Transesophageal echocardiographic study of etiology of hemodynamic fluctuations during major neurosurgical procedures

Introduction: Patients undergoing neurosurgical procedures can have a variety of hemodynamic fluctuations which affect cerebral hemodynamics, cerebral perfusion pressure, intracranial pressure; and outcome. Hence it is important to identify the etiology so that appropriate treatment can be initiated, such as infusion of fluids or blood or vasopressors. TEE has recently been found to have a major role in non-cardiac surgery. We prospectively studied the impact of TEE to identify the etiology of hemodynamic fluctuations during major neurosurgical procedures. Methods: After IEC clearance, 65 adult patients in whom TEE was otherwise indicated for expected hemodynamic changes due to intracranial lesion characteristics; head-up position with venous air embolism risk; and those undergoing intracranial aneurysm surgery, were included. We excluded patients with low GCS, refusal to consent and any contraindication to placing TEE probe. After standard anaesthesia induction, TEE probe was placed and intraoperative fluctuations were monitored based on preload changes, contractility and afterload changes along with hemodynamic changes (heart rate change <50/>100/min; and BP +/- 30 mm Hg from baseline were considered significant). Results: Significant hemodynamic changes occurred in 23 out of 65 patients. There were episodes of low systolic/mean BP and tachycardia. Twenty patients had more than 2 episodes of hemodynamic fluctuations. Seven had more than three episodes. On TEE examination, most frequent abnormality was increase in SVC collapsibility index followed by increased stroke volume variability. The SVR was also found to be reduced indicating vasodilation. Two patients had RWMA. In all patients hemodynamic instability was successfully managed. Conclusion: Our study showed intraoperative TEE use was beneficial in identifying the cause of intraoperative hemodynamic fluctuations as well as aided in management.

No conflict of interest has been declared by the author(s).