Neurocritical Care

Neurosurgery & neurocitical care
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Unresolved issues
•IV versus inhalational
•Nitrous oxide
•Opioids
•Sitting Position
•Hypothermia
•Hyperventilation
•Hypotension
•Triple H therapy
•Colloid versus crystalloid
•HS, mannitol, steroids
•Non-anaesthetic drugs


IV versus inhalational
•Sevoflurane
•Propofol
•Etomidate
•Thiopental
•Research studies- failed to show any difference


Nitrous oxide
•Opponents
•Proponents
•Research studies- no specific study.
•Avoid in- air in ventricles, risk of embolism, pneumocephalus, reduced IC compliance & need of high FiO2

Opioids
•Morphine
•Fentanyl
•Sufentanyl
•Remifentanyl


Sitting position
•Risk of VAE
•Benefits
•Studies- relatively low incidence of complications reported
•Careful patient selection, expert anaesthetic team, intra-operative monitoring


Mild hypothermia
•Mild hypothermia, 2-3 degree Celsius
•Moderate to severe hypothermia
•Research studies- conflicting results
•NABIS- no benefits
•IHAST- no benefits
•Head injury with raised ICT- clear benefit
•Immediate management of cardiac arrest- helpful


Hyperventilation
•Logic behind this
•Studies- Cochrane library report
•PaCO2 >4.0 kPa
•Routine hyperventilation avoided except as a rescue measure for herniation of brain

Induced hypotension
•Induced hypotension for global cerebral effect- not used now
•In past brief periods of controlled hypotension for surgical dissections and aneurysm clippings
•Temporary clipping of major feeding vessel
•Research- Controversy over which is better
•Clip might cause ischaemia as well plus interference with surgical field.


Triple H therapy
•Hypervolaemia
•Hypertension
•Haemodilution
•Controversies- when, what fluids, how much BP, for how long
•Oxygen carrying capacity


Crystalloid versus colloid
•Volume required
•Response time
•Duration of effect
•Interference with clotting, allergy
•CPP
•ICT


HS Mannitol Steroids
•HS
•Mannitol
•Steroids
•Research evidence


Non-anaesthetic drugs
•Nimodipine
•Mg
•Remacemide


Summary
•Nitrous oxide use is controversial
•Limited indications for hypothermia
•No routine hyperventilation
•Strict BM control
•Nimodipine, remacemide might be helpful
•Modern trend is minimally invasive surgery, awake procedures (functional neurosurgery)
•Modern technology like TCD ultrasound, JB oximetry, NIRS, laser Doppler flowmeter


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