TYK250

A 16 year-old male with severe traumatic brain injury is scheduled for decompressive craniectomy due to uncontrollable intracranial hypertension. On presentation to the operating room, the patient’s ICP is 25 mmHg, MAP is 65 mmHg, arterial oxygen saturation is 89%, and serum sodium is 149 mEq/L. All of the following would be appropriate for this patient EXCEPT:

a) Administer 5-10 mL/kg of 3% saline

b) Ensure adequate sedation and neuromuscular blockade

c) Decrease PEEP from 8 to 5 cmH20

d) Initiate vasopressor infusion

e) Hyperventilate the patient to end-tidal CO2 of 30 mmHg

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Answer

Answer c. The goals of management for this patient are increased blood pressure, decreased ICP, and optimized cerebral oxygen delivery. Although not effective or advisable in the long-term, acute hyperventilation may be indicated for ICP reduction, particularly when a definitive surgical procedure to relieve ICP is imminent; hypertonic saline and adequate sedation/paralysis will also help to reduce ICP and should be administered unless the patient is already profoundly hypernatremic. Vasopressor infusion (and possibly volume administration) are indicated to raise the BP. However, despite the potential benefit of PEEP reduction on venous return from the brain, this hypoxemic patient requires improved arterial oxygen content to minimize secondary brain injury. Thus, PEEP should be maintained (or perhaps increased) and FiO2 should be increased as needed to improve oxygen saturation.

Notes

This question originally printed in the Pediatric Anesthesiology Review Topics kindle book series, and appears courtesy of Naerthwyn Press, LLC.

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