Neurocritical Care and Perioperative Management
What the candidate must own
Know the principles of neurocritical care: airway and ventilation, haemodynamic targets (cerebral perfusion pressure, avoidance of hypotension), sedation, and the tiered management of raised intracranial pressure. Understand the specific management of subarachnoid haemorrhage (nimodipine, euvolaemia, early aneurysm securing), status epilepticus (benzodiazepines then levetiracetam or phenytoin), and the recognition of brain death. Know the perioperative considerations: anticoagulant and antiplatelet reversal, seizure prophylaxis, steroid use in tumour and spinal cord compression, and venous thromboembolism prophylaxis. Understand sodium disorders - SIADH versus cerebral salt wasting - and their management.
Traps that appear in questions
- Treating cerebral salt wasting with fluid restriction (it worsens hypovolaemia) - distinguish from SIADH.
- Forgetting that steroids are indicated for vasogenic oedema from tumours but not for traumatic brain injury.
- Missing the need to reverse anticoagulation urgently in a patient with intracranial haemorrhage.
- Confusing brain death criteria - the apnoea test requires a prerequisite PaCO2 and haemodynamic stability.
Rule of thumb
In neurocritical care, protect the brain by protecting the physiology: oxygenation, perfusion, glucose, temperature, and seizure control. Worked example: a patient with SAH and hyponatraemia with hypovolaemia and high urine output has cerebral salt wasting - treat with isotonic fluid and salt replacement, not fluid restriction.