From the Guidelines
Sodium nitrite is not recommended for managing elevated intracranial pressure (ICP) in pediatric patients, and the maximum dosage of NaCl 3% in ICP in pediatric patients is not established, however, hypertonic saline (3% solution) can be used at a dose of 0.1-1 mL/kg/hr to reduce ICP. The standard medications for treating elevated ICP in children include osmotic agents like mannitol (0.25-1 g/kg IV) or hypertonic saline, corticosteroids such as dexamethasone (0.5-1 mg/kg/day divided q6h), and in severe cases, barbiturates like pentobarbital (loading dose 5-10 mg/kg followed by 1-3 mg/kg/hr) 1. Sodium nitrite is primarily used as a treatment for cyanide poisoning as part of the cyanide antidote kit and has vasodilatory properties that could potentially worsen cerebral edema and increase ICP.
Key Considerations
- When managing elevated ICP in pediatric patients, it's essential to maintain adequate cerebral perfusion pressure while reducing intracranial volume through proper positioning (head elevation at 30 degrees), controlled hyperventilation (PaCO2 30-35 mmHg), sedation, and the aforementioned medications 1.
- Surgical interventions like external ventricular drainage or decompressive craniectomy may be necessary in refractory cases.
- The goal of ICP management is to maintain ICP below 20 mmHg while ensuring adequate cerebral perfusion pressure to prevent secondary brain injury.
- Hypertonic saline can be effective in reducing raised intracranial pressure, but it does not improve neurological outcomes or survival in states of raised intracranial pressure 1.
Management Recommendations
- Manage severe TBI children in a paediatric trauma centre or in an adult trauma centre with paediatric expertise 1.
- ICP monitoring is crucial, especially in children < 2 years old, as they are at risk for high ICP and poor outcome 1.
- The incidence of raised ICP was found high in TBI children < 2 years old, and a strong association existed between cerebral perfusion pressure and neurological outcome 1.
From the Research
Management of Elevated Intracranial Pressure (ICP) in Pediatric Patients
- The management of elevated ICP in pediatric patients involves a multifaceted approach, including monitoring of ICP, maintenance of adequate cerebral perfusion pressure, and the use of various therapies to reduce ICP 2, 3.
- The pathophysiology of head injury can explain some of the causes of raised ICP, and monitoring of ICP is crucial in guiding treatment 2.
- Interventions such as positioning, mechanical ventilation, and drug therapy have been shown to limit rises in ICP, while less common therapies include jugular venous bulb oxygen saturation monitoring and the use of trometamol (THAM) 2.
Role of Sodium Nitrite in Managing Elevated ICP
- There is no direct evidence in the provided studies on the role of sodium nitrite in managing elevated ICP in pediatric patients.
- However, the use of hyperosmolar therapy, such as mannitol and hypertonic saline, is considered a mainstay of medical therapy for elevated ICP, and should be administered as soon as possible 4.
- The goal of these interventions is to maintain or re-establish adequate cerebral blood flow and prevent herniation, and osmotherapy is considered a key component of this approach 4.
Treatment Paradigms for Elevated ICP
- The treatment of elevated ICP should proceed in an orderly step-wise fashion, including consideration of neuroimaging, intravenous sedation, manipulation of blood pressure, mannitol infusion, moderate hyperventilation, and high-dose pentobarbital therapy 5.
- The application of moderate hypothermia shows promise as a newer method for treating refractory ICP, and placement of an ICP monitor is the critical first step in management of ICP 5.
- Recent advances have shown the mortality benefits in appropriately recognizing and treating increased ICP, and multiple modalities of treatment have been explored, with evidence showing benefit in some 6.