Multiple Organ Support Introduction to Multiple Organ Support, D

IMANCUAGEMENT & PRACTICE Intensive care - Emergency Medicine - Anaesthesiology VOLUME 18 - ISSUE 1 - spring 2018

SPECIAL SUPPLEMENTS Hamilton Medical symposium: Optimising patient-ventilator synchronisation Nestlé Nutrition Institute symposium: Nutritional challenges in ICU patients Multiple organ support Introduction to multiple organ support, D. Abrams et al. From multiple organ support therapy (MOST) to extracorporeal organ support (ECOS) in critically ill patients, C. Ronco et al. Chronic respiratory dialysis, D. Abrams et al. Understanding LVAD & artificial hearts, N. Aissaoui et al.

Plus

CO2 in the critically ill, L. Morales- emergencies, I. Gonzalez Being an expert witness, Quinteros et al. A novel communication device J. Dale-Skinner Immune dysfunction in sepsis, for tracheostomy ICU patients, Role of the chaplain in the ICU, V. Herwanto et al. F. Howroyd K. Jones Hypothermia in neurocritical care The Critical Care Resuscitation Developing new approaches to patients other than cardiac arrest, Unit, L.I. Losonczy et al. patient safety, J. Welch et al. R. Helbok & R. Beer Variation in end-of-life care, How to provide better intensive Intracranial pressure monitoring A. Michalsen care? J. Takala devices, S. Patil & F. Fadhlillah Simulate or not to simulate? Caring for critically ill immunocom- Complications of decompressive M. Poggioli et al. promised patients, E. Azoulay craniectomy in neurological ©For personal and private use only. Reproduction must be permitted by the copyright holder. Email to [email protected]. must be permitted use only. Reproduction and private ©For personal

icu-management.org @ICU_Management 52 MATRIX

Isabel González Attending Physician Intensive Care Unit Complications of Complejo Hospitalario De León Altos de Nava Spain decompressive craniectomy migonzalezpe@saludcastillay- leon.es in neurological emergencies A brief report

There are a number of complications related to the use of decompressive surgery. The most important thing to bear in mind is these complications can impair recovery.

What is a decompressive craniectomy? What complications are attributable Given the wide variety of clinical manifesta- Decompressive craniectomy is a surgical to a subsequent cranioplasty? tions, the mechanism may be multifactorial. procedure where a large section of the skull 1. Infection The images correspond to the same patient is removed and the underlying dura mater 2. Bone flap resorption who presented all the possible complications exposed. Primary decompressive craniectomy of a primary decompressive craniectomy after refers to leaving a large bone flap out after Can the skull defect cause neurologi- traumatic brain injury: subdural effusions extraction of an intracranial haematoma in the cal dysfunction? or hygromas, hydrocephalus, paradoxical early phase post-TBI. Cranial reconstruction is Certain patients are particularly susceptible herniation, seizures, syndrome of trephined, undertaken between a few weeks and months to neurological signs and symptoms relating and infection. The final image demonstrates later with autologous bone (the removed bone to the presence of a large skull defect. Clini- the result after cranioplasty and ventriculo- flap is stored in the patient’s abdominal wall cal presentation can range from symptoms peritoneal shunt and decompressive catheter or a deep freezer) or an implant (titanium such as headaches, seizures, mood swings, inside the subdural hygroma. or other synthetic material). A secondary and behavioural disturbances (syndrome The most important thing to bear in mind decompressive craniectomy is used as part of of trephined) to neurological deficits due is that we usually see these complications in tiered therapeutic protocols that are frequently to cortical dysfunction (syndrome of the the ICU. Moreover, we must be very clear about used in intensive care units (ICUs) in order sinking scalp flap). the approach to follow. It is essential to know to control raised intracranial pressure and the probability of neurological deterioration ensure adequate cerebral perfusion pressure. after lumbar puncture or lumbar cerebrospinal symptoms of fluid (CSF) drainage in the setting of large What complications are attributable paradoxical herniation cranial defects, since this has been observed to a decompressive craniectomy? following decompressive craniectomy and is 1. Herniation of the cortex through may be masked and even due to symptomatic herniation. bone defect mistaken for neurological In the early stage of recovery from trau- 2. Subdural/subgaleal effusion matic brain injury following decompres- 3. Syndrome of the trephined (headache, damage from the trauma sive craniectomy, symptoms of paradoxical dizziness, irritability, mood swings herniation may be masked and even mistaken and behavioural disturbance) for neurological damage from the trauma. 4. Seizures The pathophysiology responsible for the 5. Hydrocephalus (defined as dilata- neurological manifestations has yet to be How to avoid complications tion of the ventricular system with established. A number of different theories Neurosurgeons, intensive care specialists accompanying clinical features that have been put forward, i.e. direct effects of and the other professionals involved in the required shunt placement). atmospheric pressure on the brain, alterations treatment of these patients need to carefully 6. Infection in cerebrospinal fluid hydrodynamics, and decide who will benefit from immediate 7. Paradoxical herniation changes in cerebral blood flow and metabolism. decompressive craniectomy and who are ©For personal and private use only. Reproduction must be permitted by the copyright holder. Email to [email protected]. must be permitted use only. Reproduction and private ©For personal ICU Management & Practice 1 - 2018 53 MATRIX

ventriculoperitoneal shunt. A cranioplasty procedure is necessary when the patient is clinically improved. Nevertheless, it is best performed as early as possible, since atmospheric pressure may cause local vascular dysfunction.

Conclusions Despite the successes and worldwide application of decompressive craniectomy, the procedure remains controversial and there continue to be uncertainties regarding its appropriate application. These areas of controversy can be grouped into four categories: patient selection, timing, technical considerations, outcome results and complications. In this article I have only described the complications. To what degree patients are affected by the symptoms of syndrome of the trephined is difficult to determine, since many patients are in the severe head injury recovery phase. Several studies have demonstrated that hydrodynamic abnormalities present prior to cranioplasty were reversed after the bone flap was replaced. In some cases, this was accompanied by a clinical improvement. However, this was not always so. Technically speaking, whilst the procedure is straightforward, the complications can impair recovery. Not least it represents an aggressive intervention associated with significant morbidity, not only from the initial decompression but also from the subsequent reconstructive cranioplasty. The aim of this brief review is to empha- best treated by initial monitoring and medi- tion should be followed closely, looking out sise that although decompressive surgery is cal treatment of intracranial hypertension. for signs and symptoms of syndrome of the indicated in some neurocritical patients for Correct selection for decompressive surgery trephined. cerebral oedema management, the technique is required in order to avoid an intervention Tapping and shunt treatment of CSF subdu- is not without significant complications. that increases survival at the expense of a ral hygromas should be avoided, where Furthermore, said complications are not persistent vegetative outcome. possible. There is also a risk of paradoxical always reversible, and may contribute to a In addition to using the appropriate surgical herniation in those patients with a skull worsening of the neurological outcome of technique, the patient’s neurological condi- defect, who undergo lumbar puncture and these patients.

References pressive craniectomy for head injury. J Clin inconvenient truth? Curr Opin Crit Care, 23 Nasi D et al. (2016) Paradoxical brain Neurosci, 17: 430-45. Jan. doi: 10.1097/MCC.0000000000000481. herniation after decompressive craniectomy Grindler GA et al. (2016) Decompressive [Epub ahead of print] provoked by drainage of subdural hygroma. Honeybul S (2014) Neurological suscepti- craniectomy for severe traumatic brain World Neurosurg, 91: 673: e1-4. bility to a skull defect. Surg Neurol Int, 5: 83. Hutchinson PJ et al. (2016) Trial of injury: clinical study, literature review and decompressive craniectomy for traumatic meta-analysis. Springerplus, 5: 1605. Honeybul S et al. (2018) Long-term outcome intracranial hypertension. N Engl J Med following decompressive craniectomy: an Honeybul S (2010) Complications of decom- 375: 1119-30. ©For personal and private use only. Reproduction must be permitted by the copyright holder. Email to [email protected]. must be permitted use only. Reproduction and private ©For personal ICU Management & Practice 1 - 2018