Back

ICP Management

Edit

Initial Management

Step 1: Determine if there is clinical deterioration due to edema, shift or ICP >20mHg

  • Elevate HOB at 30 degrees unless MAP <60 or brain sag
  • Control agitation, pain (lorazepam, fentanyl, propofol)
  • Place central and A-line
  • Maintain pCO2 35-40; maintain normothermia
  • Treat shivering per shivering protocol, maintain euvolemia, I=O
  • Keep CPP (= MAP - ICP) 60-110 with phenylephrine or IV norepi
  • If CPP >110, reduce with labetalol or nicardipine IV

Step 2: If there is a surgical lesion or greater than 5mm shift, call neurosurg to consider OR or EVD placement

Osmotic Therapy

Step 3: Start osmotic therapy with either 23.4 % saline OR mannitol

  • 23.4% Saline

    • order 30 cc over 10-20 min

    • effect starts in 15-30 minutes, lasts 90min-6hrs

  • Mannitol

    • order 20% mannitol 1.0-1.5g/kg IV bolus

    • can order mannitol 20% 500ml x1 dose, this is equivalent to a 100g dose)

  • If still elevated, consider short term hyperventilation to pCO2 <30 mm Hg [prolonged use an cause ischemia, can bag patient for immediate effect], paralytics, or induced hypothermia 32-34C

  • In refractory cases, may consider pentobarbital coma OR decompressive craniectomy

Step 4: Start maintenance osmotic therapy with either 3% saline OR mannitol

  • 3% Saline

    • order 3% saline at 1mg/kg/h via central line

    • check Na and Osm q6h (goal Na 150-155 meq/L)

    • wean off with care to prevent rebound edema

  • Mannitol

    • order 20% mannitol 0.5g/kg IV q4-q6h

    • check Chem 7 and serum Osm q6h

    • calculate osmolality gap (measured Osm-calculated Osm) for goal serum osm < 320, and osmolal gap < 20

    • replete UOP cc for cc, particularly in TBI and SAH prevent rebound edema

  • as a last resort – can try pentobarbitol 5-20 mg/kg bolus then 1-4 mg/kg/hr.

    • EEG required, titrate to burst suppression 1 burst per 6sec

    • pentobarbital can cause hypotension

Choosing Saline versus Mannitol

  • hypertonic saline

    • use hypertonic saline to volume expand and increase CPP

    • must be administered via a central line

    • hypertonic saline may be more effective and easier to titrate than mannitol

    • can be used for patients refractory to mannitol

    • caution with low EF, cerebral salt wasting (SAH)

    • avoid in decompensated CHF, and if hyponatremic for greater than 24h due to theoretical central pontine myelinolysis

    • side effects: flash pulm edema, volume overload, acute renal failure, rebound cerebral edema on tapering due to rapid correction of hypernatremia

    • hypernatremia can cause lethargy, seizure, coma, weakness, Na >160 is independent predictor of mortality

  • mannitol

    • use mannitol when diuresis is needed

    • avoid in renal failure

    • side effects include hypervolemia or volume depletion, pulmonary edema, hyper-k, hyper-Na (which can cause lethargy coma, seizure, weakness)

    • can cause acute renal failure that is reversible, if mannitol dose exceeds 200g daily or osmolal gap exceeds 60-70 mosmol/kg