Management of Intracranial hypertension in Intensive Care Unit:

A Literature Review

 

Praveen Kumar Jaiswal

Faculty of Nursing, SGT University, Gurgaon.

*Corresponding Author E-mail: jaiswalprav@gmail.com

 

ABSTRACT:

Intracranial hypertension (IH) is a common clinical problem in the intensive care unit (ICU) and critical care unit. IH is the result of increased intracranial pressure. High ICP can cause secondary brain injury and even death. The most common causes of increased ICP are trauma to the brain or skull and stroke. Commonly used barbiturates are pentobarbital and phenobarbital. Another method for decreasing ICP is to paralyze the patient using something like vecuronium. All the patients who are paralyzed MUST be sedated. We can also use paralytics for a patient for aggressive cooling in order to prevent shivering. Sometimes vasopressors are added in order to keep MAP high enough to maintain an adequate CPP.

 

KEYWORDS: Intracranial pressure, Intracranial hypertension, Cerebral perfusion pressure, Traumatic brain injury, Osmotic agents.

 

 


INTRODUCTION:

Intracranial hypertension (IH) is considered a very common clinical problem in the intensive care unit (ICU) and critical care unit (CCU), that requires emergent treatment. IH is the result of either a lesion in the primary central nervous system (CNS) or a complication of any other co-existing systemic disease.1

 

Any condition and factor affecting the CNS, defined as acute brain injury (ABI) [(e.g., traumatic brain injury (TBI)], has two components: primary brain injury that cannot be reversed and secondary brain injury (SBI). SBI is defined as any physiological event that occurs in the brain after the initial injury and leads to further damage to nervous tissue.2

 

It is estimated that nearly 1.5 to 2 million persons are injured and 1 million succumb to death every year in India.3

 

High ICP can cause secondary brain injury and even death, and therefore, intracranial pressure (ICP) elevations should be aggressively monitored and treated.4

 

HICP has been classically defined as an ICP > 20mmHg, and this threshold has been considered the trigger for treatment.5 It can be detected through clinical examination and intracranial pressure (ICP) monitoring, as it is mostly due to increased ICP, and confirmed by imaging tests.

 

One of the most common causes of increased intracranial pressure is an injury to the brain or skull. The trauma leads to bleeding or swelling inside the skull. That pressure from the excess fluid or the swelling can harm brain tissue or the spinal column.

 

A stroke is another common reason for increased intracranial pressure. Some types of stroke cause blood vessels to rupture in the brain. The blood pools in and around the brain. This causes pressure elevation.

 

 

Other causes of increased intracranial pressure include:

·       Excess cerebrospinal fluid

·       Aneurysm

·       Tumour

·       Infections such as encephalitis or meningitis

·       Hydrocephalus (fluid on the brain)

·       High blood pressure, usually not in isolation6

 

Clinical presentation of Intracranial Hypertension:

The clinical manifestations of increased ICP include:

·       Headache

·       Nausea

·       Vomiting

·       Increased blood pressure

·       Decreased mental abilities

·       Confusion

·       Double vision

·       Pupils that don’t respond to changes in light

·       Shallow breathing

·       Seizures

·       Loss of consciousness

·       Coma

 

Many of these symptoms can be associated with other conditions, but things like mental confusion and behaviour changes are common early signs of elevated intracranial pressure.7

 

ICP Monitoring and Assessment:

Many techniques can be used to monitor ICP including clinical examination, brain imaging, and ICP monitoring, both invasive and non-invasive monitors. The best outcome is obtained when all three techniques are combined.

 

IH Management:

Before starting any ICP-directed therapies, always try to correct any reversible cause and systemic abnormality affecting intracranial volumes and causing raised ICP.

 

Management of intracranial hypertension is divided into 2 Bundles8

1.     Basic bundle (figure 1 summarizes it)

2.     Advanced bundle

 

Basic care bundle for IH management:

 

Fig. 1 shows the basic care bundle for intracranial hypertension

Summary of the Basic care bundle for IH management:

While handling the patient with ICP issues, always ensure to maintain the patient’s neck in neutral alignment to ensure optimal flow of CSF. Next, raise HOB (head of the bed) as it helps CSF flow adequately to maintain the desired ICP. Next, avoid severe flexion at the hips because it can cause increased intra-abdominal pressure, which increases intrathoracic pressure which results in increased ICP. Always Consider loosening tight C-spine collars because tight collars can impede CSF flow. Try to Maintain a normal temperature. Brain temperature (BT), which is directly related to body temperature, may affect brain physiology. Increased body and/or BT may cause secondary brain impairment, with deleterious effects on intracranial pressure (ICP), cerebral perfusion pressure (CPP), and outcome. Plus, any kind of penetrating trauma to the brain OR surgery will increase the risk of infection and the associated fever. Shivering increases ICP, so the patient needs to be under observation. Hyperventilation can be used short-term to get a critically high ICP down stat and quickly. As CO2 is a potent vasodilator, by blowing off CO2 through hyperventilation, we lower CO2 leading to arterial vasoconstriction, this decreases cerebral blood flow including cerebral blood volume and ICP.

 

Advanced care bundle for IH management:

 

Fig. 2 shows advanced care bundle for IH management:

 

Before initiating and administering ICP-lowering therapies, use a “staircase” approach with escalating treatment intensity (starting with low risk-benefit profiles).9

Sedation:

Medications like propofol are often used for sedating the patient and to reduce ICP. but these drugs also reduce MAP (Mean Arterial Pressure). Because CPP = MAP – ICP. The patient’s CPP can go down with sedation because the MAP is down, but simultaneously ICP will also go down.

 

Mannitol:

Mannitol decreases ICP through the osmotic diuresis process. It’s hyper-osmolar, so mannitol pulls fluid from the cellular space and places it in the vascular space where it is excreted in urine. When the patient is receiving Mannitol (either q 4 or q 6 hours), always check serum osmolality before every dose. Typically, mannitol is withheld if serum osmolality is greater than 320.

 

Hypertonic Saline:

The most common hypertonic saline solution used is 3% NaCl at 30ml/hr. This is a HIGH ALERT medication. The main responsibility is monitoring serum sodium level to ensure it doesn’t get too high. Hypertonic saline works as same way as mannitol, thereby decreasing cerebral edema and ICP.

 

Barbiturates:

Barbiturates have been historically used for decreasing brain metabolism and consequently cerebral blood flow/volume and therefore HICP at the cost of serious side effects including hypotension and infections. Commonly used barbiturates are pentobarbital and phenobarbital.10

 

Paralytics:

Another method for decreasing ICP is to paralyze the patient using something like vecuronium. All the patients who are paralyzed MUST be sedated. We can also use paralytics for a patient for aggressive cooling to prevent shivering.

 

Vasopressors:

Sometimes vasopressors are added to keep MAP high enough to maintain an adequate CPP.

 

CONCLUSION:

Intracranial hypertension (IH) is considered a very common clinical problem in the intensive care unit (ICU) and critical care unit (CCU), that requires emergent treatment. SBI is defined as any physiological event that occurs in the brain after the initial injury and leads to further damage to nervous tissue. HICP has been classically defined as an ICP > 20mmHg, and this threshold has been considered the trigger for treatment. One of the most common causes of increased intracranial pressure is an injury to the brain or skull. The trauma leads to bleeding or swelling inside the skull.

That pressure from the excess fluid or the swelling can harm brain tissue or the spinal column. A stroke is another common reason for increased intracranial pressure. Some types of stroke cause blood vessels to rupture in the brain. Other causes of increased intracranial pressure include: Excess cerebrospinal fluid Aneurysm, Tumour, Infections such as encephalitis or meningitis, Hydrocephalus (fluid on the brain) High blood pressure, usually not in isolation before starting any ICP-directed therapies, always try to correct any reversible cause and systemic abnormality affecting intracranial volumes and causing raised ICP. Advanced bundle while handling the patient with ICP issues, always ensure to maintain the patient’s neck in neutral alignment to ensure optimal flow of CSF.

 

CONFLICT OF INTEREST:

The author has no conflicts of interest regarding this investigation.

 

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6.      Contributors WE. What Is Increased Intracranial Pressure (ICP)? [Internet]. WebMD. [cited 2023 Sep 8]. Available from: https://www.webmd.com/brain/what-is-increased-intracranial-pressure#:~:text=Other%20causes%20of%20increased%20intracranial%20pressure%20include%3A%201

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Received on 29.09.2023         Modified on 16.10.2023

Accepted on 25.10.2023       ©A&V Publications All right reserved

Int.  J. of Advances in Nur. Management. 2023; 11(4):260-263.

DOI: 10.52711/2454-2652.2023.00058