gms | German Medical Science

65th Annual Meeting of the German Society of Neurosurgery (DGNC)

German Society of Neurosurgery (DGNC)

11 - 14 May 2014, Dresden

Inhalational Isoflurane sedation in patients with decompressive craniectomy suffering from severe subarachnoid hemorrhage: A case series

Meeting Abstract

  • Felix Lehmann - Klinik für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Bonn
  • Marcus Müller - Klinik für Neurologie, Universitätsklinikum Bonn
  • Ági Oszvald - Klinik für Neurochirurgie, Universitätsklinikum Bonn
  • Christian Putensen - Klinik für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Bonn
  • Hartmut Vatter - Klinik für Neurochirurgie, Universitätsklinikum Bonn
  • Erdem Güresir - Klinik für Neurochirurgie, Universitätsklinikum Bonn

Deutsche Gesellschaft für Neurochirurgie. 65. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie (DGNC). Dresden, 11.-14.05.2014. Düsseldorf: German Medical Science GMS Publishing House; 2014. DocP 163

doi: 10.3205/14dgnc557, urn:nbn:de:0183-14dgnc5573

Published: May 13, 2014

© 2014 Lehmann et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.



Objective: Severe aneurysmal subarachnoid hemorrhage (SAH) may lead, primarily or during the time course, to the necessity of decompressive craniectomy (DC) in order to treat refractory elevated intracranial pressure (ICP). In some patients, adequate deep sedation, as one part of conservative treatment of elevated ICP, can’t be achieved. Recent investigations suggest that inhalative sedation protocols might not be as detrimental as considered before, and might be an option in this clinical setting.

Method: We treated 5 patients with severe SAH (Hunt & Hess 3–5, Fisher 3), all suffering from elevated ICP refractory to conservative therapeutic regime, who underwent DC. Difficulties in reaching the targeted deep sedation (Richmond Aggitation Sedation Scale (RASS) -5) with high doses of i.v. sedatives lead to the start of inhalational sedation with Isoflurane in combination with opioids.

Results: Deep sedation (Mean-Fet 0,85%) was achieved in all patients within seconds after initiation of the inhalative sedation. ICP remained stable comparing the status one hour before onset of Isoflurane sedation (1) to the status 6 (2), and 12 hours (3) afterwards (mean ICP (1) 14,2 mmHg; (2) 13 mmHg; (3) 9,4 mmHg). The mean duration of application was 8 (±5) days. Cerebral perfusion pressure (CPP) could be maintained in our therapeutical range above 70mmHg without the need for extended vasopressor usage.

Conclusions: In a setting of severe SAH and critically elevated ICP with the need for aggressive multimodal therapy, including DC and deep sedation, inhalative Isoflurane was safely applied. Our sedation goal was easily achieved and undesirable effects like a critical rise in ICP were not observed. Further investigations are warranted, since Isoflurane has better controllable pharmacokinetics, no accumulation of clinical importance and neuroprotective effects in animal models as well.