Intraoperative Secondary Insults During Orthopedic Surgery in Traumatic Brain Injury

Background: Secondary insults worsen outcomes after traumatic brain injury (TBI). However, data on intraoperative secondary insults are sparse. The primary aim of this study was to examine the prevalence of intraoperative secondary insults during orthopedic surgery after moderate-severe TBI. We also examined the impact of intraoperative secondary insults on postoperative head computed tomographic scan, intracranial pressure (ICP), and escalation of care within 24 hours of surgery. Materials and Methods: We reviewed medical records of TBI patients 18 years and above with Glasgow Coma Scale score <13 who underwent single orthopedic surgery within 2 weeks of TBI. Secondary insults examined were: systemic hypotension (systolic blood pressure < 90mm Hg), intracranial hypertension (ICP > 20mm Hg), cerebral hypotension (cerebral perfusion pressure < 50mm Hg), hypercarbia (end-tidal CO2 > 40mm Hg), hypocarbia (end-tidal CO2 < 30mm Hg in absence of intracranial hypertension), hyperglycemia (glucose > 200 mg/dL), hypoglycemia (glucose < 60 mg/dL), and hyperthermia (temperature > 38 degrees C). Results: A total of 78 patients (41 [18 to 81] y, 68% male) met the inclusion criteria. The most common intraoperative secondary insults were systemic hypotension (60%), intracranial hypertension and cerebral hypotension (50% and 45%, respectively, in patients with ICP monitoring), hypercarbia (32%), and hypocarbia (29%). Intraoperative secondary insults were associated with worsening of head computed tomography, postoperative decrease of Glasgow Coma Scale score by >= 2, and escalation of care. After Bonferroni correction, association between cerebral hypotension and postoperative escalation of care remained significant (P< 0.001). Conclusions: Intraoperative secondary insults were common during orthopedic surgery in patients with TBI and were associated with postoperative escalation of care. Strategies to minimize intraoperative secondary insults are needed.