Anesthesia arrives. They ask if you have any specific physiologic parameters that they need to consider. You tell them that she has had known intracranial disease and that you're worried about florid intracranial hypertension. You also want to avoid hypotension at all costs as it'd compromise her cerebral perfusion pressure. They take this into consideration and ensure that the patient receives hyperosmolar therapy before induction and that the head of bed remains elevated above 30 degrees. They induce with etomidate and rocuronium. The patient is intubated uneventfully.
You call the family and explain the situation. You offer to place an EVD for palliative purposes, though emphasize that her overall prognosis remains grim and that she may still remain completely neurologically devastated in spite of this intervention. Her family clearly states that they believe that she'd want to go down this path, at least for now. You obtain formal consent for a bedside EVD placement.
The patient arrives to their NCCU room. Nursing gets them quickly settled in while you briskly prepare for a right frontal EVD placement. This is completed successfully, and you note an opening pressure of 50cm H2O. The EVD is left open at 15cmH2O at the tragus. A 60mL aliquot of 23.4% NaCl is given peripherally. A femoral venous catheter is then placed for vascular access and administration of caustic medications. You notice that the patient's pupil is no longer dilated, and reactivity is preserved as tested with quantitative pupillometry.
Over the next few days, hyperosmolar therapy requirements improve and sedation is weaned. The patient's mentation improves. She ends up requiring a palliative shunt placement. She gets discharged to SAR after having spent 21 days in the hospital.
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