From the Guidelines
Intracranial pressure (ICP) can be controlled through a combination of medical and surgical interventions, with the most effective method being elevation of the head of bed to 30-45 degrees to promote venous drainage, as recommended by the American Heart Association 1. The first-line medical treatments include:
- Elevation of the head of bed to 30-45 degrees to promote venous drainage
- Hyperventilation to achieve a PaCO2 of 30-35 mmHg for short-term emergent management, although its use is limited due to its transient effect and potential to lower cerebral blood flow (CBF) 1
- Osmotic agents such as mannitol (0.25-1 g/kg IV bolus every 4-6 hours) or hypertonic saline (3% solution at 0.5-1 mL/kg/hr) to reduce cerebral edema Sedation with propofol (5-80 mcg/kg/min) or midazolam (0.05-0.2 mg/kg/hr) reduces cerebral metabolic demand, while neuromuscular blockade with agents like vecuronium (0.1 mg/kg loading dose, then 0.05-0.1 mg/kg/hr) may be necessary to prevent activities that increase ICP. Temperature control targeting normothermia or mild hypothermia (36-37°C) helps reduce metabolic demands. For refractory cases, surgical interventions include external ventricular drainage to remove CSF directly, decompressive craniectomy to create space for brain swelling, or specific treatments for underlying causes like tumor resection or hematoma evacuation. These interventions work by addressing the fundamental components of intracranial volume: brain tissue, cerebrospinal fluid, and blood volume, following the Monro-Kellie doctrine which states that the sum of these components must remain constant within the rigid skull to maintain normal ICP (10-20 mmHg) 1. In terms of the options provided, hyperventilation to achieve a PaCO2 < 4.8 kPa is not recommended as a primary treatment for ICP control, as it may have adverse effects on CBF and its effect is transient 1. Normal saline infusion and Lasix (furosemide) may be used as adjunctive therapies, but their use should be carefully considered and monitored, as they may have potential side effects and interactions with other treatments 1.
From the Research
Methods to Control Intracranial Pressure (ICP)
- The given options to control ICP are:
- A. PCO2 < 4.8 Kpa
- B. Normal saline infusion
- C. Lasix
- According to the studies, other methods to control ICP include:
- Head of bed elevation 2
- IV mannitol 2, 3
- Hypertonic saline 2, 3
- Transient hyperventilation 2, 4
- Barbiturates 2
- Sedation, endotracheal intubation, mechanical ventilation, and neuromuscular paralysis for refractory ICP 2
- CSF drainage if hydrocephalus is present 2
- Decompression of a surgical lesion, such as an intracranial hematoma/large infarct or tumor 2
- Maintenance of cerebral perfusion pressure (CPP) at 70-88 mm Hg 5
- Volume expansion, nursing patients in the flat position, and actively using catecholamine infusions to maintain the SABP side of the CPP equation 5
- The effectiveness of these methods may vary depending on the underlying cause of elevated ICP and the individual patient's condition.
Specific Options
- Option A: PCO2 < 4.8 Kpa - Hyperventilation to reduce PaCO2 can be used to control ICP, but it may cause brain ischemia after traumatic brain injury 6, 4
- Option B: Normal saline infusion - There is no direct evidence in the provided studies to support the use of normal saline infusion as a primary method to control ICP.
- Option C: Lasix - There is no direct evidence in the provided studies to support the use of Lasix as a primary method to control ICP.