What is the appropriate management for a patient with traumatic head injury and brain swelling after a piece of brain is removed and stored in a sterile solution?

Management of Decompressive Craniectomy with Bone Flap Storage

After decompressive craniectomy for traumatic brain injury with severe swelling, the removed bone flap should be stored either cryopreserved at -70°C to -80°C in a sterile bone bank or placed subcutaneously in the patient's abdominal wall, with reimplantation typically performed 6-12 weeks later once brain swelling has resolved and the patient is medically stable.

Immediate Post-Craniectomy Management

Intracranial Pressure and Cerebral Perfusion

• Maintain cerebral perfusion pressure (CPP) between 60-70 mmHg to optimize outcomes while avoiding complications of both hypoperfusion and excessive pressure 1
• Monitor ICP continuously after decompressive craniectomy, as retrospective studies demonstrate benefits of postoperative ICP monitoring following this procedure 1
• Be vigilant for secondary ICP increases due to reperfusion bleeding, new extra-axial collections, or increased brain edema after decompression 1

Osmotherapy for Intracranial Hypertension

If signs of threatened intracranial hypertension or brain herniation develop:

• Administer mannitol 20% or hypertonic saline at equiosmotic dose of 250 mOsm over 15-20 minutes 1
• Both agents have comparable efficacy at equiosmotic doses for treating intracranial hypertension 1, 2
• Mannitol dosing: 0.25-2 g/kg body weight as 15-25% solution over 30-60 minutes 3
• Hypertonic saline: 7.5% at 250 mL per bolus over 15-20 minutes, targeting serum sodium 145-155 mmol/L 2

Choose hypertonic saline when: hypovolemia or hypotension is present 2

Choose mannitol when: hypernatremia already exists or improved cerebral oxygenation is the priority 2

Critical Monitoring Requirements

• Monitor fluid, sodium, and chloride balances with both osmotic agents 1
• Mannitol requires volume compensation due to osmotic diuresis 1, 2
• Measure serum sodium within 6 hours of hypertonic saline bolus administration 2
• Avoid serum osmolality exceeding 320 mOsm/L with mannitol 2
• Avoid sodium levels exceeding 155-160 mmol/L with hypertonic saline 2

Fluid Management Strategy

Resuscitation Fluids

• Use normal saline 0.9% as the crystalloid of choice - it is the only commonly available isotonic crystalloid by real osmolality that prevents increases in brain water 4
• Ringer's lactate and Ringer's acetate are hypotonic by real osmolality and should be avoided as they can increase brain water content 4
• Never use 4% albumin solution - it significantly increases mortality in severe TBI patients (24.5% vs. 15.1% with saline, RR: 1.62, p = 0.009) 5

Blood Pressure Management

• After adequate fluid resuscitation, if hypotension persists, use small boluses of α-agonists (metaraminol or norepinephrine via central line) to maintain CPP 4
• Target mean arterial pressure (MAP) ≥ 90 mmHg in patients with isolated TBI 1

Ventilation Management

Avoid Prolonged Hypocapnia

• Do not use prolonged hypocapnia to treat intracranial hypertension - severe and prolonged hypocapnia (25 mmHg for 5 days) worsens neurological outcomes compared to normocapnia 1
• Maintain PaCO2 at 4-5 kPa (approximately 30-38 mmHg) during transfer 1
• Hypocapnia exacerbates secondary ischemic lesions by decreasing cerebral blood flow 1

Pediatric Considerations

For children with traumatic brain injury and decompressive craniectomy:

Age-Specific Blood Pressure Targets 1

• < 3 months: MAP 40-60 mmHg
• 3 months-1 year: MAP 45-75 mmHg
• 1-5 years: MAP 50-90 mmHg
• 6-11 years: MAP 60-90 mmHg
• 12-14 years: MAP 65-95 mmHg

Special Pediatric Management

• Consider hypertonic saline bolus (2.7-3%, 2-3 mL/kg) before intubation to prevent ICP rise during laryngoscopy 1
• Children have less available space around the brain until age 20, making small volume changes more clinically significant 1
• Monitor blood glucose closely as young children are more prone to hypoglycemia 1
• Use isotonic saline with 5-10% glucose as maintenance fluid with 50-60% restriction on standard rates 1

Common Pitfalls to Avoid

Contraindicated Interventions

• Never administer albumin solutions - this is associated with nearly doubled mortality at 2-year follow-up (41.8% vs. 22.2%, RR: 1.88, p < 0.001) 5
• Avoid prophylactic osmotherapy in patients without documented intracranial hypertension - it provides no benefit over crystalloids 1, 2
• Do not use hypertonic saline for volume resuscitation in hemorrhagic shock 2

Monitoring for Complications

• Watch for intraoperative brain extrusion - a gradual and controlled decompression technique with multiple small dural openings can prevent massive brain swelling during surgery 6
• Discontinue mannitol if renal, cardiac, or pulmonary status worsens 3
• Be aware that mannitol is the only ICP-lowering therapy associated with improved cerebral oxygenation 1

Transfer Considerations

• Ensure patient's trachea is intubated if GCS ≤ 8 before departure 1
• Use capnography during transfer with all values maintained at 4-5 kPa 1
• Discuss appropriate driving style with ambulance technicians, as acceleration causes hypotension and deceleration causes ICP spikes 1
• Keep eyes open (not taped) to permit regular pupillary examination, using moisturizing drops to prevent corneal drying 1