Neurosurgery

edema (prostacyclin to improve microcirculation) [12], and (5) the "cerebral ischemia model" (Robertson option), which relies upon the use of jugular venous oxygen saturation (SjVO2) monitoring to avoid global cerebral ischemia. These different options are summarized in Table 5.2. Although there is not a unified approach, with the exception of the Lund therapy, the consensus appears to be CPP at >60 mmHg [13] and MAP at >80 mmHg. Phenylephrine and norepinephrine are the most common agents used to support blood pressure in these patients. Both agents have negligible direct effects on the cerebral vasculature. Commonly used vasoactive agents are listed in Table 5.3.

Table 5.3. Vasoactive agents

Vasopressors/inotropes

Phenylephrine: 1-10 ^g/kg/min Norepinephrine: 0.05-0.2 ^g/kg/min Dopamine: 1-20 ^g/kg/min Dobutamine: 1-20 ^g/kg/min Vasopressin: 0.01-0.04 units/min Vasodilators/hypotensive agents Labetalol: 5-10 mg bolus q. 10 min, infusion at

50-100 mg/h, titrated to BP and HR Esmolol: 500 ^g/kg bolus, 3-15 mg/kg/h Clonidine: 0.1 mg q. 4 h Enlapril: 0.625-2.5 mg q. 6 h Hydralazine: 10-20 mg q. 2 h prn Sodium nitroprusside: 0.1-10 ^g/kg/min

Table 5.2. Comparison of four different approaches and the Brain Trauma Foundation guidelines for the management of acute head injuries
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