Drug therapy for Increased ICP.

Osmotic effect of Mannintol.

A vascular osmotic gradient is created by mannitol. Thus fluid moves from the tissues into the blood vessels, reducing the ICP because of the decrease in the total brain fluid content.

What corticosteroid is used for increased ICP?

Dexamethasone [Decadron]) is used to treat vasogenic edema surrounding tumors and abscesses.

What is another effective way to decrease ICP?

Drug therapy for reducing cerebral metabolism may be an effective strategy to control ICP. Reducing the metabolic rate decreases the CBF and therefore the ICP.

What else can help a patient with increased ICP?

Manage pain while being careful not to over sedate or over-medicate. Finally, the patient should remain in a quiet, calm environment with minimal noise and interruptions. Observe the patient for signs of agitation, irritation, or frustration. Teach the caregiver and the family about decreasing stimulation, and coordinate with the health care team to minimize procedures that may produce agitation.

Fever in increased ICP: what is a goal temperature?

Fever should be well controlled to maintain a temperature of 96.8° to 98.6° F (36° to 37° C) by using antipyretics (ex: acetaminophen), cool baths, cooling blankets, ice packs, or intravascular cooling devices as necessary. However, avoid letting the patient shiver or shake, since this increases the metabolic work-load on the brain. If this occurs, sedatives may be needed or a different cooling method selected.

How can high doses of barbiturates help a patient with increased ICP? what are some examples?

High doses of barbiturates (ex: pentobarbital [Nembutal], thiopental [Pentothal]) are used in patients with increased ICP refractory to other treatments.

What are complications of corticosteroids.

Hyperglycemia, increased incidence of infections, and gastrointestinal (GI) bleeding.

Is hypertonic saline solution just as good as mannitol?

Hypertonic saline infusion has been shown to be just as effective as mannitol when treating increased ICP, and both are often used concurrently when caring for a patient with a severe head injury.

Mannitol may be contraindicated in who?

If renal disease is present and if serum osmolality is elevated it may be contraindicated.

Hypertonic solution infusion requires what?

It requires frequent monitoring of blood pressure and serum sodium levels because intra-vascular fluid volume excess can occur.

What else can increase ICP?

Metabolic demands such as fever (greater than 100.4° F [38° C]), agitation or shivering, pain, and seizures can also increase ICP. The health care team should plan to reduce these metabolic demands to lower the ICP in the at-risk patient.

What should monitor when you give a patient mannitol?

Monitor fluid and electrolyte status when osmotic diuretics are used.

Prophylactic anti-seizure medication.

Monitor patients with increased ICP for seizure activity. They may need to be placed on prophylactic anti-seizure medication. (Phenytoin [Dilantin]).

What else should patients be given who are taking corticosteroids?

Patients receiving corticosteroids should concurrently be given antacids or histamine (H2)-receptor blockers (ex: cimetidine [Tagamet], ranitidine [Zantac]) or proton pump inhibitors (ex: omeprazole [Prilosec], pantoprazole [Protonix, Protonix IV]) to prevent GI ulcers and bleeding.

Mannitol acts to decrease the ICP in what two ways?

Plasma expansion and osmotic effect.

What should you assess when using corticosteroids?

Regularly monitor fluid intake and sodium levels, and perform blood glucose monitoring at least every 6 hours until hyperglycemia is ruled out.

Effect of plasma expansion of mannitol.

The immediate plasma-expanding effect of mannitol reduces the hematocrit and blood viscosity, there-by increasing CBF and cerebral oxygen delivery.

Who should you not use corticosteroids in?

These drugs are not recommended for head-injured patients.

What else do corticosteroids do?

They also improve neuronal function by improving CBF and restoring auto-regulation.

Barbiturates do what for increased ICP?

They decrease cerebral metabolism, causing a decrease in ICP and a reduction in cerebral edema. When this treatment is used, monitor the patient's ICP, blood flow, and EEG.

What is the role of corticosteroids in a patient with increased ICP?

They stabilize the cell membrane and inhibit the synthesis of prostaglandins (Fig. 12-2), thus preventing the formation of pro-inflammatory mediators.

Mannitol (Osmitrol) (25%).

This is an osmotic diuretic given IV to help decrease ICP.

Hypertonic saline solution.

This is another drug treatment used to manage increased ICP. It produces massive movement of water out of edematous swollen brain cells and into the blood vessels. This movement of water out of the brain can reduce swelling and improve cerebral blood flow.

Total burst suppression.

This is recognized by the absence of spikes showing brain activity on the EEG monitor, indicates that maximal therapeutic effect has been achieved.

Barbiturate dosing.

This is typically based on analysis of the bedside EEG tracing and the ICP. The physician orders the barbiturate infusion at a rate that achieves a desired level of brain wave suppression as a means to control ICP.