Beruflich Dokumente
Kultur Dokumente
Tatang Bisri
Professor Anesthesiology
Indonesia
In patients with acute brain disease e.c TBI
the aim of intensive medical treatment is
provide condition favourable to the recovery
of the primary brain injury, while preventing
any secondary brain damage related to
elevated ICP, systemic arterial hypotension or
hypertension, hypoxaemia and hypercarbia,
an other alteration in the interior mileu.
Why pain must be treat?
• Influence outcome in a variety of way.
• Recovery from neurosurgical anesthesia is
followed by elevation in body oxygen
consumption and serum catecholamine
concentration.
• Pain Æ Systemic hypertension has been linked
to cerebral hyperemia, edema, hemorrhage/re-
bleeding, increase ICP.
• Preventing or control pain is one of mayor factor
in limiting these adverse systemic effect.
Why Treat?
• Agitation and BP increases
– Worsen brain swelling (in areas with
impaired auto-regulation)
– Intracranial hemorrhage
• Other physiologic effects
– Endocrine, immunologic, GIT,
Genitourinary, etc
• ? Development of Chronic Pain
Pain management for intracranial
procedure
• One of the most difficult problem in pain
management.
• The use of regional anesthesia is not an option.
• Oversedation can lead to hypercarbia and
hypoxemia.
• Cognitive function might be impaired because of
surgical area involved.
Sedation for patient comfort
• Under sedation with associated agitation affects
57% - 71% adult ICU patients.
• Severe agitation affects 43% of ICU patients
• Only 50% were amnesic for their ICU stay
Sessler CN et al. Chest. 1992
Fraser GL et al. Pharmacotherapy. 2000
• ICU patients commonly remove medical devices,
such as ETT or vascular catheters and these
event are often associated with agitation
Fraser et al. Int Pharmac Abstr. 1999
Effort to avoid problems
associated with undersedation
VRS = verbal rating scale. *P < 0.05 frontal vs fronto-temporal/pterional, temporal, occipital,
and posterior fossa; #< 0.05 frontal vs posterior fossa.
1. Opioids
• Codeine PO4
1. What drug
• Morphine
to give?
• Nalbuphine
2. What mode
2. Tramadol
of delivery?
3. Paracetamol
IV 4. NSAIDS
IM • Cox 2
PCA
Analgesia and sedation strategies
Park GR, Sladen RN. Sedation and Analgesia in the Critically ill,1995
The efficacy of intramuscular codeine for
post-craniotomy pain.
Codeine phosphat IM 60 mg q 3 hr PRN and
dimenhydrinate IM 50 mg q 4 hr PRN for
nausea.
Result: IM codeine is efficacious in treating post
craniotomy pain and result in a high level of
patient satisfaction. The prevention of high rate
of nausea/vomiting warrant further investigation.
Williams JM,et al. Can J Anaesth 1997;44;A28B
Scalp nerve blocks decrease the severity of pain
after craniotomy.
Postoperative scalp block with 20 mL
ropivacaine 0,75% decreases the severity of
pain after craniotomy and that this effect is long
lasting.