Use of inhaled sevoflurane to treat post-operative intractable cerebral edema in neurosurgical intensive care unit.

Background: Burst suppression are widely used in case of refractory increased intracranial pressure for deep state of brain inactivation. Inhaled sevoflurane via the anesthetic conserving device could be useful for the sedation of patients in the intensive care unit (ICU), but prospective studies have been small study. Case report: A 53-year-old male patient with confusion, not follow to command and status epilepticus had been hospitalized and diagnosed glioblastoma multiforme at left temporal lobe. By the time initial therapy had begun with dexamethasone and anti-epileptic drug, the symptoms had improved. The patient was performed craniotomy with tumor removal during intra-operative found intractable cerebral edema and changed operation to decompressive craniectomy, in post-operative period after increased dosage of propofol and midazolam to control intracranial pressure, patient developed hypotension, then norepinephrine was titrated to maintain mean arterial pressure more than 65 mmHg and used inhaled sevoflurane to decrease dose propofol for maintain hemodynamics then during 5 day usage inhaled sevoflurane, norepinephrine could wean off and Glasgow coma scale was improve. Follow up brain EEG at 1st week showed no epileptiform discharge, antiepileptic drug could de-escalated and CT scan showed no refractory cerebral edema or hemorrhage. Ventilator was weaned off and the patient was transfer to step down ward. Conclusion: When managing intractable cerebral edema patient with inhaled sevoflurane showed that lower opioid dose intensity, promote resolving from seizures or status epilepticus, decrease dose of vasopressor to maintain hemodynamics and no adverse events supported the use of inhaled sevoflurane via the anesthetic conserving device in this patient who have clinical need for burst suppression.