Local hospital guidelines / LHH.
Local hospital guidelines / LHH.
HIMALAIA Study – Netherlands. The only RCT looking at efficacy of BP augmentation in DCI in increasing cerebral blood flow (via CT perfusion). Small n, negative study.
Tey article – XeCt to measure regional CBF, at onset of DCI suspicion, 5 days of induced HTN, hypervolemia, hemodilution. Compared XeCT before and after treatment and showed increase in regional CBF in worst vascular territories from 19 to 227ml/100g/min, significant reduction of regions with CBF <20ml/100g/min from 26 to 10%.
Baseline echo: cardiomyopathy is a contraindication
Drug of choice: Induce HTN with norepinephrine? based on reference below (we usually use phenylephrine)
Risks of Induced HTN:
Literature does not support the use of induced HTN, but how can we ignore bedside observations of patients who clinically improve with induced HTN?
Dr. Diringer’s Advice: use induced HTN in a thoughtful and individualized manner. Trial of induced HTN at onset of DCI. If patient improves, continue. If no change, back off and explore alternative treatments. If patient exam is poor (no followable exam), answer less clear but prolonged extreme elevations should be avoided.
Gathier, C., Dankbaar, J., van der Jagt, M., Verweij, B., Oldenbeuving, A., Rinkel, G., van den Bergh, W. and Slooter, A. (2015). Effects of Induced Hypertension on Cerebral Perfusion in Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. Stroke, 46(11), pp.3277-3281.
Diringer, M. Editorial. Hemodynamic Therapy for Delayed Cerebral Ischemia in SAH. Neurocritical Care Journal. Pre-print.
Interesting classification of DI, taken from Neurology India, groups DI into mild and severe based on some clinical and lab findings.
This was their protocol for diagnosis and management of DI in patients who underwent craniopharyngioma surgery.
Protocol for diabetes insipidus
Chacko, AriG et al. “Evaluation Of A Protocol-Based Treatment Strategy For Postoperative Diabetes Insipidus In Craniopharyngioma”. Neurology India 63.5 (2015): 712.
IV Haloperidol 2.5-5mg every 10-30minutes until RASS 0 to -2 or max dose of 30mg
Carrasco, Genís et al. “Dexmedetomidine For The Treatment Of Hyperactive Delirium Refractory To Haloperidol In Nonintubated ICU Patients”. Critical Care Medicine 44.7 (2016): 1295-1306.
10cm H20 prior to weaning
Initiation of weaning left to discretion of attending neurosurgeon.
RAPID WEANING (within 24 hours)
Failure of weaning = VP shunt insertion
**No differnece in incidence of HCP / need for VP shunting (62.5 vs 63.4% p=0.932)
**gradual weaning group spent 2.8 more days in the ICU (p=0.0002)
Neurocritical Care Society Guideline:
EVD weaning should be accomplished as quickly as is clinically feasible so as to minimize the total duration of EVD monitoring and VRI risk.
Two main methods to select those who will need permanent CSF diversion: clamping trial vs progressive wean.1. Clamping Trial: clamp EVD and monitor ICP, clinical status, ventricle size – determine whether VPS is required2. Progressive wean – progressively increase level of ventricular drainage (usually 5mm Hg/d) while monitoring ICP, clinical status, ventricular size, drainage volume Only 1 RCT (Klopfenstein, see reference listed) comparing the two methods. Clamping trial associated with shorter duration of EVD and ICU and hospital LOS with similar clinical outcomes.Currently decision to shunt is based on clinical deterioration. There is little information about the effects of subclinical hydrocephalus on cognitive function, chronic headache and fatigue. Studies have shown decrease in CBF in NPH, correlating with cognitive dysfunction.
Fried, Herbert I. et al. “The Insertion And Management Of External Ventricular Drains: An Evidence-Based Consensus Statement”. Neurocritical Care 24.1 (2016): 61-81. Web.
Klopfenstein, Jeffrey D. et al. “Comparison Of Rapid And Gradual Weaning From External Ventricular Drainage In Patients With Aneurysmal Subarachnoid Hemorrhage: A Prospective Randomized Trial”. Journal of Neurosurgery 100.2 (2004): 225-229. Web.
Rabinstein, A. and Lanzino, G. (2018). Aneurysmal Subarachnoid Hemorrhage. Neurosurgery Clinics of North America, 29(2), pp.255-262.
New York Organ Donor Network’s “ICU Donor Guidelines and Routine Orders”