What are the tiered methods to control refractory elevated Intracranial Pressure (ICP)?

From the Guidelines

Tiered management of refractory intracranial pressure (ICP) involves escalating interventions based on patient response, with the goal of maintaining ICP below 22 mmHg and cerebral perfusion pressure between 60-70 mmHg to prevent secondary brain injury. First-tier therapies include:

• Head elevation to 30-45 degrees
• Maintaining adequate sedation (propofol 0.3-4.0 mg/kg/hr or midazolam 0.05-0.2 mg/kg/hr)
• Analgesia (fentanyl 1-3 mcg/kg/hr)
• Neuromuscular blockade (cisatracurium 0.1-0.2 mg/kg/hr)
• CSF drainage via external ventricular drain
• Hyperosmolar therapy (mannitol 0.25-1.0 g/kg IV q4-6h or hypertonic saline 3% at 0.5-1.0 mL/kg/hr)
• Maintaining normothermia, as supported by the American Heart Association/American Stroke Association guidelines 1.

Second-tier therapies include:

• Moderate hyperventilation (PaCO2 30-35 mmHg)
• Barbiturate coma (pentobarbital loading dose 5-10 mg/kg followed by 1-4 mg/kg/hr)
• Decompressive craniectomy, which has been shown to reduce mortality rates in patients with refractory intracranial hypertension, as demonstrated in the RESCUE-ICP study 1
• Therapeutic hypothermia (32-34°C), although its effectiveness in lowering ICP is still a topic of debate, with some studies suggesting a high rate of complications 1.

These interventions work through different mechanisms: reducing cerebral blood volume, decreasing cerebral metabolic demand, removing CSF, reducing brain water content, or creating space for the swollen brain. Treatment should be tailored to the underlying pathology and guided by multimodal monitoring, as recommended by the European Stroke Organisation guidelines 1. Therapy should be withdrawn systematically once ICP normalizes, with careful monitoring for rebound effects.

From the FDA Drug Label

As with other sedative medications, there is wide interpatient variability in propofol injectable emulsion dosage requirements, and these requirements may change with time. When increased ICP is suspected, hyperventilation and hypocarbia should accompany the administration of propofol injectable emulsion. In literature reports of severely head-injured patients in Neurosurgical ICUs, propofol injectable emulsion infusion and hyperventilation, both with and without diuretics, controlled intracranial pressure while maintaining cerebral perfusion pressure.

The tiered methods to control refractory raised intracranial pressures include:

• Hyperventilation and hypocarbia to accompany the administration of propofol injectable emulsion 2
• Propofol injectable emulsion infusion to control intracranial pressure while maintaining cerebral perfusion pressure 2
• Use of diuretics in combination with propofol injectable emulsion infusion and hyperventilation to control intracranial pressure 2 It is essential to note that these methods should be used under close monitoring and with caution, as the evidence is not exhaustive, and individual patient responses may vary 2.

From the Research

Tiered Methods for Controlling Refractory Raised Intracranial Pressures

The management of refractory raised intracranial pressure involves a stepwise approach, with various interventions used in a tiered manner. The following are some of the methods used:

• First-line treatments: These include osmotic therapy, cerebral spinal fluid drainage, and mild hyperventilation 3.
• Second-line treatments: These may include the use of hyperosmolar agents such as hypertonic saline or mannitol 4, 5.
• Tier-three or "salvage" interventions: These include therapeutic hypothermia, barbiturates administration, and decompressive craniectomy, which are considered for patients with refractory intracranial hypertension 3, 6.

Pharmacologic Interventions

Pharmacologic interventions play a crucial role in the management of refractory raised intracranial pressure. These include:

• Opioids and sedatives: Used to reduce intracranial pressure and prevent secondary brain injury 7.
• Osmotic diuretics: Used to reduce intracranial pressure by creating an osmotic gradient that draws water out of the brain 7.
• Hypertonic saline solutions: Used to reduce intracranial pressure by creating an osmotic gradient that draws water out of the brain 4, 5.
• Barbiturates: Used to reduce intracranial pressure by suppressing brain activity and reducing cerebral metabolism 4, 3, 7.

Surgical Interventions

Surgical interventions, such as decompressive craniectomy, may be considered for patients with refractory intracranial hypertension. This procedure involves removing part of the skull to allow the brain to expand and reduce intracranial pressure 3, 6.