Is There an Upper Limit of Intracranial Pressure in Patients
Is There an Upper Limit of Intracranial Pressure in Patients
Authors of recent studies have championed the importance of maintaining cerebral perfusion pressure (CPP) to prevent secondary brain injury following traumatic head injury. Data from these studies have provided little information regarding outcome following severe head injury in patients with an intracranial pressure (ICP) greater than 40 mm Hg, however, in July 1997 the authors instituted a protocol for the management of severe head injury in patients with a Glasgow Coma Scale score lower than 9. The protocol was focused on resuscitation from acidosis, maintenance of a CPP greater than 60 mm Hg through whatever means necessary as well as elevation of the head of the bed, mannitol infusion, and ventriculostomy with cerebrospinal fluid drainage for control of ICP. Since the institution of this protocol, nine patients had a sustained ICP greater than 40 mm Hg for 2 or more hours, and five of these had an ICP greater than 75 mm Hg on insertion of the ICP monitor and later experienced herniation and expired within 24 hours. Because of the severe nature of the injuries demonstrated on computerized tomography scans and their physical examinations, these patients were not aggressively treated under this protocol. The authors vigorously attempted to maintain a CPP greater than 60 mm Hg with intensive fluid resuscitation and the administration of pressor agents in the four remaining patients who had developed an ICP higher than 40 mm Hg after placement of the ICP monitor. Two patients had an episodic ICP greater than 40 mm Hg for more than 36 hours, the third patient had an episodic ICP greater than of 50 mm Hg for more than 36 hours, and the fourth patient had an episodic ICP greater than 50 mm Hg for more than 48 hours. On discharge, all four patients were able to perform normal activities of daily living with minimal assistance and experience ongoing improvement.
Data from this preliminary study indicate that intense, aggressive management of CPP can lead to good neurological outcomes despite extremely high ICP. Aggressive CPP therapy should be performed and maintained even though apparently lethal ICP levels may be present. Further study is needed to support these encouraging results.
The current management of neurological trauma has undergone great change in the past 5 years. Initial studies by Becker, et al., featured a coherent strategy for diagnosing and treating intracranial hypertension, including early diagnosis of intracranial mass lesions, monitoring of parenchymal or intraventricular pressure, elevation of the head of the bed, restriction of fluids, and administration of osmotic diuretic agents. Early data from the TCDB confirmed that an intracranial ICP greater than 20 mm Hg for sustained intervals was associated with poor neurological outcome. This information led to the acceptance of the aforementioned measures as the mainstays of treatment. Muizelaar and colleagues have challenged the use of prophylactic hyperventilation therapy in treating acute head injury, although its adverse effects have been accepted by many centers. The greatest controversy concerns the treatment of blood pressure and volume status. Young and Meredith found that in patients with multiple traumas, a marked positive fluid balance associated with oxygen deliverydirected resuscitation had no adverse effects on neurological outcome or ICP. Rosner and colleagues have convincingly demonstrated that a protocol focusing on the maintenance of CPP in excess of 65 mm Hg can improve neurological outcome and patient survival. Even in these studies, however, it is unclear what ICP can be tolerated if CPP is maintained and what the effects on patient outcome are in the event of severe, sustained intracranial hypertension (ICP > 30 mm Hg).
Using the guidelines created by the American Association of Neurological Surgeons, we implemented a protocol for severe closed head injury that was focused on adequate total resuscitation, ICP monitoring, and maintenance of a CPP greater than 65 mm Hg (Fig. 1). We report our early experience with this treatment strategy.
(Enlarge Image)
Algorithm for the management of severe head injury accepted by the Neurosurgery and Trauma Services at UVA prior to this study. CHI = closed-head injury CI = cardiac index; CVP = central venous pressure; D/C = discontinue; LA = lactic acid; MVO2 sat = mixed venous oxygen saturation; NSGY = neurosurgery; OSM = serum osmolality; PCWP = pulmonary capillary wedge pressure; SBP = systolic blood pressure; UO = urine output.
Authors of recent studies have championed the importance of maintaining cerebral perfusion pressure (CPP) to prevent secondary brain injury following traumatic head injury. Data from these studies have provided little information regarding outcome following severe head injury in patients with an intracranial pressure (ICP) greater than 40 mm Hg, however, in July 1997 the authors instituted a protocol for the management of severe head injury in patients with a Glasgow Coma Scale score lower than 9. The protocol was focused on resuscitation from acidosis, maintenance of a CPP greater than 60 mm Hg through whatever means necessary as well as elevation of the head of the bed, mannitol infusion, and ventriculostomy with cerebrospinal fluid drainage for control of ICP. Since the institution of this protocol, nine patients had a sustained ICP greater than 40 mm Hg for 2 or more hours, and five of these had an ICP greater than 75 mm Hg on insertion of the ICP monitor and later experienced herniation and expired within 24 hours. Because of the severe nature of the injuries demonstrated on computerized tomography scans and their physical examinations, these patients were not aggressively treated under this protocol. The authors vigorously attempted to maintain a CPP greater than 60 mm Hg with intensive fluid resuscitation and the administration of pressor agents in the four remaining patients who had developed an ICP higher than 40 mm Hg after placement of the ICP monitor. Two patients had an episodic ICP greater than 40 mm Hg for more than 36 hours, the third patient had an episodic ICP greater than of 50 mm Hg for more than 36 hours, and the fourth patient had an episodic ICP greater than 50 mm Hg for more than 48 hours. On discharge, all four patients were able to perform normal activities of daily living with minimal assistance and experience ongoing improvement.
Data from this preliminary study indicate that intense, aggressive management of CPP can lead to good neurological outcomes despite extremely high ICP. Aggressive CPP therapy should be performed and maintained even though apparently lethal ICP levels may be present. Further study is needed to support these encouraging results.
The current management of neurological trauma has undergone great change in the past 5 years. Initial studies by Becker, et al., featured a coherent strategy for diagnosing and treating intracranial hypertension, including early diagnosis of intracranial mass lesions, monitoring of parenchymal or intraventricular pressure, elevation of the head of the bed, restriction of fluids, and administration of osmotic diuretic agents. Early data from the TCDB confirmed that an intracranial ICP greater than 20 mm Hg for sustained intervals was associated with poor neurological outcome. This information led to the acceptance of the aforementioned measures as the mainstays of treatment. Muizelaar and colleagues have challenged the use of prophylactic hyperventilation therapy in treating acute head injury, although its adverse effects have been accepted by many centers. The greatest controversy concerns the treatment of blood pressure and volume status. Young and Meredith found that in patients with multiple traumas, a marked positive fluid balance associated with oxygen deliverydirected resuscitation had no adverse effects on neurological outcome or ICP. Rosner and colleagues have convincingly demonstrated that a protocol focusing on the maintenance of CPP in excess of 65 mm Hg can improve neurological outcome and patient survival. Even in these studies, however, it is unclear what ICP can be tolerated if CPP is maintained and what the effects on patient outcome are in the event of severe, sustained intracranial hypertension (ICP > 30 mm Hg).
Using the guidelines created by the American Association of Neurological Surgeons, we implemented a protocol for severe closed head injury that was focused on adequate total resuscitation, ICP monitoring, and maintenance of a CPP greater than 65 mm Hg (Fig. 1). We report our early experience with this treatment strategy.
(Enlarge Image)
Algorithm for the management of severe head injury accepted by the Neurosurgery and Trauma Services at UVA prior to this study. CHI = closed-head injury CI = cardiac index; CVP = central venous pressure; D/C = discontinue; LA = lactic acid; MVO2 sat = mixed venous oxygen saturation; NSGY = neurosurgery; OSM = serum osmolality; PCWP = pulmonary capillary wedge pressure; SBP = systolic blood pressure; UO = urine output.
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