Episode #214 Navigating Anesthesia in Concussed Patients: Insights and Challenges

Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. We are returning to our article from our archives 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 Lifesciences, a major corporate supporter of APSF. Edwards Lifesciences has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Edwards Lifesciences – 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 Arnoley Abcejo and Jeffrey Pasternak. To follow along with us, head back over to APSF.org 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 symptoms 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.
• 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 institutions. 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 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 peri-anesthetic 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 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. 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 peri-anesthetic 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 peri-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, “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 end point. It is important to discuss with the patient that there may be a risk of worsening or continuing postconcussion symptoms as a result of proceeding with surgery and anesthesia care.

Back in 2018, we needed more research to help determine the peri-anesthetic 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 6 years. We are in luck because Arney Abcejo authored an ASA monitor article in 2022, “Perioperative Concussion: Learning from Football and Improving Patient Safety.” I will include the 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.

The authors provide additional information about the sustained pathophysiologic changes after head injury from an article by Abcejo and Pasternak in Neurosurgical Anesthesiology. Don’t worry, I will include this citation in the show notes, and I encourage you to check it. Here are the highlights:

• There are hyper- and hypometabolic 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.
• 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 recent concussion? 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 authors provide 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 (SCAT5) 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. 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 multi-disciplinary 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.

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. Mark your calendars.

If you have any questions or comments from today’s show, please email us at [email protected]. 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 APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

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Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

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