Is TIVA better than Is TIVA better than inhalation agents for inhalation agents for

elective brain surgery?elective brain surgery?

Siti Chasnak SalehDept. Anesthesiology Airlangga

Univ/ Dr. Soetomo Hosp. Surabaya

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TIVA vs INHALATION

Propofol (+opioid: fentanyl/remifenta

nil)

Sefovlurane (+ opioid:

fentanyl/remifentanil)

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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

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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

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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

Ideal IV anesthetic drug

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Pharmacokinetic

• Rapid redistribution & biotransformation • Inactive metabolites • Clearance independent of duration of administration • Duration of action unaffected by reduced renal or hepatic function • Rapid recovery

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Estimated changes in (CBF) and the (CMRO2) caused by volatile anesthetics

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Changes in (CBF) and the (CMRO2 ) caused by I V agents

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Effects of Anesthetic Agents

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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

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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

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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

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TIVA TIVA vs vs InhalationInhalation

Kaisti et al. Anesthesiology 2003; 99:603–1304/13/23 13

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PROPOFOLPROPOFOL

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

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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

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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

1st Interpretation

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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

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Anesthesiology 2001;95:616-626

Volatile anesth agents (iso/sevo)

Propofol

Volatile anesth

(iso/sevo)

Propofol

CO2 reactivity + (maintain) -

ICP ↑ ↓

CMRO2 ↓ ↓

CBF & CBV ↑ ↓

PONV < iso/sevo

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COST BENEFIT?

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CONCLUSIONCONCLUSION-1-1

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

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CONCLUSIONCONCLUSION-2-2

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.

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