thiopental and Subarachnoid-Hemorrhage

Thiopental prolongs the QT interval more than propofol, and the two induction agents were compared in patients with subarachnoid haemorrhage predisposed to electrocardiographic abnormalities and cardiac dysrhythmias.. Twenty-nine patients were studied randomly. Anaesthesia was induced with either thiopental or propofol and fentanyl; vecuronium was used as a neuromuscular blocking agent. The electrocardiogram and arterial blood pressure were monitored from before the induction of anaesthesia to 2 min after endotracheal intubation.. The median QT interval was at baseline 423 ms in the thiopental group and at 432 ms in the propofol group, and it increased in the thiopental group to 446 ms and decreased in the propofol group to 425 ms (P < 0.01 between groups). After induction and endotracheal intubation, the number of patients with increased QT dispersion was greater in the propofol group (P < 0.05). The incidence of cardiac dysrhythmias was similar in the study groups.. Thiopental and propofol are equally suitable for the induction of anaesthesia in patients with subarachnoid haemorrhage.

Topics: Anesthesia, Intravenous; Anesthetics, Intravenous; Arrhythmias, Cardiac; Electrocardiography; Female; Heart Rate; Humans; Male; Middle Aged; Monitoring, Intraoperative; Propofol; Subarachnoid Hemorrhage; Thiopental; Time Factors

The study aimed to investigate the indication and functional outcome after barbiturates and decompressive craniectomy (DC) as last-tier treatments for elevated intracranial pressure (ICP) in aneurysmal subarachnoid hemorrhage (aSAH). This observational study included 891 aSAH patients treated at a single center between 2008 and 2018. Data on demography, admission status, radiology, ICP, clinical course, and outcome 1-year post-ictus were collected. Patients treated with thiopental (barbiturate) and DC were the main target group.Thirty-nine patients (4%) were treated with thiopental alone and 52 (6%) with DC. These patients were younger and had a worse neurological status than those who did not require these treatments. Before thiopental, the median midline shift was 0 mm, whereas basal cisterns were compressed/obliterated in 66%. The median percentage of monitoring time with ICP > 20 mmHg immediately before treatment was 38%, which did not improve after 6 h of infusion. Before DC, the median midline shift was 10 mm, and the median percentage of monitoring time with ICP > 20 mmHg before DC was 56%, which both significantly improved postoperatively. At follow-up, 52% of the patients not given thiopental or operated with DC reached favorable outcome, whereas this occurred in 10% of the thiopental and DC patients.In summary, 10% of the aSAH cohort required thiopental, DC, or both. Thiopental and DC are important integrated last-tier treatment options, but careful patient selection is needed due to the risk of saving many patients into a state of suffering.

Topics: Decompressive Craniectomy; Humans; Intracranial Hypertension; Recovery of Function; Subarachnoid Hemorrhage; Thiopental

Topics: Decompressive Craniectomy; Humans; Intracranial Hypertension; Subarachnoid Hemorrhage; Thiopental; Treatment Outcome

Non-convulsive seizures (NCSZ) can be more prevalent than previously recognized among comatose neuro-intensive care patients. The aim of this study was to evaluate the frequency of NCSZ and non-convulsive status epilepticus (NCSE) in sedated and ventilated subarachnoid hemorrhage (SAH) patients.. Retrospective study at a university hospital neuro-intensive care unit, from January 2008 until June 2010. Patients were treated according to a local protocol, and were initially sedated with midazolam or propofol or combinations of these sedative agents. Thiopental was added for treatment of intracranial hypertension. No wake-up tests were performed. Using NicoletOne(®) equipment (VIASYS Healthcare Inc., USA), continuous EEG recordings based on four electrodes and a reference electrode was inspected at full length both in a two electrode bipolar and a four-channel referential montage.. Approximately 5,500 h of continuous EEG were registered in 28 SAH patients (33 % of the patients eligible for inclusion). The median Glasgow Coma scale was 8 (range 3-14) and the median Hunt and Hess score was 4 (range 1-4). During EEG registration, no clinical seizures were observed. In none of the patients inter ictal epileptiform activity was seen. EEG seizures were recorded only in 2/28 (7 %) patients. One of the patients experienced 4 min of an NCSZ and one had a 5 h episode of an NCSE.. Continuous EEG monitoring is important in detecting NCSZ in sedated patients. Continuous sedation, without wake-up tests, was associated with a low frequency of subclinical seizures in SAH patients in need of controlled ventilation.

Topics: Adolescent; Adult; Aged; Conscious Sedation; Critical Care; Electroencephalography; Female; Humans; Hypnotics and Sedatives; Intracranial Pressure; Male; Midazolam; Middle Aged; Monitoring, Physiologic; Prevalence; Propofol; Respiration, Artificial; Retrospective Studies; Status Epilepticus; Subarachnoid Hemorrhage; Thiopental; Young Adult

To report the occurrence of life-threatening hyperkalaemia following treatment with therapeutic thiopentone coma.. The neurosurgical intensive care units of Royal North Shore Hospital and Liverpool Hospital, Sydney, Australia.. Three patients treated with theraputic thiopentone coma. One patient with raised intracranial pressure secondary to a severe traumatic brain injury and two patients with refractory vasospasm secondary to subarachnoid haemorrhage. Two of the three patients developed hypokalaemia on starting thiopentone, which was resistant to potassium supplementation. All three patients developed severe hyperkalaemia during the recovery phase of coma. This was life-threatening in all three patients and fatal in one.. Severe hypokalaemia refractory to potassium therapy may occur during therapeutic thiopentone coma. Severe rebound hyperkalaemia may occur after cessation of thiopentone infusion. Protocols for the management of patients with therapeutic barbiturate coma should recognise this potentially serious complication.

Topics: Adult; Australia; Brain Injuries; Coma; Critical Illness; Female; Glasgow Coma Scale; Humans; Hyperkalemia; Hypnotics and Sedatives; Male; Middle Aged; Subarachnoid Hemorrhage; Thiopental; Treatment Outcome

Topics: Adult; Anesthesia, Intravenous; Anesthetics, Intravenous; Cerebral Hemorrhage; Child; Craniotomy; Fentanyl; Humans; Ischemic Attack, Transient; Male; Moyamoya Disease; Subarachnoid Hemorrhage; Thiopental

The effect of indomethacin, a cyclooxygenase inhibitor, was studied in the treatment of 10 patients with head injury and one patient with spontaneous subarachnoid hemorrhage, each of whom presented with high intracranial pressure (ICP) (34.4 +/- 13.1 mm Hg) and cerebral perfusion pressure (CPP) impairment (67.0 +/- 15.4 mm Hg), which did not improve with standard therapy using mannitol, hyperventilation, and barbiturates. The patient had Glasgow Coma Scale scores of 8 or less. Recordings were made of the patients' ICP and mean arterial blood pressure from the nurse's end-hour recording at the bedside, as well as of their CPP, rectal temperature, and standard therapy regimens. The authors assessed the effects of an indomethacin bolus (50 mg in 20 minutes) on ICP and CPP; an indomethacin infusion (21.5 +/- 11 mg/hour over 30 +/- 9 hours) on ICP, CPP, rectal temperature, and standard therapy regimens (matching the values before and during infusion in a similar time interval); and discontinuation of indomethacin treatment on ICP, CPP, and rectal temperature. The indomethacin bolus was very effective in lowering ICP (p < 0.0005) and improving CPP (p < 0.006). The indomethacin infusion decreased ICP (p < 0.02), but did not improve CPP and rectal temperature. The effects of standard therapy regimens before and during indomethacin infusion showed no significant changes, except in three patients in whom mannitol reestablished its action on ICP and CPP. Sudden discontinuation of indomethacin treatment was followed by significant ICP rebound. The authors suggest that indomethacin may be considered one of the frontline agents for raised ICP and CPP impairment.

Topics: Adolescent; Adult; Blood Pressure; Body Temperature; Brain Injuries; Carbon Dioxide; Cerebrovascular Circulation; Child; Cyclooxygenase Inhibitors; Female; Glasgow Coma Scale; Humans; Hyperventilation; Indomethacin; Infusions, Intravenous; Injections, Intravenous; Intracranial Pressure; Male; Mannitol; Pseudotumor Cerebri; Rectum; Subarachnoid Hemorrhage; Thiopental

In a review of 147 patients with intracranial aneurysms surgically treated by one surgeon (FAD) between 1980 and 1987, 36 selected patients received intraoperative barbiturate protection with sodium thiopental during temporary arterial occlusion. Thiopental doses of 5 to 15 mg/kg were used. Twenty-nine of 36 (81%) had ruptured aneurysms. Occlusion times ranged from 3 to 93 minutes, with a mean of 16.2 minutes. Seven patients had new neurological deficit in the immediate postoperative period, but in only two did these persist. Twenty-one patients (72%) with subarachnoid hemorrhage and 6 with incidental aneurysms made a good recovery. Of the 9 patients with significant permanent deficit, all but 2 were related to either the severity of the initial hemorrhage or to delayed vasospasm. In only one instance might temporary arterial occlusion have led to permanent neurological sequelae. Temporary arterial occlusion with barbiturate protection is a safe technique. For aneurysms that are more surgically complex, it allows for complete dissection of the aneurysm neck and identification and preservation of the surrounding vascular anatomy, while reducing the risk of intraoperative rupture and postoperative stroke.

Topics: Adult; Aged; Cerebral Arteries; Cerebral Infarction; Constriction; Female; Humans; Intracranial Aneurysm; Male; Middle Aged; Neurosurgery; Radiography; Subarachnoid Hemorrhage; Thiopental; Time Factors

In this study we report our clinical experience with supplementary thiopental loading, based on 30 patients undergoing surgery for intracranial aneurysm after a recent episode of subarachnoid haemorrhage. As standard procedure we used pentobarbitone induction, pancuronium relaxation, endotracheal intubation, maintenance with halothane 0.5%, N2O 66% in oxygen, fentanyl, and moderate hypocapnia. A thiopental load of up to 20 mg X kg-1 was supplied while the aneurysm was approached. Satisfactory and well-controlled hypotension was obtained in five cases after thiopental alone, and after thiopental and sodium nitroprusside (SNP) (means +/- s.d.) 1.3 +/- 0.9 microgram X kg-1 X min-1 in the remaining 25 patients. No ECG sign of myocardial ischaemia was observed. One disadvantage was a prolonged recovery period, which in some cases necessitated controlled ventilation for some hours. We conclude that thiopental loading can be used safely as a supplement to neuroanaesthesia for aneurysm surgery.

Topics: Adult; Anesthesia, General; Blood Pressure; Consciousness; Female; Heart Rate; Humans; Hypotension, Controlled; Intracranial Aneurysm; Male; Middle Aged; Nitroprusside; Pulmonary Gas Exchange; Rupture, Spontaneous; Subarachnoid Hemorrhage; Thiopental; Time Factors

Thirty patients with an acute midbrain syndrome were treated by high dose barbiturate therapy. Of these patients 19 had a severe head injury. In 8 patients the symptoms of acute midbrain syndrome developed after subarachnoid haemorrhage. In three patients these symptoms were caused by postoperative swelling or ischaemia. The results of those patients, who were treated with barbiturates after head injury were much better than in 16 other patients, who had no barbiturates. The indications for high dose barbiturate therapy in neurosurgery are discussed with reference to other publications and to the pathophysiological effects of barbiturates.

Topics: Adolescent; Adult; Brain Diseases; Brain Injuries; Humans; Mesencephalon; Middle Aged; Neurosurgery; Postoperative Complications; Subarachnoid Hemorrhage; Syndrome; Thiopental

The postoperative intracranial pressure (ICP) in 36 patients operated on for cerebral aneurysm following subarachnoid hemorrhage was studied. Not only was the baseline ICP significantly lower in patients whose outcome was assessed as "good" as compared with those patients with a worse outcome at 1 month after surgery, but also the height of the plateau waves and B-waves was significantly less in the patients who did well. The baseline ICP and the height of the B-wave formation were unrelated to the position of the aneurysm. Plateau waves were marginally significantly higher in aneurysms of the anterior communicating artery complex. Neither preoperative hypertension nor the use of antifibrinolytic agents made any difference to postoperative ICP. In patients with cerebral arterial vasospasm found preoperatively on the angiograms, the ICP tended to be lower in the postoperative period than in those without spasm.

Topics: Cerebral Arteries; Female; Humans; Intracranial Aneurysm; Intracranial Pressure; Male; Postoperative Complications; Postoperative Period; Subarachnoid Hemorrhage; Systole; Thiopental

Topics: Anesthesia, General; Blood Pressure Determination; Female; Halothane; Humans; Hypotension, Controlled; Intracranial Aneurysm; Preanesthetic Medication; Pregnancy; Pregnancy Complications, Cardiovascular; Propranolol; Rupture, Spontaneous; Subarachnoid Hemorrhage; Succinylcholine; Thiopental; Trimethaphan

Twenty patients with aneurysms of the internal carotid artery underwent temporary clamping, in turn, of the internal and then the common carotid artery. Cerebral blood flow, internal carotid artery pressure, and the EEG were recorded to assess the probability of cerebral ischaemia after permanent ligation. With this method of monitoring the cerebral circulation, 17 of the 20 patients had a permanent carotid ligation without neurological deficit; in the other three ligation was contraindicated. Although a correlation was observed between the reduction of cerebral blood flow and the fall in internal carotid artery pressure caused by temporary clamping (P<0·01), the scatter of data was too wide to predict cerebral blood flow from the change in carotid artery pressure. Similarly, EEG slowing was usually associated with low cerebral blood flow but exceptions occurred. Ligation was safe when, during temporary clamping, cerebral blood flow exceeded 40 ml/100 g/min, but was deemed unsafe when flow was less than 20 ml/100 g/min. In the range 20-40 ml/100 g/min, consideration of the internal carotid artery pressure permitted more patients to be safely ligated than if the decision had rested on changes in cerebral blood flow alone.

Topics: Adolescent; Adult; Aged; Anesthesia, General; Blood Pressure; Brain; Carotid Artery Diseases; Carotid Artery, Internal; Cerebrovascular Circulation; Electroencephalography; Humans; Hypertension; Intracranial Aneurysm; Ischemia; Middle Aged; Nitrous Oxide; Postoperative Complications; Respiration, Artificial; Subarachnoid Hemorrhage; Thiopental

Topics: Adult; Anesthesia, General; Craniotomy; Diagnosis, Differential; Electrocardiography; Humans; Male; Myocardial Infarction; Subarachnoid Hemorrhage; Thiopental; Wolff-Parkinson-White Syndrome