What is the care plan for a patient with anoxic brain injury?

Care Plan for Anoxic Brain Injury

The comprehensive care plan for anoxic brain injury must focus on maintaining adequate oxygenation, appropriate blood pressure, and minimizing intracranial pressure to improve mortality and neurological outcomes. 1

Initial Stabilization and Airway Management

Airway and Ventilation

• Indications for tracheal intubation:
  • GCS ≤ 8
  • Deteriorating consciousness (fall in GCS of ≥2 points or motor score drop of ≥1)
  • Loss of protective laryngeal reflexes
  • Failure to achieve PaO2 ≥ 13 kPa
  • Hypercarbia (PaCO2 > 6 kPa)
  • Spontaneous hyperventilation (PaCO2 < 4.0 kPa)
  • Seizures 1

Ventilation Parameters

• Target PaO2 ≥ 13 kPa while avoiding hyperoxia
• Maintain PaCO2 between 4.5-5.0 kPa
• Use minimum 5 cmH2O PEEP to prevent atelectasis (PEEP up to 10 cmH2O does not adversely affect cerebral perfusion) 1
• For patients with impending uncal herniation, brief hyperventilation (PaCO2 not less than 4 kPa) may be used short-term 1

Hemodynamic Management

Blood Pressure Targets

• Maintain systolic BP > 110 mmHg and MAP > 90 mmHg
• Avoid hypotension which worsens neurological outcomes 1, 2
• Position patient with 20-30° head-up tilt to reduce ICP 1

Fluid Management

• Use isotonic crystalloids (0.9% sodium chloride) as first-line IV fluid 2
• Avoid hypotonic solutions (like Ringer's lactate) which can worsen cerebral edema 2
• Do not use albumin or synthetic colloids due to increased mortality risk 2
• Target euvolemia; maintenance fluid requirements approximately 30 mL/kg/day 2
• Monitor for development of diabetes insipidus which may cause dehydration 2

Sedation and Pharmacological Management

Sedation Protocol

• Maintain appropriate sedation and analgesia via continuous infusion:
  • Propofol or midazolam for sedation
  • Opioids (fentanyl, alfentanil, or remifentanil infusion) for analgesia
  • Neuromuscular blockade as needed 1
• Consider processed EEG monitors for titration of sedation 1

ICP Management

• For raised ICP with impending herniation:
  • Mannitol (0.5 g/kg) or hypertonic saline (2 ml/kg of 3% saline)
  • Brief hyperventilation
  • Bolus of sedative drugs 1

Pharmacological Considerations

• Have available:
  • Anticonvulsants (benzodiazepines, levetiracetam)
  • Vasoactive drugs (ephedrine, metaraminol, noradrenaline, labetalol)
  • Resuscitation drugs 1
• Consider trials of amantadine or zolpidem in select cases of prolonged impaired consciousness, which have shown improvements in arousal and cognitive function in case reports 3, 4

Monitoring

Essential Monitoring

• Continuous monitoring of:
  • GCS, pupillary size and reaction to light
  • ECG, pulse oximetry
  • Invasive arterial blood pressure (preferred) or NIBP
  • Capnography
  • Urine output 1
• Maintain standardized documentation of vital signs and neurological status 1

Rehabilitation Considerations

Rehabilitation Outcomes

• Patients with anoxic brain injury typically have slower recovery rates compared to traumatic brain injury patients 5
• Physical recovery is often slower than cognitive recovery 5
• Patients with anoxic brain injury are particularly susceptible to impairments in memory, especially visual and short-term memory 6
• Neurological impairments commonly include speech and language deficits, visual field loss, cortical blindness, myoclonus, and late epilepsy 6

Special Considerations

Transport Considerations

• Ensure physiological stability before transport
• Maintain continuous monitoring during transport
• Secure all equipment properly
• Ensure smooth journey with minimal acceleration/deceleration
• Have emergency medications readily available 1

Palliative Care Integration

• Early involvement of palliative care for patients with poor prognosis
• Address clinical nihilism while acknowledging uncertainty in prognosis
• Guide surrogates in making decisions concordant with patients' goals 7

Common Pitfalls to Avoid

• Avoid hypotension which worsens neurological outcomes
• Avoid hypoxia even for brief periods
• Avoid hypotonic fluids which can worsen cerebral edema
• Avoid prolonged hyperventilation which may cause cerebral ischemia
• Avoid underestimating recovery potential in the early stages, as prognosis can be difficult to determine

By following this structured approach to care for patients with anoxic brain injury, clinicians can optimize outcomes by preventing secondary brain injury and supporting recovery.