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Table 3 Neuroprotective strategy in ICU

From: Difficult tracheal intubation in critically ill

• 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)