Intensive Care for Neurosurgical Interventions

Should we admit elective neurosurgical patients to ICU?

Deciding on which patients to admit to ICU after neurosurgery depends upon pre-op comorbidity, intra-operative interventions and likely course post-operatively.

Traditional Concerns

  • Unexpected neuroworsening
    • Bleeding
    • Oedema
    • Seizures
  • Medical compilation related to procedure per se (e.g. diabetes insipidus)
  • Unrelated medical complications
  • Lack of awareness on the ward

Who is at risk for what?

  • Rebleeding 1-2% after craniotomy
  • Incidence of new seizures < 5%
  • Relevant complications tend to occur within 4 hours

95% of patients receive intensive monitoring rather than intensive care. Higher risk patients can be identified pre-operatively.

Post-op ICU determinants

 

Do patients still require admission to an intensive care unit after elective craniotomy for brain surgery?

Post-Operative Intensive Care Unit Requirements Following Elective Craniotomy

 

Post-operative CT Scan – is it worth doing?

Early CT scanning as a routine may be a low yield investigation in any patients.

Risky procedures

  • Bleeding (e.g. after decompressive craniectomy)
  • Herniation
  • Stroke (e.g. post-clipping)
  • Overdrainage

Co-morbidities and coagulopathy may be under appreciated – it is less usual to assess platelet function as a routine for instance. A CT may cost around EU 100. However, if we want to learn we may have to look for something we don’t expect and a lot can go wrong on day one.

IMG_1523

 

Immediate versus delayed awakening in acute brain injury

Sedation holds are recommended in general intensive care patients to facilitate extubation but controversial in neurological injury. No clear answer in acute brain injury as underrepresented in the weaning trials. However, conventional weaning parameters do not predict extubation failure.

Wake-up tests can be performed in TBI safely but only in about 2/3 and may cause significant cardiopulmonary distress, brain tissue hypoxia and intracranial hypertension. Imaging may useful in deciding in which patients to adopt this strategy.

Neurological examination of critically ill patients: a pragmatic approach. Report of an ESICM expert panel

Conventional weaning parameters do not predict extubation failure in neurocritical care patients

Effects of the neurological wake-up test on intracranial pressure and cerebral perfusion pressure in brain-injured patients

Effects of the neurological wake-up test on clinical examination, intracranial pressure, brain metabolism and brain tissue oxygenation in severely brain-injured patients