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 tomography (CT) scan, intracranial pressure (ICP) and escalation of care within 24 hours of surgery. Methods We reviewed medical records of TBI patients ≥18 years old with Glasgow Coma Scale (GCS) score <13 who underwent single orthopedic surgery within 2 weeks of TBI. Secondary insults examined were: systemic hypotension (systolic blood pressure < 90mmHg), intracranial hypertension (ICP > 20mmHg), cerebral hypotension (Cerebral Perfusion Pressure < 50mmHg), hypercarbia (End-tidal CO2 > 40mmHg), hypocarbia (End-tidal CO2 < 30mmHg in absence of intracranial hypertension), hyperglycemia (glucose >200 mg/dL), hypoglycemia (glucose <60mg/dL) and hyperthermia (temperature > 38°C). Results 78 patients [41(18–81) years, 68% male] met 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 CT, postoperative decrease of GCS 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.

Intraoperative secondary insults were common during extracranial surgery in pediatric TBI. Intraoperative cerebral hypotension and hypoxia were associated with postoperative intracranial hypertension. Strategies to prevent secondary insults during extracranial surgery in TBI are needed.

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