From the Guidelines
In a patient with raised intracranial pressure (ICP) following neck dissection, giving saline IV is what not to do. The immediate management should focus on controlling the elevated ICP through appropriate interventions. Taking the patient to a High Dependency Unit (HDU) is appropriate for close monitoring, as it allows for intensive care and rapid response to changes in the patient's condition 1. Monitoring ICP directly provides valuable information about treatment effectiveness, and steroids, particularly dexamethasone, can help reduce cerebral edema and inflammation. However, administering intravenous saline should be avoided as it may worsen cerebral edema and further increase ICP, as isotonic or hypotonic fluids can expand intravascular volume and potentially exacerbate cerebral edema in patients with compromised blood-brain barrier 2.
Instead, if fluid administration is necessary, hypertonic saline or mannitol would be more appropriate as they create an osmotic gradient that pulls fluid from the brain tissue into the vasculature, thereby reducing ICP. The management should also include maintaining adequate cerebral perfusion pressure, optimizing oxygenation, and addressing the underlying cause of the raised ICP. According to the guidelines for the management of spontaneous intracerebral hemorrhage, ICP treatment should be directed at the underlying cause, especially if due to hydrocephalus or mass effect from the hematoma 3.
Some key considerations in managing raised ICP include:
- Maintaining a cerebral perfusion pressure (CPP) of 50–70 mmHg depending on the status of cerebral autoregulation
- Using hypertonic saline or mannitol to reduce ICP
- Avoiding isotonic or hypotonic fluids that can worsen cerebral edema
- Monitoring ICP and CPP closely in a critical care unit
- Addressing the underlying cause of the raised ICP, such as hydrocephalus or mass effect from the hematoma.
From the Research
Raised ICP post neck dissection: What not to do
- The following options are considered in the management of raised ICP post neck dissection:
- Take to HDU: This is a suitable action as monitoring and management of raised ICP often require close observation in a high-dependency unit 4.
- Monitor ICP: This is a crucial step in managing raised ICP, as it allows for the assessment of the effectiveness of treatment and the detection of any changes in intracranial pressure 5.
- Give steroids: There is no evidence to suggest that steroids are beneficial in the management of raised ICP post neck dissection. In fact, the use of steroids is not recommended in the treatment of raised ICP unless there is an underlying condition that would benefit from steroid therapy 6, 5.
- Give saline IV: The use of saline IV is not recommended as a first-line treatment for raised ICP. However, hypertonic saline may be used to reduce ICP in certain situations 6, 4, 5.
Inappropriate actions
- Giving steroids is not a recommended action for managing raised ICP post neck dissection, unless there is an underlying condition that would benefit from steroid therapy 6, 5.
- Giving saline IV is not a suitable first-line treatment for raised ICP. Hypertonic saline may be used in certain situations, but isotonic saline is not typically used to reduce ICP 6, 4, 5.