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These goals depend on many variables and important questions to ask and answer include:
What was status (medical and neurological) of the patient before surgery?
What neurological disease is being treated?
What other neurological disorders does the patient have?
What position was the patient in during surgery?
What procedure was performed (procedure specific and expected complications)?
What happened during surgery, e.g. blood loss, vascular injury?
What anesthetic technique was used?
To manage a postoperative neurosurgical patient the neurointensivist requires knowledge of
how the CNS reacts to stress and anesthesia as well as the potential complications associated
with each specific procedure. This chapter will focus on the following topics:
1) Who goes to and who stays in the NCCU
2) The effects of anesthetic agents on the CNS and neurosurgical patients
3) Basic complications after neurosurgical procedures
4) Emergence from anesthesia in neurosurgical patients
5) Extubation in neurosurgical patients
6) Post-operative pain
7) Postoperative nausea and vomiting
8) Basic post-operative neurosurgical care
9) Postoperative monitoring
WHO GOES TO AND WHO STAYS IN THE NEUROCRITICAL CARE UNIT (NCCU)?
Postoperative neurosurgical cases account for numerous NCCU admissions. Traditionally,
patients who had craniotomies and other invasive neurosurgical procedures were nursed
postoperatively and overnight in the NCCU as a precaution. This practice is changing somewhat
as most NCCUs also have well-developed step-down or intermediate care units that can
often manage routine uncomplicated cases. Among those patients admitted to the NCCU
primarily for precautionary/observational purposes, very few patient days are created. It is
estimated that only ~15% actually require/receive active treatment. Furthermore, when a
patient stay in the NCCU is <24h, ~50% require no interventions beyond post-anesthetic care
and frequent neurologic exams. Lastly, two-thirds of these patients require no further
interventions of any kind after the first 4 hrs.
The decision to admit a given patient to the NCCU can be subjective and surgeon specific but is
often based upon: age, co-morbidities, pre-operative condition, intra-operative details (difficult
hemostasis, unexpected cerebral edema), and need for post-operative respiratory and
hemodynamic support. That said, a patient's risk for prolonged ICU stay (>1 day) can be
anticipated by: a) preoperative radiologic findings (e.g. tumor location, mass effect), b)
PaCO2>45 mmHg) may occur in ~25% of patients usually within the first 30 to 60 minutes. About
1% of patients require re-intubation. Overall serious complications may occur in 10% of
patients. In patients who undergo emergency surgery, or have a depressed preoperative level
of consciousness (Glasgow Coma Scale 8), this risk is greater (>40%). Being aware of some
common complications and associated management strategies is fundamental to the practice
of neurocritical care.
Craniotomies: Complications can be general or specific to the type of surgery. The most
common complications are cerebral edema, seizures, vascular injury, and post-operative
hemorrhage.
General complications after craniotomy:
a. Agitation and discomfort are common and now commonly treated quite successfully
with dexmedetomidine.
b. Cerebral Infarction: Can be due to arterial or venous injury. Venous occlusion and
infarct can occur when a bleeding vein must be coagulated or when massive cerebral
edema leads to a compressive occlusion of venous outflow. One should also be
attentive to possible venous injuries after meningioma surgery located near venous
sinuses (tentorial, parasagittal, convexity, and parafalcine). Arterial infarct can occur
with either traumatic laceration or sacrifice of an artery for hemostasis. This can
occur in TBI, glioma surgery with en passant vessels, and epilepsy surgery (i.e.
anterior choroidal artery in temporal lobectomy).
c. Seizures: particularly after penetrating TBI, epilepsy surgery, subdural empyema,
and glial resection near motor cortex, but may occur in any patient post-operatively
d. Pneumocephalus: air can be retained after craniotomy and act very much like mass
lesions. Symptoms include lethargy, confusion, nausea/vomiting, and headache.
Diagnosis is easily made with head CT. Once suspected one should actively
investigate for the presence of tension pneumocephalus and CSF fistula as this will
dictate management. Tension pneumocephalus can be urgent and is surgically
evacuated. If there is a CSF leak, the leak should be managed in typical fashion
before the pneumocephalus is addressed. Simple pneumocephalus can typically be
managed expectedly as the air normally absorbs with time. Some advocate for the
use of non-rebreathing mask with 100% oxygen for 24-48 hours. Brain sagging may
be encountered as a related phenomenon often seen after intraoperative over
drainage of CSF (e.g. during aneurysm surgery). The clinical triad consists of
pneumocephalus, midbrain crowding, and neurological symptom such as decreased
mental status improving with reverse trendelenburg
e. Postoperative hematomas: Approximately 2% of patients who undergo a cranial
procedure will develop a postoperative hematoma (PICH) with 0.8% of patients
developing a hemorrhage that requires surgical evacuation. The most common PICH
presentations include:
60% present with a decreased level of consciousness (as a result PICH should
be considered in all patients who do not recover or improve in the expected
position (if possible), aspirating air from the left atrium via CVP catheter, and
achieving hemostasis as soon as possible. Another complication associated with
posterior fossa surgery is accelerated hypertension. Any unexpected or refractory
hypertension should warrant careful examination and a low threshold for imaging
looking for post-operative hemorrhage. Other complications include obstructive
hydrocephalus (if 4th ventricle compressed), upward herniation (via over drainage
through and EVD when the 4th ventricle is compressed), cranial nerve injuries, and
CSF leak and/or pseudomeningocele due to dependency of dural opening.
Craniotomy for securing ruptured aneurysm: this will be covered in another chapter
of this manual, but there are several strategies regarding the prevention and
treatment of vasospasm. In general terms the patient should be kept euvolemic
(please see appropriate chapter in this manual for a more complete discussion).
Arteriovenous Malformation (AVM): these cases generally have especially tenuous
and brittle hemostasis and very strict blood pressure control is crucial. In addition,
liberal use of sedation to prevent coughing and straining against the ventilator may
be critically important in the first few days after surgery. Seizures are also known to
occur after AVM surgery as these patients often have pre-operative seizure
disorders.
Transient mutism can occur with bilateral retraction of the cingulate gyrus or
division of the corpus callosum [12].
Neurologic Complications
The development of focal cerebral edema has been noted after coiling of aneurysms and
embolization of AVMs. This is typically managed with dexamethasone. Intracranial
hemorrhage can be seen after these procedures and management is discussed elsewhere.
Common sources of ICH include intra-operative rupture of an aneurysm, perforation of a vessel,
and reperfusion hemorrhage. More unique to endovascular procedures are possible
thromboembolic and thrombo-occlusive complications. The catheters used for these
procedures can physically disrupt atherosclerotic plaques causing emboli, create a dissection, or
generate thrombus due to their inherent thrombogenicity. Other sources of emboli include
microthrombotic shower after mechanical thrombectomy and glue emboli after embolization.
These emboli are often not noted until the post-operative period. Once symptoms are
suspected, urgent MRI/MRA is advised with concomitant initiation of generous fluid
administration. After diagnostic imaging is complete, treatment options include additional
endovascular therapy, anticoagulation, and/or hypertensive therapy via pressors.
Other complications of these procedures include arterial dissection, acute thrombus and
perforation. These complications are almost always noted during the procedure and
management options consist of blood pressure control, anticoagulation, and generous fluid
administration (depending on the problem encountered). For acute thrombus noted in the
procedure, treatment options include intra-arterial thrombolysis, mechanical thrombectomy,
and Reopro. Reopro is a potent glycoprotein IIb/IIIA inhibitor and has been found to be quite
effective in managing thrombo-occlusive events during endovascular procedures. The
implication to the neurointensivist is that due to Reopros effective anti-platelet activity one
need to carefully monitor for bleeding complications.
Other complications
It is important to recognize what may happen during surgery to best manage the patient after
surgery. Complications depend in part on position or the procedure. Some specific examples
include:
a. Ocular: Periorbital and/or conjunctival edema, as well as chemosis, tend to occur more
often in the prone position, during pterional approaches, or with orbitozygomatic
craniotomies. Posterior ischemic optic neuropathy or central retinal artery occlusion
also may occur (particularly with longer procedures). A third nerve palsy or blindness
may result from posterior communicating artery or carotid ophthalmic artery surgery.
b. Use of a lumbar drain may cause intracranial hypotension or remote hemorrhage
distant to the surgical site
c. Anterior cervical surgery: Soft tissue swelling can cause airway obstruction or swallowing
abnormalities
associated with deleterious oxygen consumption (VO2) so prevention of agitation, shivering and
coughing is important.
2) ICP: Up to 20% of patients who undergo intracranial surgery may develop increased ICP and
when it occurs half will develop clinical deterioration in large part from edema or hemorrhage
[17]. There is limited data on the specific effects of emergence and extubation on ICP.
Endotracheal suctioning has been shown to increase ICP [18]. Similarly, extubation can increase
ICP particularly when associated with coughing. The ICP increase usually lasts 2 or 3 minutes,
but is longer when intracranial compliance is reduced.
3) Hyperemia and normal perfusion pressure breakthrough (NPPB): The cerebral arteriovenous
oxygen content difference (AVDO2) often is depressed immediately after craniotomy. This is
suggestive of transient cerebral hyperemia (16). Hyperemia may result in hemorrhage or severe
edema in 312.5% of cases. An especially at-risk group is patients undergoing craniotomy for
AVM resection. Features of AVMs associated with a high-risk for postoperative hyperemic
complications, including normal perfusion pressure breakthrough, are: a) large and deep
AVMs, b) low feeding-artery pressures, c) multiple arterial inflows but only a single venous
draining vessel, and d) intense steal around the AVM nidus. Strategies used in the management
of these precarious include staged therapies (embolization and surgical), barbiturate based
anesthetic continued into the postoperative period, extremely rigorous blood pressure control
after surgery, and either invasive or non-invasive cardiovascular monitoring to optimize filling
pressure and cardiac performance
EXTUBATION IN NEUROSURGICAL PATIENTS
The goal of anesthetic emergence and subsequent extubation is to maintain stable respiratory
and cardiovascular parameters while preventing adverse CNS effects. One must be cautious as
even the physical act of extubation can cause sympathetic discharge via tracheal and laryngeal
stimulation (although it relieves the endotracheal tube stimulation itself). On one hand, a
delayed emergence with deferred extubation in the ICU may achieve better thermal and
cardiovascular stability after major neurosurgical procedures (thereby limiting secondary
insults). On the other hand, the timely diagnosis of neurosurgical complications is required to
limit CNS damage. The diagnosis of complications relies on rapid neurological examination
after early awakening and an awake patient is the best and the cheapest neuromonitoring
available. However many factors may contribute to delayed emergence including: 1)
perioperative opiate analgesia and anxiolytics, 2) metabolic disturbances (electrolyte or acidbase), 3) comorbidity, especially hepatorenal dysfunction that affect drug clearance, 4) stroke,
5) pneumocephalus or CSF hypotension and 6) seizures. Before extubation, airway and
swallowing functions should be carefully evaluated and everything should be ready for a
possible reintubation. For successful extubation, the patient should be 1) awake, 2) fully
reversed from neuromuscular relaxation and spontaneously breathing, 3) hemodynamically
stable, and 4) normothermic (Table 1 and 2).
[15]. Pain however often is underestimated and undertreated in neurosurgery patients. There
are several reasons for this: 1) the patient may not be able to communicate because of aphasia,
altered mental status, or cognitive impairment, 2) the side-effects of analgesic drugs are feared,
3) there is no consensus regarding the choice of the best anesthetic regimen for intracranial
surgery, 4) there is a lack of standardized, proactive protocols to assess and evaluate postcraniotomy pain and pain therapy, and 5) few studies have examined this question or validated
the benefits of post-operative pain control on outcomes and patient satisfaction.
Management of post neurosurgery pain
Analgesia needs will depend in part on the procedure. For example where there is extensive
muscle dissection (suboccipital approach, thoracolumbar spine surgery) more analgesia will be
required than procedures where there is little muscle dissection (anterior cervical discectomy
and fusion (ACDF) or frontal craniotomy). Basic postoperative analgesia consists of opiates,
non-steroidal inflammatory medicines, and acetaminophen-based preparations. Opioids are
the mainstay of analgesia. All opioids blunt the respiratory response to hypercarbia and so
there are concerns that opioid-induced carbon dioxide retention will trigger increases in
cerebral blood volume with subsequent aggravation of cerebral edema and intracranial
hypertension. In addition there are concerns that opioids may cause excessive sedation, miosis,
and/or interfere with recovery from anesthesia and postoperative neurological assessment.
For this reason codeine phosphate has traditionally been the most commonly used analgesic
post-craniotomy [20]. However, there may be better choices. When properly titrated,
morphine can be more efficacious and does not increase adverse side effects as compared with
codeine [21,22]. Furthermore, codeine is an unpredictable pro-drug and most of its analgesic
efficacy is derived from the 515% that is metabolized to morphine by hepatic CYP2D6. Interindividual and ethnic differences in CYP2D6 can influence codeines efficacy e.g., because of
genetic variation 15% of Caucasians do not experience any effect from codeine [23].
Consequently, morphine or fentanyl is recommended after surgery. With proper use, the
benefits of analgesia (e.g. blood pressure control) outweigh the risks. The non-narcotics
ketoprofen, tramadol, gabapentin, and acetaminophen-based agents (such as Fioricet) may be
useful as supplemental, opioid-sparing drugs. Pain control is reviewed by Nemergut et al [24].
POST-OPERATIVE NAUSEA AND VOMITING (PONV)
Postoperative nausea and vomiting are less common now that propofol is widely used an
induction agent. However PONV remains a common complication after neurosurgical
procedures. The incidence is uncertain since study design may influence the outcome and few
studies have looked specifically at neurosurgery PONV. Nevertheless PONV may complicate
between 30-70% of neurosurgical procedures [25]. While nausea is a source of patient
discomfort, PONV can cause major complications in post-operative patients particularly those
undergoing craniotomy. Vomiting can lead to aspiration (particularly with a compromised
swallowing reflex and impaired consciousness), electrolyte disturbances, ICP increases, and
intracranial bleeding. During the pre-ejection phase of the vomiting reflex there is sympathetic
stimulation. This can complicate control of blood pressure postoperatively. Furthermore, during
the ejection phase increased intra-abdominal (>100 mmHg) and intra-thoracic pressures
directly translates into elevated ICP [26].
General risk factors for PONV include: 1) female gender, 2) previous PONV or motion sickness,
3) non-smoker, 4) duration of surgery >60 minutes, and 5) early post-operative opioids [26].
Specific neurosurgical risk factors include: 1) surgery location (i.e., infratentorial surgery near
the area postrema at the floor of the fourth ventricle), 2) CSF cisternal space opened (chemical
meningitis), 3) awake procedure vs. general anesthesia, 4) intraoperative CSF leak and
subsequent pneumocephalus, 5) use of a fat graft for a CSF leak, and 6) a lumbar intrathecal
catheter and intracranial hypotension [27].
Management of PONV
Various pharmaceutical agents can be used to manage PONV. Serotonin (5HT 3) antagonists,
such as ondansetron, are effective but expensive. Trimethobenzamide is another popular
choice and is thought to inhibit the chemoreceptor trigger zone. Cyclizine is a cheap
antihistamine commonly prescribed whenever opiates are given. Alternatives include dopamine
antagonists, e.g. metoclopramide or droperidol. Steroids also work but there may be a ceiling
effect (5-8mg). There are synergistic effects of dexamethasone and ondansetron. Intravenous
ondansetron administration (4mg) at the time of dural closure can help reduce the incidence of
PONV and the use of rescue antiemetics. Neufeld et al [25] preformed a recent meta-analysis
of 7 prospective, randomized, placebo-controlled trials that together included 448 patients and
found that ondansetron only had a significant impact on vomiting.
BASIC POSTOPERATIVE NEUROSURGICAL CARE
Basic postoperative neurosurgical management is centered on the ABCs of care: 1) Maintain a
secure airway, 2) Adequate respiration to maintain oxygen saturation, 3) Hemodynamic
stability and fluid management. Normo-homeostasis may be regarded as neuroprotective
[28]. Other aspects of postoperative neurosurgical care (seizure control, prevention and
management of infection, venous thromboembolism, ventriculostomy care) are beyond the
scope of this review but clearly are fundamental to critical care. The typical postoperative
patient probably does not require gastrointestinal prophylaxis unless they are on steroids or
remain mechanically ventilated.
Respiratory care
Adequate oxygenation and ventilation are required to balance oxygen delivery to the brain,
cerebral blood flow, cerebral perfusion pressure, and ICP. The Brain Trauma Foundation
recommends maintaining PaO2 >60 mmHg and oxygen saturation >90% for traumatic brain
injury (TBI) patients (BTF). These are sensible goals that have carried over into postoperative
neurosurgical care of all patients. The following respiratory complications may be observed:
Airways obstruction: This may be caused by many factors e.g. laryngospasm, soft tissue swelling
around the pharynx (especially children) or laryngeal or glottic edema (anterior cervical surgery,
carotid endarterectomy), foreign bodies (loose teeth), hypotonia of pharyngeal muscles from
the remaining anesthetic, and viscous fluids (blood after transphenoidal surgery). In all patients
who develop airway obstruction, a patent airway must be achieved immediately (head tilt chin
lift, airway adjuncts, or intubation). The signs of airway obstruction include stridor, tachypnea,
tracheal tug (downward displacement of the trachea during inspiration), use of accessory
muscles, Intercostal and supraclavicular muscle recession, and reduced oxygen saturation (late
signs)
Hypoventilation
A reduced ventilatory capacity can be caused by a depressed neurogenic respiratory drive and
neuromuscular disorders. Etiologies include opioid drugs, hypothermia, metabolic alkalosis
secondary to intermittent positive pressure ventilation, or by mechanical difficulty in breathing.
Impaired chest expansion may result from parenchymal lung disease (e.g. obstructive airways
disease secondary to smoking), muscle weakness (e.g. electrolyte derangement, neuromuscular
disorders), hindered diaphragm movement (pain, obesity), and the residual effect of paralyzing
agents on the chest wall musculature.
Hypoxemia
The principal causes of hypoxemia include: 1) a reduced FiO2, 2) hypoventilation associated
with a depressed consciousness or airway obstruction and 3) ventilation/perfusion mismatch
(e.g. lung collapse, pneumonia, atelectasis, bronchospasm, pulmonary edema, pneumothorax,
pulmonary embolism). Thoracic and abdominal surgery often may alter the chest expansibility,
and contribute to decreased oxygen saturation. This cause is less frequent after neurosurgery
(unless a thoracotomy was performed for thoracic disc or anterior decompression).
Neurogenic pulmonary edema (NPE)
NPE is a potential complication of CNS insults such as intracranial hemorrhage, SAH,
uncontrolled generalized seizures, TBI, and tumors. The postulated cause is sympathetic
discharge. The treatment is mainly supportive (mechanical ventilation possibly limiting PEEP,
alpha-adrenergic blocking agents while managing ICP).
Who should be ventilated? Intubation and mechanical ventilation is indicated in neurosurgical
patients in the following conditions: inability to protect the airway or manage secretions; need
to reduce ICP by ventilation control; PaO2 <60 mmHg despite supplemental O2; PaCO2 >50
mmHg, or pH <7.2; respiratory rate >40/minute or <10/minute; muscle fatigue; airway
compromise; and hemodynamic instability. Orotracheal intubation with rapid sequence
induction is the preferred technique. Nasotracheal intubation should be avoided particularly
when there is a basilar skull fracture or skull base surgery. Maintenance of normocapnia is the
major goal of ventilation therapy in neurosurgical patients. Whereas hypocapnia, achieved
through short periods of hyperventilation, is a potent cerebral vasoconstrictor (and can reduce
ICP) it can exacerbate brain ischemia in patients with brain injury. Hyperventilation also
decreases venous return, cardiac output, and PVO2 and may increase V/Q mismatch.
Mechanical ventilation goals have changed from achieving normal blood gases to reducing the
risks of ventilator-induced lung injury i.e. lung-protective ventilation strategy [29]. Positivepressure ventilation with a tidal volume of 6 ml/kg (or less) of an ideal body weight is used to
maintain a plateau pressure <30 cmH2O. Positive end-expiratory pressure (PEEP) is adjusted to
keep FiO2 <0.6 to prevent oxygen toxicity, with an oxygenation goal of PaO 2 >60 mmHg or SaO2
>90%. The risks and benefits of lung-protective ventilation in neurosurgical patients are unclear.
One must be aware that lung-protective ventilation may lead to permissive hypercapnia that
can be problematic in patients with elevated or borderline ICP. In addition, variable clinical
responses to PEEP may occur in neurosurgical patients secondary to PEEPs effect on
hemodynamic and respiratory variables. High levels of PEEP may decrease CPP due to
decreases in cardiac output and increases in ICP [30]. Fortunately, the influence of PEEP on ICP
is less prominent in patients with stiff lungs (e.g., acute lung injury/ARDS) as they may be the
patients who most need PEEP. PEEP should be applied carefully in patients with increased ICP,
and ICP should be monitored simultaneously.
Cardiovascular management
Cardiovascular disturbances (e.g. hypotension, hypertension, dysrhythmias and myocardial
failure) are common in patients who undergo neurosurgery. They occur as consequences of
medical or surgical therapy, central neurogenic effects on the heart and the autonomic system,
or from concurrently associated medical conditions that interact with CNS pathology. One
challenge commonly encountered in the NCCU is balancing the risks/benefits of antiplatelet/anticoagulant agents used in acute coronary syndrome against the risk of postoperative hemorrhage. Each case needs to be carefully evaluated before a treatment strategy
is initiated. Potential iatrogenic induced cardiovascular problems include: diuretic and steroidinduced hypovolemia and hypokalemia-induced ventricular irritation, bradycardia with low
cardiac output caused by surgical stimulation of the vagal nucleus in the brainstem, and a
Cushings-like response with poor venting of ventricular perfusate during endoscopic third
ventriculostomy. Prone and seated positions are associated with low cardiac output, venous
return and blood pressure.
Blood pressure control
Changes in blood pressure are common postoperative complications. Many times the surgeon
will have specific BP parameters depending on where the goal is to prevent hematomas or
preserve perfusion.
Hypotension
Fluid loss from the intravascular space (bleeding) and extravascular space (e.g. vomiting,
diarrhea, and sweating) can contribute to hypovolemia (Table 5). This may exacerbate cerebral
ischemia. Fluid therapy is discussed below. Circulation support to influence CBF is achieved best
by increasing blood pressure, as cardiac output appears not to vary with CBF. The drug of
choice to increase blood pressure is phenylephrine. With active baroreflexes, bradycardia may
occur. Careful anticholinergic administration then is necessary to augment the
sympathomimetic hypertensive action. Patients with low myocardial reserve may require an
inotrope, such as dopamine or epinephrine.
Hypertension
Increased blood pressure may be associated with pain, emergence from anesthesia, and the
underlying disease which can lead to postoperative hemorrhage and exacerbate edema. Acute
hypertension is associated with increased mortality in the NCCU (9). The precise level that
represents a risk varies and depends on patient, disease, procedure, lesion size, traumatic
disruption of vessels, and premorbid blood pressure. Strategies to limit commons irritants or
triggers of hypertension include prevention and timely treatment of bladder distention, pain
and shivering. Since sympathetic stimulation is responsible for the blood pressure increase,
beta-blocker infusions are largely used. Esmolol and labetalol are effective agents since they
have no significant effect on ICP. Cardene is a calcium-channel blocker that is used frequently
with good success. Nitroglycerin, and sodium nitroprusside are cerebral vasodilators and these
agents may increase cerebral blood volume. The specific agent used will depend on several
factors including the perceived integrity of autoregulation and management strategy being
employed for a given patient (i.e. Lund vs. Rosner theories regarding the relationship between
ICP and MAP). In patients with severe hypertension post operatively, the elevated blood
pressure also should considered to be a sign of intracranial pathology. This is particularly
important after posterior fossa surgery. Lastly, one should always carefully consider a patients
home medication regimen and be mindful of complications from that regimen being altered in
the perioperative period (such as rebound phenomena from beta blocker withdrawal).
Fluid status
Osmolality is the primary determinant of water movement across the intact bloodbrain
barrier. Reduced serum osmolality can increase cerebral edema and ICP. The goals of fluid
management after neurosurgery are: 1) maintain intravascular volume, 2) preserve CPP, and 3)
minimize cerebral edema. In neurosurgical patients, and often in the postoperative period,
intravascular volume is depleted (e.g. diuretic use, osmotherapy, or long spinal surgeries where
large volume losses may be encountered). Systemic hypotension (MAP <70 mmHg) and
negative fluid balance (<594 ml) independently aggravate outcome in TBI patients [31]. Basic
fluid and electrolyte requirements must be considered in the postoperative period. In clinical
practice, fluid management requires circulating blood volume assessment (Table 5). A patient
generally is asymptomatic until the circulating volume has decreased by at least 10%. A
persistently low urine output (<0.5 ml/kg/hour) may indicate inadequate fluid replacement and
thirst often is the first sign of reduced intravascular volume even though other vital signs are in
the normal range. However when diuretics or mannitol are given, urinary output can be
misleading. Lastly, thirst is not present if the patient is drowsy or sedated.
New technologies have also become quite helpful in hemodynamic assessment, volume
management, and the institution of more specific goal-directed therapy in ICU patients. One is
arterial pulse contour wave analyses which require invasive arterial lines to obtain data. There
are several manufacturers who make analogous equipment taking advantage of arterial pulse
pressure (PP) waveform analysis to provide continuous assessments of volume status and
cardiac hemodynamics. There is more than one methodological strategy employed to derive
such parameters including: a) calibrated PP analysis relying on thermodilution for calibration
(PiCCO) and b) statistical analysis via computer-derived algorithms (Vigileo). One of the more
common variables assessed is stroke volume variation (SVV) which is used to optimize volume
status in ICU patients such as those with subarachnoid hemorrhage. Non-invasive technologies
also exist that assist in fluid management and hemodynamic monitoring. These include
impedance cardiography (ICG) and a device that relies on bioreactivity and detecting phase
shifts that occur when an alternating current is passed through the thorax (Cheetah NICOM).
Lastly, critical care ultrasound techniques such as IVC compressibility are also used to assess
volume status. All of these technologies are crucial to the increasingly adopted goal-directed
therapy with more restrictive use of crystalloid administration (unless contraindicated) in the
perioperative period.
Fluid therapy
Complications can result from inadequate or excessive volume replacement. Inadequate
volume can cause hypotension, perfusion deficits, and acute kidney injury. Excess fluid therapy
can exacerbate heart failure, pulmonary function or cerebral edema. There are few human data
about the impact of fluids on the brain that can guide rational fluid management in
neurosurgical patients. The optimal fluid to prevent secondary brain damage after neurological
insult also is unknown. Fluid administration that reduces osmolality should be avoided. Small
volumes of lactated Ringers (13L) are unlikely to be detrimental and may be used. When
larger volumes are needed a more isotonic fluid e.g. normal saline (0.9% NS) is preferred. Rapid
NS infusion may cause a dose-dependent hyperchloremic metabolic acidosis (normal anion
gap). When large volumes are needed, a combination of isotonic crystalloids and colloids
should be considered. However Hetastarch and Dextran should be avoided since coagulation
disorders, platelet dysfunction, and kidney injury may occur. While hypertonic saline is gaining
popularity for treatment of intracranial hypertension it is not recommended for fluid
resuscitation or volume replacement. One advantage HTS seems to have over mannitol in
treating ICP is its ability to move fluid from the body's own extravascular space into the
circulation across a sodium gradient without necessarily risking hypotension from diuresis [32].
Hyperglycemia is an independent predictor of poor outcomes, and so it is reasonable to avoid
glucose-containing fluids.
about 15% of patients. An ICP monitor should be considered in the following circumstances:
large vascular tumors, severe edema, trauma surgery, deeply sedated patients where an exam
cannot be obtained (or a patient fails to wake up), known operative complications (e.g.
aneurysm rupture, known vessel occlusion), and large fluid shifts are expected.
Other monitors
For most patients the extent of specialized neuromonitoring should be based on the clinical
presentation and the experience of the responsible physician. This includes 1) bedside CBF
assessment (e.g. jugular bulb oximetry, Transcranial Doppler sonography [TCD] Thermal
diffusion flowmetry, Near infrared spectroscopy [NIRS]), 2) Microdialysis and brain tissue
oxygen tension (PbtO2) and 3) Electroencephalography (cEEG).
Imaging
Imaging is a snap-shot in time. CT investigations in critically ill neurosurgical patients are useful
to monitor the course of the illness and for the early detection of complications and should be
considered when neurological deterioration occurs or the expected postoperative
improvement does not occur. When early detection of ischemia is necessary MRI is superior to
CT since diffusion weighted imaging (DWI) can recognize ischemic injury within 30-60 minutes
of onset. In addition, CT-angiograms and CT-perfusion scans are rapidly improving technologies
that are broadening diagnostic imaging options for practitioners. There is a well-documented
risk of transporting patients to scanners and portable CT scanners are becoming increasingly
adopted in NCCUs.
Surgical drains
Many procedures require use of post-operative drains. This can entail hemovacs or JP drains
left after craniotomy or lumbar drains left after spinal surgeries where there is a concern for
CSF fistula formation. The neurointensivist should always communicate clearly with the
surgical team to fully understand what compartment the drain was left in (subgaleal, epidural,
subdural). This is crucial to evaluating both the quality (blood, CSF) and quantity of drain
output. It is advisable to never remove a post-operative drain until you have specifically
discussed its purpose with the surgeon.
CONCLUSION
Following a neurosurgical procedure, the patient remains vulnerable to secondary CNS injury
because of the pathological changes associated with the disease, the nuances of the procedure
itself, and the physiological changes associated with management. The level of care after
surgery should be no less than that given during the procedure. Whereas the surgeon may
influence patient's anatomy, it is the neurointensivist role in collaboration with the
neurosurgeon to ensure the patient's physiological stability and to navigate the transition from
pre- and intra-operative care through recovery and return to the ward.
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Table 1. Systemic and brain conditions necessary for rapid postoperative awakening and
extubation after a neurosurgical procedure
Brain Conditions
Normal pre-operative level of consciousness
Surgery < 6 hours
Systemic Conditions
Normothermia (~36oC)
Normovolemia, normotension
(70 mmHg < MAP< 120 mmHg)
No major CNS or vascular injury
Spontaneous ventilation and PaCO2 <50
mmHg
No brain swelling
Normoglycemia (glucose 4-8 mmolL)
Antiepileptic prophylaxis when indicated
Normosmolality (>280 mOsm/kg)
Intact lower cranial nerves (IX,X,XII) - airway Hemoglobin ~9g/dl
protection
Normal coagulation status
No major swelling of face and tongue
Table 3. Factors associated with readiness to wean ventilator support in neurosurgical patients.
Clinical assessment
Adequate cough
Absence of excessive tracheobronchial secretions
Resolution of disease acute phase for which the patient was intubated;
Normal intracranial pressure (ICP)
Objective measurements
Clinical stability
o Stable cardiovascular status (i.e. heart rate 140beats/min; systolic BP 90-160
mmHg, no or minimal vasopressors)
o Stable metabolic status
Adequate oxygenation
o SaO2 > 90% on FIO2 0.4 (or PaO2/FIO2 150 mmHg)
o PEEP 8mmHg
Adequate pulmonary function
o Respiratory rate 35 breathes/minute
o Maximal inspiratory pressure -20 to -25 cm H2O
o VT >5 mL/kg
o VC >10 mL/kg
o Rapid shallow breathing index <105 breaths/min/L
o No significant respiratory acidosis
Abbreviations: BP = blood pressure; FIO2 = inspiratory oxygen fraction; PaO2 = arterial oxygen
tension; PEEP = positive end-expiratory pressure; SaO2 = arterial oxygen saturation; Rapid
shallow breathing index = respiratory rate/VT; VT = tidal volume; VC = vital capacity.
Adapted with permission from Boles J, Bion J, Connors A, et al. Weaning from mechanical
ventilation. Eur Respir J 2007; 29:103356.29
750
15
<100
Normal
Normal
Normal (<2 s)
14-20
>30
Normal
750-1500
15-30
>100
Normal
Reduced
Prolonged
20-30
20-30
Anxious
1500-2000
30-40
>120
Reduced
Reduced
Prolonged
30-40
5-15
Confused
2000
40
140
Reduced
Reduced
Prolonged
35
Negligible
Drowsy
5. Match the anesthetic agent with the description. Each response may be used once, more
than once or not at all
a) Enflurane
b) Etomidate
c) Halothane
d) Isoflurane
e) Ketamine
f) Thiopental
1.
2.
3.
4.
5.
6.
6. Risk factors for postoperative intracranial hematomas include the following except
a) Blood loss >500mls
b) Young age
c) Postoperative hypoxia
d) Meningioma surgery
e) Seizure
7. A 63 year old woman is now 32 hours s/p subocciptial craniectomy for resection of a
cerebellar metastasis (primary being melanoma). She continues to be awake and alert but
the nurse notes she has been struggling to control her blood pressure. She has given
labetolol twice and now has started a Cardene infusion to control the blood pressure. You
were called as the Cardene drip was started because her blood pressure remains 192/100
and she is beginning to look uncomfortable. The next step in the management should be:
a) Give her another prn dose of labetolol
b) Increase the Cardene until you control the blood pressure
c) Place an EVD
d) Carefully examine the patient and order a head CT
e) Give 4mg intravenous morphine
8. True or false: Postoperative nausea and vomiting is more common in:
a) Males
b) Non-smokers
c) Surgery <60 minutes
d) Posterior fossa surgery
e) CSF leak
9. All the following statements are true about lung-protective ventilation strategy except:
a) Tidal volumes of 5-7cc/kg of ideal body weight are recommended
b) Permissive hypercapnia should be avoided as it may exacerbate intracranial
hypertension
c) Elevated PEEP may help reduce FiO2 to <0.6 and improve gas exchange
d) Plateau pressures should be kept <30cm H2O
e) The use of pressure control ventilation may prevent barotrauma but at the
expense of variability in tidal volume
10. A patient has recently returned from the angio suite to your ICU after elective coiling of a
complicated bi-lobed anterior communicating artery aneurysm. There was some concern of
a prolapsed coil, although complete obliteration of the aneurysm, so the patient was
started on Reopro overnight. A few hours after arrival you are notified the patient is
hypotensive and diaphoretic. The next most appropriate step in the management of this
case would be:
a) Order and EKG and cardiac biomarkers
b) Order a fluid bolus
c) Obtain a stat head CT
d) Order neosynephrine to raise SBP to 140
e) Inspect the groin-site and distal pulses