Abstract
Brain insult in neurosurgical patients is highly dependent on hydroelectrolytic and haemodynamic disturbances. The magnitude of their effect is related to blood-brain barrier integrity and characteristics of cerebral perfusion pressure. Moderate disturbances in ionic balance or CPP may lead to interstitial oedema or worsening of cerebral ischaemia. As a consequence, intracranial pressure (ICP) may rise and neurological status worsen. This study discusses the cerebral effects of intercompartimentary water and electrolyte movements, which themselves are either secondary to early neurological dysfunction, as insipid diabetes, the syndrome of inappropriate ADH secretion, and/or to renal losses of sodium, or iatrogenic, after administration of mannitol or furosemide. Understanding the early mechanism underlying these disorders is essential for treatment. Early interstitial oedema is mainly a consequence of low plasma osmolality, whereas low oncotic pressure plays a minor role. Worsening of cerebral ischemia by hyperglycaemia should contra-indicate glucose for perioperative infusion. Keeping CPP at normal levels is essential, especially in case of disturbances of the autoregulation of the cerebral circulation. Normovolaemia and the choice of an appropriate agent for plasma volume expansion are essential. Correction of hypovolaemia is best obtained with (except for packed red cells when necessary) normal saline, 4 % human albumin or hydroxyethylstarch. The benefit of utilizing hypertonic electolytic or HES solutions in neurosurgical patients has still to be assessed.
Published Version
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