79th PostGraduate Assembly in Anesthesiology 2025

Intraoperative Intracranial Pressure Instability in a Polytrauma Patient Undergoing Emergent Fasciotomy: Anesthetic Challenges

INTRODUCTION

Polytrauma patients with traumatic brain injury (TBI) who require emergent lower extremity fasciotomies are at risk of intraoperative intracranial pressure (ICP) instability.
The choice of medications, ventilation strategy, or anesthetic technique greatly impact the ICP and hence neurologic and mortality outcomes.
Learning objectives: to discuss the modalities and indications of ICP monitoring, as well as the treatment of intraoperative intracranial hypertension.

CASE REPORT

21-year-old female involved in a high-speed motor vehicle collision as an unhelmetedmotorcycle passenger, initially combative and then unresponsive, requiring on field intubation.
On arrival to the ED, she was hemodynamically unstable with a FAST exam positive for retroperitoneal bleeding, requiring massive transfusion protocol of 15 pRBCs.
Initial evaluation identified skull, spine, lower extremity, and open-book pelvic fractures, as well as bilateral pneumothorax.
Glasgow Coma Scale score was 6 and head CT showed left frontal SDH, severe cerebral edema with minimal ventricular space and right sphenoid fracture with pneumocephalus.
Due to small ventricle size, placement of external ventricular drain (EVD) failed; hence a right frontal intraparenchymal ICP monitor was placed at bedside, with readings of around 10 mmHg.
The patient was emergently taken to the ICU, where she was found to have signs of bilateral lower extremity compartment syndrome, and emergency surgery was planned for fasciotomies.
On arrival to the operating room, ICP precipitously rose to 40 mmHg.
Neuroprotective measures were immediately initiated, including reverse trendelenburg positioning, administration of 1g/kg of 20% mannitol, and switching volatile anesthetics to propofol and increasing fentanyl infusions, which allowed surgery to proceed safely. Any external stimulation was stopped to avoid any pain.
OUTCOMES: Patient was transferred to the floor on POD 16 and discharged to a rehab facility on POD 44. Developed paroxysmal sympathetic hyperactivity (bouts of fever/tachycardia) requiring propranolol and clonidine but no other neuro deficits.

DISCUSSION

Intracranial hypertension during non-neurosurgical interventions is known to occur within the first two weeks after TBI. (1)
“ICP monitoring is recommended in comatose patients with (GCS ≤ 8) when evidence of structural brain damage is seen on initial CT imaging.”ACS Best Practices In The Management Of Traumatic Brain Injury 2024 Guidelines.
In patients with radiologic signs of severe TBI, invasive ICP and arterial pressure monitoring should be established prior to surgery. (2)
The gold standard for ICP measurement is an EVD as this has both diagnostic and therapeutic value. An intraparenchymal transducer is an alternative when rapid placement is needed, especially in the setting of severe cerebral edema or distorted ventricular anatomy.
Releasing compartment pressures may lead to systemic vasodilation by releasing the accumulated metabolites like potassium or lactic acid, triggering a compensatory increase in ICP.
Maintenance of anesthesia should be intravenous as inhalational agents increase ICP. Propofol is widely used for neuro-sedation and ICP reduction but may cause hypotension, so close monitoring is required.
Normocapnia (PaCO₂ 35–45 mmHg) is therefore the target in TBI management, as both extremes—hypocarbia and hypercarbia—are associated with poor outcomes due to their harmful effects on cerebral physiology.
Rescue measures for acutely increasing ICP include reverse Trendelenburg positioning, increasing opioids, avoiding pain stimulation, and hyperosmolar agents like mannitol. (3)
Furthermore, interventions like neuromuscular blocking, deepening sedation, and starting propofol and fentanyl infusions help reduce cerebral metabolic demand and avoid straining.

79th PostGraduate Assembly in Anesthesiology 2025

Intraoperative Intracranial Pressure Instability in a Polytrauma Patient Undergoing Emergent Fasciotomy: Anesthetic Challenges

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