treatment recommendations

SICU Brian Injury Management Guidelines has been an extensive work in progress and have been compiled as a consensus statement by Dr. Sebastian Schulz-Stubner MD, PhD
SICU Treatment Recommendations for Intraparenchymal Hemorrhage (IPH),
Subarachnoid Hemorrhage (SAH) and Traumatic Brain Injury (TBI)
Monitoring1,2
Basic monitoring
As needed
As needed
As needed
PAC/PICO/LidCO
As needed
As needed
As needed
ICP-Monitoring
As needed
As needed
As needed
12-lead ECG on
admission
As needed
As needed
As needed
As needed
As needed
As needed
As needed
As needed
As needed
As needed
As needed
As needed
Chest X- Ray
As needed
As needed
As needed
As needed
As needed
As needed
Therapeutic Goals and treatment options1-3
35 mmHg-40 mmHg 35 mmHg-40 mmHg 35 mmHg-40 mmHg
(tolerate moderate
(tolerate moderate
(tolerate moderate
self-hyperventilation self-hyperventilation self-hyperventilation
in spontaneous
in spontaneous
in spontaneous
breathing modes
breathing modes
breathing modes
during weaning)
during weaning
during weaning)
when no signs of
Set end tidal CO2
vasospasm are
Set end tidal CO2
alarms at low of 30
present)
alarms at low of 30
mm Hg and high of
Set end tidal CO2
mm Hg and high of
alarms at low of 30
mm Hg and high of
> 70 mmHg (adjust > 70 mmHg (adjust
> 70 mmHg (adjust
PEEP and FiO2 as
PEEP and FiO2 as
PEEP and FiO2 as
< 20 mmHg (for ICP < 20 mmHg (for ICP < 20 mmHg (for ICP
treatment use
treatment use CSF-
treatment use
Mannitol or
drainage, Mannitol
Mannitol,
hypertonic NaCl to
or hypertonic NaCl
hypertonic NaCl to
Osmolarity ~ 330
to Osmolarity ~ 330
Osmolarity ~ 330
mosmol/l or Na+ ~
mosmol/l; deep
mosmol/l; CSF-
155 mmol/l; CSF-
sedation with
drainage if possible,
drainage if possible,
fentanyl and
deep sedation with
deep sedation with propofol/midazolam/
fentanyl and
fentanyl and
lorazepam, consider propofol/midazolam/
propofol/midazolam ketamine or dexmed lorazepam, consider
/lorazepam,
for special cases,
ketamine or dexmed
consider ketamine
muscle relaxation if
for special cases,
or dexmed for
necessary; consider muscle relaxation if
special cases, use barbiturates to EEG- necessary; consider
neuromuscular
burst suppression if
barbiturates to
blockade if
refractory, short
EEG-burst
necessary; consider
term (< 6 hours)
suppression if
barbiturates to
hyperventilation for
refractory, short
EEG-burst
peak control if no
term (< 6 hours)
suppression if
manifest vasospasm, hyperventilation for
refractory, short
consider mild
peak control,
term (< 6 hours)
hypothermia to 34°C
consider mild
hyperventilation for
if refractory,
hypothermia to 34°C
peak control,
consider
if refractory,
consider mild
decompressive
consider
hypothermia to
craniectomy if ICP >
decompressive
34°C if refractory,
35 mmHG for > 8 h craniectomy if ICP >
consider
refractory to
35 mmHG for > 8 h
decompressive
everything
refractory to
craniectomy if ICP>
mentioned above
everything
35 mmHG for > 8 h
mentioned above
refractory to
everything
mentioned above
CPP > 60 mmHg
CPP > 60 mmHg
CPP > 60 mmHg
(use volume and
(use volume and
(use volume and
norepinephrine/
norepinephrine/
norepinephrine/
dobutamine as
dobutamine as
dobutamine as
needed),
Tolerate MAP 110-
keep BPsyst < 160
130 mmHg and
mmHg if aneurysm
avoid quick
is not secured,
reductions in BP
BPsyst > 160 mmHg
and or optimizing CI
or specific goals
according to clinical
picture for treatment
of vasospasm
Temperature
~ 36-37° C (use
~ 36-37° C (use
~ 36-37° C (use
acetaminophen,
acetaminophen,
acetaminophen,
external cooling,
external cooling,
external cooling,
(if cooling initiated, (if cooling initiated,
(if cooling initiated,
orders for anti-
orders for anti-
orders for anti-
shivering required) shivering required)
shivering required)
Volumestatus15
Euvolemia (by CVP Euvolemia (by CVP Euvolemia (by CVP
or PAOP, PICCO,
or PAOP, PICCO,
or PAOP, PICCO,
LidCO or systolic
LidCO or systolic
LidCO or systolic
pressure variation)
pressure variation)
pressure variation)
Hypertension/Hyper-
volemia for therapy
of vasospasm as
needed for
optimization of CI
Urine output
> 0.5 ml/kg/h (use
> 0.5 ml/kg/h (use
> 0.5 ml/dg/h (use
volume, furosemide volume, furosemide volume, furosemide
as needed after
as needed after
as needed after
assurance of
assurance of
assurance of
euvolemia)
euvolemia)
euvolemia)
> 8 mg/dl
> 8 mg/dl
> 8 mg/dl
Glucose16
80 - 110 mg% (use
80 – 110 mg% (use
80 –110mg% (use
insulin sliding scale insulin sliding scale
insulin sliding scale
or insulin infusion or infusion as needed
or infusion as
as needed according
according to
needed according to
SICU Insulin
SICU Insulin
SICU Insulin
Protocol)
Protocol)
Protocol)
4-5 mmol/l (replace 4-5 mmol/l (replace
4-5 mmol/l (replace
as needed)
as needed)
as needed)
2-2.5 mmol/l
2-2.5 mmol/l (replace
2-2.5 mmol/l
(replace as needed)
as needed)
(replace as needed)
Special Medication/Orders
Analgesia
Avoid oversedation Avoid oversedation Avoid oversedation
to allow neuroexam! to allow neuroexam! to allow neuroexam!
Morphine/Fentanyl Morphine/Fentanyl Morphine/Fentanyl
preferable as bolus
preferable as bolus
preferable as bolus
as needed if
as needed if
as needed if
refractory to weaker refractory to weaker refractory to weaker
opioids like Codeine opioids like Codeine opioids like Codeine
and Tramadol,
and Tramadol,
and Tramadol,
Acetaminophen 650 Acetaminophen 650 Acetaminophen 650
mg q 6 as baseline
mg q 6 as baseline
mg q 6 as baseline
Titrate to VAS or
Titrate to VAS or
Titrate to VAS or
Riker-scale
Riker-scale
Riker-scale
Prefer use of PCA
Prefer use of PCA
Prefer use of PCA
Sedation
Propofol or
Propofol or
Propofol or
Midazolam or
Midazolam or
Midazolam or
Lorazepam or
Lorazepam or
Lorazepam or
Dexmed as needed
Dexmed as needed
Dexmed as needed
Titrate to Riker 4
Titrate to Riker 4
Titrate to Riker 4
Nimodipine
60 mg q 4 hours
Consider for tSAH
Crystalloid for
Crystalloid for
Crystalloid for
maintenance,
maintenance,
maintenance,
Hetastarch as
Hetastarch as
Hetastarch as
needed, Blood
needed, Blood
needed, Blood
products as needed
products as needed
products as needed
Nutrition
Early tube feeding
Early tube feeding
Early tube feeding
as tolerated, dose
as tolerated, dose
as tolerated, dose
according to
according to
according to
dietician, otherwise dietician, otherwise dietician, otherwise
Lansoprazol
Thrombosis
Pneumatic
Pneumatic
Pneumatic
prophylaxis17-24
compression device, compression device, compression device,
post insult day 3:
post insult or
post trauma day 3:
Heparin 5000 U s.c.
clipping day 3:
Heparin 5000 U s.c.
Heparin 5000 U s.c.
Antibiotics
Prophylactic
Prophylactic
Prophylactic
antibiotics (e.g.
antibiotics (e.g.
antibiotics (e.g.
nafcillin) for
nafcillin) for
nafcillin) for
surgery/ventricu-
surgery/ventricu-
surgery/ventricu-
lostomy according to lostomy according to lostomy according to
surgeon preference
surgeon preference
surgeon preference
Anticonvulsants
Phenytoin for
Phenytoin for
Phenytoin for one
documented seizures documented seizures
week if no
or for two weeks
or during the first 21 documented seizure
according to
days according to
surgeons preference surgeons preference
Metoprolol
As tolerated in
As tolerated in
As tolerated in
patients with known patients with known patients with known
Titrate to HR ~70-80 Titrate to HR ~70-80 Titrate to HR ~70-80
ACE-Inhibitor
As tolerated in
As tolerated in
As tolerated in
patients with known patients with known patients with known
Colace/Senna/Meto-
Dulcolax/consider
Dulcolax/consider
Dulcolax/consider
clopramide
neostigmin if no
neostigmin if no
neostigmin if no
improvement
improvement
improvement
Albuterol/
As needed
As needed
As needed
Ipatropium
(Indications:
(Indications:
(Indications:
obstructive
obstructive
obstructive
physiology on
physiology on
physiology on
ventilator flow
ventilator flow
ventilator flow
volume loop or
volume loop or
volume loop or
capnometry)
capnometry)
capnometry)
Ventilation strategy
prefer lung
prefer lung
prefer lung
protective
protective
protective
ventilation with TV ventilation with TV ventilation with TV
~ 5-8 ml/kg body
~ 5-8 ml/kg body
~ 5-8 ml/kg body
weight for acute
weight for acute
weight for acute
lung injury
lung injury
lung injury
PEEP25-27
5 cm H20 or
5 cm H20 or
5 cm H20 or
adjusted to
adjusted to
adjusted to
Pressure/Volume
Pressure/Volume
Pressure/Volume
Use recruitment
Use recruitment
Use recruitment
maneuver as needed maneuver as needed maneuver as needed
Intubation
Orotracheal, early
Orotracheal, early
Orotracheal, early
tracheostomy if
tracheostomy if
tracheostomy if
ventilation seems to ventilation seems to ventilation seems to
be necessary > 10
be necessary > 10
be necessary > 10
Restraints
To prevent
To prevent
To prevent
unplanned
unplanned
unplanned
extubation as needed extubation as needed extubation as needed
Extubation
Stop tube feedings 6 Stop tube feedings 6 Stop tube feedings 6
hours prior to
hours prior to
hours prior to
extubation. Stop
extubation. Stop
extubation. Stop
insulin infusion
insulin infusion
insulin infusion
accordingly
accordingly
accordingly
Position28-34
(flat in patients with
vasospasm
according to
surgeons preference)

Abbreviations
BNP: Brain Natriuretic Peptide
BP: Blood Pressure
CAD: Coronary Artery Disease CDC: Centers for Disease Control and Prevention CHF: Congestive Heart Failure CPP: Cerebral Perfusion Pressure CRP: C-reactive protein CVC: Central Venous Catheter CVN: Central Venous Nutrition CVP: Central Venous Pressure ET: Endotracheal GCS: Glasgow Coma Scale HOB: Head of bed ICB: Intracranial Bleeding ICP: Intracranial Pressure MAP: Mean Arterial Pressure MRSA: Methacillin resistant Staph. Aureus PAOP: Pulmonary Artery Occlusion Pressure (Wedge-Pressure) PEEP: Positive Endexpiratory Pressure SAH: Subarachnoid Hemorrhage TBI: Traumatic Brain Injury TCD: Transcranial Doppler Sonography Schulz-Stubner S, Schmutzler-Baas A: Neurochirurgische Intensivmedizin [Neurosurgical Critical Care]. Stuttgart, Schattauer, 2001 Wijdicks E: The Clinical Practice of Critical Care Neurology. Philadelphia, Chesnut RM: Guidelines for the management of severe head injury: what we know and what we think we know. J Trauma 1997; 42: S19-22 Engelhard K, Werner C, Mollenberg O, Kochs E: S(+)-ketamine/propofol maintain dynamic cerebrovascular autoregulation in humans. Can J Anaesth 2001; 48: 1034-9 Kohrs R, Durieux ME: Ketamine: teaching an old drug new tricks. Anesth Albanese J, Arnaud S, Rey M, Thomachot L, Alliez B, Martin C: Ketamine decreases intracranial pressure and electroencephalographic activity in traumatic brain injury patients during propofol sedation. Anesthesiology 1997; 87: 1328-34 Werner C, Reeker W, Engelhard K, Lu H, Kochs E: [Ketamine racemate and S-(+)-ketamine. Cerebrovascular effects and neuroprotection following focal ischemia]. Anaesthesist 1997; 46 Suppl 1: S55-60 Bourgoin A, Albanese J, Wereszczynski N, Charbit M, Vialet R, Martin C: Safety of sedation with ketamine in severe head injury patients: Comparison with sufentanil. Crit Care Med 2003; 31: 711-717 Piek J: Decompressive surgery in the treatment of traumatic brain injury. Curr Narayan RK: Development of guidelines for the management of severe head Coles JP, Minhas PS, Fryer TD, Smielewski P, Aigbirihio F, Donovan T, Downey SP, Williams G, Chatfield D, Matthews JC, Gupta AK, Carpenter TA, Clark JC, Pickard JD, Menon DK: Effect of hyperventilation on cerebral blood flow in traumatic head injury: clinical relevance and monitoring correlates. Crit Care Med 2002; 30: 1950-9 Rosner MJ, Coley IB: Cerebral perfusion pressure, intracranial pressure, and head elevation. J Neurosurg 1986; 65: 636-41 Rosner MJ, Daughton S: Cerebral perfusion pressure management in head injury. J Trauma 1990; 30: 933-40; discussion 940-1 Raabe A, Seifert V, Schmiedek P, Steinmetz H, Bertalanffy H, Steiger HJ, Stolke D, Forsting M: [Recommendations for the management of unruptured intracranial aneurysms]. Zentralbl Neurochir 2002; 63: 70-6 Clifton GL, Miller ER, Choi SC, Levin HS: Fluid thresholds and outcome from severe brain injury. 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Neurosurgery 1992; 30: 830-2; discussion 832-3 Chan AT, Atiemo A, Diran LK, Licholai GP, McLaren Black P, Creager MA, Goldhaber SZ: Venous thromboembolism occurs frequently in patients undergoing brain tumor surgery despite prophylaxis. J Thromb Thrombolysis 1999; 8: 139-42 Brosnan C, Razis P: Complications of treatment: pulmonary embolism following craniotomy for meningioma. J Neurosurg Anesthesiol 1999; 11: 119-23 [Heparin in neurosurgery. 10th Seminar on Neuro-anesthesia-resuscitation. (1). Paris Creteil, 3-4 November 1988]. Agressologie 1989; 30: 333-66 Videtta W, Villarejo F, Cohen M, Domeniconi G, Santa Cruz R, Pinillos O, Rios F, Maskin B: Effects of positive end-expiratory pressure on intracranial pressure and cerebral perfusion pressure. Acta Neurochir Suppl 2002; 81: 93-7 Wolf S, Schurer L, Trost HA, Lumenta CB: The safety of the open lung approach in neurosurgical patients. 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These recommendations are an approach to early goal directed therapy and should
serve as a reference for residents and fellows. They do not replace the individual
assessment and a clinical care decision for every single patient.

For the SICU-Neuro-Recommendation-Workgroup on March 31st 2005:
S. Schulz-Stubner, MD, PhD J. Steven Hata, MD

Source: http://www.anesth.uiowa.edu/Portals/0/SICU/SICUneuro.pdf