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.
Neurosurgery also arrives. You quickly explain the situation. They talk to their attending and they agree to place an EVD for palliative purposes, though they're worried that the patient's overall prognosis is poor and that this is not curative. You talk to the patient's family, who clearly state that they believe that she'd want to go down this path, at least for now.
You and the neurosurgery resident notify the NCCU charge nurse and team. The patient arrives to their NCCU room. Nursing gets them quickly settled in while your neurosurgery colleague briskly prepares for a right frontal EVD placement. This is completed successfully, with 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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