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Raised ICP - intraop (Management of raised ICP (medical emergency) (Check…
Raised ICP - intraop
Management of raised ICP (medical emergency)
Check anaesthetic factors
A - intubate if GCS<8 or unable to maintain resp goals
B - Avoid hypoxia, hypercapnia
C - Avoid hypotension (keep MAP>80), ensure adequate venous drainage (ETT ties, C collars, 30 deg up, head neutral)
D - Avoid volatile agent overdose, appropriate sedation/analgesia/MR to reduced CMR02, optimise vent, prevent coughing
E - Avoidhypothermia
F - Avoid hypotonic solutions (CSL) - Albumin in TBI (SAFE study)
G - Avoid glucose containing solutiom
Hyperventilation
Will reduce CBF and reduce ICP
Aim PaC02 30-35 - any lower will compromise cerebral perfusion and 02 delivery
Osmotherapy
Reduces brains tissue oedema - no consistent evidence on which osmotherapeutic agent is better
Mannitol
Reduces ICP within minutes with max effect after 30 mins
1g/kg (=5ml/kg of 20%)
Also reduces blood viscosity which may improve 02 delivery
Side effects:
Volume overload and LVF then dehydration and hypernatraemia due to diuretic effects (should not be given unless hypovolaemia is corrected)
Renal failure (avoid serum osmolality >320 mOsm/l
Thrombophlebitis (infuse into large vein)
Hyperkalaemia
Anaphylaxis
Rebound increased ICP
May be more effective if given with Frusemide
Hypertonic saline
2ml/kg of 7.5% is typical, keeping Na <155
Benefits - greater exclusio by BBB, may have greater osmotic effect, increases CBF, increases myocardial contractility
Glucose - Prevent hyperglycaemia which is associated with poor neurological outcome in patients with TBI (keep BSLs 6-10)
Seizure control - Prevent/treat seizures to reduce cerebral 02 demand with phenytoin 15mg/kg at rate of <50 mg/min with ECG and BP monitoring
Surgical - Evacuate space occupying lesion, drain CSF via external ventricular drain
Rescue therapy for refractory intracranial HTN
Barbiturate coma
High dose thiopentone bolus to achieve burst suppression with EEG or if no monitoring, as much as can CVS cope with
Reduces CMR02 and is an anticonvulsant (reduces ICP)
Risks: significant hypotension and reduced CPP
Hypothermia
Reduces CMR02 (reduced ICP) but unknown whether this improves outcome (awaiting result of Polar and Eurotherm trials)
Decompressive craniectomy
Early decompressive craniectomy in patients with severe TBI results in reduced ICP but worse functional outcomes (DECRA) - awaiting results from RESCUEicp trial
Importance of ICP
ICP is a major determinant of CPP
Normally 5-15mmHg
Raised ICP (>20mmHg) may result in brain herniation and irreversible brainstem injury