Article
Review of literature, safety and feasibility of long-term volatile sedtion with isoflurane in patients with severe SAHCF and CVDB contributed equally
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Authors
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Charlotte Flüh
- Department of Neurosurgery, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Deutschland
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Christian von der Brelie
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Deutschland
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Norbert Weiler
- Department of Anaesthesiology and Surgical Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Deutschland
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Michael Synowitz
- Department of Neurosurgery, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Deutschland
| Published: | June 9, 2017 |
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Outline
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Objective: Despite many positive effects, use of volatile anaesthetics in intensive care neurosurgical patients is rare. We aimed at evaluating the (long-term) use of isoflurane administered via the anaesthetic conserving device (AnaConDa®) in patients with severe aneurysmatic subarachnoid haemorrhage (SAH) on our neurosurgical intensive care unit (NICU) with regard to safety and feasibility.
Methods: We performed a systematic review of literature on Pubmed database. Additionally, 7 patients with severe SAH were sedated with isoflurane in addition to conventional continuous intravenous sedation between January and July 2016 on our NICU. We analysed the course of intracranial pressure (ICP), partial cerebral tissue oxygen pressure (ptiO2), pulmonary function, incidence of delayed cerebral ischemia (DCI), length of weaning phase, short-term outcome at discharge, unusual clinical findings and dosage of conventional sedatives.
Results: The review of the literature revealed that the use of isoflurane in critically ill neurosurgical patients might be safe, although sample sizes are small, and studies were exclusively monocentric and not randomized. Currently, systemized data on long-term use of isoflurane of SAH patients is not available: Only one study reported long-term sedation in three SAH patients. One other study evaluated the use of isoflurane in SAH patients, but gave the drug for only one hour. In our patients, use of isoflurane was safe in the majority of cases regarding the ICP. Two patients with a baseline ICP of 20mmHg and 9mmHg developed a critical ICP crisis, which emerged quickly and led to an immediate cessation of isoflurane administration. When both patients were sedated with isoflurane again in the later course of treatment with an ICP of less than 15mmHg when starting the administration (one patient had undergone decompressive hemicraniectomy in the meantime), isoflurane was tolerated without a rise in ICP and on a long-term basis. In patients with stable ICP isoflurane was given for a minimum of 5 hours and a maximum of 12 days. PtiO2 and pulmonary function were not altered in five of seven patients. DCI occurred in 6 of 7 patients. We did not observe long term complications. As unusual clinical findings, two patients developed abnormalities regarding pupillary diameter. Other sedatives like midazolam could be reduced in two patients.
Conclusion: Isoflurane should only be administered to SAH patients, when baseline ICP is not higher than 15mmHg and patients are not at risk of developing an ICP crisis. Continuous ICP monitoring is absolutely mandatory. As there is a lack of systemized data, larger prospective and randomized trials on the long term use of isoflurane in SAH patients are urgently needed.
