Anesthesia during surgery for pediatric traumatic brain injury

Abstract

Survival and neurological outcomes in children with traumatic brain injury (TBI) remain poor, despite the great effort toward improving outcomes in such patients. No single anesthetic protocol is suitable for all children with TBI undergoing surgical procedures. Although propofol offers advantages in terms of cerebral blood volume, a larger dose is required in children, increasing the risk of propofol infusion syndrome. Intracranial pressure monitoring should be considered when managing children with TBI. Hyperventilation (PCO2 of <25 mmHg) may cause cerebral ischemia. Temperature management is also very important, and hypothermia (32-33 °C) followed by rapid rewarming (0.5 °C every 2 h) is not recommended. Notably, hyperthermia in the early phase of TBI may cause poor neurological outcomes. Hemodynamic parameters are also critical, and the cerebral perfusion pressure should be >40 mmHg. Hypertonic saline may be used to avoid hyponatremia, which may cause brain edema and intracranial hypertension. Adequate postoperative sedation is required in the intensive care unit. Several pharmacological therapies have been developed to improve outcomes in children with TBI. Corticosteroid administration, however, is not recommended. Phenytoin may be used to prevent posttraumatic seizures. Barbiturates can be used to reduce intracranial pressure. Cerebrospinal fluid drainage may also effectively reduce intracranial pressure.