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. Crit Care Med 2002; 30: 739-45
Van Den Berghe G, Wouters PJ, Bouillon R, Weekers F, Verwaest C, Schetz
M, Vlasselaers D, Ferdinande P, Lauwers P: Outcome benefit of intensive insulin therapy in the critically ill: Insulin dose versus glycemic control. Crit Care Med 2003; 31: 359-66
Kakkar VV, Stringer MD: Prophylaxis of venous thromboembolism. World J
Iorio A, Agnelli G: Low-molecular-weight and unfractionated heparin for
prevention of venous thromboembolism in neurosurgery: a meta-analysis. Arch Intern Med 2000; 160: 2327-32
Inci S, Erbengi A, Berker M: Pulmonary embolism in neurosurgical patients.
Surg Neurol 1995; 43: 123-8; discussion 128-9
Hamilton MG, Hull RD, Pineo GF: Venous thromboembolism in
neurosurgery and neurology patients: a review. Neurosurgery 1994; 34: 280-96; discussion 296
Frim DM, Barker FG, 2nd, Poletti CE, Hamilton AJ: Postoperative low-dose
heparin decreases thromboembolic complications in neurosurgical patients. 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. Acta Neurochir Suppl 2002; 81: 99-101
Marini JJ: Efficacy of lung recruiting maneuvers: It's all relative. Crit Care
Drakulovic M, Torres A, Bauer T, Nicolas J, Nogue S, Ferrer M: Supine body
position as a risk factor for nosocomial pneumonia in mechanically ventilated patients. Lancet 1999; 354: 1851-8
Torres A, Carlet J: Ventilator-associated pneumonia. European Task Force on
ventilator-associated pneumonia. Eur Respir J 2001; 17: 1034-45
Torres A, Serra-Battles J, Ros E, Piera C, Puig de la Bellasca J, Cobos A:
Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation. Ann Intern Med 1992; 116: 540-3
Orozco-Levi M, Torres A, Ferrer M, Piera C, el-Ebiray M, de la Bellacasa J:
Semirecumbent position protects from pulmonary aspiration but not completely from gastroesophageal reflux in mechanically ventilated patients. Am J Respir Crit Care Med 1995; 152: 1387-89
Porchet F, Bruder N, Boulard G, Archer DP, Ravussin P: [The effect of
position on intracranial pressure]. Ann Fr Anesth Reanim 1998; 17: 149-56
Higashi S, Futami K, Matsuda H, Yamashita J, Hashimoto M, Hasegawa M,
Tokuda K, Hassan M, Hisada K: Effects of head elevation on intracranial hemodynamics in patients with ventriculoperitoneal shunts. J Neurosurg 1994; 81: 829-36
Meixensberger J, Baunach S, Amschler J, Dings J, Roosen K: Influence of
body position on tissue-pO2, cerebral perfusion pressure and intracranial pressure in patients with acute brain injury. Neurol Res 1997; 19: 249-53 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
Padmashree Dr. D. Y. Patil College of Nursing Sant Tukaram Nagar, Pimpri, Pune – 411 018 Mail : info.nursing@dpu.edu.in, Website: nursing.dpu.edu.in BASIC B.Sc. NUSING THIRD YEAR Subject code:3 Subject: Mental HealthNursing Faculty: Mrs. Nisha Naik Lectures lectures serial Perspectives of Mental Health and Mental Health 1 Nursing : evolution of mental health serv
Asthma Induced by Isocyanates: a Model of IgE-independent Asthma Cristina E. Mapp, Piera Boschetto, Deborah Miotto, Edoardo De Rosa Department of Clinical and Experimental Medicine, Section of Hygiene and Occupational Medicine, University of Ferrara Abstract. Developments in the understanding of causes and natural history of asthma induced by isocyanates may allow improved preventive strat