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Table 3 Neuroprotective strategy in ICU
| • Head neutral | |
| • Head up | |
| • No compression on internal jugular veins | |
| • Maintain normal intrathoracic pressure, avoid airway obstruction, brochospasm, straining, coughing | |
| • Premedication before intubation with | |
| ◦ Fentanyl 2 mcg/kg (caution for bradypnea, bradycardia and respiratory arrest) | |
| • Rapid sequence induction with ketamine and midazolam or ketamine and propofol or etomidate | |
| • Muscle relaxant | |
| ◦ Rocuronium preferable | |
| ◦ Succinylcholine (fasciculations can cause increase in ICP; hyperkalemia in patients with extrajunctional receptors) | |
| • Hemodynamic and metabolic targets | |
| ➢Mean arterial pressure MAPs 90 to 100 mmHg (titrate according to baseline MAP± 20%) | |
| ➢PaO2 80 to 100 mmHg | |
| ➢PaCO2 30 to 35 mmHg | |
| ➢pH 7.35 to 7.45 | |
| ➢Normoglycemia | |
| ➢Normothermia | |
| ➢Adequate sedation/analgesia | |
| • Potential cerebrovasodilators should not be used | |
| ➢Vasopressin | |
| ➢Calcium channel blockers | |
| ➢NTG | |
| ➢Nitroprusside | |
| • For acute rise in intracranial pressure | |
| ➢Hyper ventilate to achieve PaCO2 25 to 30 mmHg | |
| ➢Hypertonic saline OR mannitol bolus | |
| ➢Deepen sedation (boluses of midazolam) |
