Neurosurgery

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Table 5.1. Treatment of elevated ICP

Conventional measures

1. Elevation of head and relief of potential venous obstruction

2. Elevation of MAP (if appropriate)

3. PaCO2 of 30-35 mmHg, or 25-30 mmHg if there are signs of brain herniation

4. Mannitol 0.5-1.0 g/kg q. 6 h prn and furosemide 20 mg prn. Keep serum osmolality <320.

5. Maintain hypovolemia; monitor CVP, if possible.

6. Ventriculostomy for drainage of CSF, if applicable.

7. Sedation with opiates, benzodiazepines and/or propofol

8. Fine-tune the level of PEEP, if applicable.

9. Maintain normovolemia.

Aggressive measures (in patients refractory to conventional measures)

1. Induction of hypothermia to 33-34°C

2. Maximal EEG suppression with induction of propofol or barbiturate coma

3. Hyperventilation to PaCO2 of 20-25 mmHg (monitor SjvO2 or PbrO2)

4. Hypertonic saline (3% or 7.5% 25-50 ml/h); monitor serum sodium Extreme measures

1. Decompressive craniectomy

2. Excision of infarcted tissues ± lobectomy

This can be accomplished with maintenance of normovolemia and infusion of phenylephrine at 1-10 ^g/kg/min, or norepinephrine at 0.05-0.2 ^g/kg/min.

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