FUNDAMENTALS OF

NEUROANESTHESIA
ABDUL HANNAN SHAHID
RESIDENT SKMCH & RC
AIMS OF NEUROANESTHESIA

• Maintenance of adequate cerebral perfusion pressure

• Control of intracranial pressure
• Brain weighs only 2% of body weight
• Receives 15% of cardiac output (700 mL/min or 50 mL/100 g/min)
• 20% of Oxygen consumption at rest
• Relies only on aerobic metabolism
CEREBRAL BLOOD FLOW

• Can be described by Hagen-Poiseuille Law

• CBF =
CEREBRAL PERFUSION PRESSURE

• Effective pressure that results in blood flow to the brain

MAP =Mean Arterial Pressure

• CPP = MAP - ICP

ICP = Intracranial Pressure

• CPP varies with MAP
AUTOREGULATION

• Maintains CBF between the range of 50-150mmHg (60-160mmHg)

• Outside these limits varies passively with Perfusion Pressure
• Impaired or abolished in the presence of brain tissue acidosis, following head injury,
acute intracranial disease
 CBF

Oxygen Anesthetic
Metabolism CO2 Tension Temperature Viscosity
Tension Agents
METABOLISM

• Determines CBF
• Increased CBF with increased Metabolism i.e. seizures, pain, anxiety
• Decreased CBF with decreased Metabolism i.e. hypothermia, coma, with anesthetic drugs
CARBON DIOXIDE TENSION

• CBF is extremely sensitive to changes in CO2

• Manipulation of CO2 levels can produce a profound effect on CBF
• Increase or decrease of 4% CBF for each 1 mmHg change in PaCO2
OXYGEN TENSION

• Decrease in PaO2 leads to Increased CBF because of vasodilation

• The activation of oxygen-sensitive ion channels leads to the release of vasoactive
substances such as NO, adenosine, and prostacyclin that result in vasodilation
• A value of <7kPa (53mmhg) is required before cerebral vasodilatation occurs
TEMPERATURE AND VISCOSITY

• Hypothermia reduces cerebral metabolism by 5% per °C, thereby reducing CBF

• No effect on CBF when the HCT is between 30% and 50%
INTRACRANIAL PRESSURE

• Intracranial pressure is the pressure within the intracranial cavity relative to atmospheric
pressure
• Normal ICP is 5–12mmhg
 Intracranial Vault

Blood CSF
Brain Parenchyma
10% 5%
85%
(100-130ml) (75ml)
MONRO-KELLIE DOCTRINE

• Since the intracranial contents are contained within the rigid skull vault, any increase in
the volume of one component must be offset by a reduction in the volume of the other
component if the pressure is to remain the same
 Raised ICP
Causes
Increase in
Increase in Brain Increase in CSF
Cerebral Blood Increase in ECF
Substance Volume
Volume

Increased
Tumor Increased CBF Cerebral Edema
Production
• Abscess • Decreased • Decreased
• Hematoma Cerebral Absorption
Venous
drainage
SIGN AND SYMPTOMS OF RAISED ICP

• Early: headache, vomiting, seizures, focal neurology, papilledema

• Late: increasing BP and bradycardia. Agitation, drowsiness, coma, Cheyne–Stokes
breathing, apnea. Ipsilateral, then bilateral, pupillary dilatation; decorticate, then
decerebrate posturing
ANESTHETIC AGENTS

• IV agents
• Inhalational agents
• Neuromuscular blocking drugs
• Opiates
• Diuretics
IV AGENTS

• All IV agents decrease cerebral metabolism, CBF, and ICP, with the exception of
ketamine.
• Ketamine increases CBF and ICP.
INHALATIONAL AGENTS

• Volatile agents decrease cerebral metabolism BUT increase CBF because of vasodilation
that may cause increase in ICP.
• Halothane causes the greatest increase in ICP, and isoflurane the least.
• ICP is unaffected by concentrations of <1 MAC of isoflurane, sevoflurane, and
desflurane.
• Nitrous oxide increases ICP, CBF and cerebral metabolism.
NEUROMUSCULAR BLOCKING DRUGS

• Succinylcholine may cause increase in intracranial pressure due to muscle fasciculation

and increased venous pressure.
• The non-depolarizing agents do not have an effect on ICP.
OPIATES

• Fentanyl and morphine have little effect on intracranial pressure or blood flow.
DIURETICS & STEROIDS

• Mannitol is a large molecule that does not cross the intact blood brain barrier.
• It is used in prevention and treatment of cerebral edema and it causes a reduction in ICP.
• The usual dose is 0.5 – 1g/kg.
• Furosemide at dose of 1mg/kg produces reduction in ICP to the same extent as mannitol
at 1g/kg. It is advantageous as it also reduces CVP.
• Dexamethasone at dose of 8-16mg is useful to reduce cerebral edema associated with
tumors.
A-AGONISTS

• Phenylephrine and noradrenaline

• Fewer alpha receptors in the cerebral vasculature
• Selective effect on systemic vascular resistance

• Cerebral vascular resistance is relatively unaffected