Management of raised intracranial pressure

Based on data from head-injured patients showing worse outcome in patients with ICP greater than 20-25 mmHg,66,67 raised ICP should be treated above this threshold. However, ICP therapy has side effects and needs to be selectively targeted if it is not to be counterproductive. As clinical signs, particularly in unconscious patients on a ventilator, are not reliable, ICP should be monitored when it is expected to be high or when active treatment is instigated in unconscious patients. For head-injured patients there are guidelines when monitoring of ICP is appropriate.68 For all other patients the decision to insert monitors must be based on the CT scan and the clinical presentation. Possible indications for ICP monitoring are listed in Box 7.3. Raised ICP has been predominantly studied in head-injured patients and most treatment algorithms are designed for this group of patients. However, depending on the dominant mechanism leading to intracranial hypertension, these algorithms can easily be adapted to suit the needs of patients with other forms of brain injury. Based on an algorithm that has been successfully used in a wide range of brain-injured patients over recent years (Figure 7.16), the therapeutic options to lower ICP are discussed in the following section.

Addenbrooke's NCCU: ICP/CPP management algorithm

All patients with or at risk or intracranial hypertension must have invasive arterial monitoring, CVP line, ICP monitor, and RT SjvO2 catheter at admission to NCCU.

— Aim to establish multimodality monitoring within the first six hours of NCCU stay.

— Interventions in stage II targeted to clinical picture.

— CPP 70 mmHg set as a target, although CPP > 60 mmHg is often acceptable.

— Check recruitment to research protocols.

Evacuate significant SOLs and consider CSF drainage before escalating medical Rx. Rx in italics and Grades III and IV only after approval by NCCU consultant

Nccu Medical Icp

Figure 7.16 Addenbrooke's Hospital Neurosciences Critical Care Unit algorithm for treatment of raised ICP.

Abbreviations: ICP = intracranial pressure; CPP = cerebral perfusion pressure (cerebral perfusion pressure = mean arterial blood pressure - ICP); CVP = central venous pressure; SjvO2 = jugular venous oxygen saturation; SOL = space occupying lesion, Rx = therapy; PAC = pulmonary artery catheter; SpO2 = oxygen saturation (pulse-oximeter); PaO2 and Paco2 = arterial partial pressure of O2 and CO2; EVD = external ventricular drainage. Reproduced with permission of DK Menon

Figure 7.16 Addenbrooke's Hospital Neurosciences Critical Care Unit algorithm for treatment of raised ICP.

Abbreviations: ICP = intracranial pressure; CPP = cerebral perfusion pressure (cerebral perfusion pressure = mean arterial blood pressure - ICP); CVP = central venous pressure; SjvO2 = jugular venous oxygen saturation; SOL = space occupying lesion, Rx = therapy; PAC = pulmonary artery catheter; SpO2 = oxygen saturation (pulse-oximeter); PaO2 and Paco2 = arterial partial pressure of O2 and CO2; EVD = external ventricular drainage. Reproduced with permission of DK Menon

Box 7.3 Indications for intracranial pressure monitoring

Head injury (based on guidelines of the Brain Trauma Foundation64) Severe head injury (GCS 3-8) with abnormal admission CT scan Severe head injury (GCS 3-8) with normal admission CT scan and two of the following criteria: Age > 40 years

Systolic blood pressure < 90 mmHg Unilateral or bilateral motor posturing

Intracerebral and subarachnoid haemorrhage GCS < 9

Postoperatively following intraoperative complications Hydrocephalus

Various aetiologies with GCS < 9 and CT evidence of brain oedema Metabolic (e.g. hepatic failure)

Hypoxia/ischaemia (e.g. large stroke, post cardiac arrest) CNS infections (see Box 7.1)

Hydrocephalus and benign intracranial hypertension

Adapted from Minns,4 Miller and Dearden,9 and Campkin and Turner.65

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