Prone ventilation in a patient with traumatic brain injury, bifrontal craniectomy and intracranial hypertension

Abstract

Background Prone position during mechanical ventilation has shown to improve oxygenation and decrease mortality in patients with acute respiratory distress syndrome (ARDS). Prone ventilation has been described in trauma patients, but there is paucity of data on prone ventilation in patients with traumatic brain injury. Case We present the case of a 23 year old male who presented with a closed head injury and was intubated for depressed mental status. Imaging revealed a left parietal epidural hematoma and multiple intracranial hemorrhages. He was also found to have elevated intracranial pressure (ICP). Medical management, external ventricular drain (EVD) as well as left hemicraniectomy and evacuation of the epidural hematoma all failed to lower the ICP. The patient eventually underwent bifrontal craniectomy and extension of left hemicraniectomy. One week later, he developed aspiration pneumonia and ARDS. Despite traumatic brain injury and bifrontal craniectomy, the patient was placed on prone ventilation for three days. He was maintained on higher than usual tidal volumes, and positive-end expiratory pressure (PEEP) was increased cautiously due to elevated ICP. He also developed fever of central origin and was placed on a normothermia protocol with a venous cooling catheter, which was discontinued after 10 days upon resolution of the fever. The patient eventually had a cranioplasty and was weaned off the ventilator. He was discharged home after neurorehabilitation. Conclusion Most of the studies on prone ventilation excluded patients with traumatic brain injury and reduced intracranial compliance. Our case demonstrates that non-conventional modes of ventilation like prone position ventilation as well as higher tidal volumes and moderate PEEP, if employed cautiously, can be used successfully in patients with traumatic brain injury, intracranial hypertension and craniectomy.