TIGHT BRAIN CHECKLIST EFFECTIVE MANAGING BULGING BRAIN

I Gede Herry Yudiskara, Ida Bagus Krisna Jaya Sutawan

ANASTHESIA AND REANIMATION DEPARTEMENT OF UDAYANA MEDICAL FACULTY

SANGLAH HOSPITAL, DENPASAR

Introduction
Brain relaxation is important aspect of neuroanastheisa during intracranial surgery. Optimal brain
relaxation improve the operating condition, minimize the severity of refraction injury, with potensial
for providing patient with better outcome.
Objective
To describing how tight brain checklist can make effective action and communication beetwen
surgeon and anesthetist on bulging brain during craniotomy
Methods
We use tight brain checklist on male, 65 year old patient with haemorrhagic stroke (intracranial and
intraventricular haemorrhagic) who undergo trepanation decompression and clot evacuation. He was
170 cm tall and 65 kg wight, laboratory result were normal. Patient ASA III with geriatric, hemiplegia
dextra because previous hemorrhagic stroke and now with GCS E3V2M5. We gave midazolam 2
mg as premedication, Fentanyl 100 mcg for analgetic, propofol titration for induction and patient
hypnotize on 80 mg, we use rocuronium 40 mg as muscle relaxan. We gave mannitol 0.5 gr/kg 30
minute before opening duramater
Results
When the brain bulging, we ensure no airway pressure, further reduction of ETCO 2, MAP between
83-88 mmHg, no jugular compression, head up until 45°, change volatile to TIVA propovol, giving
more analgetic and mannitol. Since no improvement of brain relaxation, as the checklist, we
recommended to remove the hematomas. The result was completely relaxed brain.
Discussion
The surgeons visual and tactile assement remains the foundation of evaluation for brain relaxation.
On perioperative bulging brain, an anesthetist must know the right action or recommendation for the
surgeons to make the brain relaxed. Modified tight brain checklist from Miller Anesthesia textbook
as ABCDE neuroanasthesia, is easy schema to follow for perioperative bulging brain management.
Conclusions

Tight brain checklist can be use as standar operational procedure for bulging brain
management during craniotomy
References
1. Cottrell J E, Young L W 2010, Cottrell and Youg’s Neuroanesthesia 5th edn, Mosby Elsevier, USA
2. Miller R D. 2015, Miller’s Anesthesia 8th edn, Elsevier Saunders, Canada
3. Mahajan S, Bhagat H, Cerebral oedema : Pathophysiological mechanisms and experimental
therapies. Journal of Neuroanasthesiology and critical care 2016;3;28-22
4. Li J, Gelb W, Flexman M A, Ji F, Meng L, Definition, evaluation, and management of brain
relaxation during craniotomy 2016;11-1