A small compilation of nurse anesthesia care plans

These anesthesia care plans are meant to inspire nurse anesthesia residents when they are making their care plans. Always make sure you fully understand and "own" your care plan. Your plan must be specific for your patient and should always be with the most up-to-date information.

Traumatic Brain Injury

Cause of Brain Injury

Sudden trauma causes injury to the brain. The head hits an object suddenly and violently, or the object pierces the skull and enters brain tissue. It can lead to death and disability. Events cause secondary injury, which manifests over time due to hypotension and hypoxia. You may see alterations in cerebral blood flow and increased intracranial pressure.

Global injuries are often the result of diffuse axonal injury due to rapid deceleration and rotation, resulting in shearing between neocortical grey and white matter

ICP Determinants

Brain 12%, intracellular water 78%, and CSF and blood for a total volume of 1,200-1,500 mL

Normal ICP 5-15 mmHg

Elevated ICP

  • HA, N/V, papilledema, focal neurologic deficits, altered ventilation, and LOC, seizures, and coma

Symptoms

Varies with the severity of the injury

Glasgow Coma Scale

  • 3 - 15 based on verbal, motor, and eye-opening is used to classify the severity of the injury
  • In general, a GCS of 13 or above is mild, 9-12 moderate, and 8 or below severe injury

Other important issues, such as length of loss of consciousness, post-traumatic amnesia, and pupils (fixed pupils have poor prognosis)

Mild

Brief loss of consciousness, headache, confusion, lightheadedness, dizziness, blurred vision, ringing in ears, bad taste in mouth, fatigue, or lethargy

Changes in sleep patterns, behavioral changes, memory, concentration, and attention issues

Moderate

As above, persistent headache, vomiting and nausea, convulsions, seizures, coma, dilation of one or both pupils, slurred speech, weakness or numbness in extremities, loss of coordination, restlessness, or agitation

Treatment

X-rays, CT scans, surgeries as indicated, rehabilitation (PT/OT/speech/psychiatry/psychology and social support)

Anesthetic Considerations

Increase in cerebral metabolic rate for oxygen (CMRO2) = increase in CBF

  • This concept is known as cerebral coupling

An increase in PaCO2 = vasodilation and increased CBF

Decrease PaO2 <50 mmHg increases CBF

Autoregulation of CBF with MAP 50-150

  • Outside these parameters, there is decreased/increased flow
  • After traumatic brain injury, this autoregulation may be disrupted, and flow becomes pressure-dependent

Anesthesia Affects CBF

Inhalational Agents

Increase CBF = increased ICP

Decrease CMRO2

Decrease CPP (MAP-ICP)

IV Agents 

Decrease CBF, CMRO2, ICP, and CPP except for etomidate

Ketamine increases CBF, CMRO2, ICP, but decreases CPP

Induction

The goal is to reduce CBV

  • Thiopental and propofol both reduce CBF and ICP

Avoid ketamine and etomidate

Opioids are used to blunt sympathetic response to laryngoscopy but can cause increased CBF

Consider the use of NS as opposed to the hypotonic LR (LR osmolality 273, NS osmolality 308), which decreases the risk of increased ICP

Avoid hyperglycemia

Elevate HOB, if possible, to facilitate gravity drainage

Emergence

Avoid hypertension, tachycardia