开颅术后的重症监护

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1、開顱術後重症醫療處置台北醫學大學-萬芳醫院神經外科國立陽明大學急重症研究所廖國興醫師96年8月07日Whichforcraniotomy?BraintumorsVascularlesionsBraintraumaEpilepsysurgeryBraindamagePrimaryinsultSecondaryinsultBrainedemaIschemiaHypoxiaetc.Primaryinsult:dependonpathogenesisSecondaryinsult:preventableandtreatableCausesofSecondaryinsultsSyst

2、emicinsultsImmediate:a.Hypotensionb.Hypoxemiac.AnemiaDelayed:a.Coagulopathyb.Hyperthermia(increasedCMRo2)c.HyponatremiaCausesofSecondaryinsultsIntracranialinsultsHigherICP(decreasedCBF)a.Hematomasb.Edema(capillarycompression)c.BrainswellingsecondarytohyperemiaBrainshift(herniation,arterial

3、compression)Vasospasm(decreasedCBF)Epilepticseizures(increasedCMRo2)Prevent2ndinjuryinpost-opcareA.B.CClinicalphysicalexaminations:GCS,pupilsize,musclepower,etcMonitoringdeviceImageexaminationsA.B.CAirway:adequateE-Ttubeposition,sputumsuction,preventcompresionBreathing:ventilation,oxygenat

4、ionCirculation:hypertensionandhypotension,adequatetissueperfusion,EKGrhythm,post-OPAMI,etcRepeatneurologicalexaminationsGCS(Glasgowcomascale)PupilsizeandlightreflexMusclepowerandDTRCranialnervesassessmentifpatientcooperatedIfGCSdown≧2=>highsuspicionandmorealertGlasgow昏迷指數表分數E：睜開眼睛V：語言能力M：運

5、動功能6可依照檢查者命令動作5對答如流,邏輯正常僅可定位疼痛點4自動睜開眼睛言語內容混淆僅可閃躲外來疼痛刺激3聽聲音睜眼言語短促，不恰當去大腦皮質型僵直反射2在疼痛下睜眼呻吟聲，聽不懂去腦幹型僵直反射1完全不睜開眼睛完全無言語反應不論如何刺激，全無動作NeurologicalmonitoringEVD(Externalventriculardrainage):shorttractvs.longtractMostcommonentrysite:Kocher’spointTiplocation:lateraland3rdventriclesKeypointsinEVDcareP

6、atentorclamp?CSFdrainageamount:CSF450-500ml/day=>20ml/h,avoiddrainageinsufficiencyoroverZeropointandfixedlevelKeypointsinEVDcareClosesystemAvoidcontaminationFragileshunt,avoidover-stretchMeasurementofICPfromfluidlevelandmonitorICPandCPPICP≦20mmHgCPP=MAP-ICPCPPlevel:60-70mmHgTripleHtherapyi

7、naneurysmalSAH:HypertensionHemodilutionHypervolemiaICPFiberopticICP:insertedinparenchymalorsubduralspaceAdvantages:noobstruction,artifact-freeDisadvantage:expensive,noCSFdrainageCraniotomywounddrainageDrainoutcraniotomyblood,avoidEDHorSDHJ-PdrainageExudrain:cl