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.
- Unexpected neuroworsening
- 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-operative CT Scan – is it worth doing?
Early CT scanning as a routine may be a low yield investigation in any patients.
- Bleeding (e.g. after decompressive craniectomy)
- Stroke (e.g. post-clipping)
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.
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.