title: Reciprocal influence of refractory hypoxemia and high intracranial pressure on the postoperative management of an urgent neurosurgical procedure.
abstract: A 20-year-old man was admitted in the neurology ICU after the drainage of a large frontal hematoma related to the spontaneous bleeding of a recently diagnosed cavernoma. On admission the Glasgow coma score was 4/15, with evidence of sub-falcorial herniation and elevated intracranial  pressure. On the 4th postoperative day the patient developed acute lung injury, with an apparently normal bedside chest x-ray examination. Several episodes of critical oxygen desaturation (S(pO(2)) < 75%) occurred, which were not responsive to increasing PEEP and recruitment  maneuvers. Hypoxemia was complicated by further increase in intracranial pressure. Ventilation in the prone position was not tolerated. The introduction of inhaled nitric oxide allowed a rapid and sustained improvement of both arterial oxygenation and cerebral hemodynamics. Interactions between  acute brain and lung injury are complex. The correction of hypoxemia can usually be achieved by increasing PEEP or by alveolar recruitment maneuvers. Ventilation in the prone position can also be helpful in improving oxygenation, but is not always possible. The potential benefit of inhaled  nitric oxide in similar cases has been described, but has still to be further explored.
authors.affiliation: Department of Intensive Care Medicine, Cliniques St-Luc, Université Catholique de Louvain, Brussels, Belgium.
authors.forename: Mieke
authors.initials: M
authors.lastname: Vanhoonacker
authors.forename: Jean
authors.initials: J
authors.lastname: Roeseler
authors.forename: Philippe
authors.initials: P
authors.lastname: Hantson
mesh_terms: D000328:Adult; D002543:Cerebral Hemorrhage / Q000601:surgery*; D006801:Humans; D000860:Hypoxia / Q000453:epidemiology*; D019586:Intracranial Hypertension / Q000453:epidemiology*; D008297:Male; D019635:Neurosurgical Procedures; D009569:Nitric Oxide / Q000008:administration & dosage; D010101:Oxygen Consumption; D053717:Pneumonia, Ventilator-Associated / Q000628:therapy*; D011182:Postoperative Care; D016684:Prone Position; D014057:Tomography, X-Ray Computed; D014692:Ventilation-Perfusion Ratio
chemical_list: D009569:Nitric Oxide