You are called to review a 55-year-old female following difficult, prolonged surgery for clipping of a left middle cerebral artery aneurysm. She returned to the ICU intubated, ventilated and with an external ventricular drain (EVD) in situ three hours earlier. She now has frank blood in the EVD. Her blood pressure is 180/100 mmHg, and her intracranial pressure has increased to 57 mm Hg. Outline your approach
Answer and interpretation
- This is a very urgent situation
- Likely diagnosis is a surgical catastrophe
- Will need urgent CT +/- angiogram
- Contact surgical team
- Control ICP and defend CPP
- Prepare for OT
- Contact family once urgent situation settled
- PaO2 >90 mmHg, O2 sats >95%
- CO2 32–38mmHg
- Check ETT ties
- Check BP for accuracy, probably allow BP to be a bit on the high side initially (SBP 150 – 170) but not excessively. Avoid hypotension. Treat hypotension carefully (probably noradrenaline rather than metaraminol boluses) to prevent large swings in BP
Urgent CT +/- Angiogram
- Get junior to call CT
- Start packing, obtaining equipment, medications
Contact Surgical Team
- Check reading; level, zero, draining
- ETT ties not tight
- Head up 45 degrees
- Mild hyperventilation (CO2 34 – 38 mmHg)
- Thiopentone bolus 2 – 5 mg/kg
- Lower drain (5 – 10 cm above foramen magnum) and drain CSF
- Consider osmolar therapy
- Mannitol (100 mL 20%)
- Hypertonic saline (dose)
- Target osm 320
- Maintain CPP if able
- Probably target CPP of 50-60
- Prepare for OT
- Check G+H
- Check coags
- Contact anesthestic/OT co-ordinator
- Cease feeds
- Pass rate: 87%
- Highest mark: 6.9
Additional Examiners’ Comments:
- Some candidates failed to recognise this as an emergency situation and treat appropriately in collaboration with the neurosurgeon.
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.