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DECREASED INTRACRANIAL PRESSURE WITH OPTIMAL

HEAD ELEVATION OF 30 OR 45 DEGREES IN TRAUMATIC


BRAIN INJURY PATIENTS (LITERATUR REVIEW)
Heni Maryati*
*Lecture of Pemkab Jombang Institute of Health Science Departement of Medical Surgical
and Critical Care Nursing Jombang Indonesia
Email: zahra.zubir@yahoo.com
ABSTRACT
Introduction: Intracranial pressure (ICP) can be elevated in traumatic brain injury. Raised ICP is a lift
threatening conditions. Unless recognized and treated early to reduce cerebral perfusion pressure (CPP)
and progress to brain herniation and death. Management of elevated ICP is, in part, dependent on the
underlying cause. The purpose of this literature review was to find a management of a noninvasive
physical intervention procedural for decreasing intracranial pressure for brain injury and reduce the
duration of treatment invasive. Method: Systematic searches were undertaken using Medline database,
PubMed and Cochrane, restricted from 2011 to 2016. There 12 articles included by searching through
the appropriate key word topic, but only 5 articles were selected based on the inclusion criteria. Results:
Medical options for treating elevated ICP include head of bed elevation, IV mannitol, hypertonic saline,
transient hyperventilation, barbiturates. A head elevation of 30 or 45 degrees is optimal for decreasing
intracranial pressure. Discussion: Head elevations of 30 or 45 degrees is optimal a conventional nursing
of a noninvasive physical intervention procedure for decreasing intracranial pressure for brain injured.
Is the most effective management that showed simple, inexpensive treatment procedure and can be
applied in variety ages today, independent nursing intervention without side effect. Recommended in
clinical practice, intensive care unit staff members need to cautiously perform head elevation of 30 or
45 degrees its physiologic effect and potential hazard.

Key words: management intracranial pressure, head elevation, traumatic brain injury patients

INTRODUCTION elevated ICP6.. Intracranial pressure (ICP) can


Traumatic brain injury (TBI) and its be elevated in traumatic brain injury.
complications are the leading of mortality and Management of elevated ICP is, in
morbidity. In the US alone over 2,300 deaths, part, dependent on the underlying cause.
42,000 hospitalizations, and 404,000 Medical options for treating elevated ICP
Emergency Department visits occurs annually include head of bed elevation, IV mannitol,
among children 0 -14 years old related to TBI. hypertonic saline, transient hyperventilation,
Mortality with severe TBI is often the result of barbiturates, and if ICP remains refractory,
a refractory increase in intracranial pressure sedation, endotracheal intubation, mechanical
(ICP). Therefore prevention and management of ventilation, and neuromuscular paralysis.
raised ICP is increasingly recognized as central Surgical options include CSF drainage if
to current neuro-critical care. Increased ICP is hydrocephalus is present and decompression of
an important caused of secondary brain injury in a surgical lesion, such as an intracranial
TBI and both degree and duration of high ICP is hematoma/ large infarct or tumor, if the
associated with poor outcomes. Sustained patients condition is deemed salvageable3. The
increased to 20 mmHg for >5 min may need purpose of this literature review was to find a
treatment. Though the efficacy of treatment method and technique of a noninvasive physical
based on ICP monitoring has been questioned intervention procedural for decreasing
intracranial pressure (ICP). Increased intracranial pressure for brain injury, reduce the
intracranial pressure (ICP) is associated with duration of treatment invasive, and reduce the
worse outcome after traumatic brain injury cost of treatment. Head elevation a conventional
(TBI). The current guidelines and management nursing procedure for brain injured individuals
strategies are aimed at maintaining adequate with intracranial hypertension. It is performed
cerebral perfusion pressure and treating with the intent of reducing intracranial pressure
(ICP) by means of a noninvasive physical
intervention. Head up position may have than at 10 and 15 degrees. Patients with
beneficial effect on intracranial pressure (ICP) increased intracranial pressure significantly
via changes in mean arterial pressure (MAP), air benefitted from a head elevation of 10, 15, 30
way pressure, central venous pressure and and 45 degrees compared with 0 degrees. A
cerebral spinal fluid displacement. However, in head elevation of 30 or 45 degrees is optimal for
some circumstances head up position may decreasing intracranial pressure4. According to
decrease MAP with in turn will result in a research Agbeko RS, et al (2012) that in severe
paradoxical rise in ICP trough auto regulation pediatric traumatic brain injury, the relations
the degree of head elevation has to be titrated by ship between change in head of the bead and
evaluating the most adequate cerebral perfusion change in intracranial pressure was negative and
pressure (CPP) for each patient by means of linier. The lowest intracranial pressure was
trans cranial. A change in head position can lead usually, but not always, achieved at highest
to a change in intracranial pressure, however, head 0f the bed angles depend, in parts, on the
there a conflicting data regarding the optimal subjects height.
degree of elevation that decreases intracranial The other therapies to reduce elevated
pressure in post craniotomy patients. Patients intracranial pressure if ICP not remains
with increased intracranial pressure refractory used osmotic agents, such as
significantly benefitted from a head elevation of mannitol, hypertonic saline and the other
10, 15,30 and 45 degrees compared with 0 therapies, such as hyperventilation and
degrees. A head elevation of 30 or 45 degrees is barbiturates. Recording the research Scalfani, et
optimal for decreasing intracranial pressure. al (2012) that in cerebral blood flow (CBF) is
Recommended in clinical practice, intensive reduce after severe traumatic brain injury (TBI)
care unit staff members need to cautiously with considerable regional variation osmotic
perform head elevation of 30 - 45 degrees with agents are used to reduce elevated intracranial
a thorough understanding of its physiologic pressure (ICP). In 8 patients with acute TBI, we
effect and potential hazard4. measured regional CBF with positron emission
tomography before and 1 hour after
METHOD administration of equi osmolar 20% mannitol (1
A literature review revealed that ml/kg) or 23,4 % hypertonic saline (0,686
studies have been conducted in a range of ml/kg) in regions with focal injury and baseline
countries by using a variety of management to hypo perfusion CBF < 25 ml per 100 gr/min.
screen leaners decrease intracranial pressure for Result that osmotic therapy reduce the number
traumatic brain injury patients. It was of hypo-perfuse brain regions by 40% (p ,
conventional nursing of a noninvasive physical 0,001) 5. Recording the research Mangat HS
intervention procedure for decreasing (2012) that in hyperosmolar agents are
intracranial pressure for brain injured reduce the commonly used as an initial treatment for the
duration of treatment invasive, and reduce the management of raised intracranial pressure
cost of treatment. (ICP) after several traumatic brain injury (TBI).
A head elevation of 30 or 45 degrees They have an excellent adverse effect profile
is optimal for decreasing intracranial pressure. compared to other therapies, such as
Is the most effective management that showed hyperventilation and barbiturates, which carry
simple, inexpensive treatment procedure and the risk of reducing cerebral perfusion.
can be applied in variety ages today, The hyperosmolar agent mannitol has
independent nursing intervention without side been used for several decades to reduce raised
effect. It was conventional nursing of a ICP, and there is accumulating evidence from
noninvasive physical intervention procedure for pilot studies suggesting beneficial effects of
decreasing intracranial pressure for brain hypertonic saline (HTS) for similar purposes. In
injured. According to research J. Adv Nurs ideal therapeutic agent for ICP reduction should
(2015) that a changes in head position can lead reduce ICP while maintaining cerebral
to a change intracranial pressure. Compared perfusion (pressure). While mannitol can cause
with a degree 10,15,30 and 45 degrees of head dehydration over time, HTS helps maintain
elevation resulted in lower intracranial pressure. normovolemia and cerebral perfusion, a finding
Intracranial pressure at 30 degrees was not that has led to a large amount of pilot data being
significantly different in comparison to 45 published o benefits of HTS, albeit in small
degrees of head elevation and was lower that cohorts. Prophylactic therapy is not
recommended with mannitol, although it may 45 degrees is optimal for decreasing
be beneficial with HTS. To date, no large intracranial pressure. Is the most effective
clinical trial has been performed to directly management that showed simple, inexpensive
compare the two agents. The best current treatment procedure and can be applied in
evidence suggest that mannitol is effective in variety ages today, independent nursing
reducing ICP in the management of traumatic intervention without side effect. It was
intracranial hypertension and carries mortality conventional nursing of a noninvasive physical
benefit compared to barbiturates. Current intervention procedure for decreasing
evidence regarding the use of HTS in severe intracranial pressure for brain injured.
TBI is limited to smaller studies, which a benefit The other therapies to reduce elevated
in ICP reduction and perhaps mortality7. intracranial pressure used osmotic agents, such
According to research Mangat HS,et al (2015) as mannitol, hypertonic saline and the other
that a Hypertonic saline (HTS) given as bolus therapies, such as hyperventilation and
therapy was more effective than mannitol in barbiturates. Mannitol can cause dehydration
lowering the cumulative and daily ICP burdens over time, HTS helps maintain normovolemia
after severe TBI. Patients in the HTS group had and cerebral perfusion. Prophylactic therapy is
significantly lower number of ICU days. not recommended with mannitol, although it
may be beneficial with HTS. To date, no large
RESULTS clinical trial has been performed to directly
Systematic searches were undertaken compare the two agents. The best current
using Medline database, Pubmed and Cochrane evidence suggest that mannitol is effective in
, restricted from 2011 to 2016. There 7 articles reducing ICP in the management of traumatic
included by searching through the appropriate intracranial hypertension and carries mortality
key word topic, but only 3 articles were benefit compared to barbiturates.
selected based on the inclusion criteria.
Management of raised ICP includes care air CONCLUSION AND
way, ventilation and oxygenation, adequate RECOMMENDATION
sedation and analgesia, neutral neck position, Head elevations of 30 or 45 degrees is
head end elevation 30 or 45 degrees and short optimal a conventional nursing of a noninvasive
term hyperventilation, and hyperosmolar physical intervention procedure for decreasing
therapy (manitol or hypertonic saline) , in intracranial pressure for brain injured. Is the
critically raised ICP barbitural coma, moderate most effective management that showed simple,
hypothermia and surgical decompression. inexpensive treatment procedure and can be
applied in variety ages today, independent
DISCUSSION nursing intervention without side effect.
Intracranial pressure (ICP) can be In clinical practice, intensive care unit
elevated in traumatic brain injury. Management staff members need to cautiously perform head
of elevated ICP is, in part, dependent on the elevation of 30 or 45 degrees its physiologic
underlying cause. Medical options for treating effect and potential hazard.
elevated ICP include head of bed elevation, IV
mannitol, hypertonic saline, transient REFERENCES
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