Page 160 - Critical Care Notes

4223_Tab05_141-174 29/08/14 8:28 AM Page 154

NEURO
■ Monitor fluids and electrolytes.
■ Insert Foley catheter if necessary and monitor urine output.
■ Consider packed RBC transfusions to treat anemia.
■ Monitor and control blood glucose levels.
■ Institute seizure precautions and start antiepileptic drug (AED) therapy.
■ Institute aneurysm precautions: bedrest; dark, quiet room with minimal stim-
ulation and nonstressful environment; pain control (consider fentanyl); ↑ HOB
15°–30°; stool softeners and bowel regimen (avoid enemas). Restrict visitors.
■ Avoid Valsalva maneuver, straining, forceful sneezing, and acute flexion of
head and neck. Eliminate caffeine from diet.
■ Administer analgesics for pain control; use nonsedating agents. Control
anxiety. Consider midazolam.
■ Administer nimodipine (Nymalize) for cerebral vasodilation. Therapy should
start within 96 hr of SAH.
■ Provide DVT and stress ulcer prophylaxis.
■ Monitor and treat heparin-induced thrombocytopenia.
Triple-H Therapy to Prevent Vasospasms
■ Hypovolemia is treated with colloids and crystalloids to keep CVP
10–12 mm Hg and PCWP 14–20 mm Hg.
■ Hemodilution is used to keep hematocrit level at 33%–38%.
■ Hypertensive therapy is given to keep SBP 110–160 mm Hg.
■ Also monitor levels of oxygenation.
■ Administer oral nimodipine.
Prepare patient for surgery:
■ Surgical aneurysm repair: surgical clipping. Complete obliteration of
aneurysm recommended.
■ Endovascular (aneurysm) coiling: obstruction of aneurysm site with coil.
Coiling preferred over clipping.
■ After aneurysm repair, immediate cerebrovascular imaging is recommended
to identify remnants or recurrence of aneurysm.
■ Stenting of a ruptured aneurysm is not recommended.
Complications
Additional management is aimed at preventing the following complications:
■ Increased ICP
■ Coma and brainstem herniation
■ Rebleeding: greatest risk within first 24 hr of rupture. Assess for ↑ ICP and
fresh bloody CSF, sudden and severe headache, altered LOC, new neuro-
logical deficits
■ Cerebral vasospasm, delayed cerebral ischemia, cerebral infarction,
changes in LOC, headache, new neurological deficits, seizures
■ Seizures
154