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Increased Intracranial Pressure After Massive Blood Loss -A Case Report

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Increased Intracranial Pressure After Massive Blood Loss -A Case Report Anesth Pain Med 2010; 5: 166～168 ￭Case Report￭ Increased intracranial pressure after massive blood loss -A case report- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea Ji Hyun Park, In-Gu Jun, Hyo Jung Son, and Mijeung Gwak A 4-year old boy with supravalvular ascending aortic stenosis damage. underwent sliding aortoplasty. After cardiopulmonary bypass wean- ing, aorta suture site was torn accidentally and the patient was in hypovolemic shock. Emergency cardiopulmonary bypass was rein- CASE REPORT stituted and the aorta was repaired. After removal of the aortic clamp, bradycardia and hypertension were noted. We suspected increased intracranial pressure due to hypoxic brain damage after A 4-year old boy, 25 kg weight and 110.6 cm height, with massive blood loss and the patient was treated to lower the severe stenosis at supravalvular ascending aorta was presented intracranial pressure. Physicians should be aware of the signifi- cance of the hemodynamic change associated with increased for sliding aortoplasty under cardiopulmonary bypass. intracranial pressure to prevent further neurologic damage. (Anesth The initial blood pressure was 103/57 mmHg and the pulse ∼ Pain Med 2010; 5: 166 168) rate was 92 beats/minute. He was under total intravenous Key Words: Hypoxic brain damage, Intracranial pressure, Massive anesthesia using propofol and remifentanil. No clinically hemorrhage. significant hemodynamic change was seen during extracorporeal cardiopulmonary bypass (CPB) and aortoplasty was performed without an event. The mean blood pressure during CPB was Acute massive blood loss during surgery may lead to maintained at 40-60 mmHg. After successful weaning of CPB, devastating hypoxic multiple organ failure. We report a case of the sutured ascending aorta was accidentally torn during mani- a child presented with supravalvular ascending aortic stenosis pulation. Sudden massive blood loss resulted in hypovolemic who underwent sliding aortoplasty. Acute massive hemorrhage shock. Intravenous fluid was given immediately, but the sys- occurred after weaning of cardiopulmonary bypass as the tolic blood pressure was too low to be detected. Cardiac sutured aorta was ruptured. This disaster led to hypovolemic massage was performed by the surgeon and epinephrine 0.01 shock and after successful resuscitation, the patient demon- mg was administered. Blood was transfused simultaneously. Ice strated hemodynamic changes assumed to be Cushing reflex, bags were placed near the patient’s head to decrease the brain which is a sign of increased intracranial pressure as a result of temperature for an effect of decreased cerebral metabolic rate hypoxic ischemic brain damage. Adverse neurologic outcome and methylprednisolone 0.5 mg/kg was also administered remains to be one of major problems even after successful intravenously. Both regional cerebral oximetry (Invos, Soma- Ⓡ resuscitation of hypovolemic shock. Thus anesthesiologists netics , Troy, USA) was initially 71−76%. But during cardiac should be informed of the neuroprotective strategies in case of massage, both regional cerebral oximetry was detected as 10− signs of increased intracranial pressure after hypoxic brain 15%. Emergency CPB was reinstituted after 10 minutes of cardiac massage and the torn aorta was repaired successfully. Received: August 24, 2009. The regional cerebral oximetry increased to 60% within 10 Revised: 1st, September 4, 2009; 2nd, October 27, 2009. minutes after reinstitution of the CPB (Fig. 1). Propofol 100 Accepted: December 29, 2009. mcg/kg/min and remifentanil 0.2 mcg/kg/min were continuously Corresponding author: Mijeung Gwak, M.D., Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of infused during CPB. After removal of the aortic clamp, the Medicine, Asanbyeongwon-gil 86, Songpa-gu, Seoul 138-736, Korea. Tel: heart rate was between 50−60 beats per minute and mean 82-2-3010-3876, Fax: 82-2-470-1363, E-mail: [email protected] arterial pressure was between 100−120 mmHg. The regional 166 Ji Hyun Park, et al：Increased ICP after massive blood loss 167 Fig. 1. Five minutes after the weaning of first CPB, (A) aorta is torn and cardiac massage is performed for 10 minutes. (B) Second cardiopulmonary bypass is reinstituted and regional cerebral oximetry is detected as 10−15% for a total of 20 minutes. rSO2 Rt: right regional cerebral oximetry, rOS2 Lt: left regional cerebral oximetry, MBP: mean Fig. 2. Brain MR image on 6th day after surgery. Extensive hypoxic blood pressure. ischemic encephalopathy involves posterior cerebral cortex and central gray matter with bilateral descending transtentorial herniation. cerebral oximetry was detected as 65−70% for both right and left. We suspected increased intracranial pressure (IICP) due to Cushing reflex, which is the sign of increased intracranial hypoxic brain damage after massive blood loss and mannitol pressure, is critical and important for anesthesiologists. 1g/kg, lasix 1 g/kg, thiopental 1 mg/kg, and dexamethasone Cushing reflex was first recognized by Harvey Cushing in 0.1 mg/kg were administered. A bolus of regular insulin 2.5 1,901 as the occurrence of hypertension, bradycardia, and res- unit was given since the blood sugar test revealed to be 310 piratory irregularity secondary to increased intracranial pressure mg/dl. Both pupils were isocoric and normally reactive to [1]. It is also called vasopressor response in which the light. The duration of second CPB was 270 minutes. Weaning pressure on the brainstem affects the vagus nerve to occur as from second CPB was possible with continuous infusion of bradycardic response [2]. Together with the adaptive increase epinephrine 0.3μg/kg/min, norepinephrine 0.2μg/kg/min, and in systolic blood pressure, this warning sign is a protective isoproterenol 0.2μg/kg/min. Assuming that the patient had reaction of the brain to preserve an adequate cerebral perfusion IICP, we maintained the mean blood pressure at 60−90 pressure [3,4]. mmHg. The patient was transferred to pediatric intensive care Increased intracranial pressure during surgery should be unit after the surgery. On the sixth day after the surgery, brain managed immediately to prevent further consequences. The magnetic resonance image showed extensive hypoxic ischemic optimal goal is to provide adequate oxygen by appropriate encephalopathy involving posterior cerebral cortex and central management to decrease the intracranial pressure and maintain gray matter with bilateral descending transtentorial herniation the cerebral perfusion pressure. For that purpose, several drugs (Fig. 2). The patient suffered quadriplegia and stuporous can be used including mannitol, barbiturate, and steroid. As in mentality secondary to hypoxic brain damage. He was referred our case, mannitol and steroid were used in an attempt to to rehabilitation team for physical therapy. decrease the ICP and stabilize further edema formation in addition to appropriate hemodynamic management [5,6]. The increased blood pressure and decreased heart rate in our DISCUSSION case was suspected as Cushing reflex for several reasons. Blood pressure may rise as an effect of epinephrine given Acute massive hemorrhage during surgery may result in during cardiac massage but the heart rate should not have serious hypoxic ischemic brain damage. The hypoxic brain decreased if it was the sole cause. We also ruled out damage in this case resulted in brain swelling which led to bradycardia caused by remifentanil that we used since the IICP followed by brain herniation. Prompt recognition of blood pressure would not be significantly high if this drug was 168 Anesth Pain Med Vol. 5, No. 2, 2010 overused. Also, if anesthetic depth was insufficient, heart rate should have increased. In addition, the continuously checked central venous pressure during cardiac massage did not REFERENCES increase which showed that the rise in blood pressure was not due to volume overload. 1.Cushing H. The blood pressure reaction of acute cerebral The regional cerebral oximetry plays an important role compression, illustrated by cases of intracranial hemorrhage. Am J Med Sci 1903; 125: 1017-44. during cardiac surgery in which neurologic complication is 2. Doba N, Reis D. Localization within the lower brain stem of a common. As in our case, the cerebral oximetry decreased as receptive area mediating the pressor response to increased the perfusion pressure had decreased. However after the second intracranial pressure (the Cushing response). Brain Res 1972; 47: CPB, it returned to normal. This phenomenon can be presumed 487-91. by some reasons. The cerebral oximety probes are usually 3. Agrawal A, Timothy J, Cincu R, Agarwal T, Waghmare LB. Bradycardia in neurosurgery. Clin Neurol Neurosurg 2008; 110: placed on the forehead of the patient which reflects the 321-7. fronto-temporal lobes but the brain ischemia in this patient was 4.Kalmar AF, Van Aken J, Caemaert J, Mortier EP, Struys MM. in the posterior cortex [7]. Value of Cushing reflex as warning sign of brain ischaemia during In cardiac surgery, anesthesiologists should always be aware neruoendoscopy. Br J Anaesth 2005; 94: 791-9. of possible neurologic complications in emergent situations. In 5. Rangel-Castilla L, Gopinath S, Robertson CS. Management of case of increased intracranial pressure after massive blood loss intracranial hypertension. Neurol Clin 2008; 26: 521-41. 6. Kofke WA, Stiefel M. Monitoring and intraoperative management detected by hypertension and bradycardia, the increased blood of elevated intracranial pressure and decompressive craniectomy. pressure should not be aggressively lowered since brain Anesthesiol Clin 2007; 25: 579-603. damage would be aggravated by decreased cerebral perfusion. 7. Tan ST. Cerebral oximetry in cardiac surgery. Hong Kong Med J 2008; 14: 220-5..
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