1. Critical care management of Increase Intracranial Pressure
พญ.อิศราภรณ์ พูนสวัสดิ์ พบ.
Aitsaraporn Phunsawat MD.
Department of anesthesiology, Faculty of medicine
Naresaun University Hospital

2. Anatomy of the cranium Cranium is a rigid box containing
1. brain 80% (1300 ml)
2. blood 12% (110 ml)
3. CSF 8% (65 ml)
All of these contents are maintained a balanced pressure referred to as intracranial pressure (ICP)

3. Intracranial pressure
The normal range for ICP varies with age
Age group
ICP normal (mmHg)
Infant
< 7.5
Child
< 10
Adult
< 15
( cm H2O)
Best Practice & Research Clinical Anaesthesiology.2007;21: 517–38

4. Intracranial pressure
Transient elevation with straining, coughing, or trendelenberg position
Sustained ICP ≥20: abnormal
ICP 20-40mmHg : moderate ICH (intracranial hypertension)
Sustained ICP ≥ 40 mm Hg indicate severe, life- threatening ICH
Mild 20-29,moderate 30-40,severe_> 40,persist>_5 min
Goal: Keep ICP≤ 20 mmHg
Neurol Clin 2008;26: 521–41

5. Monro-Kellie Doctrine (Compensatory mechanism)
The skull is a rigid bowl that offers little flexibility for changes in the size of the three intracranial components. To maintain normal pressure in the skull, any increase in the size of one component initially will lead to a compensatory decrease in one or both of the other two.

6. Brain displaced to moderate degrees to accommodate an expanding mass.
Slow expansion
Rapid expansion
Cerebral herniation
1.Subfalcine
2.Uncal transtentorial
3.Tonsillar
4.Trancalvarial
5.Transtentorial(Central)
6.Upward transtentorial

7. Adverse effect of ICH Decreased CPP Brain herniation
Brain ishemia brain edema increase ICP
Brain herniation

8. Conditions Associated with Increased ICP
Intracranial mass lesions
Increased brain volume (cytotoxic edema)
Subdural hematoma
Epidural hematoma
Brain tumor
Cerebral abscess
Intracerebral hemorrhage
Cerebral infarction
Global hypoxia-ischemia
Reye's syndrome
Acute hyponatremia

9. Conditions Associated with Increased ICP
Increased blood and brain volume (vasogenic edema)
Increased CSF volume
Hepatic encephalopathy
Traumatic brain injury
Meningitis
Encephalitis
Hypertensive encephalopathy
Eclampsia
Subarachnoid hemorrhage
Dural sinus thrombosis
Altitude-related cerebral edema
Communicating hydrocephalus
Noncommunicating hydrocephalus
Choroid plexus papilloma

10. Extracranial cause (secondary)
Prevent cause, Prevent ICH

11. Clinical Signs of Increased ICP

12. Clinical Signs of Increased ICP
Signs which are almost always present
Depressed level of consciousness (lethargy, stupor, coma)
Hypertension, with or without bradycardia
Cushing triad: hypertension, bradycardia, and respiratory depression
Symptoms and signs which are sometimes present
Headache
Vomiting
Papilledema
Sixth cranial nerve palsies

14. Neurogenic Patterns of Respiration
Type
location
Cheynes - Stokes Respiration
Diffuse forebrain injury
Central neurogenic hyperventilation
Midbrain ,such as thalamus
Apneustic
(pause at full inspiration)
Mid to caudal pontine, brainstem or Basilar a. occlusion
Ataxic
(radom deep and shallow breaths)
Medulla lesion (terminal stage)
Cluster
(irregular breaths and pause)
Lower medulla

15. ICP Monitoring
Powerpoint Templates

16. Indirect Monitoring Techniques
Monitoring Clinical Status
1. Level of alertness and GCS;
2. Pupillary examination;
3. Ocular motor examination (with special attention to the third and sixth cranial nerves);
4. Motor examination with special attention for hemiparesis;
5. Presence of nausea or vomiting;
6. Complaints of headache; and
7. Current vital signs and the recent course.
Best to Correlate with ICP

17. Neuroimaging
CT-brain
MRI

18. Neuroimaging

19. Transcranial Doppler ultrasonography (TCD)
Measure basal arterial cerebral blood flow,
40 to 70 cm/s.
Diffuse Increase ICP compress cerebral arteries increase flow velocity
TCD is insufficiently sensitive and specific to provide a noninvasive alternative to ICP monitoring.

20. Direct ICP Monitoring
1. Fontanometry 2. Epidural pressure monitoring 3. Subdural pressure monitoring 4. Parenchymal measuring 5. Ventricular pressure monitoring 6. Lumbar pressure monitoring
Neurol Clin 2008;26: 521–41

21. Direct ICP Monitoring

22. Indications for ICP monitoring
(1) the condition leading to ICP elevation
is amenable to treatment
(2) ongoing direct assessment of ICP will be of consequence in decisions regarding treatment interventions
(3) the risks of device placement do not outweigh the potential benefits.
Brain trauma foundation 2007
Neurol Clin 2008;26: 521–41

23. management of increased ICp

24. Treatment of increased ICP
CPP=MAP-ICP
CBF = CPP / CVR
The goals of ICP treatment 1. Maintain ICP ≤ mmHg. 2.Maintain CPP ≥ 60 mmHg by maintaining adequate MAP. 3. Avoid factors that aggravate or precipitate elevated ICP.
Neurol Clin 2008;26: 521–41

26. Management of ICP Head elevation 15 ˚ - 30˚ Hyperventilation
Control BP
Hyperosmolar therapy
Sedative and paralysis
Steroid
Decompressive craniectomy and lumbar drainage

27. Head elevation venous out flow resistance
CSF from intracranial spinal compartment
Position above heart and prevent kinking or compression of jugular v.(c-spine precaution)
The mean ICP was significantly lower when the patient's head was elevated at 30° than at 0° (14.1 ± 6.7 mm Hg vs ± 8.3 mm Hg).
J Neurosurg 1992;76:207–11.

28. Head elevation
The anesthetized or hypovolemic pts may response to head elevation by developing systemic hypotension
Must treat to avoid adverse impact to CPP
Neurol Clin 2008;26: 521–41

29. Oxygenation and Ventilation
Respiratory dysfunction is common esp in head trauma.
Hypoxia and hypercapnia can ICP
Adequate ventilation: Pao2 ≥60 mmHg
Paco2:30-35 mmHg
Neurol Clin 2008;26: 521–41

30. Oxygenation and Ventilation
intrathoracic pressure are transmitted directly through the neck to the intracranial cavity
Increase intrathoracic pressure: increase ICP
decreased venous return to the right atrium and a rise in jugular venous pressure,
increase in CBV and in ICP
Decreased venous return also leads to a drop in cardiac output and blood pressure, thereby reducing CPP
PEEP

31. Oxygenation and Ventilation
The consequences of PEEP on ICP depend on
lung compliance,
ICP
MAP
Minimal consequences for ICP are usually observed when lung compliance is low
J Trauma 2005;58:571–6.

32. Hypercapnia and hypocapnia
Cerebral vasodilate  CBF and ICP
 PaCO2 1 mmHg  CBF 2 ml/100g/min
In situations of reduced intracranial compliance
Increased ICP and reduced CPP
In situations of reduced cerebral blood flow and oxygen delivery, where ICH is not a problem
improvements in cerebral blood flow

33. Hyperventilation Cerebral vasodilate  CBF and ICP
Hyperventilation PaCO2, which can induce constriction of cerebral arteries
Cerebral vasodilate  CBF and ICP
PaCO2 1 mmHg  CBF 2 ml/100g/min
PaCO2 1 mmHg  CBV 0.04 ml/100g/min
Aim: Paco mmHg
Hyperventilation may produce a decrease in CBF sufficient to induce ischemia.
Hyperventilation should be avoided during the first 24 hours after injury when cerebral blood flow (CBF) is often critically reduced.
Neurol Clin 2008;26: 521–41

34. Hyperventilation Most effective use of hyperventilation is acutely
The vasoconstrictive effect :11-20 hours
When hypocarbia is induced and maintained for several hours, it should be reversed slowly, over several days, to minimize this rebound hyperemia
Prophylactic hyperventilation (PaCO2 of 25 mm Hg
or less) is not recommended.
Crit Care Clin 1997;13:163–84.

36. Decompressive Abd Pressure
intra-abdominal P.(abdominal compartment syndrome), can ICP by obstructing cerebral venous outflow.
Immediate reductions in ICP with decompressive laparotomy
Neurol Clin 2008;26: 521–41

37. Decompressive Abdominal Pressure
17 pts with intractable ICH that is refractory to medical treatment (abdominal compartment syndrome is not present)
abdominal fascial release can effectively reduce ICP (30.0± ±3.2)
J Trauma 2004;57:687–93.

38. Hyperthermia
metabolic rate 10-13% per 1°C and is a potent vasodilator.
Induce dilation of cerebral vessels can
CBF and ICP.
Fever during the post injury period worsens neurologic injury in TBI
Neurosurgery 1996;38:533–41

39. Hypothermia Prophylactic hypothermia Cochrane review in 2004
Not significantly associated with decrease mortality when compare with normothermic controle
Cochrane review in 2004
not find any evidence supporting the use of hypothermia during the treatment of TBI,
a statistically significant increased risk of pneumonia and other potentially harmful side-effects
Although routine induction of hypothermia is not indicated at present,hypothermia may be an effective adjunctive treatment of increased ICP refractory to other medical management

40. Hypertension Common in pts who have ICH Esp 2° to HI
Characterize by a SBP increase greater than diastolic increase.
Associate with sympathetic hyperactivity
Neurosurgery 1996;38:533–41.

41. Hypertension
Not reduce BP in HT pts associated with untreated intracranial mass lesions
cerebral perfusion maintain by the higher BP.
In the absence of an intracranial mass lesion, controversy to treat HT
Neurol Clin 2008;26:521–41

42. Hypertension When autoregulation is impaired, common after TBI,
HT may CBF and ICP,cerebral edema ,risk for post-op intracranial hemorrhage
Keep SBP mmHg
Neurol Clin 2008;26:521–41

43. Hypertension
Vasodilating drugs e.g. nitroprusside, NTG, and nifedipine, can ICP and catecholamines
Sympathomimetic-blocking antiHT drugs,
β-blocking drugs ( esmolol)
α-central acting receptor agonists (clonidine)
are preferred ( reduce BP without affecting the ICP)
Agents with a short half-life have an advantage when BP is labile.
Neurol Clin 2008;26:521–41

44. Treatment of anemia
Mechanism: CBF for maintain cerebral oxygen delivery when severe anemia.
Anemia has not been clearly shown to exacerbate ICP after TBI,
a common practice is to maintain Hb ≥ 10 g/dL.
Neurol Clin 2008;26:521–41

45. Prevention of seizures
Seizure occur 15-20% in severe HI.
Seizures can CMR and ICP
In severe TBI, 50% of seizures may be subclinical and can be detected only with continuous EEG monitoring
J Neurosurg 1999;91:750–60

46. Prevention of seizures
Significant risk factors for later seizures
- brain contusion
- subdural hematoma
- depressed skull fracture
- penetrating head wound
- loss of consciousness or amnesia ≥1 day
- age ≥ 65 years
Neurol Clin 2008;26:521–41

47. Barbiturates Dose-dependent CBF and CMRO2 ICP by CBF and CBV
High-dose barbiturate administration is recommended to control elevated ICP refractory to maximum standard medical and surgical treatment.
Dose-dependent CBF and CMRO2
ICP by CBF and CBV
Neuroprotective effect
Hemodynamic stability is essential before and during barbiturate therapy.
Barbiturate coma: EEG shows a burst suppression pattern.

48. Barbiturate coma
Complications during treatment with barbiturate coma include
- hypotension in 58%of patients
- hypokalemia in 82%
- respiratory complications in 76%
- infections in 55%
- hepatic dysfunction in 87%
- renal dysfunction in 47%
Acta Neurochir 1992;117:153–9

49. Propofol
recommended for the control of ICP, but not for improvement in mortality or 6 month outcome.
High-dose propofol
Hypotension and propofol infusion syndrome

50. Propofol infusion syndrome
Acute refractory bradycardia leading to asystole, in the presence of one or more of the following:
metabolic acidosis (base deficit > 10 mmol/l),
rhabdomyolysis,
hyperlipidaemia,
enlarged or fatty liver.
propofol infusions at doses higher than 4 mg/kg/h for greater than 48 h duration

52. Hyperosmolar therapy

53. Mannitol onset 1-5 min peak effect 20-60 min
Duration hrs depending on the clinical condition
Dose:Bolus g/kg
Urgent reduce ICP :initial dose of 1 g/kg
Can be repeated g/kg q 2-6 hrs.
Neurol Clin 2008;26:521–41

54. Mannitol
Sosm optimal is mOsm and should ≤ 320 mOsm to avoid S/E e.g. hypovolemia, hyperosmolarity, and renal failure.
Attention to replacing fluid that is lost because of mannitol-induced diuresis, or intravascular volume depletion
Neurol Clin 2008;26:521–41

55. Mannitol
Osmotic effect of mannitol serum tonicity ( draws edema fluid from cerebral parenchyma)
Neurol Clin 2008;26:521–41

56. Mannitol Mannitol has rheologic
( Hct and blood viscosity ( o2 delivery to the brain)
CSF production, lead to prolonged ICP
free radical scavenging effects.
Neurol Clin 2008;26:521–41

57. Loop diuretic Furosemide Dose: 0.5-1 mg/kg Synergize with mannitol
Greater ICP, less brain edema, prolong elevation of plasma osmolarity
Effect from CSF formation via alter Na+ transport across choroid plexus

58. Hypertonic saline
Concentration %,

59. Hypertonic saline
Osmotic force to draw water from the interstitial space of the brain parenchyma into the intravascular compartment in the presence of an intact BBB
intracranial volume and ICP.
augments volume resuscitation
circulating BV, MAP,and CPP
modulation of the inflammatory response by adhesion of leukocytes to endothelium
Effective to reduce refractory increased ICP
Anesth Analg 2006;102:1836–46

60. Hypertonic saline Adverse effects
- hematologic and E’lyte abnormalities
HypoNa+ should be excluded before administering HTS, to reduce the risk for central pontine myelinolysis
Serum Na is maintained mmol/L in TBI.
repeated until ICP is controlled or Na 155 mmol/L
After 3–4 days of HTS therapy, boluses of furosemide to mobilize tissue Na.
J Trauma 2001;50:367–83
Anesth Analg 2006;102:1836–46

61. Steroids Common use for 1° and metastatic brain tumors
Decrease vasogenic cerebral edema.
ICH decreases in 2-5 days
The most commonly used regimen
- Dexamethasone 4 mg q 6 hours IV.
Other neurosurgical disorders, such as TBI or spontaneous ICH
- not have a benefit
Curr Opin Oncol2004;16:593–600

62. CSF drainage Decrease ICP immediately by reducing intracranial volume
If brain is diffuse swollen, the ventricles may collapse, limited usefulness
Special consideration
- large hemispheric mass
- infratentorial mass
Result in subfalcine herniation, upward trantentorial herniation
Neurol Clin 2008;26: 521–41

63. Surgical interventions
Resection of mass lesions
Decompressive craniectomy
Failure of medical therapy
Persistent cerebral swelling or increase ICP
Prevent transtentorial herniation
Anesthesiology Clin 2007;25:

64. Prevent secondary brain damaged
Avoid hyper or hypoglycemia
Maintain glucose level mg/dL
A relative reduction in mortality of around 30% in patients with severe HI after the introduction of protocol
Correct electrolyte imbalance
Infection control
Prevent other organs dysfunction

66. THE END !!