Neurosurgical and Postoperative Critical Care
Postoperative priorities
After craniotomy or spine surgery, the ICU focuses on detecting complications: hemorrhage, edema, seizures, hydrocephalus, and CSF leak. Neurologic checks are the most sensitive monitor - a declining exam often precedes imaging changes. Watch for postoperative hyponatremia and its cause (SIADH vs CSW), and manage airway and hemodynamics.
Specific scenarios
Understand the post-craniectomy patient (decompressive craniectomy) - protect the flap, avoid pressure, and monitor for hydrocephalus and syndrome of the trephined. After pituitary surgery, watch for diabetes insipidus and CSF leak. Recognize the risk of venous thromboembolism and the timing of prophylaxis after neurosurgery.
Traps
- Attributing postoperative decline to "expected swelling" while missing an expanding hematoma.
- Overlooking airway compromise from neck swelling after spine surgery.
- Misdiagnosing hyponatremia and giving free water when CSW is present.
Rule of thumb
Any unexplained postoperative neurologic decline = urgent CT and reassessment of airway, ventilation, and hemodynamics.
Worked example
A patient 6 h after craniotomy becomes drowsy with a new pupillary asymmetry. This is a surgical emergency - obtain immediate CT and alert neurosurgery; do not wait for scheduled imaging.