You're listening to the Anesthesia Patient Safety Podcast , the official podcast of the Anesthesia Patient Safety Foundation . We're bringing you the very best from the APSF newsletter and website , as well as the latest information in perioperative patient safety . Thanks for joining us .
Hello and welcome back to the Anesthesia Patient Safety Podcast . My name is Allie Bechtel and I'm your host . Thank you for joining us for another show . We are returning to our article from our archive show to continue our discussion on keeping patients with concussions safe during anesthesia care .
Before we dive into the episode today , we'd like to recognize Edwards Life Sciences , a major corporate supporter of APSF . Edwards Life Sciences has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care . Thank you , edwards Life Sciences . We wouldn't be able to do all that we do without you .
During this episode , we will take a look at a past article that was published in the APSF newsletter that you can find on our website . Keep in mind that things may have changed a lot since the publication of these articles , but they are of interest from our archives . Our featured article is from the October 2018 newsletter .
It is Is a Concussed Brain , a Vulnerable Brain Anesthesia After Concussion , by Arnie Apsejo and Jeffrey Pasternak , and click on the newsletter heading . The fourth one down is newsletter archives . Then scroll down to the October 2018 newsletter and select our featured article today . I will include a link in the show notes as well .
Let's do a quick review from last week . Remember a concussion is the functional manifestations of mild traumatic brain injury due to any blow , jolt or strike to the cranium , with or without loss of consciousness . The diagnosis is clinical , with the most common symptom being headache .
Other symptoms include unsteadiness , difficulty concentrating , confusion , photophobia , nausea , drowsiness , amnesia , sensitivity to noise , tinnitus and hyperexcitability . Symptoms often resolve in the first week after injury , but recovery may take longer , especially for patients with repeated concussions .
The cerebral pathophysiology of concussion includes acute increases in cerebral metabolic rate , with later changes of increased blood flow , reduced metabolism and altered vascular responsiveness to changes in systemic blood pressure , arterial carbon dioxide , tension and brain activity .
Treatment involves physical and cognitive rest with the following goals Minimize physical activity , rest at home if possible , avoid making significant decisions , minimize activities , including reading , social visits and video games , and gradual return to activities as tolerated . Now it's time to return to the article right where we left off , with anesthesia after concussion .
Since this is a common injury , we may see patients for surgery and anesthesia care after sustaining a concussion . The authors report on the use of anesthesia for surgery and other procedures in patients who had recently sustained concussions at their institution . Here is what they observed from this retrospective review . Anesthesia after concussion is common .
They provided anesthesia to almost 15% of patients with concussion within the first year of their injury .
Interestingly , 44% of all anesthetics occurred within one month of the injury and almost one-third within the first week For patients requiring anesthesia care , the most common cause of concussion was motor vehicle accident-related injuries , and this included 36% of patients and 49% of all anesthetics .
The second most common cause was fall-related injuries , which involved 35% of patients and 31% of anesthetics . Finally , sports-related concussions made up 20% of the cohort and 13% of all anesthetics . Elective procedures after a recent concussion were not uncommon .
In this group , 5% of patients underwent elective procedures with anesthesia that were completely unrelated to the injury that resulted in the concussion . Within one week following their concussion , anesthetics were provided to patients who did not have a formal diagnosis of concussion .
7% of the patients did not receive a formal concussion diagnosis until at least one week following the injury . There were 29 anesthetics provided for patients before the concussion diagnosis was made . The authors remind us that the perianesthetic period is not a restful time .
Presenting to the hospital for surgery and anesthesia care often involves entering a foreign and stressful environment , meeting new people , answering many questions , making significant decisions all with bright lights , lots of noise , physical demands of moving to different locations or different beds .
The postoperative period may be difficult as well , since patients may have pain and require frequent monitoring and interruptions for medications and assessments . Another key point is that the concussed brain may be a vulnerable brain . Another key point is that the concussed brain may be a vulnerable brain .
Patients may experience significant physiologic changes throughout the perioperative period , including changes in blood pressure due to pain , surgical stimulation , blood loss , changes in autonomic function and pharmacologic effects . The vulnerable post-concussion brain with impaired blood flow autoregulation may be at risk for hypo and hyperperfusion during the perioperative period .
Patients with recent concussion may be at risk from hypoxia and other physiologic changes in carbon dioxide tension and blood glucose concentration , placing patients at higher risk for secondary injury to their vulnerable brain . Thus , the perianesthetic period may be a time when the vulnerable concussed brain with altered physiology is at risk for secondary injury .
Patients with chronic , repeated concussions may also be vulnerable during the perioperative anesthetic period . These patients may experience cognitive impairment , dementia and motor symptoms even before presenting to the operating room . The authors ask the important question . The authors ask the important question is recent concussion a possible patient safety risk ?
It seems likely that the acutely concussed brain and the brain that has suffered chronic , repeated concussions . Both represent vulnerable brains . So what can anesthesia professionals do to help keep patients with concussions safe during anesthesia care ?
Anesthesia professionals need to remain vigilant during the preoperative evaluation to identify patients with diagnosed or undiagnosed concussion , especially in patients with recent trauma . Keep in mind that concussions may be due to sports-related injuries , motor vehicle accidents , falls and assaults .
Patients with persistent post-concussive symptoms may benefit from delaying elective surgery until symptom resolution or new data support a different endpoint . It is important to discuss with the patient that there may be a risk of worsening or continuing post-concussion symptoms as a result of proceeding with surgery and anesthesia care .
Back in 2018 , we needed more research to help determine the perianesthetic risk for patients with acute and chronic repeated concussions , along with recommendations to help guide clinicians to help minimize the risk to a potentially vulnerable brain .
We made it to the end of the APSF article , but it's time to see if there have been any updates in the past six years . We are in luck because Arnie Absejo authored an ASA Monitor article in 2022 , perioperative Concussion Learning from Football and Improving Patient Safety . I will include this citation in the show notes as well .
Over the past 17 years , we have learned a lot about concussions , including defining chronic traumatic encephalopathy for patients who sustained repetitive head injuries leading to histologic , cognitive and pathophysiologic neurologic changes .
Additional information about the sustained pathophysiologic changes after head injury from an article by Absejo and Pasternak in Neurosurgical Anesthesiology . Don't worry , I will also include this citation in the show notes and I encourage you to check it out .
Here are the highlights there are hyper and hypo metabolic changes in cerebral function leading to an energy supply-demand mismatch . There may be systemic hemodynamic changes that occur after concussion , including diminished heart rate variability during stress and altered autonomic dysregulation blood pressure responsiveness autonomic dysregulation blood pressure responsiveness .
There may be diminished cerebral autoregulatory processes and pathophysiologic changes in cerebral blood flow . We have learned more about the subclinical cerebral physiologic changes that may last for weeks or months after the injury since 2018 . A 2018 study in young athletes reported that cerebral autoregulation was impaired even in patients with a normal Glasgow Coma Scale .
What about symptoms in patients with recent concussion after surgery ? For this we can look at the 2021 article by D'Souza and colleagues . Recent Preoperative Concussion and Postoperative Complications a Retrospective Matched Cohort Study . The authors found no difference in postoperative headache agitation , nausea or pain .
On multivariate analysis Univariate analysis in patients within 30 days after concussion revealed significantly higher rates of postoperative headache and high pain scores after surgery . Additional research in this area is definitely needed . What can anesthesia professionals do to improve anesthesia patient safety for patients with ?
Just like in 2018 , there is still a lot that we do not know , since there are no prospective studies Based on the current literature . The author provides some excellent considerations . Patients with recent concussion may need anesthesia , and this is rather common . Making the clinical diagnosis of concussion is easy and an important step .
Check out the Sport Concussion Assessment Tool to rule out concussive symptoms after head injury . Check out the show notes for more information For patients with symptoms from a recent concussion . You may want to consider delaying elective procedures that require anesthesia .
It is important that after any traumatic brain injury leading to concussive symptoms , patients should undergo a minimum of 24 hours of physical and cognitive rest . Minimum of 24 hours of physical and cognitive rest . We don't have any recommendations for ideal timing for elective surgery and anesthesia after concussion at this time .
Another important consideration is that the cerebral pathophysiologic changes may last for weeks after the injury , even after symptoms resolve , with persistent changes in brain physiology , metabolism and function . At the author's institution . The recommendation is for multidisciplinary decision making on delaying elective surgery in patients with recent concussion who remain symptomatic .
There are practice recommendations from the Brain Trauma Foundation for severe traumatic brain injury which may be considered for patients with concussion as well . The guidelines recommend avoiding unnecessary hyperventilation , avoiding unnecessary corticosteroids , maintaining normotension and avoiding hypoxia . Containing normotension and avoiding hypoxia .
A patient with a recent concussion may present to an operating room near you , and anesthesia professionals must remain vigilant for a history of concussion , as well as the signs and symptoms preoperatively , and be able to diagnose concussion . Future studies will help us to continue to modify our practice to help keep patients with concussion safe during anesthesia care .
What a great review , past and present . We'll be back next week for an all-new show from the June 2024 APSF newsletter , so mark your calendars . If you have any questions or comments from today's show , please email us at podcast at apsforg .
Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice . We hope that you will visit aSForg for detailed information and check out the show notes for links to all the topics we discussed today , if you have not done so already .
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Until next time , stay vigilant so that no one shall be harmed by anesthesia care .