reanimat

Because of the long-term effects of computed tomography (CT) radiation exposure (lifetime risk of fatal cancer resulting from one head CT in a 1-yr-old child is as high as one in 1500), the neurosurgical decision to order a CT scan also should be considered a treatment decision, weighing the knowledge gained against the risk of long-term radiation exposure.

Cerebrospinal fluid (CSF) drainage may be associated with an increased risk of complications from hemorrhage and malpositioning.

Cardiorespiratory side effects are very common and potentially toxic with barbiturate therapy, including decreased cardiac output, hypotension, and increased intrapulmonary shunt resulting in lower cerebral perfusion pressure and hypoxia. Thus, high-dose barbiturate therapy has been reserved for extreme cases of intracranial hypertension resistant to first-tier medical and surgical care.

Arguing against the use of prophylactic hyperventilation, published evidence discussed in the guideline indicates that the use of hyperventilation is associated with cerebral blood flow (CBF) reductions and that prolonged and or significant hypocarbia is associated with poor outcome in pediatric patients with severe traumatic brain injury (TBI). As a result, advanced neuromonitoring for evaluation of cerebral ischemia may be considered if hyperventilation is to be used in the management of refractory intracranial hypertension.

Analgesic or sedative-induced reductions in arterial blood pressure can lead to cerebral ischemia as well as vasodilation and can exacerbate increases in cerebral blood volume and intracranial pressure (ICP). In the absence of advanced neuromonitoring, care must be taken to avoid this complication.

Risks of neuromuscular blockade include the potential devastating effect of hypoxemia secondary to inadvertent extubation, risks of masking seizures, increased incidence of nosocomial pneumonia (shown in adults with severe TBI), cardiovascular side effects, immobilization stress (if neuromuscular blockade is used without adequate sedation/analgesia), and increased intensive care unit (ICU) length of stay. Myopathy is most commonly seen with the combined use of nondepolarizing agents and corticosteroids. Incidence of this complication varies between 1% and over 30% of cases.

Six hours after etomidate administration, adrenocorticotropic hormone stimulation tests were performed on each patient; four of the eight showed adrenal suppression. It is unclear if this degree of adrenal suppression is different from that normally observed in pediatric TBI. No patient showed clinical signs of adrenal insufficiency such as electrolyte disturbances or blood pressure lability, and no patient received steroid therapy.

Contraindications

The use of lumbar drainage is contraindicated in the setting of a focal mass lesion or shift.