- Maintenance of anesthesia can be accomplished via an inhalational volatile agent or via a total intravenous anesthetic (TIVA).15 Both approaches must be carefully titrated to the hemodynamic profile while assuring adequate sedation/hypnosis and analgesia. Awareness during anesthesia and the acute pain response can be mitigated during TIVA by assuring that both a sedative hypnotic (e.g., Propofol, benzodiazepine) and an analgesic (e.g.; narcotic) are being administered. Narcotic dose can be titrated to hemodynamics.
- Adequate IV access must be assured immediately (e.g., large bore peripheral IV, intraosseous, rapid infusion catheter (RIC), Cordis central line). Placement of additional IV access or an arterial line (if indicated for continuous monitoring of beat-to-beat blood pressure) can be undertaken without delaying the start of the operation.
- Sending a baseline set of labs, to include coagulation studies and base excess, at the start of the case can set a reference point for the remainder of the resuscitation. Consider validation of Point of Care (POC) testing (e.g., iSTAT values) with traditional laboratory assays. Ensure all laboratory equipment and POC equipment are maintained within the manufacturer’s biomedical engineering standards.
- The maintenance of anesthesia and the resuscitation can be guided by following the trend in mean arterial pressure (MAP). While the ideal blood pressure is controversial, a MAP < 55 mmHg has been associated with acute kidney injury and myocardial injury during anesthetics for non-cardiac surgery.16 Maintaining a MAP > 60 mmHg will facilitate end organ perfusion without exacerbating any unsecured bleeding.
- Traumatic brain injury (TBI) represents a unique situation in which isolated episodes of hypotension can worsen mortality.17 It is, therefore, advisable to maintain systolic blood pressure > 110 mmHg in patients with documented or suspected TBI. (See Neurosurgery and Severe Head Injury CPG18)