ICP and Cerebral perfusion pressure
Keep ICP < 20 mmHg
CPP > 45-60 mmHg, Age < 10 yrs
CPP > 50-70 mmHg, Age > 10 yrs
THE DESIRED CPP SHOULD BE SET DAILY BY THE PICU CONSULTANT IN CHARGE
Indications of ICP monitoring: These are suggestions only
Severe TBI GCS < 8 with abnormal admission head CT (haematoma, contusion, cerebral oedema and/or compressed brain cisterns).
Severe TBI GCS < 8 with normal admission head CT if two of the following features
- motor posturing
- systemic hypotension
- certain patients in whom serial neurological examination is precluded by sedation, NMB or anaesthesia.A physician may choose to monitor ICP in certain patients in whom serial neurological examination is precluded by sedation, NMB or anaesthesia.
- conscious patients with traumatic mass lesions suggestive of a risk of neurological deterioration (diffuse cerebral oedema or temporal lobe contusion on CT) may be monitored based on the opinion of the treating physician.
Maintenance of Normal CPP
Cerebral perfusion pressure = Mean Arterial Pressure - ICP
- CPP should be corrected whenCPP < the set age appropriate number for 5 min
- CPP < 10 mmHG below the set age appropriate number for any length of time
Give volume if low CVP or clinically indicated
Start on noradrenaline infusion
Algorithm for maintaining CPP
Is there an easily correctable or transient cause?
- Inadequate sedation/ analgesia
These should be excluded and corrected before proceeding with further treatment.
Emergency Management of Increased ICP
- Consider repeat head CT to rule out space occupying lesion.
- Add neuromuscular blocking agent if not already used.
- Mannitol 0.25 g/kg IV (20%) over 20min. repeat to max 0.5 gm/kg q 6hr as needed. Hold if measured serum osmolality is > 320 mosm/L.
- Give 10 ml /kg of crystalloids ( 0.9% NaCl or Hartmann's) concomitant with mannitol.
- 2.7 % saline infusion 0.1 to 1 ml/kg/hr as a sliding scale. The minimum needed to maintain ICP < 20 mmHg should be used.
- Rapid changes in serum sodium should be avoided (< 10 mmol/L/day)
- Thiopentone therapy
- bolus dose of 3-5 mg/kg
- then IVI maintenance to maintain ICP, or burst supression on EEG (typically 1 - 5 mg/kg/hr).
- Carefull BP monitoring and cardiac output during Thiopentone infusion.
- Should aim to wean thiopentone once ICP controlled for 24 hours.
This is intended as a guide only. In some cases, it may be appropriate to tolerate higher ICP and maintain appropriate CPP rather than starting on thiopentone.
Algorithm for emergency management raised ICP
- Head of bed elevated 30° and head in midline
- Aim to keep PaCO2 between 4.5- 5 kPa on ABG. Lower targets may sometimes be applied for short periods in severe refractory intracranial hypertension, but only under consultant guidance.
- Maintain core temp between 36° and 37° C
- Allow patient to re-warm passively if patient is hypothermic on admission to PICU
- Ranitidine IV 1 mg/kg 8 hourly until feed is established
- Early enteral feed (if no contraindication), ensure NG feeding protocol is followed
- Ensure appropriate DVT prophylaxis
- Consider a loading then maintenance dose of phenytoin IV.
- Ensure 2 hourly oral care
- U&E, and osmolality 8 hourly, or more frequent, as long as cerebral oedema and ICP are been treated
- Use 0.9% saline for maintenance regardless of age or serum sodium
- If hypoglycemic ( SG < 3.5 mmol/L) then change to 2.5-5 % dextrose/ 0.9% saline
- Serum soduim should be maintained above 140 mml/l during active ICP management
- This could be achieved by 3 % saline infusion. (6.5 - 10ml/kg)
- Consider giving 10 ml /kg of 0.9% NaCl concomittent with mannitol
- Ensure adequate sedation and analgesia
- 100% O2 for 5 min prior to suctioning
- Give Fentanyl 2 micrograms/kg IV prior to suctioning
- If ICP> 20 mmHg for >5 min or > 25 mmHg for any length of time despite the previous measures consider neuromuscular blocker prior to each suctioning
The Use of Hypothermia for TBI should not be adopted outside a clinical trial
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Dr Rim Alsamsam January 2016, to be reviewed January 2019.