Total Intravenous Anesthesia Including Ketamine versus Volatile Gas Anesthesia for Combat-related Operative Traumatic Brain Injury

• Published in: Anesthesiology (Philadelphia) 2008-07, Vol.109 (1), p.44-53
• Main Authors: GRATHWOHL, Kurt W, BLACK, Ian H, SPINELLA, Phillip C, SWEENEY, Jason, ROBALINO, Joffre, HELMINIAK, Joseph, GRIMES, Jamie, GULLICK, Richard, WADE, Charles E
• Format: Article
• Language: English
• Subjects: Adolescent; Adult; Anesthesia; Anesthesia, General - methods; Anesthesia, General - trends; Anesthesia, Intravenous - methods; Anesthesia, Intravenous - trends; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Anesthetics, Inhalation - administration & dosage; Biological and medical sciences; Brain Injuries - drug therapy; Brain Injuries - epidemiology; Brain Injuries - surgery; Glasgow Outcome Scale - trends; Humans; Ketamine - administration & dosage; Medical sciences; Retrospective Studies; Volatilization; Warfare
• ISSN: 0003-3022; 1528-1175
• DOI: 10.1097/ALN.0b013e31817c02e3

Traumatic brain injury is a leading cause of death and severe neurologic disability. The effect of anesthesia techniques on neurologic outcomes in traumatic brain injury and potential benefits of total intravenous anesthesia (TIVA) compared with volatile gas anesthesia (VGA), although proposed, has not been well evaluated. The purpose of this study was to compare TIVA versus VGA in patients with combat-related traumatic brain injury. The authors retrospectively reviewed 252 patients who had traumatic brain injury and underwent operative neurosurgical intervention. Statistical analyses, including propensity score and matched analyses, were performed to assess differences between treatment groups (TIVA vs. VGA) and good neurologic outcome. Two hundred fourteen patients met inclusion criteria and were analyzed; 120 received VGA and 94 received TIVA. Good neurologic outcome (Glasgow Outcome Score 4-5) and decreased mortality were associated with TIVA compared with VGA (75% vs. 54%; P = 0.002 and 5% vs. 16%; P = 0.02, respectively). Multivariate logistic regression found admission Glasgow Coma Scale score of 8 or greater (odds ratio, 13.3; P < 0.001) and TIVA use (odds ratio, 2.3; P = 0.05) to be associated with good neurologic outcomes. After controlling for confounding factors using propensity analysis and repeated one-to-one matching of patients receiving TIVA with those receiving VGA with regard to Injury Severity Score, Glasgow Coma Scale score, base deficit, Head Abbreviated Injury Score, and craniectomy or craniotomy, the authors could not find an association between treatment and neurologic outcome. Total intravenous anesthesia often including ketamine was not associated with improved neurologic outcome compared with VGA. Multiple confounders limit conclusions that can be drawn from this retrospective study.