Summary of anesthetic considerations based on the 2016 Brain Trauma Foundation Guidelines for the Management of Severe Traumatic Brain Injury

Parameter/modality	Recommendation/comment	Anesthetic consideration
Treatment phase
Hyperosmolar therapy	Hyperosmolar therapy with mannitol or hypertonic saline may lower intracranial pressure, but there is insufficient evidence to support the use of one rather than the other.	Hyperosmolar agents are often required preoperatively and intraoperatively. When using mannitol, the anesthetist must be aware of fluid shifts; hypovolemia in a patient with concurrent hemorrhagic shock can be exacerbated.
Cerebrospinal fluid drainage	An EVD zeroed at the midbrain with continuous drainage of CSF may be considered to lower ICP; this may be more effective than intermittent use. The use of an EVD to lower ICP in patients with an initial GCS <6 during the first 12 hours of injury may be considered.	Continuous monitoring requires constant intraoperative vigilance; excessive drainage can lead to brain herniation.
Ventilation therapies	Hyperventilation is recommended as a temporizing measure for the reduction of elevated ICP. Hyperventilation should be avoided during the first 24 hours after injury when CBF is often critically reduced. Prolonged hyperventilation with a PaCO₂ of 25 mmHg or less is not recommended.	The target PaCO₂ is 35 to 45 mmHg; PaCO₂ is a powerful determinant of CBF. Low PaCO₂ levels result in low CBF and cerebral ischemia whereas high PaCO₂ levels can result in cerebral hyperemia and high ICP.
Anesthetics, analgesics, sedatives	The use of barbiturates to induce burst suppression as measured by EEG as prophylaxis against an elevated ICP is not recommended. High dose barbiturate administration is recommended to control elevated ICP refractory to maximum standard medical and surgical treatment. Propofol is recommended to help control ICP, but caution is required as high-dose propofol is associated with significant morbidity.	Patients with ICP elevation refractory to standard medical treatment may present to the operating room on a barbiturate infusion. High dose propofol should be avoided.
Steroids	The use of steroids is not recommended. High-dose methylprednisolone is associated with increased mortality.	Steroids are contraindicated and should not be administered in the OR.
Infection prophylaxis	General critical care protocols and practices should be followed to prevent ventilator-associated pneumonia; periprocedural antibiotics for intubation are no longer recommended.	Antibiotics before intubation are not required (a change from the previous 3rd edition guidelines).
Seizure prophylaxis	Early (within seven days of injury) administration of phenytoin is recommended to decrease the incidence of post-traumatic seizures. There is insufficient evidence to recommend levetiracetam (Keppra) over phenytoin regarding efficacy in preventing post-traumatic seizures.	Seizure prophylaxis with phenytoin is often initiated in the operating room. Intravenous fosphenytoin or levetiracetam should be considered instead of phenytoin due to risks associated with extravasation of phenytoin. Active seizures should be treated according to the standard of care (ie, midazolam or lorazepam).
Prophylactic hypothermia	Not recommended to improve outcomes in patients with diffuse injury.	Temperature monitoring for TBI patients is mandatory; normothermia should be maintained.
Monitoring phase
Intracranial pressure monitoring	Management of severe TBI patients using information from ICP monitoring is recommended to reduce post-injury mortality.	Although not supported by evidence meeting current standards, ICP should be measured in TBI patients with a GCS of 3 to 8 and an abnormal CT scan (ie, a scan that reveals hematomas, contusions, swelling, herniation, or compressed basal cisterns). ICP monitoring may also be indicated in severe TBI patients with a normal CT scan who are older than 40 years of age, have hypotension (SBP <90 mmHg), or exhibit unilateral or bilateral motor posturing.
Cerebral perfusion pressure monitoring	CPP monitoring is recommended to decrease mortality.	CPP is proportional to the gradient between MAP and mean ICP; MAP can be modulated directly by the anesthetist (ie, with vasopressors, fluids) and requires close monitoring (ie, with arterial catheter) and treatment in the operating room.
Advanced cerebral monitoring	Jugular bulb monitoring of arteriovenous oxygen content difference may be considered. Brain tissue oxygen monitoring is no longer recommended due to insufficient evidence.	Anesthetists should be aware of the presence of jugular bulb monitors, and how to correctly interpret the information provided by these devices.
Thresholds
Blood pressure	Maintaining SBP ≥100 mmHg for patients 50 to 69 years old or at ≥110 mmHg for patients 15 to 49 or >70 years old may be considered to decrease mortality and improve outcomes.	Monitoring blood pressure (ie, arterial catheter) and avoiding hypotension in patients with severe TBI is a major perioperative goal.
Intracranial pressure	Treatment for ICP greater than 22 mmHg is recommended because values above this level are associated with increased mortality.	In practice, a combination of ICP values, clinical exam, and brain CT findings are required to make management decisions.
Cerebral perfusion pressure	The recommended CPP value is 60 to 70 mmHg.	The exact threshold for CPP is unclear, and depends on the patient's autoregulatory status.
Advanced monitoring	A jugular venous saturation <50% may be a threshold to avoid in order to reduce mortality and improve outcomes.	Anesthetists should be aware of the presence of jugular bulb monitors, and how to correctly interpret the information provided by these devices.

EVD: external ventricular device; CSF: cerebrospinal fluid; ICP: intracranial pressure; GCS: Glascow coma scale; CBF: cerebral blood flow; EEG: electroencephalogram; OR: operating room; TBI: traumatic brain injury; CT: computerized tomography; SBP: systolic blood pressure; CPP: cerebral perfusion pressure; MAP: mean arterial pressure.

Adapted from: Carney N, Totten AM, O'Reilly C, et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery 2017; 80:6.

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Summary of anesthetic considerations based on the 2016 Brain Trauma Foundation Guidelines for the Management of Severe Traumatic Brain Injury