PAIN MANAGEMENT FOR

TRAUMATIC BRAIN INJURY

Tatang Bisri
Professor Anesthesiology
Indonesia
In patients with acute brain disease e.c TBI
the aim of intensive medical treatment is
provide condition favourable to the recovery
of the primary brain injury, while preventing
any secondary brain damage related to
elevated ICP, systemic arterial hypotension or
hypertension, hypoxaemia and hypercarbia,
an other alteration in the interior mileu.
 Why pain must be treat?
• Influence outcome in a variety of way.
• Recovery from neurosurgical anesthesia is
followed by elevation in body oxygen
consumption and serum catecholamine
concentration.
• Pain Æ Systemic hypertension has been linked
to cerebral hyperemia, edema, hemorrhage/re-
bleeding, increase ICP.
• Preventing or control pain is one of mayor factor
in limiting these adverse systemic effect.
 Why Treat?
• Agitation and BP increases
– Worsen brain swelling (in areas with
impaired auto-regulation)
– Intracranial hemorrhage
• Other physiologic effects
– Endocrine, immunologic, GIT,
Genitourinary, etc
• ? Development of Chronic Pain
 Pain management for intracranial
procedure
• One of the most difficult problem in pain
management.
• The use of regional anesthesia is not an option.
• Oversedation can lead to hypercarbia and
hypoxemia.
• Cognitive function might be impaired because of
surgical area involved.
 Sedation for patient comfort
• Under sedation with associated agitation affects
57% - 71% adult ICU patients.
• Severe agitation affects 43% of ICU patients
• Only 50% were amnesic for their ICU stay
Sessler CN et al. Chest. 1992
Fraser GL et al. Pharmacotherapy. 2000
• ICU patients commonly remove medical devices,
such as ETT or vascular catheters and these
event are often associated with agitation
Fraser et al. Int Pharmac Abstr. 1999
Effort to avoid problems
associated with undersedation

ƒ Oversedation Æ that lead to prolonged

ventilatory support, longer ICU stay,
medical evaluation for failure to awaken,
increase risk of infection, high cost.

Riker RR, WCA 2000, Canada

Complication of neurosurgical pain
management

• Mental status changes

• Elevation of PaCO2
• Hypoxemia
• Hypotension
• Nerve injury
• Infection (aspiration pneumonia)
 Controversial topic
• Not everyone agrees • Recent evidence
that it is a serious shows that pain is not
problem an insignificant
• Treatment entails risk problem
of • Widespread
– Sedation undertreatment of
– Miosis pain
– Respiratory depression • Increasing use of
– PONV remifentanil
• Use of NSAIDs: risk of • ? Development of
bleeding chronic pain
Postoperative pain in neurosurgery : A pilot
study in brain surgery
The conventional wisdom that most
neurosurgical patients have reduced analgesic
requirements was recently challenged.
Reported that 60% of their craniotomy patient
suffered pain; in two third their patient, pain
was moderate and severe.

De Beneddittis G, et al. Neurosurger 1996;38(3):466-70

A postal questionnaire was sent to 183
consultant member of Neuroanesthesia
Society of Great Britain and Ireland, replies
received from 110 neuroanesthetist in 37
different neurosurgical centre. More than half
believed that postoperative neurosurgical pain
was undertreated.

Stoneham MD. Eur J Anesthesiol 1995;12(6):571-5

Most patient report minimal pain after intracranial surgery, but
that a small subset of patients, many of whom have undergone
frontal craniotomies, require aggresive treatment of
postoperative pain.
Dunbar, P. J. et al. Anesth Analg 1999;88:335-40.

Figure 1. Most intracranial surgery patients reported no postoperative pain to

postanesthesia care unit nurses. A small number did report severe to
moderate pain.
Moderate to severe pain for the firdt 2 days and that pain is
inadequate treated.
Gottschalk A, et al.J. Neurosurgery 2007
The intensity of postoperative pain in neurosurgery is
affected by the site of craniotomy. Frontal craniotomy patient
experienced the lowest pain score, and required significantly
less opioid than patient undergoing posterior fossa
interventions.
Can J Anesth 2007;54(7):544-48.
 Cumulative
dose of codeine
Craniotomy site Patients Mild Moderate Severe at 48 hr (mg)

Frontal * 68 33 (49) 22 (32) 13 (19) 453 ± 417 #

Fronto- 78 12 (15) 46 (59) 20 (26) 657 ± 630
temporal/pterional
Temporal 46 4 (9) 31 (67) 11 (24) 603 ± 448
Parietal 34 12 (32) 17 (50) 8 (24) 530 ± 676
Occipital 21 5 (24) 13 (62) 3 (14) 446 ± 362
Posterior fossa 52 8 (15.0) 25 (48) 19 (37) 816 ± 697

VRS = verbal rating scale. *P < 0.05 frontal vs fronto-temporal/pterional, temporal, occipital,
and posterior fossa; #< 0.05 frontal vs posterior fossa.

Thibault M, et al. Can J Anesth 2007;54(7):544-48

Pain after craniotomy. A time for
reappraisal?
No statistically significant differences in
severity of pain or used of codein phosphate
were found when comparing patients
undergoing craniotomy at different site.

Quiney N et al. British J. Neurosurgery 1996;10(3):295-300

 Systemic Analgesics

1. Opioids
• Codeine PO4
1. What drug
• Morphine
to give?
• Nalbuphine
2. What mode
2. Tramadol
of delivery?
3. Paracetamol
IV 4. NSAIDS
IM • Cox 2
PCA
 Analgesia and sedation strategies

Head injury, Head injury,

mechanical spontaneous breathing,
ventilation, GCS ≤ 8 GCS > 8

Analgesia Opioid NSAID

Sedation Midazolam, Propofol, Light sedation: propofol,

Barbiturat. midazolam

Park GR, Sladen RN. Sedation and Analgesia in the Critically ill,1995
The efficacy of intramuscular codeine for
post-craniotomy pain.
Codeine phosphat IM 60 mg q 3 hr PRN and
dimenhydrinate IM 50 mg q 4 hr PRN for
nausea.
Result: IM codeine is efficacious in treating post
craniotomy pain and result in a high level of
patient satisfaction. The prevention of high rate
of nausea/vomiting warrant further investigation.
Williams JM,et al. Can J Anaesth 1997;44;A28B
Scalp nerve blocks decrease the severity of pain
after craniotomy.
Postoperative scalp block with 20 mL
ropivacaine 0,75% decreases the severity of
pain after craniotomy and that this effect is long
lasting.

Nguyen A, et al. Anesth Analg 2001;93:1272-6

Post-operative analgesia for craniotomy patients :
current attitudes among neuroanesthetist.
IM codein phosphate was mainstay of post-operative
analgesia for 97% neuroanesthetist.
Suggest that PCA with morphine could be a safe
alternative to codeine phosphate.

Stoneham MD. Eur J Anesthesiol 1995;12(6):571-5

Pain following craniotomy : a prelimary study
comparing PCA mophine with intramuscular
codeine phosphate.
A RCT of 30 patient undergoing craniotomy. PCA
using morphine 1 mg bolus with a 10 min lockout
interval and no back ground infusion.
Results: there was a small, but non-significant,
reduction in pain score in the PCA group. No
significant differences in PONV, sedation score,
and respiratory rate.

Stoneham, et al. Anesthesia 1996;51(12):1176-78

A double-blind comparison of codeine and
morphine for postoperative analgesia following
intracranial surgery.
18 patient received codeine phosphate 60 mg
and 18 patient received morphine sulphate 10
mg, both by IM.
Results: in the dosis used, morphine is a safe
alternative to codeine for analgesia after
neurosurgery and has a more persistent action.

Goldsack C, et al. Anesthesia 1996;51(11):1029-32.

Postoperative Nausea and Vomiting : A
retrospective analysis in patient undergoing
elective craniotomy.
Results: PONV occur frequently after
craniotomy. Infratentorial surgery, female
gender, and younger age are significant risk
factor for this complication.

Jennifer F, et al.J. Neurosurg Anesthesiology 1997;9(4):308-12

 Summary
1. Increasing attention
2. No small problem
3. Consider local anesthesia
4. Use of morphine is SAFE in controlled environment
5. Multi modal strategy