Anesthetic agents in trauma surgery: are there differences?

Overall, no ideal induction or maintenance technique is available for the traumatized, hypovolemic patient. As a result of the multiple insults that produce hypovolemia and the heterogeneous population of patients sustaining trauma, it is unlikely that a controlled human study of this anesthetic dilemma will ever be performed. One must balance the potential incidence of recall of operation or unacceptable sympathectomy-induced vasodilation against the anesthetic techniques available. Bogetz and Katz addressed the recall issue by documenting how many patients sustaining major trauma and requiring operation were really anesthetized. They stressed that many of the patients evaluated were too hemodynamically unstable to tolerate the usual dose of anesthetics administered during elective operations. They postulated that hypotension, hypothermia, and acute alcohol intoxication found in many trauma patients should make recall infrequent. Two groups of patients were analyzed for incidence of recall. The groups were separated based on the continuity of anesthetic administered. In 37 patients given ketamine for induction and low-dose inhalational agent for maintenance, with no gaps in anesthetic administration of over 20 minutes, 4 of 37 (11%) patients had recall. Recall was reported by 6 of 14 (43%) patients in whom it was considered clinically unwise to administer an anesthetic for intubation or whose anesthetic needed to be interrupted for more than 20 minutes secondary to hemodynamic instability. If these figures are representative of the worldwide incidence of recall in our traumatized patients, we may need to redefine the role of anesthesia in trauma. We may need to consider ourselves, not inappropriately, resuscitologists rather than anesthesiologists.