drug has better controllable pharmacokinetics, no clinically relevant accumulation of the drug itself, and potential neuroprotective effects (so far reported in different animal models).

Keywords

decompressive craniectomy - intracranial pressure - sedation - subarachnoid hemorrhage - volatile anesthetics


Publication History

Article published online:
29 August 2019

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  • References

  • 1 Güresir E, Raabe A, Setzer M. et al. Decompressive hemicraniectomy in subarachnoid haemorrhage: the influence of infarction, haemorrhage and brain swelling. J Neurol Neurosurg Psychiatry 2009; 80 (07) 799-801
    CrossrefPubMedGoogle Scholar
  • 2 Rangel-Castilla L, Gopinath S, Robertson CS. Management of intracranial hypertension. Neurol Clin 2008; 26 (02) 521-541
    CrossrefPubMedGoogle Scholar
  • 3 Martin J, Heymann A, Bäsell K. et al. Evidence and consensus-based German guidelines for the management of analgesia, sedation and delirium in intensive care—short version. Ger Med Sci 2010; 8: Doc02
    PubMedGoogle Scholar
  • 4 Shafer A. Complications of sedation with midazolam in the intensive care unit and a comparison with other sedative regimens. Crit Care Med 1998; 26 (05) 947-956
    CrossrefPubMedGoogle Scholar
  • 5 Holmström A, Akeson J. Desflurane increases intracranial pressure more and sevoflurane less than isoflurane in pigs subjected to intracranial hypertension. J Neurosurg Anesthesiol 2004; 16 (02) 136-143
    CrossrefPubMedGoogle Scholar
  • 6 Holmström A, Akeson J. Sevoflurane induces less cerebral vasodilation than isoflurane at the same A-line autoregressive index level. Acta Anaesthesiol Scand 2005; 49 (01) 16-22
    PubMedGoogle Scholar
  • 7 Bazin JE. Effects des agents anesthésiques sur la pression intracrânienne. Ann Fr Anesth Reanim 1997; 16 (04) 445-452
    CrossrefPubMedGoogle Scholar
  • 8 Villa F, Iacca C, Molinari AF. et al. Inhalation versus endovenous sedation in subarachnoid hemorrhage patients: effects on regional cerebral blood flow. Crit Care Med 2012; 40 (10) 2797-2804
    CrossrefPubMedGoogle Scholar
  • 9 Bösel J, Purrucker JC, Nowak F. et al. Volatile isoflurane sedation in cerebrovascular intensive care patients using AnaConDa(®): effects on cerebral oxygenation, circulation, and pressure. Intensive Care Med 2012; 38 (12) 1955-1964
    CrossrefPubMedGoogle Scholar
  • 10 Purrucker JC, Renzland J, Uhlmann L. et al. Volatile sedation with sevoflurane in intensive care patients with acute stroke or subarachnoid haemorrhage using AnaConDa®: an observational study. Br J Anaesth 2015; 114 (06) 934-943
    CrossrefPubMedGoogle Scholar
  • 11 Diringer MN, Bleck TP, Claude Hemphill III J. et al.; Neurocritical Care Society, Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society's Multidisciplinary Consensus Conference. Neurocrit Care 2011; 15 (02) 211-240
    CrossrefPubMedGoogle Scholar
  • 12 Connolly Jr ES, Rabinstein AA, Carhuapoma JR. et al; American Heart Association Stroke Council, Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; Council on Cardiovascular Surgery and Anesthesia; Council on Clinical Cardiology. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2012; 43 (06) 1711-1737
    CrossrefPubMedGoogle Scholar
  • 13 Komotar RJ, Schmidt JM, Starke RM. et al. Resuscitation and critical care of poor-grade subarachnoid hemorrhage. Neurosurgery 2009; 64 (03) 397-410 , discussion 410–411
    CrossrefPubMedGoogle Scholar
  • 14 Sessler CN, Grap MJ, Brophy GM. Multidisciplinary management of sedation and analgesia in critical care. Semin Respir Crit Care Med 2001; 22 (02) 211-226
    Article in Thieme ConnectPubMedGoogle Scholar
  • 15 Sessler CN, Gosnell MS, Grap MJ. et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 2002; 166 (10) 1338-1344
    CrossrefPubMedGoogle Scholar
  • 16 Baron R, Binder A, Biniek R. et al; DAS-Taskforce 2015. Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015)—short version. Ger Med Sci 2015; 13: Doc19
    PubMedGoogle Scholar
  • 17 Soukup J, Schärff K, Kubosch K, Pohl C, Bomplitz M, Kompardt J. State of the art: sedation concepts with volatile anesthetics in critically Ill patients. J Crit Care 2009; 24 (04) 535-544
    CrossrefPubMedGoogle Scholar
  • 18 Dorfer C, Frick A, Knosp E, Gruber A. Decompressive hemicraniectomy after aneurysmal subarachnoid hemorrhage. World Neurosurg 2010; 74 (4-5) 465-471
    CrossrefPubMedGoogle Scholar
  • 19 Teitelbaum JS, Ayoub O, Skrobik Y. A critical appraisal of sedation, analgesia and delirium in neurocritical care. Can. J Neurol Sci 2011; 38 (06) 815-825
    PubMedGoogle Scholar
  • 20 Bösel J, Dziewas R. Sedation and weaning in neurocritical care: can concepts from general critical care be applied? [article in German]. Nervenarzt 2012; 83 (12) 1533-1541
    CrossrefPubMedGoogle Scholar
  • 21 Roberts DJ, Hall RI, Kramer AH, Robertson HL, Gallagher CN, Zygun DA. Sedation for critically ill adults with severe traumatic brain injury: a systematic review of randomized controlled trials. Crit Care Med 2011; 39 (12) 2743-2751
    CrossrefPubMedGoogle Scholar
  • 22 Roberts RJ, Barletta JF, Fong JJ. et al. Incidence of propofol-related infusion syndrome in critically ill adults: a prospective, multicenter study. Crit Care 2009; 13 (05) R169
    CrossrefPubMedGoogle Scholar
  • 23 Reade MC, Finfer S. Sedation and delirium in the intensive care unit. N Engl J Med 2014; 370 (05) 444-454
    CrossrefPubMedGoogle Scholar
  • 24 Pisani MA, Kong SY, Kasl SV, Murphy TE, Araujo KL, Van Ness PH. Days of delirium are associated with 1-year mortality in an older intensive care unit population. Am J Respir Crit Care Med 2009; 180 (11) 1092-1097
    CrossrefPubMedGoogle Scholar
  • 25 van den Boogaard M, Schoonhoven L, Evers AW, van der Hoeven JG, van Achterberg T, Pickkers P. Delirium in critically ill patients: impact on long-term health-related quality of life and cognitive functioning. Crit Care Med 2012; 40 (01) 112-118
    CrossrefPubMedGoogle Scholar
  • 26 Chui J, Mariappan R, Mehta J, Manninen P, Venkatraghavan L. Comparison of propofol and volatile agents for maintenance of anesthesia during elective craniotomy procedures: systematic review and meta-analysis. Can J Anaesth 2014; 61 (04) 347-356
    CrossrefPubMedGoogle Scholar
  • 27 Hans P, Bonhomme V. Why we still use intravenous drugs as the basic regimen for neurosurgical anaesthesia. Curr Opin Anaesthesiol 2006; 19 (05) 498-503
    CrossrefPubMedGoogle Scholar
  • 28 Massei R, Calappi E, Parma A, Granata G. Effects of inhalation anesthetics on intracranial pressure and cerebral blood flow velocity [article in Italian]. Minerva Anestesiol 1994; 60 (11) 643-647
    PubMedGoogle Scholar
  • 29 Kitano H, Kirsch JR, Hurn PD, Murphy SJ. Inhalational anesthetics as neuroprotectants or chemical preconditioning agents in ischemic brain. J Cereb Blood Flow Metab 2007; 27 (06) 1108-1128
    PubMedGoogle Scholar
  • 30 Deng J, Lei C, Chen Y. et al. Neuroprotective gases—fantasy or reality for clinical use?. Prog Neurobiol 2014; 115: 210-245
    CrossrefPubMedGoogle Scholar
  • 31 Pagel PS. Myocardial protection by volatile anesthetics in patients undergoing cardiac surgery: a critical review of the laboratory and clinical evidence. J Cardiothorac Vasc Anesth 2013; 27 (05) 972-982
    CrossrefPubMedGoogle Scholar
  • 32 Lee HT, Ota-Setlik A, Fu Y, Nasr SH, Emala CW. Differential protective effects of volatile anesthetics against renal ischemia-reperfusion injury in vivo. Anesthesiology 2004; 101 (06) 1313-1324
    CrossrefPubMedGoogle Scholar
  • 33 Fukuda S, Warner DS. Cerebral protection. Br J Anaesth 2007; 99 (01) 10-17
    CrossrefPubMedGoogle Scholar
  • 34 Plachinta RV, Hayes JK, Cerilli LA, Rich GF, Rich GF. Isoflurane pretreatment inhibits lipopolysaccharide-induced inflammation in rats. Anesthesiology 2003; 98 (01) 89-95
    CrossrefPubMedGoogle Scholar
  • 35 Kunst G. From coronary steal to myocardial, renal, and cerebral protection: more questions than answers in anaesthetic preconditioning?. Br J Anaesth 2014; 112 (06) 958-960
    CrossrefPubMedGoogle Scholar
  • 36 Fujii M, Yan J, Rolland WB, Soejima Y, Caner B, Zhang JH. Early brain injury, an evolving frontier in subarachnoid hemorrhage research. Transl Stroke Res 2013; 4 (04) 432-446
    CrossrefPubMedGoogle Scholar
  • 37 Kooijman E, Nijboer CH, van Velthoven CTJ. et al. Long-term functional consequences and ongoing cerebral inflammation after subarachnoid hemorrhage in the rat. PLoS One 2014; 9 (06) e9058
    PubMedGoogle Scholar
  • 38 Altay O, Suzuki H, Hasegawa Y, Ostrowski RP, Tang J, Zhang JH. Isoflurane on brain inflammation. Neurobiol Dis 2014; 62: 365-371
    CrossrefPubMedGoogle Scholar
  • 39 Altay O, Suzuki H, Hasegawa Y. et al. Isoflurane attenuates blood-brain barrier disruption in ipsilateral hemisphere after subarachnoid hemorrhage in mice. Stroke 2012; 43 (09) 2513-2516
    CrossrefPubMedGoogle Scholar