Neurocritical Care and Neuroanesthesia
Core concepts
Understand the principles of neurocritical care: airway and ventilation, hemodynamic targets, sedation, and temperature control. Know the management of elevated ICP (head-of-bed, sedation, osmotherapy, CSF drainage, decompressive surgery) and the avoidance of secondary injury. Understand the neuroanesthesia considerations: maintenance of cerebral perfusion, avoidance of hypotension, and the effects of anesthetic agents on cerebral blood flow and metabolism. Know the management of status epilepticus (benzodiazepines, then antiepileptics, then anesthetic agents). Understand the recognition and management of cerebral salt wasting vs SIADH after SAH or surgery. Know the basics of brain death determination.
Traps
A common trap is treating hyponatremia after SAH as SIADH when it is cerebral salt wasting (volume-depleted), leading to fluid restriction that worsens ischemia. Another is failing to recognize nonconvulsive status epilepticus in a comatose patient (needs EEG). Watch for over-sedation masking neurologic decline. Questions may test that hyperventilation is temporary and that normocapnia is the goal otherwise.
Worked rule of thumb
Hyponatremia after SAH: assess volume status. Cerebral salt wasting is hypovolemic and treated with saline; SIADH is euvolemic and treated with fluid restriction. In a comatose patient with unexplained decline, obtain an EEG to rule out nonconvulsive status epilepticus.