ICU TUTORIAL BY SN FLORA & SN SONI

Brain volume 1400ml-1500ml (80%) Blood volume 150ml (10%) CSF volume 150ml (10%)

According to MONRO-KELLIE HYPOTHESIS : Intracranial vault is an enclosed space. When the volume of any of these components increases, one or both of the other components must decrease proportionally or there will be an increase in ICP.

 Intracranial pressure (ICP) is the pressure that is produce by the three component in the intracranial vault. Normal ICP is less than15mmHg Cerebral perfusion pressure (CPP) is a pressure at which the brain tissue is perfuse and is used to estimate an adequacy of cerebral blood flow. CPP = MAP ICP. MAP = SBP+2DBP/3 Normal CPP is 60- 100mmHg. If CPP less than 60mmHg will cause hypoperfusion and cerebral ischemia. If CPP more than 150mmHg will disrupt the blood brain barrier and cause hyperperfusion and potential for cerebral edema.

 Brain matter
Cerebral oedema due to trauma, meningitis Space occupying lesion, eg. Tumour/ hematoma, arteriovenous malformation

Cerebrospinal fluid
Hydrocephalus due to obstruction or reduced absorption .

Cerebral blood volume

Severe hypertension Increase cerebral blood flow eg. Hyperthermia, increased metabolic rate. Vasodilatation due to hypoxia, hypercarbia, acidosis Venous congestion

Impaired cerebral

blood flow Original cause of raised ICP Further increased

In ICP

Cerebral ischemia

Cerebral oedema

1. Compromised cerebral blood flow 2. Worsening cerebral insult and ischemia (irreversible if prolonged) 3. Compensatory hypertension worsening cerebral hemorrhage 4. Conning (brain matter push out from foramen magnum 5. Death

 Symptom :
Headache Vomting Photophobia Decrease or absent of reflexes e.g cough gag, corneal reflex.

Sign :
Neck stiffness Reduced GCS Focal neurology Papilooedema Cushings sign :increase SBP, widened pulse pressure, bradycardia, temp: hyperthermia, ICP >15mmHg, respiration: cheyne stokes ( tachypnoea slowly apnea)

 Cerebral resuscitation also known as cerebral protection. Cerebral resuscitation are measures taken to maintain a normal ICP of 5-15mmHg and as well protect the brain from secondary brain injury. Secondary brain injuries that occur after initial injury example as a result of hypoxemia/ hypovolemia/ hypotension, hypocapnia/ hypercapnia, hyperthermia, hypoglycemia, cerebral edema or cerebral ischemia. This is to protect the brain from getting further insult and rise to further neurological deficit.

Nursing interventions for cerebral resuscitation.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Maintain adequate oxygenation and ventilation. Maintain proper head positioning. Prevent valsalva maneuver Suctioning. Prevent unnecessary auditory stimuli. Limit pain stimuli. Prevent seizures. Maintain normothermia. Maintain euvolemia (adequate blood volume). Blood pressure control. Osmotic diuretic as prescribed. Decrease metabolic requirement of the brain. Maintain normoglycemia .

1. Maintain adequate oxygenation and ventilation.

Maintain patent airway by intubation and ventilation if patient is unable to maintain patent airway or when GCS 8/15. Monitor ABG to keep PaCO2 between 3545mmHg ; PaO2 80-100mmHg (>60mmHg) Rationale : PaCO2< 30mmHg will cause vasoconstriction and lead to cerebral ischemia. Rationale : PaCO2 >45mmHg will dilate the blood vessel and will lead to cerebral edema. PaO2<60mmHg must be avoided because adequate cerebral perfusion cannot be maintained and can cause cerebral ischemia

2. Maintain proper head positioning.

Elevate HOB to 30 degrees except in spine/cervical injury. Maintain neutral alignment of head and neck . Avoid overextension and over flexion of head. Ensure that trachy ties or cervical collar are not too tight. Avoid extreme hip flexion. Rationale : to promote venous return that can reduce ICP.

3. Prevent Valsalva Maneuver

Avoid Valsava maneuver e.g. constipation or straining, coughing and muscle flexion. Because it will increase the intra thoracic pressure and intra abdominal pressure which will increase intra cranial pressure. Do log roll when turning patient.

4. Suctioning.
Suctioning only when needed. To Prevent Isometric Exercise - eg: give IV Fentanyl before suctioning or any procedure Limit each suction episode to <10sec. Limit the number of catheter pass to a minimum. Hyperoxgenation the patient with 100% O2 before, during and after suctioning. Rationale; to prevent hypoxemia that can lead increase ICP.

5. Prevent unnecessary auditory stimuli.

Maintain a quiet, relaxing environment Decrease external stimuli in the room as light or noise. Limit visitors if appropriate and encourage them talk quietly with patient and try to keep conversation as non stressful as possible for patient. Minimize vigorous activity by assisting ADL.

6. Limit pain stimuli

Use only those stimuli required to elicit a response during neurological assessment Perform neurological assessment at specified intervals Limit painful procedures e.g. insertion if IV lines. Plan nursing care so patient have adequate rest. Avoid tension on tubes- CBD Rationale : to prevent increase ICP

7. Prevent seizures.
Administer anticonvulsant therapy to decreased the cerebral metabolism. -Prophylactic anticonvulsant e.g. IV Phenytoin. Calcium Antagonist ( Nimodipime ) - for subarachnoid haemorrhage to reduce cerebral spasm Treatment Of Epilepsy eg. Diazepam or Phenytoin - control seizures to reduce cerebral metabolic rate Steroids eg. Dexamethasone - for brain tumour - reduce cerebral oedema

8. Maintain normothermia
monitor body temperature as required; 4hourly Administer antipyretic if temperature >37.5 C. Tepid sponging if temperature>38 C Avoid shivering rewarming blanket if temp. <35 C. Rationale : for every 1 C in body temp. increase, the CBF increase 5% to 6% and will increase ICP

9. Maintain euvolemia (adequate blood volume).

Keep CVP 7-10mmhg Monitor intake and output chart accurately Administer isotonic fluid for infusion Avoid D5% as it will increase risk of cerebral edema. Administer blood and blood product if there significant blood loss/ hemorrhage.

10. Blood pressure control

Hypotension is directly related to cerebral ischemia Maintain MAP>90mmHg at all times with CPP>60 -150mmHg Hypotension should be treated with fluid bolus (fluid challenge) or vasopressor e.g. infusion Noradrenaline to keep MAP>90mmHg. Do not omit/ stop IV nimodipine simply. It is used to prevent brain damage caused by reduced blood flow to the brain resulting from aneurysm, a dilated or ruptured blood vessel in the brain. Control of blood pressure will maintain an adequate cerebral perfusion pressure (CPP) CPP = MAP - ICP If hypertension SBP> 170mmHg, titrate accordingly vasopressor. Administer calcium channel blocker e.g T. Amlodipine to control Bp.

11. Osmotic diuretic as prescribed

E.g mannitol 20% hypertonic saline 3 to 5 % IV to pull fluid from the swollen brain into the plasma decrease intracranial volume, reduce cerebral edeme and decrease ICP Strict I/O charting, monitor for in crease water & electrolyte imbalance.
osmotic diuretic ( Mannitol 20% ) loop diuretic ( Frusemide )

12. Decrease metabolic requirement of the brain.

Sedation to reduce anxiety iv midazolam or propofol Keep GCS 2+T/15, Rikers sedation -3 for 2448hours for cerebral resuscitation. Analgesia to reduce pain e.g. morphine but IV fentanyl is the best choice if patient is hemodynamicaly unstable. Rationale; anxiety, restlessness and pain will increase metabolic demand and increase ICP

13. Maintain Normoglycemia

Cerebral tissue need glucose for the source of energy and about 20% is utilize by the cerebral. Maintain blood glucose 4-6mmol/L and monitor every 4hours. Administer insulin accordingly to sliding scale Rationale: maintain normal glucose levels to avoids raising cerebral metabolism. If blood glucose >7mmol/L will cause further cerebral edema due to osmosis.

 Component of Triple H are:

HYPERVOLAEMIC HPERTENSIVE HEMODILUTION

 About 20% neuro patient experience vasospasm its narrowing of blood vessels response to irritation from blood accumulating in the subarachnoid space. This makes it harder for nutrient and O2 to reach the rest of the brain and if vasospasm persistent, it can result in another strokes. This condition can be treated with Hypertension, Hypervolemic, Hemodilution therapy commonly known as Triple H. Triple H therapy is combines with intravenous medication and large volume of intravenous fluids to elevate the BP, increase blood volume and thin the blood, driving blood flow through and around affected vessels esp. in the cerebral.

 The fluids is used to achieve volume expansion which is increase the volume status may increases cardiac output, when the Bp is increase thereby increasing cerebral blood flow in the ischemic areas. Patient hydration must be achieve and maintain.

 Hypertension is achieved simply with volume expansion when patient enough hydration, but vasoactive drug eg. Dopamine/ Noradrenaline may use to maintain a desire level of hypertension to keep MAP >90 or SBP 140160mmHg. So that increase of cerebral blood flow (CBF) and cerebral perfusion pressure (CPP) can be achieve.

 Hemodilution is the most controversial component of triple H. In hemodilution, must achieve a hematocrit of 30-35% , because is believe to be a reasonable to compromise between O2 carrying capacity. This treatment is maintance the high circulating blood volume and increase perfusion pressure and decrease blood viscosity in the cerebral.

REFERENCE
1. 2. 3. 4. Dennison R>D 2007. PASS CCRN, third edition chapter 7 : the neurologic system and disorder. by Elsiever Mosby. Dessmon YH Tai Thomas WK Lew and Loo Shi. Bedside ICU Handbook 2nd edition. (2007) Susan F. Wilson, RN, PhD, AORN, FND and Jean Foret Giddens, RN, PhD, AORN, FND. Health Assesment for Nursing Practice and Protocol third edition (2009.) www.medscape.Com/viewarticle/553110_2 : current and future medical theapies for cerebral resuscitation.-Neurosurgery focus 2006 by J. Mocco,MD,Brad E. Zacharia, BS, Ricardo J. Komator, MD, E. Sander Connoly Jr., MD allnurses nurses.com//triple-h-therapy-348846 : Triple H therapy neuro Intensive Care.

5.

EVERYONE HAS A ROLE IN MANAGING PATIENT WITH RAISED ICP