What are the degrees of increased Intracranial Pressure (ICP)?

From the Guidelines

Intracranial pressure (ICP) is typically classified into three degrees of severity: mild, moderate, and severe, with thresholds generally considered to be greater than 20–25 mmHg for intracranial hypertension, as stated in the consensus summary statement 1.

Degrees of Increased ICP

The degrees of increased ICP can be broken down as follows:

• Mild elevation: 15-20 mmHg
• Moderate elevation: 21-40 mmHg
• Severe elevation: above 40 mmHg These classifications are crucial for guiding management decisions, as cerebral perfusion pressure decreases as ICP rises, potentially leading to ischemia and herniation 1.

Management of Increased ICP

Management strategies for increased ICP vary depending on the severity of the elevation and may include:

• Conservative measures for mild elevations, such as head elevation to 30 degrees and ensuring adequate oxygenation
• More aggressive interventions for moderate elevations, including osmotic diuretics, hyperventilation, and possibly CSF drainage
• Immediate action for severe elevations, potentially including barbiturate coma, decompressive craniectomy, or therapeutic hypothermia It is essential to note that normal ICP in adults ranges from 5-15 mmHg, and sustained pressures above 20 mmHg require treatment to prevent secondary brain injury 1.

Importance of ICP Monitoring

ICP monitoring is a fundamental aspect of neurocritical care, particularly for patients with acute brain injury (ABI), as it provides valuable information for directing medical and surgical therapy 1. The use of ICP monitoring, in combination with clinical evaluation and imaging, is essential for guiding treatment decisions and improving patient outcomes 1.

From the Research

Degrees of Increased Intracranial Pressure (ICP)

The degrees of increased ICP can be understood through the various thresholds and management strategies outlined in medical literature.

• Increased ICP is a pathological state that can lead to brain damage or death if not managed properly 2.
• The overall goal for patients with intracranial hypertension is to lower ICP below 20 mm Hg and to maintain cerebral perfusion pressure (CPP) between 60 mm Hg and 90 mm Hg 3.
• Elevated ICP may lead to brain damage or death by two principle mechanisms: 1) global hypoxic-ischemic injury, as a consequence of reduced cerebral perfusion pressure (CPP) and cerebral blood flow; and 2) mechanical distortion and compression of brain tissue as a result of intracranial mass effect and ICP compartmentalization 2.

Management of Increased ICP

• Treatment of critically raised 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 2.
• Commonly used therapeutic interventions to lower ICP include decompressive surgery, osmotherapy, hyperventilation, barbiturate-induced metabolic suppression, and hypothermia 3.
• The selection of these interventions must be tailored to each patient by considering the particular diagnosis and intracranial pathophysiology 3.
• Emerging evidence suggests that cerebral autoregulation may fail at excessively high CPP (CPP greater than 100 mm Hg) as well as at low CPP (CPP less than 60 mm Hg) and that maximal cerebral autoregulation capacity may be achieved at an optimal CPP of 70 mm Hg to 90 mm Hg 3.

Individualized Approach to Managing Increased ICP

• Increased ICP can rapidly escalate into a catastrophic event, and prompt initiation of an individualized ladder approach to clinical management is crucial 4.
• Nurses need to initiate a prompt and effective care plan that includes intensive monitoring of symptoms and continuous assessment of the patient's neurological condition 4.
• The care of cancer patients with increased ICP can be very challenging, and nurses must continue to recognize the importance of utilizing best available evidence to support a collaborative interdisciplinary clinical plan of care 4.

Treatment Options for Intracranial Hypertension

• Hypertonic saline and mannitol are two commonly used treatments for intracranial hypertension, with some studies suggesting that hypertonic saline may be more effective in reducing intracranial pressure 5.
• However, there is currently insufficient evidence to support a formal recommendation on the use of any specific hyperosmolar medication in patients with acute increased intracranial pressure 5.
• Osmotherapy is considered the mainstay of medical therapy for increased intracranial pressure, and should be administered as soon as possible 6.