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Management of raised intra cranial presssure in children


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Management of raised intra cranial presssure in children

  1. 1. Management of Acute raised Intracranial Pressure Dr. Farhan Shaikh Consultant Pediatric Intensivist, Academic Coordinator Internal Assessor for Quality Rainbow Children, Hyderabad
  2. 2. <ul><li>10 Year old girl brought in the ER with history of.. </li></ul><ul><li>Intermittent Fever without chills x 5 days </li></ul><ul><li>Erythematous maculo papular rash x 3 days </li></ul><ul><li>Yellow discoloration of eyes x 3 days </li></ul><ul><li>Excessive sleepiness & irrelevant talk x 3 days </li></ul>What is your First Step ?
  3. 3. <ul><li>? Viral Hepatitis with Encephalopathy </li></ul><ul><li>? Dengue fever with hepatitis </li></ul><ul><li>? Collagen vascular disorder with acute hepatitis </li></ul>
  4. 4. <ul><li>? Viral Hepatitis with Encephalopathy </li></ul><ul><li>? Dengue fever with hepatitis </li></ul><ul><li>? Collagen vascular disorder with acute hepatitis </li></ul><ul><li>Any child brought with altered sensorium in ER should be assumed to have Raised Intracranial pressure </li></ul><ul><li>In Grade 2 encephalopathy 30% and in Grade 3, 60% shall have cerebral edema </li></ul>
  5. 5. <ul><li>Child more likely to die due to raised ICP than other complications </li></ul><ul><li>First manage raised ICP </li></ul><ul><li>concurrent investigations to find the main cause of hepatitis can be carried out later. </li></ul>
  6. 6. <ul><li>Intracranial hypertension (ICP) is defined as an ICP > 20 mmHg for more than 5 minutes. </li></ul><ul><li>However, herniation or coning can occur even at ICP of less than 20, depending upon the area of the brain suffering injury and edema. </li></ul>
  7. 7. <ul><li>80% is Brain Tissue,10% each blood and CSF </li></ul><ul><li>Normal ICP values are 2-6 mmHg for infants and 3-7 mmHg for young children. </li></ul><ul><li>The normal ICP for older children and adults is 0-10 mmHg. </li></ul>
  8. 8. Monroe- Kellie Doctrine <ul><li>Sum of the intracranial volumes of blood, brain, cerebrospinal fluid and other components is constant and an increase in any one of these must be offset by an equal decrease in another, otherwise ICP rises. </li></ul>
  9. 9. Venous blood CSF Arterial Blood Brain Venous Blood CSF New Mass (Blood,Tumour etc) Arterial Blood Brain Brain Arterial Blood New Mass (blood,Tumor etc.) Ven.bld CSF ICP 0 10 20 30 40 50 60 Monroe- Kellie Doctrine Normal ICP Compensated ICP Un-compensated ICP
  10. 10. <ul><li>Intra cranial pressure can increase when.. </li></ul><ul><li>The Brain volume increase (e.g. Cerebral edema) </li></ul><ul><li>When CSF Volume increases (e.g. Hydrocephalus) </li></ul><ul><li>When the blood volume in the cranium increases (e.g. Bleed or hemorrhage) </li></ul><ul><li>When there is new mass occupying space inside the cranium (e.g. Tumor) </li></ul>
  11. 11. Factors which increase the cerebral flow and thus increase the ICP <ul><li>Hypoxia. </li></ul><ul><li>Hypercapnia. </li></ul><ul><li>Pain. </li></ul><ul><li>Low cerebral perfusion pressure. </li></ul><ul><li>Exaggerated hypertension </li></ul>Walters F, Intracranial Pressure & Cerebral Blood Flow
  12. 12. PaCO2 Vs ICP <ul><li>Carbon dioxide causes cerebral vasodilation. </li></ul><ul><li>Thus, hyperventilation brings PaCO2 down and causes cerebral vessels constriction leading to a mean reduction in intracranial pressure of about 50% within 2-30 minutes. </li></ul>
  13. 13. <ul><li>When PaCO2 is less than 25 mmHg there is no further reduction in CBF. </li></ul><ul><li>Therefore there is no advantage in inducing further hypocapnia as this will only lead to less oxygen delivery to the tissues. </li></ul>
  14. 14. <ul><li>Vasoconstriction after reducing the PaCO2, will only last for a short time (5 h). </li></ul><ul><li>If low PaCo2 is continued, there is a gradual increase in CBF and then, if the PaCO2 is brought suddenly to normal, it will lead to cerebral hyperaemia. </li></ul><ul><li>Hence, to prevent this, when long term ventilation is required, normocapnia should be maintained. </li></ul>
  15. 15. Monitoring of the ICP <ul><li>Clinical </li></ul><ul><li>Using Gadgets </li></ul>
  16. 16. Assessment of mental status: Glasgow Coma Scale (GCS)
  17. 18. Severity of illness <ul><li>Mild GCS score of 13 or higher </li></ul><ul><li>Moderate: GCS score of 9 to 12 </li></ul><ul><li>Severe: GCS < 9 </li></ul>
  18. 19. Small reactive Diancephlic - Small reactive Unilateral dilatation - Uncal herniation Large fixed - Tectal Pons - Pin point Mid brain - mid position fixed
  19. 20. Decorticating Decerebrating Flaccid
  20. 21. Severe Head Injury-Irrespective of GCS <ul><li>Unequal pupils </li></ul><ul><li>Asymmetric motor examination </li></ul><ul><li>3. Open head injury with CSF leak or exposed brain </li></ul><ul><li>4. Neurological deterioration (GCS decreased by> 2 points) </li></ul><ul><li>5. Depressed skull fracture </li></ul>
  21. 22. Traumatic Brain Injury <ul><li>Primary Brain Injury: </li></ul><ul><li>Occurs at the time of impact. </li></ul><ul><li>Axonal tissue is torn or contused, blood supply disrupted and bone fractured. </li></ul><ul><li>Very little can be done by the intensivist to prevent this </li></ul>
  22. 23. Secondary Brain Injury: <ul><li>The secondary injury is entirely preventable. </li></ul><ul><li>most important factors are hypoxia and/or ischemia are the greatest threats </li></ul>
  23. 24. Treatment <ul><li>First tier </li></ul><ul><ul><li>Head in Midline and head elevation by 30 degrees </li></ul></ul><ul><ul><li>Airway Protection </li></ul></ul><ul><ul><li>Sedation and analgesia </li></ul></ul><ul><ul><li>aggressive fever and seizure control </li></ul></ul><ul><ul><li>Hyperosmolar therapy </li></ul></ul><ul><ul><li>Neuromuscular blockade </li></ul></ul><ul><ul><li>CSF drainage via ventriculostomy </li></ul></ul><ul><ul><li>Mild hyperventilation (PaCO 2 : 35-40 mm hg) </li></ul></ul>
  24. 25. Head elevation of 30° <ul><li>This improves venous drainage with minimal effect on arterial pressure [2]. </li></ul><ul><li>Keep head in midline, ensuring there is no pressure on, or kinking, of the neck veins, </li></ul><ul><li>Most optimal position is, head in midline with 30°elevation.(if more, then will affect the cerebral arterial pressure) </li></ul>Carter BG, Butt W. A prospective study of outcome predictors after severe brain injury in children. Intensive Care Med. 2005 Jun;31(6):840-845:
  25. 26. Airway & Ventilation <ul><li>Hypoxemia must be avoided to prevent secondary brain injury. </li></ul><ul><li>Depth of coma alone can NOT determine the safety of the airway. </li></ul><ul><li>Airway reflexes must be assessed independently of the GCS. </li></ul>
  26. 27. Indication for intubation <ul><li>Upper airway obstruction or loss of airway protective reflexes </li></ul><ul><ul><li>Loss of pharyngeal muscle activity and tone </li></ul></ul><ul><ul><li>Inability to clear secretions </li></ul></ul><ul><ul><li>Persistant Seizures </li></ul></ul><ul><li>Abnormal breathing due to </li></ul><ul><ul><li>Chest wall dysfunction </li></ul></ul><ul><ul><li>Respiratory muscle dysfunction </li></ul></ul><ul><ul><li>Cervical spine injury </li></ul></ul>
  27. 28. Indications for intubation <ul><li>Arterial partial pressure of carbon dioxide (PaCO 2 ) </li></ul><ul><ul><li>Hypercarbia: PaCO 2 >45 mm Hg </li></ul></ul><ul><li>Pupils </li></ul><ul><ul><li>Anisocoria >1 mm </li></ul></ul><ul><li>Glasgow Coma Scale (GCS) score </li></ul><ul><ul><li>GCS <8 </li></ul></ul><ul><ul><li>Fall in GCS score of >3, irrespective of initial GCS </li></ul></ul>
  28. 29. Precautions in traumatic brain injury (TBI) <ul><li>Nasotracheal intubation should be avoided: possibility of base of skull fractures. </li></ul><ul><li>All trauma patients with supraclavicular injury should be assumed to have cranial and cervical spine injuries until proven otherwise. </li></ul>
  29. 30. Rapid sequence intubation(RSI) Aim - <ul><li>Pharmacologic agents to facilitate RSI </li></ul><ul><ul><li>Midazolam . Give Thiopentone if blood pressure normal </li></ul></ul><ul><ul><li>Etomidate drug of choice (reduces ICP) and elevates BP </li></ul></ul><ul><ul><li>Lidocaine (reduces ICP), Atropine (prevents bradycardia) </li></ul></ul><ul><ul><li>Rocuronium (short acting paralytic) </li></ul></ul><ul><li>Followed by benzodiazepine with or without narcotic infusion for continued sedation </li></ul>
  30. 31. Ventilation <ul><ul><li>keep Normo capnia during long term ventilation. When ICP rises bring PaCO2 to late 30s (35 to 40) </li></ul></ul><ul><ul><li>Only in resistant raised ICP, transiently hyperventilate to PaCO2 30-35. </li></ul></ul>
  31. 32. Circulation <ul><li>Hypotension should be identified and corrected as rapidly as possible with fluid resuscitation. </li></ul><ul><li>Use normal saline ,hypotonic fluid should not be used. </li></ul>
  32. 33. Role of CT Scan <ul><li>A CT scan has no therapeutic effect! </li></ul><ul><li>A scan must not come in the way of effective resuscitation - many patients are rushed to scan too soon (hence the ‘doughnut of death’). </li></ul>
  33. 34. Management of Pain & Agitation <ul><li>Midazolam with or without fentanyl Infusion OR Morphine infusion </li></ul><ul><li>Problems: Difficult to assess neurologic exam, Risk of hypotension </li></ul><ul><li>Management of Movement </li></ul><ul><li>Neuromuscular blockade may be required – use only when necessary </li></ul>
  34. 35. Nursing Activities and ICP Rising (1993) Journal of Neuroscience Nursing, 25(5) ICP When a cumulative effect of care activities on ICP is observed, further activities should be delayed if possible. The optimal rest period needed to prevent or minimize cumulative increases in ICP is likely to vary individually, but it is suggested that care be planned to allow for 1-hour rest periods when possible.
  35. 36. Suctioning Practices <ul><li>Measures used to counter raised ICP with suctioning </li></ul><ul><ul><li>Hyper-oxygenation </li></ul></ul><ul><ul><li>Mild / moderate hyperventilation </li></ul></ul><ul><li>Brown & Peeples (1992) Heart & Lung, Parsons & Shogan (1982) Heart & Lung </li></ul><ul><ul><li>Intratracheal / intravenous Lidocaine </li></ul></ul><ul><li>Donegan & Bedford (1980)Anaesthesia </li></ul><ul><li>Wainright & Gould (1996) Intensive & Critical Care Nursing, </li></ul><ul><ul><li>Individualize suctioning practices according to the patient’s response </li></ul></ul>Wainright & Gould (1996)
  36. 37. Seizure Control <ul><li>Seizures lead to acute rise in ICP and cerebral edema. </li></ul><ul><li>Nonconvulsive status epilepticus is common </li></ul><ul><li>Can lead to refractory raised ICP and can cause cerebral edema. </li></ul>
  37. 38. Seizure control <ul><li>Prophylactic anti-seizure therapy in High-risk patients: </li></ul><ul><li>1.GCS < 10 </li></ul><ul><li>2.Cortical contusion </li></ul><ul><li>3.Depressed skull fracture </li></ul><ul><li>4.Subdural or Extra dural Hematoma 5.Penetrating head injury </li></ul><ul><li>6.Seizures within 24 hours of injury </li></ul>
  38. 39. <ul><li>Maintance fluid should be given as Normal (0.9%) Saline. </li></ul><ul><li>Avoid Hypoglycemia </li></ul><ul><li>Keep blood glucose 80 to 120mg% </li></ul><ul><li>Keep [Na+]serum = 145-150 mmol/l </li></ul><ul><li>Keep serum Osmolality between 310-320 mOsm </li></ul>
  39. 40. Hyperosmolar therapy - 20% Mannitol <ul><li>Mannitol causes “cerebral dehydration” by osmotic effect. </li></ul><ul><li>It also causes reflex vasoconstriction (in intact autoregulation) and a decrease in CBV as it reduces blood viscosity </li></ul><ul><li>Should not be used if Serum osmolarity is above 320 mOsm /L, during Hypotension or Renal failure. </li></ul>
  40. 41. 20% Mannitol Vs 3% Saline <ul><li>Inadequate evidence to discriminate between the use of hypertonic saline vs mannitol as hyperosmolar therapies in pediatric TBI. </li></ul><ul><li>The Neurologist 2009;15: 193–207 </li></ul><ul><li>Hypertonic saline has similar efficacy with mannitol and may be used interchangeably, especially in patients with hypotention </li></ul><ul><li>Recommendations from the Pediatr Crit Care Med 2003 guidelines </li></ul>
  41. 42. <ul><li>The dose of mannitol for raised ICP is 0.25g to 0.5g/kg as rapid iv bolus. </li></ul><ul><li>The effect of a single bolus of mannitol on ICP begins within 10 minutes, peaks between 20 and 60 minutes, and has a duration of 4 to 6 hours </li></ul>
  42. 43. Hypertonic (3%) Saline <ul><li>Osmotic effect same as Mannitol, also has anti-inflammatory and immuno modulatory effects </li></ul><ul><li>Its favorable effect on systemic hemodynamic, effective for blood pressure restoration in haemorrhagic shock </li></ul><ul><li>- Anaesthesia, 2009, 64, pages 990–1003 </li></ul><ul><li>- Cochrane Database of Systematic Reviews2007; </li></ul><ul><li>- Neurosurgery. 2005; 57:207–215 </li></ul><ul><li>3mls/kg should increase the serum [Na+] by approximately 2mmol/l. </li></ul><ul><li>Given as infusion at 3% Saline at 0.5 to 1ml/kg/hr </li></ul>
  43. 44. CSF Drainage <ul><li>CSF drainage via ventriculostomy is a first line option for refractory elevated ICP </li></ul><ul><li>Lumbar drainage may be added in patients with open cisterns on imaging and without major mass lesions or midline shift. </li></ul><ul><li>Removal of few milliliters will significantly decrease ICP. </li></ul>Indian J Crit Care Med April-June 2004 Vol 8 Issue 2 Pediatric Critical Care.Basic Science and Clinical Evidence.Derek S Wheeler Springer
  44. 45. Role of corticosteroids <ul><li>Lack of sufficient evidence for beneficial effect in routine use in TBI </li></ul><ul><li>Potential for increased complications and suppression of adrenal production of cortisol. </li></ul><ul><li>Can be used to reduce peri-lesional edema in tumors </li></ul>Indian J Crit Care Med April-June 2004 Vol 8 Issue 2 Pediatric Critical Care.Basic Science and Clinical Evidence.Derek S Wheeler Springer
  45. 46. <ul><li>Only after these factors have been addressed should attention shift to a “cerebral perfusion pressure” strategy. </li></ul><ul><li>i.e. </li></ul><ul><li>Cerebral perfusion pressure (CPP) = Mean Arterial Pressure - ICP </li></ul>
  46. 47. Treatment <ul><li>Second tier </li></ul><ul><ul><li>More aggressive hyperventilation (Paco2:<30 mm hg) </li></ul></ul><ul><ul><li>High dose barbiturates </li></ul></ul><ul><ul><li>Hypothermia </li></ul></ul><ul><ul><li>Decompressive craniectomy </li></ul></ul>
  47. 48. ICP Monitoring <ul><li>ICP monitoring is: </li></ul><ul><li>Appropriate for patients with severe head injury. (GCS 3-8 after resuscitation). </li></ul><ul><li>b) MANDATORY in patients with severe head injury (GCS 3-8) AND an abnormal CT scan. </li></ul><ul><li>(haematomas, contusions, cerebral oedema &/or compressed basal cisterns) </li></ul><ul><li>ICP monitoring can be done in infants with severe TBI with open frontanelle and/or sutures </li></ul>
  48. 49. ICP monitoring Technology
  49. 50. CPP target <ul><li>Targets are not well established but a level of <40mmHg should be avoided at any age. </li></ul><ul><li>Pediatr Crit Care Med 2003 Vol. 4, No. 3 S31 </li></ul><ul><li>There are good cohort data to confirm that cases with lower ICPs and higher CPPs are more likely to do well. </li></ul><ul><li>Childs Nerv Syst. 2005 Mar;21(3):195-9. </li></ul>
  50. 51. <ul><li>Adequate CPP varies with age; </li></ul><ul><li>1m - 1y > 40mmHg </li></ul><ul><li>1y - 4y > 50mmHg </li></ul><ul><li>5y - 8y > 60mmHg </li></ul><ul><li>8y and over > 70mmHg </li></ul>
  51. 52. Percussion (arterial orP1) wave Tidal(rebound or P2 ) wave Low pressure wave s/o compliant cranium P1 P2 Dichrotic ( Venous or P3 ) wave P3 High pressure wave s/o Non-compliant cranium
  52. 54. Barbiturate “coma” <ul><li>Barbiturates reduce cerebral metabolism and reduction in cerebral blood flow </li></ul><ul><li>Keep continuous EEG monitoring till burst suppression is achieved </li></ul><ul><li>Invasive BP monitoring, watch for hypotension </li></ul><ul><ul><li>Pentobarbital 10mg/kg followed by infusion at 1 mg/kg/hr, titrated to effect </li></ul></ul><ul><ul><li>Thiopental - loading dose of 5mg/kg over 30 minutes, followed by infusion of 1-5 mg/kg hour </li></ul></ul><ul><ul><ul><ul><li>Eisenberg HM.J Neurosurg 88;6915-23. Cochrane Database Syst Rev. 2000;CD000033 </li></ul></ul></ul></ul>
  53. 55. Reducing Cerebral Metabolic Rate: Hypothermia <ul><li>Hypothermia will have neuroprotective effect by lowering the cerebral metabolism. </li></ul><ul><li>It has adverse effects e.g. hypotension, cardiac arrhythmias, shivering, etc. </li></ul><ul><li>Achieved by selective head cooling or cooling blankets, keeping the rectal temperature around 32-35degC </li></ul><ul><li>Few supporting Pediatric data hence presently not mentioned in the standard guideline. </li></ul><ul><li>Current recommendation is to “avoid hyperthermia” or fever and if possible hypothermia in resistant cases. </li></ul><ul><li>Ped Crit Care Med 2003;4(3 Suppl):S72-S75 </li></ul>
  54. 56. Decompressive craniotomy <ul><ul><li>portion of cranium removed and dura opened to allow room for brain to swell and minimize ischemia </li></ul></ul><ul><ul><li>Insufficient data to strongly recommend, but has a beneficial effect in some studies in children </li></ul></ul><ul><ul><li>It can reduce the ICP and “save” the child, but may increase chances of vegetative states and disability. Select patients carefully. </li></ul></ul>Indian J Crit Care Med April-June 2004 Vol 8 Issue 2 Pediatric Critical Care.Basic Science and Clinical Evidence.Derek S Wheeler Springer
  55. 57. TO SUMMARISE Neurological examination, Signs and symptoms suggestive of raised ICP or GCS < 8 Care of Airway, Breathing, Circulation Endotracheal Intubation CT Scan / MR Imaging If resectable mass/ hydrocephalous/ bleed Insertion of ICP catheter and ICP & CPP monitoring Targer ICP<20 & CPP >40 mmHg Surgical resection/ ventriculostomy/ CSF diversion / evacuation Head midline elevated 20-30o Minimum stimu lation, Adequate Sedation & Analgesia Normocarbia PaC02 LATE 30 S Normoxia Pa02 > 60 mmHg Sp02>92% Normovolimia Prevent or treat fever & seizures
  56. 58. ICP > 20mmHg Heavy sedation +/-NM Blockade Osmotherapy: mannitol / HTS Mild Hyperventilation PaCo2 30-35 ICP still >20mmmHg Refractory Intra Cranial Hypertension Barbiturate therapy Moderate Hypothermia Rectal Temp Around 32-35 DegC Brief Hyperventilation PaCO2 below 30 Decompressive Craniectomy Pediatric Critical Care.Basic Science and Clinical Evidence.Derek S Wheeler Springer 2 nd TIER THERAPY
  57. 60. THANK YOU