Craniectomy / SDH questions

  1. 0
    Hi! I'm new to a neuro ICU.

    Had a head trauma patient with a subdural and a shift. Low GCS at first, but they did a massive craniectomy (entire parietal/temporal bone flap). By the time I got the patient (3 hours post-op) he was following commands and nodding to some questions off sedation. Pupils equal and brisk, moving all extremities equally. The neurosurgeon seemed surprised and impressed. Follow-up CT scan showed the shift had resolved.

    Two questions:
    1. Should I worry about too much fluids with this patient? Would it cause brain swelling? He was getting maintenance fluid and he was on a protocol for potassium replacement (standard for trauma patients, not necessarily neurosurg patients). So with a K rider I was running 250 ml/hr intake. I decreased the maintenance to KVO but didn't know if they maybe needed the fluid as traumas often do.

    2. What kind of prognosis and outlook would this patient have? I encouraged the family that it's good he's able to wake and follow commands, but cautioned them that swelling might still occur. Could this patient be, you know, okay today and then swell tomorrow and be in a coma forever? Could they be okay today and then still suffer cognitive deficit or personality changes as TBI patients often do?

    I mean, it's great that this patient seemed resolved, but that's without half their skull in place. What happens from now on?

    Chris
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  3. 8 Comments so far...

  4. 1
    I would hope the patient was on 0.9NS for their maintenance fluid and was also receiving Mannitol. The combination would help to move fluid out of the cell and into the intravascular. I do think that fluid rate was a bit high, even for a trauma patient. No doubt they received plenty of fluids in the OR to correct any trauma related hypovolemia.

    As for outcome, I would be encouraging but realistic. It is a real possibility that the patient could still swell, even with the craniectomy. I always tell my patient's family members that brain injuries are like a marathon, not a sprint. For every step you take forward you will take two back and it is important to be patient.
    fiveofpeep likes this.
  5. 0
    For some reason we use D5 .45%. Also I think they reserve mannitol for actual cases of swelling and not for prophylaxis anymore? But I'm not sure.

    That's a good point. I'll remember to say that.
  6. 0
    we do mannitol prophylactically for many patients. havent seen any side effects yet and we have a really high success rate with a very high acuity neuro population. we give hypertonic saline boluses for emergencies
  7. 1
    I think the pt is still at risk for swelling but with the crani it might not cause extreme neuro changes. And I don't think that the fluids were too much but then again it depends on what his lactic acid is, base deficit and UOP. Mannitol shouldn't be given unless his ICP's are elevated. As far as his future...no one knows but I have seen pt with GCS 3, crani to getting their flap back months later...there is hope
    fiveofpeep likes this.
  8. 0
    On my unit we use mannitol for increased ICP's, not to prevent swelling. If a CT shows cerebral edema we hang a hypertonic saline like 3%, and in extreme cases I have seen 24% used.

    If a bone flap was removed soon enough I have seen good outcomes, but the majority of the time I see it major damage has been sustained and it significantly effects the patients quality of life.
  9. 0
    You could probably back off the fluids a bit but I am wondering why you are using D5.45% on a neurosurg patient. Usually just normal saline for them. Also as for the outcome only time will tell but if the flap came off early should give room to swell and will have to wait and see.
  10. 0
    I would have backed off the fluids a bit and kept the total of fluids going in above but around the maintenance rate your MD has ordered. If you have say LR at 75, diprivan at 10, K at 10, and pressors/blockers going in at a high dose keep in mind the total amount of fluid being infused/hour for this patient. I have seen really high infusion rates in order to prevent vasospasms etc. but it is all according to your patients diagnosis/treatment. There is always more than one way to do things and thinking critically about a situation is something you will gain with experience. For the other posts, we give mannitol pre and post surgery, and sometimes not at all to patients with the same diagnosis. Just depends on the MD a lot of times, and the patient condition.
    Based on your patient, having a GCS of 3 then waking and following commands is great. Yes there is a chance they could regress and become very critical but at least they were able to improve to that point. I try and tell families it is great that they are able to follow commands and nodding appropriately and they are able to hear what is being asked of them and complete a cognitive task. But I also remind them that with any type of head injury and surgery the patient can become unstable again and that they should just think positive and hope for the best. Only time will tell the extent of their recovery. Best of luck.
  11. 0
    250 is a good bit of fluids. Maybe they should have him on NS with 20meQ KCL and give him scheduled doses of KCL through the NG or dobhoff. As a neuro patient there is still the risk of spasms, as stated, but you don't want to overload. They sometimes write for TIVF + PO= XYZ (TIVF- Total Intravenous Fluids). He has a flap now so he has room to swell, but thats not what we want. Yes, we use 3% on a continual rate (like 30-50ml/ hour) w/wo maintenance . (must check sodium levels every 4 or 6 hours). We use 23% if needed or prn ICPs (mostly the NP or MD has ordered us to give it). However, it all depends on the unit and MDs. Hope your guys stays well. Stay on top of his neuro checks, lytes, and scans!


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