General Critical Care

Yesterday ,there was a dilemmatic debate about postoperative pain management in mechanically ventilated patient after a procedure for evacuation of intracerebral hemorrhage.

The concept of sedating patient to decrease cerebral metablic demand is still an obsessive idea for most middle eastern neurosurgeons especially in Peri and post operative period .

Our patient was 70s years old male without significant medical history except for recent hospital discharge for recent onset Af and uncontrolled hypertension with possibility of coronary artery disease .Patient was admitted with sudden onset altered mental state, irritability and vomiting with left sided weakness and CT evidence of intracerebral hemorrhage with concomitant severe hypertension. Patient was intubated and ventilated and anti -seizures medications were given with GCS 7/15.Patient later on underwent evacuation and readmitted again to intensive care unit .Neurosurgeon ordered both midazolam and fentanyl continuos infusion .The concern was "it's not blindly indicated for every patient and it's individualized and discretionary"

And our patient was normotensive with blood pressure 110/60 and heart rate 60s and patient was volume depleted to some extent due to osmotic diuresis and an attack of hemetemsis preoperatively.

So my decision was to hold any narcotic or sedative agent as long as there is no alarming hemodynamic instability. Neurosurgeon was angery and accused critical care team of being harmful to his patient.

So I was wondering,what is the usual approach for critical care physicians across diverse communities ?

And the logistic question the authority of medical intervention following surgical intervention goes to intensivist or the main surgeon ?