Intracranial Pressure Management

Principles for Using Tiers

When possible, use lowest tier treatment
There is no rank order within a tier
It is not necessary to use all modalities in a lower tier before moving to the next tier
If considered advantageous, tier can be skipped when advancing treatment

Between the Tiers

Re-examine the patient and consider repeat CT to re-evaluate intracranial pathology
Reconsider surgical options for potentially surgical lesions
Consider extracranial causes of ICP elevation
Review that basic physiologic parameters are in desired range (e.g., CPP, blood gas values)
Consider consultation with higher level of care if applicable for your health care system

Tier Zero (Basic Severe TBI Care - Not ICP Dependent) comic_bubble

Expected Interventions:

Admission to ICU
Endotracheal intubation and mechanical ventilation
Serial evaluations of neurological status and pupillary reactivity
Elevate HOB 30-45°
Analgesia to manage signs of pain (not ICP directed)
Sedation to prevent agitation, ventilator asynchrony, etc. (not ICP directed)
Temperature management to prevent fever
- Measure core temperature
- Treat core temperature above 38°C

Consider anti-seizure medications for 1 week only (in the absence of an indication to continue)
Maintain CPP initially ~ 60 mmHg
Maintain Hb > 7g/dl
Avoid hyponatremia
Optimize venous return from head (e.g. keeping head midline, ensure cervical collars are not too tight)
Arterial line continuous blood pressure monitoring
Maintain SpO2 ~ 94%

Expected Interventions:

Recommended Interventions:
Insertion of a central line
End-tidal CO2 monitoring

ICP < 22 mmHg

ICP > 22 mmHg

PbtO₂ > 20 mmHg

Type A

Type B

PbtO₂ < 20 mmHg

Type C

Type D

Critical Neuroworsening

A serious deterioration in clinical neurologic status such as:

Spontaneous decrease in the GCS motor score of ≥1 points (compared with the previous examination)
New decrease in pupillary reactivity
New pupillary asymmetry or bilateral mydriasis
New focal motor deficit
Herniation syndrome or Cushing's Triad which requires an immediate physician response

Response to Critical Neuroworsening

Emergent evaluation to identify possible cause of neuroworsening.
If herniation is suspected:

empiric treatment

hyperventilation
bolus of hypertonic solution

consider emergent imaging or other testing
rapid escalation of treatment

Possible Causes of Neuroworsening

expanding intracranial mass lesion
cerebral edema
elevated ICP
stroke
electrolyte or other metabolic disturbance

medical comorbidity
medication effect
impaired renal or hepatic function
systemic hypotension
seizure or post-ictal state
hypoxemia/tissue hypoxia

CNS infection
infection or sepsis
substance withdrawal
dehydration
hyper or hypothermia

Treatment Not Recommended

Mannitol by non-bolus continuous intravenous infusion
Scheduled infusion of hyperosmolar therapy (e.g., every 4–6 h)
Lumbar CSF drainage
Furosemide
Routine use of steroids
Routine use of therapeutic hypothermia to temperatures below 35°C due to systemic complications
High-dose propofol to attempt burst suppression
Routinely decreasing PaCO2 below 30 mmHg/4.0 kPa
Routinely raising CPP above 90 mmHg

Tier 1 comic_bubble

Maintain CPP 60-70 mmHg
Increase analgesia to lower ICP
Increase sedation to lower ICP
Maintain PaCO2 at low end of normal (35-38 mmHg/4.7-5.1 kPa)
Mannitol by intermittent bolus (0.25-1.0 glkg)

Hypertonic saline by intermittent bolus
CSF drainage if EVD in situ
Consider placement of EVD to drain CSF if parenchymal probe used initially
Consider anti-seizure prophylaxis for 1 week only (unless indication to continue)
Consider EEG monitoring

Tier 2 comic_bubble

Mild hypocapnia range 32-35 mmHg/4.3-4.6 kPa
Neuromuscular paralysis in adequately sedated patients if efficacious
Perform MAP Challenge to assess cerebral autoregulation and guide MAP and CPP goals in individual patients
- Initiate or titrate a vasopressor or inotrope to increase MAP by 10 mmHg for not more than 20 minutes
- Monitor and record key parameters (MAP, CPP, ICP and Pbt 0 2) before, during, and after the challenge
- Adjust vasopressor/inotrope dose based on study findings
Raise CPP with fluid boluses, vasopressors, and/or inotropes to lower ICP when autoregulation is intact

Tier 3 comic_bubble

Pentobarbital or Thiopentone coma titrated to ICP control if efficacious
Secondary decompressive craniectomy
Mild hypothermia (35-36°C) using active cooling measures

Tier 1

Maintain CPP 60-70 mmHg
Increase analgesia to lower ICP
Increase sedation to lower ICP
Maximum PaCO2 at low end of normal (35-38 mmHg/4.7-5.1 kPa)
CSF drainage if EVD in situ

Mannitol by intermittent bolus (0.25-1.0 g/kg)
Hypertonic saline by intermittent bolus
Consider antiseizure prophylaxis for 1 week only (unless indication to continue)
Consider EEG monitoring

Tier 2

Mild hypocapnia (range 32-35mmHg/4.3-4.6 kPa)
Neuromuscular paralysis in adequatelysedated patients if efficacious in lowering ICP
Perform MAP challenge to assess cerebral autoregulation and guide MAP and CPP goals in individual patients
- Should be performed under direct supervision of a physician who can assess response and ensure safety
- No other therapeutic adjustments (i.e. sedation) should be performed during the MAP Challeng
- Initiate or titrate a vasopressor or inotrope to increase MAP by 10 mmHg for not more than 20 minutes
- Monitor and record key parameters (MAP, CPP, ICP and PbtO2) before, during, and after the challenge
- Adjust vasopressor/inotrope dose based on study findings
Raise CPP with fluid boluses, vasopressors, and/or inotropes to lower ICP when autoregulation is intact

Tier 3

Pentobarbital or thiopentone coma titrated to ICP control if efficacious
Secondary decompressive craniectomy
Mild hypothermia (35–36°C) using active cooling measures
Hyperventilation to PaCO2 of 30–32 mm Hg/4.0–4.3 kPa

Tier 1

Maintain CPP 60–70 mm Hg
Increase CPP to a maximum of 70 mm Hg with fluid, vasopressors, and/or inotropes
Maintain PaCO2 > 35 mm Hg/4.7 kPa
If PaO2 is already in desired range, further increase PaO2 by increasing FiO2 to 60%
Consider EEG monitoring

Tier 2

Ventilator management to increase PaO2 as high as 150 mm Hg/20kPa
Decrease ICP to a threshold <22 mmHg
Consider CSF drainage
Increase sedation to improve mechanical ventilation and PbtO2
Neuromuscular paralysis in adequately sedated patients if efficacious in increasing PbtO2
Perform MAP challenge to assess cerebral autoregulation and guide MAP and CPP goals in individual patients
- Should be performed under direct supervision of a physician who can assess response and ensure safety
- No other therapeutic adjustments (i.e., sedation) should be performed during the MAP challenge
- Initiate or titrate a vasopressor or inotrope to increase MAP by 10 mmHg for not more than 20 minutes
- Monitor and record key parameters (MAP, CPP, ICP, and PbtO2) before, during, and after the challenge
- Adjust vasopressor/inotrope dose based on study findings
Raise CPP to increase PbtO2 when supported by MAP challenge
Increase CPP above 70 mm Hg with fluid boluses, vasopressors, and/or inotropes

Tier 3

Increase PaCO2 to 45–50 mm Hg/6.0–6.7 kPa (but avoid intracranial hypertension)
Consider normobaric hyperoxia to achieve a PaO2 above 150 mm Hg/20 kPa
If PbtO2 remains <20 mm Hg despite PaO2 and CPP/MAP optimization, consider transfusing 1 unit of PRBCs if Hgb <9 g/dL

Tier 1

Maintain CPP 60–70 mm Hg
Increase CPP to a maximum of 70 mm Hg with fluid, vasopressors, and/or inotropes
Increase analgesia to lower ICP/improve ventilation and PbtO2
Increase sedation to lower ICP/improve ventilation and PbtO2
Maintain PaCO2 >35 mm Hg/4.7 kPa
Mannitol by intermittent bolus (0.25–1.0 g/kg)

Hypertonic saline by intermittent bolus
CSF drainage if EVD in situ
Consider placement of EVD to drain CSF if parenchymal probe used initially
If PaO2 is already in desired range, further increase PaO2 by increasing FiO2 to 60%
Consider antiseizure prophylaxis for 1 week only (unless indication to continue)
Consider EEG monitoring

Tier 2

Ventilator management to increase PaO2 as high as 150 mm Hg/20kPa
Increase sedation to improve ICP and PbtO2
Neuromuscular paralysis in adequately sedated patients if efficacious in decreasing ICP or increasing PbtO2
Perform MAP challenge to assess cerebral autoregulation and guide MAP and CPP goals in individual patients
- Should be performed under direct supervision of a physician who can assess response and ensure safety
- No other therapeutic adjustments (i.e., sedation) should be performed during the MAP challenge
- Initiate or titrate a vasopressor or inotrope to increase MAP by 10 mmHg for not more than 20 minutes
- Monitor and record key parameters (MAP, CPP, ICP, and Pbt O2) before, during, and after the challenge
- Adjust vasopressor/inotrope dose based on study findings
Raise CPP to decrease ICP and/or increase PbtO2 when supported by MAP challenge
Increase CPP above 70 mm Hg with fluid boluses, vasopressors, and/or inotropes

Tier 3

Pentobarbital or thiopentone coma titrated to ICP control if efficacious
Secondary decompressive craniectomy
Consider normobaric hyperoxia to achieve a PaO2 above 150 mm Hg/20 kPa
If PbtO2 remains <20 mm Hg despite PaO2 and CPP/MAP optimization, consider transfusing 1 unit of PRBC if Hgb <9 g/L

Download the Posters

SIBICC Poster (ICP monitoring) with cropmarks

SIBICC Poster (ICP & brain tissue oxygen monitoring) with cropmarks

Algorithm Overview

This section will detail the steps and considerations in the management algorithm for intracranial pressure.

comic_bubble

CONFERENCE REPORTS AND EXPERT PANEL

A management algorithm for patients with intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC)

Expected Interventions:

Expected Interventions:

Type A: BASIC CARE Applies to all sTBI Patients

TYPE B: - ICP Elevated – Brain Oxygenation Normal

TYPE C: ICP Normal – Brain Hypoxic

TYPE D: ICP Elevated – Brain Hypoxic

Download the Posters

Algorithm Overview