开颅术后的重症监护幻灯片课件.pptVIP

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 Which for craniotomy? Brain tumors Vascular lesions Brain trauma Epilepsy surgery Brain damage Primary insult Secondary insult Brain edema Ischemia Hypoxia etc. Primary insult: depend on pathogenesis Secondary insult: preventable and treatable A.B.C Airway: adequate E-T tube position, sputum suction, prevent compresion Breathing: ventilation, oxygenation Circulation: hypertension and hypotension, adequate tissue perfusion, EKG rhythm, post-OP AMI, etc Repeat neurological examinations GCS (Glasgow coma scale) Pupil size and light reflex Muscle power and DTR Cranial nerves assessment if patient cooperated If GCS down ≧2 = high suspicion and more alert Glasgow 昏迷指數表 分數 E：睜開眼睛 V：語言能力 M：運動功能 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 Neurological monitoring EVD (External ventricular drainage): short tract vs. long tract Most common entry site: Kocher’s point Tip location: lateral and 3rd ventricles Key points in EVD care Patent or clamp ? CSF drainage amount: CSF 450-500 ml/day = 20 ml/h, avoid drainage insufficiency or over Zero point and fixed level Key points in EVD care Close system Avoid contamination Fragile shunt, avoid over-stretch Measurement of ICP from fluid level and monitor ICP and CPP ICP ≦ 20 mmHg CPP = MAP- ICP CPP level: 60-70 mmHg Triple H therapy in aneurysmal SAH: Hypertension Hemodilution Hypervolemia ICP Fiberoptic ICP: inserted in parenchymal or subdural space Advantages: no obstruction, artifact-free Disadvantage: expensive, no CSF drainage Craniotomy wound drainage Drain out craniotomy blood, avoid EDH or SDH J-P drainage Exudrain: close system, avoid opening frequent, easily insertion, avoid ascending infection