開顱術後重症醫療處置,台北醫學大學-萬芳醫院 神經外科 國立陽明大學 急重症研究所 廖國興 醫師 96年8月07日,Which for craniotomy?,Brain tumors Vascular lesions Brain trauma Epilepsy surgery,Brain damage,Primary insult Secondary insultBrain edemaIschemiaHypoxiaetc.,Primary insult: depend on pathogenesis Secondary insult: preventable and treatable,Causes of Secondary insults,Systemic insultsImmediate:a. Hypotensionb. Hypoxemiac. AnemiaDelayed:a. Coagulopathyb. Hyperthermia (increased CMRo2)c. Hyponatremia,Causes of Secondary insults,Intracranial insultsHigher ICP (decreased CBF)a. Hematomasb. Edema (capillary compression)c. Brain swelling secondary to hyperemiaBrain shift (herniation, arterial compression)Vasospasm (decreased CBF)Epileptic seizures (increased CMRo2),Prevent 2nd injury in post-op care,A.B.C Clinical physical examinations: GCS, pupil size, muscle power, etc Monitoring device Image examinations,A.B.C,Airway: adequate E-T tube position, sputum suction, prevent compresion Breathing: ventilation, oxygenation Circulation: hypertension and hypotension, adequate tissue perfusion, EKG rhythm, post-OP AMI, etc,Repeat neurological examinations,GCS (Glasgow coma scale) Pupil size and light reflex Muscle power and DTR Cranial nerves assessment if patient cooperated If GCS down 2 = high suspicion and more alert,Glasgow 昏迷指數表,Neurological monitoring,EVD (External ventricular drainage):short tract vs. long tract Most common entry site: Kochers point Tip location: lateral and 3rd ventricles,Key points in EVD care,Patent or clamp ? CSF drainage amount:CSF 450-500 ml/day = 20 ml/h, avoid drainage insufficiency or over Zero point and fixed level,Key points in EVD care,Close system Avoid contamination Fragile shunt, avoid over-stretch Measurement of ICP from fluid level and monitor,ICP and CPP,ICP 20 mmHg CPP = MAP- ICP CPP level: 60-70 mmHg Triple H therapy in aneurysmal SAH:HypertensionHemodilutionHypervolemia,ICP,Fiberoptic ICP: inserted in parenchymal or subdural space Advantages: no obstruction, artifact-free Disadvantage: expensive, no CSF drainage,Craniotomy wound drainage,Drain out craniotomy blood, avoid EDH or SDH J-P drainage Exudrain: close system, avoid opening frequent, easily insertion, avoid ascending infection,