- VS: Continuous blood pressure, heart rate, and oxygenation monitoring; strict monitoring of inputs and outputs
- Blood pressure: Normotensive to slightly (<5%) hypotensive to reduce risk of perfusion breakthrough in high-flow lesions
- Fluids: Isotonic IV fluids at maintenance levels (usually normal saline)
- CSF drainage: Keep external ventricular drain at 20 cm above external auditory meatus and monitor output per physician.
- Diet: NPO
- HOB: Bed rest, head of bed at 30 degrees
- Nursing: Maintain age-appropriate normotension, oxygenation. Repeat neurological examination hourly and report changes.
- Medications: Antihypertensives (labetolol or nipride), antiepileptics, antibiotic (if EVD inserted), stool softener, multivitamin, pain management (usually short-acting narcotics such as morphine) Are the author’s preferred list. Avoid aspirin and any long-acting sedating agents unless specific orders are provided to the contrary.
- Perfusion breakthrough: Normal perfusion pressure breakthrough is a phenomenon that is thought to occur after resection of high-flow AVMs in which the blood previously transmitted through the AVM is redirected to smaller, normal vasculature after the AVM has been removed, with subsequent inability of the vessels to handle the increased flow. This can result in brain swelling, increased ICP, seizure, neurological dysfunction, or hemorrhage. The problem may be minimized by staged preoperative embolization and rigorous blood pressure control postoperatively.
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