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1

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Increased Intracranial Pressure Increased Intracranial Pressure (IICP)(IICP)

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Increased Intracranial Pressure Increased Intracranial Pressure (IICP)(IICP)

2

ICP : ICP : 5 5 -- 15 15 mm Hgmm Hg

Intracranial volume : brain Intracranial volume : brain 80 80 %%((11,,900 900 ml)ml) CSF CSF 10 10 % %

blood blood 10 10 %%

Normal relationship of the compartment

3

Monro-Kellie

** �������������� ก�������ก ���ก���� ���������������� �!� #$����������� ����#�����%���&���� ��%������������������'�#�� ��( �)!�* #$����

��� '����)���ก ���ก���� &� �!� **

ก��กก���ก������ � ก����ก��������

Compensatory phase

– ก��ก�������� CSF

– ก����ก������� CSF

– ก�������ก�����ก�� ��� CSF

– ก����!����"���#��� ����

4

!$����%����&�"'��������(� ก��!�� )��)�

• ��"��ก������"����!����"�����ก� %��

• "*�+� '����ก�� / ����ก� %��

• ก���� ��+�����-.�ก�� ��� CSF �������

“ Compliance I

ก�����"��� ก��"� � ��"'�ก����!����"�� ����������./

[������������ �!���+ก���� '����)���ก� ���ก���� * ����� �!���+ก���� ��%�,���������]

5

����"0������� � ก����ก������������"0������� � ก����ก��������

• !����"�� #/����������������./

• !����"������� ��#��� ����������./

• !����"� CSF ������./

Conditions associated with increased ICP

Intracranial mass lesions• Subdural hematoma• Epidural hematoma• Brain tumor• Cerebral abscess• Intracerebral hemorrhage

Increased brain volume (cytotoxic edema)• Cerebral infarction• Global hypoxia-ischemia• Acute hyponatremia

6

Conditions associated with increased ICP

Increased blood and brain volume (vasogenic edema)• Hepatic encephalopathy• Traumatic brain injury• Meningitis• Encephalitis• Hypertensive encephalopathy• Eclampsia• Subarachnoid hemorrhage• Dural sinus thrombosis

Increased CSF volume• Communicating hydrocephalus• Noncommunicating hydrocephalus• Choroid plexus papilloma

Cerebral edema

� Vasogenic edema - extracellular edema

( brain tumor & meningitis )

� Cytotoxic edema - intracellular space

diffuse brain swelling

( hypoxic & anoxic episode)

� Interstitial edema - periventricular tissue

( acute & chronic hydrocephalus )

7

Herniation syndrome of the brain

�� Supratentorial herniationSupratentorial herniation- Cingulate herniation- Central or transtentorial herniation- Lateral transtentorial herniation( uncal herniation )

� Infratentorial herniation

Normal relationship of the compartment

8

Uncal & transtentorial herniation

Central transtentorial herniation

9

Herniation syndrome of the brain

Infratentorial herniation (Cerebellar tonsil)

Herniation syndrome of the brainTemporoparietal epidural hematoma

- Uncal herniation with lateral brainstem compression

- Compression & stretching of CN IIIunilateral dilatation of pupil

- Displacement of midbrain compression of piramidal tractcontralateral hemiparesisplantar extensor responses

(babinski’s sign) - Cerebellar tonsil

10

Herniation syndromes

��R"�S�T��ก���ก�Tก���"��U 7V"���������WUX��Y�����X��� V�� IICP

Regional CBF CPP in areas CO2 ( hypercapnia)O2 ( hypoxemia ) Acidosis VasodilatationCBF CBV ICP Local Autoregulation "#$%

Regional CBF IICP &'ก)*+,-. Vasopressure ischemic Response MAP 01* CBF Edema 01* IICP

11

Z!� Autoregulation ���

CBF / CPP ICPCPP No CBF Herniation Death

Clinical signs of increased ICP

Signs which are almost always present• Depressed level of consciousness

(lethargy, stupor, oma)• Hypertension, with or without bradycardia

Symptoms and signs which are sometimes present• Headache• Vomiting• Papilledema• Sixth cranial nerve palsies

12

ก����'����� � ก����ก�����

1. Ventricular catheter

2. Subarachanoid screw

3. Epidural monitoring

4. Intraparenchymal

5. Subdural catheter

ICP monitoring

13

ICP waveform

14

Noninvasive ICP monitoring

Transcranial Doppler (TCD) ultrasonography

• measures the velocity of blood flow in thebasal cerebral arteries

• shows characteristic changes with increasing ICP

15

Adjuncts to ICP monitoring

JUGULAR VENOUS OXYGEN SATURATION

(SJVO2) • assesses the adequacy of global cerebral

oxygen delivery

BRAIN TISSUE PO2 (PBTO2) MONITORING• measures regional oxygen tension

Provide continuous information regarding the adequacy of CPP and CBF

at the tissue level

Strategies & Interventions

for

Increased Intracranial Pressure

To maintainICP below 20 mmHg

and CPP above 70 mmHg

In routine intensive care unit (ICU) practice, the goal of ICP management is to maintain levels

below 20 mmHg.

16

Protocol for ICP management in monitored patient

Surgical decompression

• Consider repeat CT scanning • Definitive surgical intervention • Ventricular drainage• If a ventricular catheter is in place, the

system should be opened to drainage and 5-10 ml of CSF removed

• Lumbar CSF drainage (5-20 ml/hr)• Decompressive hemicraniectomy

17

ก��b�T�� ก��b�T�� ventricular drainageventricular drainage

SurgerySurgery

* Craniectomy * Craniotomy* V-P shunt / V-A shunt

18

Sedation

Intravenous sedation to attain a motionless, quiet state

• A combination of a sedative-hypnoticand analgesic agent is usually most effective

• The preferred regimen is the combinationof an opioid, such as fentanyl (1-3 lg/kg/hr) orsufentanil (0.1-0.6 lg/kg/hr), to provide analgesiaand propofol (0.3-3 mg/kg/hr) for sedation

• Propofol may be the ideal sedative to usein patients with elevated ICP

CPP optimization

• Pressor infusion if CPP is less than70 mmHg

• Reduction of blood pressure if CPP is greater than 110 mmHg.

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CPP = MAP - ICP

Cardiac support & blood pressure controlCardiac support & blood pressure control

Hypotension Hypotension cerebral ischemiacerebral ischemiaSevere hypertension Severe hypertension cerebral edemacerebral edema

Elevated BP frElevated BP froom Cusm Cushhiningg’’ s response s response should not be treatedshould not be treated

Maintain BPs Maintain BPs 140 140 -- 150 150 mmHgmmHg

CPP = CPP = 70 70 mmHgmmHg

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Osmotherapy

• Mannitol 0.25-1.0 g/kg intravenously(repeat every 1-6 hours as needed)

HyperventilationHyperventilation

��! ��! Tidal volume Tidal volume 12 12 -- 15 15 ml/kgml/kg

��กk���T�� ��กk���T�� PaCOPaCO22 26 26 -- 30 30 mmHgmmHg

pH pH 77..3535--77..4545

End tidal COEnd tidal CO2 2 should be monitoredshould be monitored

PetCO2 30-35 mmHg

Hypocarbia Vasoconstriction Reduce CBFHypocarbia Vasoconstriction Reduce CBF

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High-dose pentobarbital therapy

• Load with 5-20 mg/kg, • Infuse 1-4 mg/kg/hr

• Pentobarbital typically requires a loading dose of 10-20 mg/kg, given in repeated

5 mg/kg boluses, until a state of flaccid coma with preserved pupillary reactivity is attained

Hypothermia

• Cool core body temperature to 32-33°C• Prolonged hypothermia can be dangerous

because of increased risk of infectious complications,

coagulopathy, and electrolyte derangements,• Rewarming should always be done slowly, over at least

a day, and passively, without active heating, to avoid rebound cerebral edema or a systemic inflammatory response syndrome

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� Elevate head of bed 15-30 degrees.

� Normal saline (0.9%) at 80-100 cc/hr (avoid hypotonic fluids)

� Intubate and hyperventilate (target pCO2 26-30 mmHg)

� Mannitol 20% 1-1.5 g/kg via rapid intravenous

infusion

� Foley catheter

� CT scan and urgent neurosurgical consultation

Emergency measures for ICP reduction

Respiratory supportRespiratory support

Positive airway pressurePositive airway pressure(Mechanical Ventilator)(Mechanical Ventilator)

Positive end expiratory pressurePositive end expiratory pressure(PEEP) < ICP(PEEP) < ICP

Intensive care

23

��T���ก���S��7qX�������T�7�� �b��T���ก���S��7qX�������T�7�� �b

Ventilation monitoringVentilation monitoring

ก��r���q!�XXกqXกs�tb�ก"XT �S���!�ก�Tก��r���q!�XXกqXกs�tb�ก"XT �S���!�ก�Tก��V�ก�"��U 7กs�tquv7ก��V�ก�"��U 7กs�tquv7

��T�� ��T�� PaCOPaCO22 b������������7�ก��ก��b������������7�ก��ก���"��U 7V"�qX �"��U 7V"�qX alveolar ventilation alveolar ventilation

Noninvasive ventilatory monitoringNoninvasive ventilatory monitoring

�"w7ก����T �"w7ก����T PCOPCO2 2 �7���� �bqX� !"#� �7���� �bqX� !"#� X ����X�7WUX X ����X�7WUX ((End tidal COEnd tidal CO22))

PetCOPetCO22 ������US�ก��� ������US�ก��� PaCOPaCO22 "�����"����� 11--5 5 ����.."�X�"�X�

(( 3030--35 35 ����.."�X�"�X�) )

Capnography Capnography

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Maintain patent airway & Maintain patent airway & adequate ventilation adequate ventilation

T T����� ��WUXbS��"w7����7�v7 T T����� ��WUXbS��"w7����7�v7 ((use protocoluse protocol))"�����7��กk��ก���� �b"�����7��กk��ก���� �b��!��! OO22 100 100 % % ก�X7ก��T T����� ก�X7ก��T T����� 11//2 2 -- 1 1 7���7���T V�T V�ก����!ก����!���WUX��� �� �b���WUX��� �� �b

Prevent hypercapnia & hypoxemiaPrevent hypercapnia & hypoxemia

Evidence :Evidence : Assessment Assessment (breath sound)(breath sound)

Patient Preparation Patient Preparation (positioning, information)(positioning, information)

HyperoxygenationHyperoxygenation

((100100% FiO% FiO22 11min,min, PaOPaO2 2 100100% SaO% SaO2 2 > > 9595%%))

Hyperventilation Hyperventilation (tidal volume(tidal volume 1212--15 15 ml/kg)ml/kg)

Normal saline instillation Normal saline instillation ((r��������ก��� r��������ก��� support)support)

Maintenance of asepsis Maintenance of asepsis (CDC guidelines)(CDC guidelines)

ก��T T������7��X��XT���Xก��T T������7��X��XT���X"#IJ*KLMNK-ON hypercapnea & hypoxia secondary brain damage

กO)PQP"#IJ* sharp increase ICP cerebral ischemia

25

ก��T T������7��X��XT���Xก��T T������7��X��XT���X

Catheter selection Catheter selection ((11//22--22//3 3 of EET)of EET)

Depth of insertion Depth of insertion ( ( "J.RS "J.RS carina)carina)

Negative pressure Negative pressure ( < ( < 150 150 mmHg)mmHg)

Duration of procedureDuration of procedure (<(<15 15 sec)sec)

Number of passesNumber of passes ((2 2 passes)passes)

Post Post -- suctioningsuctioning ((1010--min rest period)min rest period)

(Day et al., (Day et al., 20012001: JBI, : JBI, 20052005; Price et al, ; Price et al, 20032003))

ก��T T������7��X��XT���Xก��T T������7��X��XT���Xก����!ก����! neuromuscular blockage drugs neuromuscular blockage drugs �Tก��rX�Tก��rX

((���� ���� blood pressure blood pressure �T��T�)) �!Xก���7��b� ���U��!Xก���7��b� ���U�

ก����! ก����! PEEP PEEP �7� !"#� �7� !"#� IICP IICP ���q!X��R"r��rT! ���q!X��R"r��rT!

((PEEP PEEP IICP , PEEP IICP , PEEP ��U ��U < ICP < ICP "�XTY� "�XTY� ))

(Day et al., (Day et al., 20012001: JBI, : JBI, 20052005; Price et al, ; Price et al, 20032003))

26

Positioning & Turning� Neutral head alignment at all times

� Avoid knee & hip flexion

� 300 head elevation - every 100 of head elevation, the ICP thought to drop by 1 mmHg (Wong, 2000)

� Turn patient & ensure neutral head alignment at all times

� Passive limb exercises no significant rise in ICP

� A set of activities after ET suctioning significant rise in ICP

Temperature controlTemperature control

�� Hypothermia blanket Hypothermia blanket

����T���� ����T���� shivering shivering IICPIICP

�� Antipyretic drugs : Antipyretic drugs : Paracetamol is effective Paracetamol is effective

As a general standard, acetaminophen and cooling blankets should be given to all patients

with sustained fevers in excess of 38.30C

27

Seizure controlSeizure control

MMaintenance for euvolemiaaintenance for euvolemia��T���"�����7 ��T���"�����7 serum osmolarity , electrolyte serum osmolarity , electrolyte V��V�� glucoseglucose

0.9% (normal) saline or lactated Ringer's solution,(Isotonic)

Phenytoin (Dilantin) Phenytoin (Dilantin)

Fluids managementFluids management

L O C (Glasgow coma score)L O C (Glasgow coma score)Pupillary size & reactionPupillary size & reactionEye movementEye movementMotor functionMotor functionReflexesReflexesVital signsVital signs

Neurological assessmentNeurological assessment

Identifying the patient at Identifying the patient at riskrisk

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Glasgow Coma ScaleGlasgow Coma Scale

ก������� ก����� ก������������

����� 4����������"#ก 3���������%&'(�� 2��*��� 1

,�-��'��-����� 5/0'/� 4�����-�(1��2�3 3/* �/"# ��*�(1��2� 2��*�(�* �/"# 1

����������(ก�4 6(ก(6� �����%&'(�� 5�7 89�9���" 489� �:4�(ก�4 389���#"#�:4�(ก�4 2��*������������# 1

��7�uกbS�7�7"4�������7�uกbS�7�7"4�����

���bT ����Z��bS�����qX"4��������bT ����Z��bS�����qX"4�����

����T�����!X� ก����T�����!X� ก

r����7XRbb���r����7XRbb���

Management of Urinary elimination & bowel function

29

��V�7ก�bก���ก��� ����r����!��ก�7� !"#� ��V�7ก�bก���ก��� ����r����!��ก�7� !"#�

��T�������7�� ��T�������7�� LabLab

"~Xก�7X�ก����ก "~Xก�7X�ก����ก

��T���ก����! ���T���ก����! �

T V��RqX7��� T V��RqX7���

"~Xก�7Y���V��กt!X7 "~Xก�7Y���V��กt!X7 -- Pressure sore, DVT, RI, UTIPressure sore, DVT, RI, UTI

General nursing managementGeneral nursing management

Drug therapyDrug therapy

��T���X�ก��q!���� qX ���UrT!�����T���X�ก��q!���� qX ���UrT!���

Osmotic diureticOsmotic diuretic

CorticosteroidsCorticosteroidsAnticonvulsantsAnticonvulsantsAntacidAntacidStool softenersStool softenersHistamine blockersHistamine blockersAntipyretics Antipyretics

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Managing factors known to IICPManaging factors known to IICP

VasalVasalvava�� s maneus maneuvvererBowel managementBowel managementIsometric muscle contractionIsometric muscle contractionControl Control sshiveringhiveringEmotional upset & noxious stimEmotional upset & noxious stimuuliliClustering of nursing activitiClustering of nursing activitieess

Managing factors known to IICPManaging factors known to IICP

Control environmental stimuli Control environmental stimuli

: : excessive noise, unnecessary lighting, painful stimuli, excessive noise, unnecessary lighting, painful stimuli,

unfamiliar voiceunfamiliar voice

31

"45����ก��� ������U����X �7� !"#� ��U��IICP

# ��ก���T�qX cerebral tissue perfusion �7WUXb�ก ����T�7�7ก����ก���k�� , ��X��� ��WXb�ก��XT��WXT�7��X�T�ก��

q!X� ��7���7R7 : • GCS 1P1N T.OP pupil U+TVW. I$'XYกY)Y%O+ZS0#N1P1N

K[OI#OIO)\].กO)"K1RMS.&J[TSN0T.TO.-S%1N J)RS"K1RMS.&J[0^^"ก)_NNSJ)RS"ก)_N"J%$%P SBP #QNTVW. Pulse pressure ก[-ONTVW. $̀ab) -̀O1N0+Z0)N JO%]b"'c.0^^ cheyne-stokes '[Pd$)e* SO"b$%. L̀ก"ก)_N ก)*+,ก

• ICP >15 mmHg• CPP <70 mmHg

ก��� ����

� #LN"ก+01* L̂.fVก neuro signs & vital signs

� ]J-กO)a%O^O1"aRMS1P01*'hSNกL. IICP

� )LกeO)*PL^TSN MAP ]J-S%QZ].)*PL^ 100 mmHg

� )LกeO)*PL^S,iJjQIYกO%]J-S%QZ].)*PL^'ก+Y

� PQ01]J-&P-)L^%O barbiturates, sedatives +OI0k.กO))LกeO

� J1$ก"1$M%N#YMNก)*+,-.f$M&IZaVN')*#NKl

� 'hSNกL. Rebleeding ( ruptured aneurysm )

32

q�T"������Y���7ก���S����T�7�� �b��!���

q!X� ��7���7R7

� LOC 1P1N K[OI#OIO)\].กO)&S1P1N "#IJ*"J.$%[

� JO%]b")_[+RW. &P-%Y."#$%NK)RPK)OP ก)*#L^ก)*#ZO%

� mnN"#$%NJO%]b&P-%Y."#$%N"#IJ*

� "#$%NกO)foONO.TSN"K)RMSN`Z[%JO%]bkYP'ก+Y

ก��� ����

� ')*"IY.fON"PY.JO%]b� bLPfZO.S. "'1$M%.fZO.S.� PQ01K[OI`RW.].fON"PY.JO%]b� PQP"#IJ*S%ZONI$')*#YfpYjOa� PQ01")RMSNกO)]J-.WoO� Percussion & vibration \-O&IZI$T-SJ-OI� ]J-%O1*1O%"#IJ*

33

V��V�7ก���� �br����"������Y��ก��V�ก�"��U 7กs�t�T�

q!X� ��7���7R7� JO%]b].1Lกei*+-SNSSก0)NIOก SL+)OกO)JO%]b K[OI1VกkYP'ก+Y JO%]b&IZ#IMoO"#IS

� LOC 1P1N

� Spontaneous tidal volume < 7 ml/kg

� PaO2 < 80 mmHg PaCO2 > 45 mmHg

ก��� ����� ')*"IY.1Lกei*กO)JO%]b

� PQ01fON"PY.JO%]b]J-U1ZN I$กO))*^O%SOกOdP$

� PQ01]J-kQ-'v[%&P-)L^SSกwY"b.01*"K)RMSN`Z[%JO%]b

� PQ01]J-กO)JO%]bI$')*#YfpYjOa

� ]J-กO)a%O^O1"aRMS1P01*'hSNกL.jO[* IICP

� +YP+OI')*"IY. Spo2 01* ABG "'c.)*%*y

34

���U ��XY���r����TR�qX7vS�V�� electrolytes( 7vS�q�T �t�T� ��7��WXT� )

q!X� ��7���7R7� 'n##O[*SSกIOก ( > 200 ml/hr )

� Specific gravity < 1.005

� SZS."a1$% 'Oก0J-N kY[J.LN0J-N

� CVP < 5 mmHg

� Na > 145 mmEq/L

� Serum osmolarity > 300 mOsm/kg

ก��� ����

� #LN"ก+SOกO) / SOกO)0#PN� PQ01]J-&P-)L^.WoOS%ZONaS"a$%N� L̂.fVก I/O� ก)i$I$ DI 0af%lSOb]J- Minirin %Ob*SSก{fpY|jO%]. 15-30 .Of$ 'n##O[*b*SSก.-S%1N +-SN)*ILP)*[LNกO)]J- IV fluid "a)O*SOb"กYP.WoO"กY. I$jO[*.WoO"'c.aYe (water intoxication) &P- +-SN')*"IY.)*PL^K[OI)Q-#Vก+L[ kQ-'v[%b*I$SOกO)wVI1N

� +)[b[LP)*PL^ electrolytes f,ก[L.

35

���U ��XY���r����TR�qX7vS�V�� electrolytes( 7vS��ก�7 �t�T� ��7��WXT�US� )

q!X� ��7���7R7� I > O

� LOC 1P1N SO"b$%.

� CVP > 12 mmHg

� Na <135 mEq/L

� Serum osmolarity < 280 mOsm/Kg

ก��� ����

� #LN"ก+SOกO) / SOกO)0#PN

� L̂.fVก I/O

� PQ01]J-&P-)L^.WoO < 1,000 ml/d

� \-O Na ]."1RSP+MoO 0af%lb*]J- 3% NaCl

� PQ01]J-&P-)L^%OTL^'n##O[*+OI0k.กO))LกeO

� +)[b[LP)*PL^ electrolytes f,ก[L.

36

���U ��Xก���ก�TY���V��กt!X7 : กO)+YP"`RWS ( RI, UTI, wound infection, invasive procedures) 0k1กPfL^, DVTq!X� ��7���7R7� .S.].fZO"P$%[.O.y &IZI$กO)"K1RMS.&J[ J)RSI$กO)"K1RMS.&J[.-S% I$SO"b$%. #oO1Lก

� JO%]bJS^"J.RMS% +-SN]`-0)NIOกTVW. 1Lกei*"#IJ*T-. #$T,Z."J1RSN I$ก1YM. I$&T-

� 0k1^[I 0PN I$ discharge I$ก1YM.� 1Lกei* CSF T,Z. I$&T-� Braden score >16� TOP.WoO

��X��������������กก���V���6��ก�������5�������� Tr���������

q!X� ��7���7R7� กO)^OP"b_^"กYPTVW.ก)*fL.JL.� TOPK[OI)Q-01*T-SIQ1"ก$M%[กL^กO)'XY L̂+Y+L[ กO))LกeO กO)a%Oก)ilU)K

� กO)boOกLP"[1O"T-O"%$M%I� #\O.กO)il]. ICU ")ZN)$^ S,'ก)il 01*"K)RMSNIRSI$IOก .ZOก1L[

� กO)#RMS#O)bOกf$IkQ-)LกeO01*PQ01

37

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