Template:Increased ICP treatment: Difference between revisions

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#*Most studies used 250 mL bolus of 7.5% saline with dextran<ref>Holmes, J. Therapeutic uses of Hypertonic Saline in the Critically Ill Emergency Department Patient. EB Medicine 2013</ref>
#*Most studies used 250 mL bolus of 7.5% saline with dextran<ref>Holmes, J. Therapeutic uses of Hypertonic Saline in the Critically Ill Emergency Department Patient. EB Medicine 2013</ref>
#*Initial 250 cc bolus of 3% will reduce ICP and can be delivered through a peripheral line
#*Initial 250 cc bolus of 3% will reduce ICP and can be delivered through a peripheral line
#*target sodium 145-155mg/dL
#*Target sodium 145-155mg/dL
#*Higher osmotic gradient and less permeable across BBB than mannitol
#*Higher osmotic gradient and less permeable across BBB than mannitol


Revision as of 22:20, 29 August 2016

Increased ICP Treatment[1]

Head of Bed elevation

  • 30 degrees or reverse Trendelenburg will lower ICP[2]

Maintain cerebral perfusion

  • CPP = MAP-ICP
    • If MAP <80, then CPP<60
    • Ultimately no Class 1 evidence for optimal CPP
  • Transfuse PRBCs with goal Hb > 7 mg/dl
  • Provide fluids and vasopressors if needed for goal cerebral perfusion pressure (CPP) of 70-80 mmHg[3][4][5]
    • Mortality increases 20% for each 10 mmHg loss of CPP
    • Avoid dips in CPP < 70 mmHg, which is associated with cerebral ischemia and glutamate increase[6]
  • Vasopressors
    • Phenylephrine increases CPP without increasing ICP in animal models[7][8]
    • May be beneficial when patient is tachycardic (reflex bradycardia), but avoid phenylephrine if patient is already bradycardic (Cushing's reflex)
    • Phenylephrine may be associated with less cell injury as compared to norepinephrine in TBI[9]
  • IV fluids
    • Maintain normovolemic
    • Do not use free water, low osmolal, and dextrose solutions

Osmotherapies

Therapies include either mannitol or hypertonic saline. In choosing the appropriate agent, coordinate with neurosurgery and take into account the patient's blood pressure. Mannitol may cause hypotension due to the osmotic diuresis.

  1. Mannitol
    • If SBP>90
    • Bolus 20% @ 0.25-1 gm/kg as rapid infusion (target Osm 300-320 mOsm/kg)
    • Reduces ICP within 30min; duration of action of 6-8hr
    • Monitor I+O to maintain euvolemia
  2. Hypertonic Saline
    • Obtain baseline serum osmolarity and sodium
    • Most studies used 250 mL bolus of 7.5% saline with dextran[10]
    • Initial 250 cc bolus of 3% will reduce ICP and can be delivered through a peripheral line
    • Target sodium 145-155mg/dL
    • Higher osmotic gradient and less permeable across BBB than mannitol

Prevent Cerebral Constriction

  • Hyperventilation does not improve mortality, and should only be used transiently before definitive surgical treatment
  • Hyperventilation to PaCO2 < 30 mmHg never indicated, and decreases cerebral blood flow to ischemic levels[11]
  • Maintain PaCO2 35-40 mmHg

Seizure Control

  • Treat immediately with benzodiazepines and antiepileptic drugs (AEDs)
  • Consider propofol for post-intubation sedation
  • Seizure prophylaxis reduces seizures but does not improve long-term outcomes[12]
    • AEDs prevent early seizures (which occur between 24 hrs - 7 days), with NNT = 10 by Cochrane Review[13]
    • Risk factors for post-traumatic seizures:
  • Treat any clinically apparent and EEG confirmed seizures
    • Consider prophylaxis in patients with any risk factors as above
    • Phenytoin or fosphenytoin first line agent by BTF guidelines[14]
      • Load 20 PE/kg IV, then 100 PE IV q8hrs for 7 days
      • Measure serum levels to titrate to therapeutic levels
    • Levetiracetam may be used as alternative[15]
      • 20 mg/kg load, followed by 1000 mg q12h for 7 days
      • Levetiracetam may have less frequent and severe adverse drug side effects events as compared to phenytoin

Intubation Pretreatment

Goal cerebral perfusion pressure (CPP) ~60mmHg

  • If need for RSI, consider pretreatment with lidocaine and/or fentanyl
  • Also ensure adequate sedation (prevent gag reflex)

Decrease metabolic rate

  • Provide adequate sedation and analgesia
  • Avoid hyperthermia
  1. ↑ Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons. Guidelines for the management of severe traumatic brain injury. J Neurotrauma. 2007;24 Suppl 1(supplement 1):S1-S106.fulltext
  2. ↑ Schwarz S et al. Effects of body position on intracranial pressure and cerebral perfusion in patients with large hemispheric stroke. Stroke. 2002; 33: 497-501
  3. ↑ Bouma GJ et al. Blood pressure and intracranial pressure-volume dynamics in severe head injury: relationship with cerebral blood flow. J Neurosurg 77:15-19, 1992
  4. ↑ Rosner MJ et al. Cerebral perfusion pressure management in head injury. J Trauma 30:933-941, 1990
  5. ↑ Kirkman MA, Smith M. Intracranial pressure monitoring, cerebral perfusion pressure estimation, and ICP/CPP-guided therapy: a standard of care or optional extra after brain injury? Br J Anaesth. 2014 Jan;112(1):35-46.
  6. ↑ Vespa P. What is the Optimal Threshold for Cerebral Perfusion Pressure Following Traumatic Brain Injury? Neurosurg Focus. 2003;15(6).
  7. ↑ Friess SH et al. Early cerebral perfusion pressure augmentation with phenylephrine after traumatic brain injury may be neuroprotective in a pediatric swine model. Crit Care Med. 2012 Aug;40(8):2400-6.
  8. ↑ Watts AD et al. Phenylephrine increases cerebral perfusion pressure without increasing intracranial pressure in rabbits with balloon-elevated intracranial pressure. J Neurosurg Anesthesiol. 2002 Jan;14(1):31-4.
  9. ↑ Friess SH et al. Differing Effects when Using Phenylephrine and Norepinephrine To Augment Cerebral Blood Flow after Traumatic Brain Injury in the Immature Brain. J Neurotrauma. 2015 Feb 15; 32(4): 237–243.
  10. ↑ Holmes, J. Therapeutic uses of Hypertonic Saline in the Critically Ill Emergency Department Patient. EB Medicine 2013
  11. ↑ Stocchetti N et al. Hyperventilation in head injury: a review. Chest. 2005 May;127(5):1812-27.
  12. ↑ Khan AA, Banerjee A. The role of prophylactic anticonvulsants in moderate to severe head injury. Int J Emerg Med. 2010 Jul 22;3(3):187-91.
  13. ↑ Thompson K, Pohlmann-Eden B, Campbell LA. Pharmacological treatments for preventing epilepsy following traumatic head injury (Protocol). Cochrane Database of Systematic Reviews 2012, Issue 6. Art. No.: CD009900.
  14. ↑ Khan AA, Banerjee A. The role of prophylactic anticonvulsants in moderate to severe head injury. Int J Emerg Med. 2010 Jul 22;3(3):187-91.
  15. ↑ Szaflarski JP et al. Prospective, randomized, single blinded comparative trial of intravenous levetiracetam versus phenytoin for seizure prophylaxis. Neurocrit Care 2010;12:165-172.
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