GEORG E. COLD • BENT L. DAHL

Topics in Neuroanaesthesia and Neurointensive (are

Springer-Verlag Berlin Heidelberg GmbH

Georg E. Cold . Bent L. Dahl

Topics in Neuroanaesthesia and Neurointensive Care Experimental and Clinical Studies upon Cerebral Circulation, Metabolism and Intracranial Pressure

Springer

Dr. GEORG E. COLD

Department of NeuroanaesthesiaÄrhus University Hospital8000 Ärhus, Denmark(E-mail:gcold@aaa.dk)

Dr. BENT 1. DAHLDepartment of NeuroanaesthesiaÄrhus University Hospital8000 Ärhus, Denmark

ISBN 978-3-642-07537-7 ISBN 978-3-662-04845-0 (eBook)DOI 10.1007/978-3-662-04845-0

Library of Congress-Cataloging-in-Publication-DataCold, G. E. (Georg Emil), 1938- . Topics in neuroanaesthesia and neurointensive care: experi­mental and cIinical studies upon cerebral circulation, metabolism, and intracranial pressure /Georg E. Cold and Bent L. Dahl. p.; cm,

IncIudes bibliographical references and index.1. Cerebral circulation. 2. Anesthesiology. 3. Pharmacology. 4. Brain-Effect of drugs on. I. Dahl,Bent L., 1956- . II. Tide.[DNLM: 1. Brain-blood supply. 2. Anesthetics-pharmacology. 3. Brain-drug effects. 4. Brain-me­tabolism . 5. Intensive Care. 6. Intracranial Pressure. 7. Neurosurgical Procedures . WL 302 C688t2002] RC388.5.C6652002 616.8-dc21

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Preface

The science of neuroanaesthesia and neurointensive care is fascinating, and the amounts of experimental and clinical studies are overwhelming. Surely, everyone can surf Medline and other database systems in order to get information. If you, however, ask for head injury, cerebral ischaemia or barbiturate, you will get hun­dreds, may be thousands of titles and even the same number of abstracts.

The aims of this book are to review important experimental and clinical data with emphasis on up-dated references. The text within each issue and sub-issue systematically covers experimental and clinical data separately, and details con­cerning cerebral blood flow, cerebral metabolism, intracranial pressure etc. are reviewed accordingly.

In our survey of the literature we did not use Medline or other database sys­tems systematically. Rather, we used available medical journals which covered the topics of anaesthesia, neuroanaesthesia and neurointensive care. In this way we hope that relevant literature is presented. On the other hand, we cannot exclude that some important issues are omitted.

The book covers 12 topics. In three chapters methodology of CBF measure­ments, regulation of CBF, and intracranial pressure are described. In the next 6 chapters inhalation anaesthetics, hypnotic agents, analgesics, muscular relaxants, drugs used for control of blood pressure, and the sitting position are reviewed. The last three chapters cover head injury, subarachnoid haemorrhage and cere­bral ischaemia.

We hope that the present book might offer some help in daily practice in neuroanaesthesia and in the care of neurointensive patients, when suddenly questions concerning therapy and management arise. Furthermore, we believe that the book might offer an assistance to researchers within the field of neuroanaesthesia, neurosurgery and neurointensive care in finding relevant up­dated references, and be an inspiration to people who want to perform even deeper exploration into the field of neuroscience.

Arhus, Denmark, April 2001 GEORG EMIL COLD

BENT LOB DAHL

Contents

Chapter 1 Methods of cerebral blood flow measurement .

Hydrogen clearance . . . . . . . . . . . . . . Microsphere technique ........... . The integral method of CBF measurement. Venous outflow technique ... . Autoradiographic method .. . The Kety and Schmidt method. The intraarterial approach ... Inhalation and intravenous method . Arterio-venous oxygen difference and jugular saturation Single-photon emission computed tomography. Positron emission tomography (PET) . Stable Xenon method ........... . MR imaging methods Doppler flowmetry . Laser flowmetry References . . . . . .

Chapter 2 Regulation of cerebral blood flow ((BF)

Human studies of CBF. . . . . . . . . Human studies of cerebral metabolic rate oxygen (CMR02) Regulation of CBF (viscosity, haemodilution and cardiac output Regulation by arterial oxygen tension (Pa02) Metabolic regulation . . Neurogenic regulation .......... . Nitric oxide (NO) ............ . The effects of different drugs upon CBF Regulation by arterial carbon dioxide (PaC02) Cerebral autoregulation References . . . . . . . . . . . . . . . . . . . . . .

Chapter 3 Intracranial pressure .

Methodology . . . . Patophysiology . . . Invasive or surgical approach to control of ICP-hypertension. Medical approach to control of ICP-hypertension Control of cerebral blood volume . . . . . . . . . . . . . . . . . .

1

1 1 2 2 2 3 3 4 4 4 5 5 6 6 7 7

13

13 13 16 16 17 19 20 21 21 26 30

43

43 44 47 47 47

VIn Contents

Cerebral arteriolar vasoconstriction Metabolic control of ICP Lidocaine ..... . Analgetics . . . . . . . . . Muscular relaxation . . . Osmotic agents and diuretics Kappa-opioid receptor agonists Corticosteroids . . Calcium blockers. . . . . . . . . Inhibitors of excitatory amino acidss .. THAM ................... . Strategies in the control of ICP-hypertension References ................... .

Chapter 4 Inhalation anaesthetics .

50 56 59 59 60 60 65 65 65 66 66 66 69

83

Effects of volatile anaesthetics on ion gates and cellular enzyme system 83 Halothane (experimental studies) . 85 Haltohane (human studies) ... 88 Enflurane (experimental studies) 90 Enflurane (human studies) 91 Isoflurane (experimental studies) 92 Isoflurane (human studies). . . . . . . . 99 Sevoflurane (experimental studies ., 102 Sevoflurane (human studies). . . . . . 103 Desflurane (experimental studies) ., 104 Desflurane (human studies) . . . . . . 105 Nitrous oxide (experimental studies) . 106 Nitrous oxide (human studies) 107 Xenon . . . . . . . . 108 General conclusion 109 References ..... 110

Chapter 5 Hypnotic agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

Receptor action ............. 125 Barbiturate (experimental studies) . . 126 Barbiturate (human studies) . . . . . . 130 Methohexitone (experimental studies) 132 Methohexitone (human studies) . 132 Althesin (experimental studies . 132 Althesin (human studies) . . . . . 133 Etomidate (experimental studies . . . . . . 133 Etomidate (human studies) ....... 134 Ketamin (experimental studies) . . . 135 Ketamin (human studies) ...... 136 Diazepam (experimental studies) . 137 Diazepam (human studies) . . . . . 138 Midazolam (experimental studies) 138 Midazolam (human studies) . . . 139 Propofol (experimental studies) . 139 Propofol (human studies) .... 141

Droperidol (experimental studies) . Droperidol (human studies) GABA ... Etanolone . References .

Chapter 6 Analgesics

Action of receptors and transmitters Morphine (experimental studies) Morphine (human studies) Pethidine ............. . Phenoperidine ......... . Fentanyl (experimental studies) Fentanyl (human studies ... . Neurolept anaesthesia ..... . Sufentanil (experimental studies) Sufentanil (human studies) .... Alfentanil (experimental studies . Alfentanil (human studies) . . . . Remifentanil (experimental studies) Remifentanil (human studies) .... Comparative studies of central analgetics Nalaxone (experimental studies) . Nalaxone (human studies) References . . . . . . . . . . . . . .

Chapter 7 Neuromuscular blocking agents and local analgesics

Succinylcholine (experimental studies) . Succinylcholine (human studies) .... D-tubocuranine (experimental studies) D-tubocuranine (human studies) . Pancuronium . . . . . . . . . . . . . Atracurium (experimental studies) Atracurium (human studies) Cisatracurium . Vecuronium ......... . Pipecuronium ........ . Lidocaine (experimental studies) Lidocaine (human studies) Procaine .. Tetracaine . Ropivacaine References .

Chapter 8 Drugs used for control of blood pressure . .

Sodium Nitroprusside (experimental studies) . Sodium Nitroprusside (human studies) ....

Contents IX

· 143 .144 .144

· .145 · .145

· . 159

· . 159 · .159 · .160

· .. 160 · .160

· 161 · .162 · . 163 · . 163 · .164 · . 165 · . 165 · .166 · .166 · .167 · .168 · . 168

· .. 168

· .173

· 173 .173 .174 .174

· .174 · .174 · . 175 · . 175 · . 175 · .175 · . 175

.177 · 178 · 178 · 178

· .. 178

· 183

.184 · .186

X Contents

Nitroglycerin (experimental studies) Nitroglycerin (human studies) .... Trimethaphan (experimental studies) Trimethaphan (human studies) . . . . ATP and adenosine (experimental studies) ATP and adenosine (human studies) Theophylline . Dipyridamole. . . . . . . Isotlurane . . . . . . . . . a and ~ blocking agents Ketanserin ..... . Postoperative period Calcium blockers. . . Central az-agonists ............. . Angiotensin converting enzyme inhibitors Prostaglandin El .. Clinical application Hypertensive drugs References .....

Chapter 9 The sitting position

Cardiovascular effects . . Cerebrovascular and spinal cord dynamics Air embolism . . . . . . . . . Treatment of air embolism . Clinical application Reference .......... .

Chapter 10 Acute head injury

Experimental studies Ischaemia ...... . Cerebral oedema .. . Cellular integrity and biochemical disorders Primary damage in human head injury . Secondary damage in human head injury .. Prognostic indicators . . . . . . . . . . . . . . Regulation of cerebral circulation and metabolism. Neurological assessment and monitoring Biochemical studies and monitoring . . . . . . . Therapy in acute head injury .......... . Guidelines for intensive care unit management . References ..................... .

Chapter 11 Aneurysmal subarachnoid haemorrhage.

Epidemiology. . . . . Experimental models Intracranial pressure

186 187 187 188 189 190 191 191 191 192 193 193 194 194 197 197 197 198

· .. 201

211

211 · 212 · 212 · 215 · 216 · 217

· 221

· 221 · .. 228 · .. 229

· 231 · 235 · 236 · 239 · 241 · 249

. . 251

. . 256 · .. 265 · .. 268

· 291

· 291 · 292

· .. 293

Central and cerebral haemodynamics . Vasospasm ..... . CSF biochemistry . Cardiac arrhythmia Treatment ..... . Monitoring .... . Perioperative management References . . . . . . . . . .

Chapter 12 Ischaemia . ..

Ischaemic thresholds Spreading depression Reperfusion after ischaemia Brain oedema . . . . . . . . . Biochemical changes in the ischaemic cell Gene expression .... . . . . Cerebral acidosis and glucose Temperature. . . . Different receptors Other drugs References . . . . .

Contents XI

.294 · .297 · .302 · .303 · .303 · .313 · .316 · .321

· .337

· .337 · .340 · .341 · .344 · .346 · .360 · .367 · .369 · .370 · .374

. ........... 376

Subject Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405

Abbreviations

A AMPA AVD02 AVS BBB CA CBF CBV CMR02 CPP CVR CSF CT CT-Xe DAI DHE EAA ECG EDRF EEG ET GABA HI HSP ICAM-I ICP LOI IVP MABP MAC MAC MR MRI MG NAME NIRS NMDA NMMA OEF PAF PET PKC PVI QIO SAH

Adenosine Alpha-amino-3-hydroxy-5-methyl-4-isovasole proprionic acid Arterio-venous oxygen content difference N,N -propylenedinicotinamide Blood-brain barrier Cerebral autoregulation Cerebral blood flow Cerebral blood volume Cerebral metabolic rate of oxygen Central venous pressure Cerebral vascular resistance Cerebrospinal fluid Computerized tomography Stable Xenon computerized tomography Diffuse axonal injury Dihydroergotamine Excitatory amino acid Electrocardiogram Endothelium-derived relaxing factor (NO) Electroencephalogram Endothelin y-aminobutyric acid Head injury Heat shock protein Intercellular adhesion molecule-l Intracranial pressure Lactate/oxygen index Intraventricular pressure Mean arterial blood pressure Middle cerebral artery occlusion Middle cerebral artery Magnetic resonance Magnetic resonance imaging Nitroglycerin NG-nitro-L-arginine methyl ester Near-infrared spectroscopy N-methyl-d-aspartate NG-monomethyl-L-arginine Oxygen extraction fraction Platelet -activating factor Positron emission tomography Protein kinase C Pressure volume index The ratio of metabolic rates at two temperatures differing by lOOC Subarachnoid haemorrhage

XIV

SD SNP SOD SPECT TCD THAM TMP VIP

Abbreviations

Spreading depression Sodium nitroprusside Superoxide dismutase Single photon emission computed tomography Transcranial Doppler Trishydroxy-methylaminomethan Trimethaphan Vasoactive intestinal polypeptide