From the Research
The most recent and highest quality study 1 recommends a comprehensive management protocol for the treatment of intracranial pressure (ICP) crises, emphasizing the importance of ICP monitoring, mechanical ventilation, fluid therapy, and hypertonic saline infusion in guiding patient care.
Key Recommendations
- ICP monitoring should be initiated to guide therapy, with a treatment threshold of 20-25 mmHg, while maintaining cerebral perfusion pressure between 60-70 mmHg 1.
- First-tier treatments include head elevation to 30 degrees, maintaining adequate sedation, ensuring normothermia, and avoiding hypotension with a target systolic blood pressure above 90 mmHg.
- Osmotic therapy with mannitol (0.25-1 g/kg IV) or hypertonic saline (3-23.4% solution) should be administered for acute ICP elevations above 20-25 mmHg.
- Hyperventilation to a PaCO2 of 30-35 mmHg can be used temporarily for acute elevations.
- CSF drainage via an external ventricular drain should be considered when available.
- Second-tier therapies for refractory ICP include barbiturate coma (pentobarbital or thiopental), therapeutic hypothermia (32-34°C), and decompressive craniectomy.
Rationale
The management of elevated ICP is crucial to prevent secondary brain injury and improve patient outcomes. The latest evidence 1 highlights the importance of a comprehensive management protocol, including ICP monitoring, mechanical ventilation, and fluid therapy. By following these recommendations, healthcare providers can reduce intracranial hypertension, improve cerebral blood flow, and optimize oxygen delivery to brain tissue, ultimately improving morbidity, mortality, and quality of life for patients with elevated ICP.
Considerations
- The selection of therapeutic interventions must be tailored to each patient, considering the particular diagnosis and intracranial pathophysiology 2.
- The treatment itself is not without risk, and the risks and benefits of medical and surgical intervention must be carefully evaluated and individualized for each patient 2.
- Future research should focus on developing appropriate intervention protocols for both invasive and noninvasive neuromonitoring in managing ICP crisis patients 1.