
Journal of Shanghai Jiao Tong University (Medical Science) ›› 2025, Vol. 45 ›› Issue (9): 1099-1105.doi: 10.3969/j.issn.1674-8115.2025.09.002
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Received:2025-05-19
Accepted:2025-08-28
Online:2025-09-28
Published:2025-09-30
Contact:
TIAN Hengli
E-mail:tianhlsh@126.com
Supported by:CLC Number:
CHEN Hao, TIAN Hengli. Exploration and practice of enhanced recovery after surgery in neurocritical care[J]. Journal of Shanghai Jiao Tong University (Medical Science), 2025, 45(9): 1099-1105.
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URL: https://xuebao.shsmu.edu.cn/EN/10.3969/j.issn.1674-8115.2025.09.002
| Component | Content | Management principle |
|---|---|---|
| Vital signs assessment | Temperature, heart rate, blood pressure, respiratory rate, etc | Abide by the principles of damage control resuscitation (DCR) |
| Assessment of injury severity (AIS and ISS scores) and neurological status (GCS, NIHSS, and mRS scores) | AIS, GCS, NHISS, and mRS scores | Perform assessment jointly by the Department of Emergency Medicine and the Departments of Neurology and Neurosurgery |
| Coagulation function assessment and early intervention | Base on history of anticoagulant use, preoperative complete blood count, coagulation studies, etc | Administer hemostatic agents to prevent worsening of hemorrhage |
| Vomiting assessment | According to the PONV Simple Risk Assessment Scale | Initiate prophylactic antiemetic therapy and perform gastrointestinal decompression via nasogastric tube in patients with a risk score ≥3 |
| Aspiration pneumonia assessment | Findings suggestive of aspiration pneumonia based on clinical history and chest computed tomography (CT) results | Administer prophylactic antibiotics in patients requiring endotracheal intubation and/or mechanical ventilation |
| Seizure risk assessment | High-risk factors: cerebral contusion and laceration, extensive subarachnoid hemorrhage (SAH), cortical hemorrhage, and anticipated severe postoperative cerebral edema or cerebral ischemia | Administer antiepileptic drugs (AEDs) routinely in patients with established epilepsy, and use prophylactically in patients at high risk for seizures |
Tab 1 ERAS protocol in neurocritical care: admission and preoperative management
| Component | Content | Management principle |
|---|---|---|
| Vital signs assessment | Temperature, heart rate, blood pressure, respiratory rate, etc | Abide by the principles of damage control resuscitation (DCR) |
| Assessment of injury severity (AIS and ISS scores) and neurological status (GCS, NIHSS, and mRS scores) | AIS, GCS, NHISS, and mRS scores | Perform assessment jointly by the Department of Emergency Medicine and the Departments of Neurology and Neurosurgery |
| Coagulation function assessment and early intervention | Base on history of anticoagulant use, preoperative complete blood count, coagulation studies, etc | Administer hemostatic agents to prevent worsening of hemorrhage |
| Vomiting assessment | According to the PONV Simple Risk Assessment Scale | Initiate prophylactic antiemetic therapy and perform gastrointestinal decompression via nasogastric tube in patients with a risk score ≥3 |
| Aspiration pneumonia assessment | Findings suggestive of aspiration pneumonia based on clinical history and chest computed tomography (CT) results | Administer prophylactic antibiotics in patients requiring endotracheal intubation and/or mechanical ventilation |
| Seizure risk assessment | High-risk factors: cerebral contusion and laceration, extensive subarachnoid hemorrhage (SAH), cortical hemorrhage, and anticipated severe postoperative cerebral edema or cerebral ischemia | Administer antiepileptic drugs (AEDs) routinely in patients with established epilepsy, and use prophylactically in patients at high risk for seizures |
| Component | Content | Management principle |
|---|---|---|
| Assessment of anesthesia-related risk | Anesthesia classification (ASA classification) | Evaluate anesthesia-related risk and select appropriate anesthetic methods |
| Airway intervention | Respiratory status, arterial blood gas (ABG) results, etc | Administer intravenous expectorant drugs as primary therapy and use inhaled corticosteroids as indicated |
| Gastrointestinal intervention | Abdominal ultrasonography (US) and CT findings, etc | Administer antacids to reduce the incidence of stress ulcers |
| Formulation of surgical plan | Individualized surgical plan based on the location and severity of the patient's injury/hemorrhage | Formulate surgical plan according to patient condition and preoperative imaging; complete preparatory tasks including family communication and surgical consent documentation |
| Determination of the surgical site skin preparation method | Designed according to the surgical incision | Minimize the area of scalp shaving |
| Assessment of preoperative surgical incision status | Classification of cleanliness of surgical incision | Administer prophylactic antibiotics; perform wound debridement and achieve hemostasis |
Tab 2 ERAS protocol in neurocritical care: preoperative preparation
| Component | Content | Management principle |
|---|---|---|
| Assessment of anesthesia-related risk | Anesthesia classification (ASA classification) | Evaluate anesthesia-related risk and select appropriate anesthetic methods |
| Airway intervention | Respiratory status, arterial blood gas (ABG) results, etc | Administer intravenous expectorant drugs as primary therapy and use inhaled corticosteroids as indicated |
| Gastrointestinal intervention | Abdominal ultrasonography (US) and CT findings, etc | Administer antacids to reduce the incidence of stress ulcers |
| Formulation of surgical plan | Individualized surgical plan based on the location and severity of the patient's injury/hemorrhage | Formulate surgical plan according to patient condition and preoperative imaging; complete preparatory tasks including family communication and surgical consent documentation |
| Determination of the surgical site skin preparation method | Designed according to the surgical incision | Minimize the area of scalp shaving |
| Assessment of preoperative surgical incision status | Classification of cleanliness of surgical incision | Administer prophylactic antibiotics; perform wound debridement and achieve hemostasis |
| Component | Content | Management principle |
|---|---|---|
| Formulation and implementation of the anesthetic plan | Implementation of an individualized anesthetic plan with intraoperative monitoring and management of anesthetic depth | Based on the patient's systemic status and surgical site requirements, minimize intraoperative administration of anesthetics and opioids, and implement goal-directed fluid therapy (GDFT) |
| Implementation of nursing care | Intraoperative nursing implementation according to surgical requirements | Position the patient according to anesthesia and surgical requirements; closely monitor patient condition during surgery, focusing on correct positioning and prevention of compression on limbs, nerves, and major blood vessels; maintain patency of urinary catheters, drainage tubes, and intravenous lines |
| Surgical procedure | Application of damage control surgery (DCS) techniques with strict adherence to minimally invasive principles | For patients with acute epidural/subdural hematoma combined with malignant intracranial hypertension or cerebral hernia, perform cranial drilling at the thickest part of the hematoma before traditional decompression and aspirate part of the hematoma to relieve intracranial pressure and achieve the golden treatment time for brain function; avoid injury to important blood vessels and functional brain areas; in cerebral hemorrhage surgery, perform long-axis minimally invasive procedures with white matter fiber bundles as the protection target |
| Suture | Closure of the dura, subcutaneous tissue, and skin using absorbable sutures | Prefer intradermal suturing for skin closure to avoid the need for suture removal |
| Insertion of drainage tube | Placement of drainage tubes in the subdural space, hematoma cavity, and cerebral ventricles | Determine drain placement according to the surgical plan and intraoperative findings; use antimicrobial-impregnated catheters whenever possible |
Tab 3 ERAS protocol in neurocritical care: intraoperative management
| Component | Content | Management principle |
|---|---|---|
| Formulation and implementation of the anesthetic plan | Implementation of an individualized anesthetic plan with intraoperative monitoring and management of anesthetic depth | Based on the patient's systemic status and surgical site requirements, minimize intraoperative administration of anesthetics and opioids, and implement goal-directed fluid therapy (GDFT) |
| Implementation of nursing care | Intraoperative nursing implementation according to surgical requirements | Position the patient according to anesthesia and surgical requirements; closely monitor patient condition during surgery, focusing on correct positioning and prevention of compression on limbs, nerves, and major blood vessels; maintain patency of urinary catheters, drainage tubes, and intravenous lines |
| Surgical procedure | Application of damage control surgery (DCS) techniques with strict adherence to minimally invasive principles | For patients with acute epidural/subdural hematoma combined with malignant intracranial hypertension or cerebral hernia, perform cranial drilling at the thickest part of the hematoma before traditional decompression and aspirate part of the hematoma to relieve intracranial pressure and achieve the golden treatment time for brain function; avoid injury to important blood vessels and functional brain areas; in cerebral hemorrhage surgery, perform long-axis minimally invasive procedures with white matter fiber bundles as the protection target |
| Suture | Closure of the dura, subcutaneous tissue, and skin using absorbable sutures | Prefer intradermal suturing for skin closure to avoid the need for suture removal |
| Insertion of drainage tube | Placement of drainage tubes in the subdural space, hematoma cavity, and cerebral ventricles | Determine drain placement according to the surgical plan and intraoperative findings; use antimicrobial-impregnated catheters whenever possible |
| Component | Content | Management principle |
|---|---|---|
| Blood pressure mana-gement | Protocol-guided management with early intensive blood pressure-lowering strategy | Reduce systolic blood pressure to 140 mmHg for hypertensive neurocritical patients and maintain for 24 h; minimize blood pressure fluctuations while avoiding systolic pressure below 120 mmHg |
| Multimodal monito-ring of neurological critical care | Monitoring of intracranial pressure (ICP), arterial blood pressure (ABP), cerebral perfusion pressure (CPP), brain temperature, cerebral blood flow (CBF), and video-electroencephalography (VEEG) | Provide individualized treatment guided by optimal CPP |
| Nutritional support | Nutritional Risk Screening 2002 (NRS 2002) and Patient-Generated Subjective Global Assessment (PG-SGA) scoring | Administer nutrition therapy according to nutrition department consultation; avoid severe hyperglycemia and promote early oral intake |
| Drain management | Standardized drain management according to clinical practice guidelines or consensus | Manage drainage tube height, volume, speed, and indwelling time; maintain meticulous monitoring records |
| Sedation and analgesia management | Assessment of pain location, characteristics, and intensity | Administer sedative and analgesic agents such as propofol, midazolam, or dexmedetomidine according to patient needs |
| Airway management | Management of pulmonary complications | Use intravenous and nebulized medications, perform bronchoscopic suction, provide airway care; administer inhaled corticosteroids and antibiotics as indicated; promote early extubation and high-flow oxygen therapy |
| Gastrointestinal system management | Stress-related mucosal damage (SRMD) prophylaxis and gastrointestinal mucosal protection | Provide jejunal feeding, proton pump inhibitors (PPIs), gastric mucosal protective agents, and probiotics |
| Venous thromboembolism (VTE) mana-gement | Caprini Risk Assessment and Autar DVT Risk Assessment Scale | Exclude contraindications to prophylactic interventions; implement combined physical and pharmacological prophylaxis for high-risk patients |
| Enhanced early rehabilitation | Respiration, motor function, sensation, swal-lowing, speech, cognition, and mental status | Promote arousal, respiratory muscle training, hemiplegia rehabilitation, swallowing and language training; accelerate transfer to rehabilitation facilities |
Tab 4 ERAS protocol in neurocritical care: postoperative management in NICU
| Component | Content | Management principle |
|---|---|---|
| Blood pressure mana-gement | Protocol-guided management with early intensive blood pressure-lowering strategy | Reduce systolic blood pressure to 140 mmHg for hypertensive neurocritical patients and maintain for 24 h; minimize blood pressure fluctuations while avoiding systolic pressure below 120 mmHg |
| Multimodal monito-ring of neurological critical care | Monitoring of intracranial pressure (ICP), arterial blood pressure (ABP), cerebral perfusion pressure (CPP), brain temperature, cerebral blood flow (CBF), and video-electroencephalography (VEEG) | Provide individualized treatment guided by optimal CPP |
| Nutritional support | Nutritional Risk Screening 2002 (NRS 2002) and Patient-Generated Subjective Global Assessment (PG-SGA) scoring | Administer nutrition therapy according to nutrition department consultation; avoid severe hyperglycemia and promote early oral intake |
| Drain management | Standardized drain management according to clinical practice guidelines or consensus | Manage drainage tube height, volume, speed, and indwelling time; maintain meticulous monitoring records |
| Sedation and analgesia management | Assessment of pain location, characteristics, and intensity | Administer sedative and analgesic agents such as propofol, midazolam, or dexmedetomidine according to patient needs |
| Airway management | Management of pulmonary complications | Use intravenous and nebulized medications, perform bronchoscopic suction, provide airway care; administer inhaled corticosteroids and antibiotics as indicated; promote early extubation and high-flow oxygen therapy |
| Gastrointestinal system management | Stress-related mucosal damage (SRMD) prophylaxis and gastrointestinal mucosal protection | Provide jejunal feeding, proton pump inhibitors (PPIs), gastric mucosal protective agents, and probiotics |
| Venous thromboembolism (VTE) mana-gement | Caprini Risk Assessment and Autar DVT Risk Assessment Scale | Exclude contraindications to prophylactic interventions; implement combined physical and pharmacological prophylaxis for high-risk patients |
| Enhanced early rehabilitation | Respiration, motor function, sensation, swal-lowing, speech, cognition, and mental status | Promote arousal, respiratory muscle training, hemiplegia rehabilitation, swallowing and language training; accelerate transfer to rehabilitation facilities |
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