Neuro-ICU: Day 1 - Critical Care Canada · ICP A Stepwise Approach Stephan A. Mayer, MD Professor,...

ICPA Stepwise Approach

Stephan A. Mayer, MDProfessor, Neurology & Neurosurgery

Director, Neurocritical Care,

Mount Sinai Health System

ICP: Basic Concepts

• Monroe-Kellie doctrine:

skull = fixed volume

• 3 components of

intracranial volume

• Normal ICP

–≤20 cm H20

–≤15 mm Hg

CSF150 ml

Blood 150 ml

Parenchyma

1200 ml

Causes of Increased ICP:

Space Occupying

Lesion

Increased CSF

Inc. Blood Volume

(Vasogenic edema)

Inc. Brain Volume

(Cytotoxic edema)

Hematoma, Tumor, Abscess

Hydrocephalus

Trauma, Tumor, Abcess,

Hypertensive encephalopathy

Infarction, Ischemia

Methods to Reduce Elevated ICP

• Remove Mass Lesion Surgical Evacuation

• Reduce CSF Volume Ventricular Drainage

• Reduce Cerebral Hyperventiation, Barbiturates,

Blood Volume Hypothermia

• Reduce Parenchymal Osmotic Diuretics

Volume (Mannitol, Hypertonic Saline)

CPP can influence ICP when you run out of room

0

25

50

75

Cerebral Perfusion Pressure (mm Hg))

Cere

bra

l B

loo

d F

low

(ml/100 g

/min

)

Zone of Normal

Autoregulation

Maximum

Constriction

Maximum

DilatationPassiveCollapse

0

25

50

ICP

(m

m H

g)

Stephan A. Mayer, MD

1501251007550250GOAL

CPP can influence ICP when you run out of room

0

25

50

75

Cerebral Perfusion Pressure (mm Hg))

Cere

bra

l B

loo

d F

low

(ml/100 g

/min

)

Zone of Normal

Autoregulation

Maximum

Constriction

Maximum

DilatationPassiveCollapse

0

25

50

ICP

(m

m H

g)

Vasodilatory Cascade Zone

Autoregulation Breakthrough Zone

Stephan A. Mayer, MD

1501251007550250GOAL

Outcome after Acute Ischemic Stroke by

Admission Blood Pressure

90 –

80 –

70 –

60 –

50 –

40 –

30 –

20 –

10 –

0 –n = 18

< 120

n = 29

121 -140

n = 39

141 -160

n = 78

161 -180

n = 49

181 -200

n = 87

> 200

Post neuro

logic

al outc

om

e %

Systolic BP on admission (mm Hg)

C

90 –

80 –

70 –

60 –

50 –

40 –

30 –

20 –

10 –

0 –n = 18

< 120

n = 29

121 -140

n = 39

141 -160

n = 78

161 -180

n = 49

181 -200

n = 87

> 200

Early

neuro

logic

al dete

riora

tion %

Systolic BP on admission (mm Hg)

A

90 –

80 –

70 –

60 –

50 –

40 –

30 –

20 –

10 –

0 –Post neuro

logic

al outc

om

e %

Diastolic BP on admission (mm Hg)

D

n = 38

< 70

n = 39

71 -80

n = 48

81 -90

n = 43

91 -100

n = 30

101 -110

n = 102

> 110

90 –

80 –

70 –

60 –

50 –

40 –

30 –

20 –

10 –

0 –n = 38

< 70

n = 39

71 -80

n = 48

81 -90

n = 43

91 -100

n = 30

101 -110

n = 102

> 110

Early

neuro

logic

al dete

riora

tion %

Diastolic BP on admission (mm Hg)

B Castillo J, et al. Stroke. 2004;35:520-526.

Lund protocol

• Reduce CMRO2 with sedation— Miazolam, thiopental, fentanyl

• Reduce BP and capillary hydrostatic

pressure (CPP 50-60 mm Hg)— IV Metoprolol (.2 mg/kg/hr) and clonidine (.5 mcg/kg prn)

• Dihydroergotamine .1-.8 mcg/kg/hr

• Maintain normal hematocritt, CVP, and albumin

levels

MAP GOAL

MMM: “Imaging” Vasodilatory

Cascade Physiology

MMM: “Imaging” Perfusion Pressure

Breakthrough Physiology

MAP GOAL

Indications for ICP Monitoring

• Coma (Glasgow Coma Scale score ≤8)

• CT evidence of intracranial mass effect– Extra-axial mass lesion

– Midline shift

– Effacement of basal cisterns

– Exception: severe TBI with motor posturing

• Prognosis is such that aggressive ICU care is warranted

Clinical Signs

• Increased ICP

–Depressed level of consciousness

–Pressor response

–Projectile vomiting

–CN 6 palsies

• Brainstem herniation

–CN 3 palsey

–Motor posturing

–Lower extremity rigidity

–Loss of lateral EOMs

–Hyperventilation

Parenchymal

Micosensor

Richmond Bolt

Epidural Monitor

Ventricular catheter

ICP/CPP Treatment Thresholds

Guideline

• ICP treatment should be initiated at an upper threshold of 20 mm Hg.

Option

• Cerebral Perfusion Pressure should bemaintained at a minimum of 60 mm Hg.

Emergency Treatment of Increased ICP

• Un-monitored patient with clinical signs of herniation

–Elevate head of bed 30°

–Normal saline 100 ml/hr

–Intubate and hyperventilate (pCO2 30 mm Hg)

–Mannitol 20% 1.0 to 1.5 g/kg rapid IV infusion

–Foley catheter

–CT scan and neurosurgical evaluation

Critical Pathway for Treatment of Intracranial Hypertension in the Severe Head Injury Patient

(Treatment Option)

May Repeat Mannitolif Serum Osmolarity

< 320 mOsm/L &Pt euvolemic

High Dose

Barbiturate therapy

• Hyperventilation to PaCO2 < 30 mmHg

• Monitoring SjO2, AVDO2, and/orCBF

Recommended

Other Second

Tier Therapies

NO

YES NO

YES NO

YES NO

CarefullyWithdraw

ICP Treatment

ConsiderRepeatingCT Scan

YES

Second Tier Therapy

Intracranial Hypertension?

Hyperventilation to PaCO2 30 - 35 mmHg


Mannitol (0.25 - 1.0 g/kg IV)


Ventricular Drainage (if available)

Intracranial Hypertension?*

Maintain CPP 70 mmHg

Insert ICP Monitor

ICP

PROTOCOL

SURGICAL DECOMPRESSION

SEDATION

CPP OPTIMIZATION

OSMOTHERAPY

HYPERVENTILATION

PENTOBARBITAL

HYPOTHERMIA7

6

5

4

3

2

1

Columbia

Stepwise ICP

Protocol

2002

SURGICAL DECOMPRESSION

SEDATION

CPP OPTIMIZATION

OSMOTHERAPY

HYPERVENTILATION

HYPOTHERMIA

PENTOBARBITAL7

6

5

4

3

2

1

Revised

Columbia

Stepwise ICP

Protocol

2010

Ventricular Drainage

3-way stopcock turned off to drainage system

drainage

bag

100cc syringe of sterile

water

transpac positioned at ear

level

1LEVEL

ICU Intravenous sedation

• Goal is reversibility to allow repeated neurologic assessment

• Alternatives (in intubated pts):

–Fentanyl or Remifentanyl

–Midazolam

–Propofol » Ultrashort acting

» Allows “wake-up” in 5-15 mins

» Reduces ICP, CMRO2

» Drawbacks: hypotension, infection

2

PENTOBARBITAL ISHYPOTHERMIA IS

Complications of pentobarbital

•Hypotension

•Immunosuppression

• An extra 4 weeks in coma

• ICU neuromyopathy

CPP

OPTIMIZATION:

Dopamine

infusion

resulting in

increased MAP

and CPP, and

decreased ICP

3

Osmotherapy

• Mannitol– 0.25 to 1.5 g/kg IV wide open

– Dose up to Q1H on an as-needed basis

– Mechanisms:

» Acute dehydrating effect (osmotic gradient across BBB)

» Secondary hyperosmolality (diuretic effect)

» Reflex vasoconstriction (viscosity effect)

• Hypertonic Saline– Varying concentrations: 3%, 7.5%, 10%, and 23.4%

– Optimal dosing not known

4

30 ml 23.4% Bullets

Effect of Hypertonic Saline in CBF in SAH patients

TSENG M-Y, Stroke 2003;34:1389.)

• 10 poor grade

SAH patients

• 2 mL/kg of

23.5% saline

• ICP fell 74%

• CPP rose 27%

• CBF rose 23%

• Peak effect @

20-60 minutes

MAP

CPP

ICP

TCD

CVR

Hyperventilation

HYPERVENTILATION IS THE MOST RAPID WAY TO REDUCE ICP

EXCESSIVE HYPERVENTILATION CAN WORSEN CEREBRAL ISCHEMIA

MECHANISM OF ACTION:

HYPOCARBIA INDUCES SERUM AND CSF ALKALOSIS

ALKALOSIS INDUCES CEREBRAL VASOCONSTRICTION

VASOCONSTRICTION REDUCES CEREBRAL BLOOD VOLUME

TIME COURSE:

ICP IS REDUCED ALMOST IMMEDIATELY

PEAK REDUCTION IN 5-10 MINUTES

Hyperventilation Can Have Sustained Effects In Patients With Vasodilatory Vasogenic Cerebral Edema

5

Hypothermia

MECHANISM OF ACTION:

PROFOUNDLY REDUCES REDUCES CEREBRAL METABOLISM, AND HENCE CEREBRAL BLOOD VOLUME

TARGET

32-33° C

INDICATION

PENTOBARBITAL-REFRACTORY ICP

COMPLICATIONS:

ARRYTHMIA AND CARDIOVASCULAR DEPRESSION

IMMUNOSUPPRESSION

COAGULOPATHY

METABOLIC: SHIVERING AND REWARMING

6

HYPOTHERMIA FOR ICP CONTROL:TRAUMATIC BRAIN INJURY

• Shiozaki (J Neurosurg 1993)

– Randomized controlled study of hypothermia (34°C) for ICP refractory to pentobarbital (N=33).

– Hypothermia resulted in:

»Lower ICP (36.9 to 26.5 mm Hg)

»Increased CPP

»Reduced CBF and CMRO2

»Reduced arteriojugular venous oxygen differences

– Survival was 50% in hypothermia patients compared to 18% in the control group (P<.05).

1

6

5

4

3

2

SECOND TIERStep Up

THIRD TIERAdvance as Needed

HEMICRANIECTOMY or SALVAGE CRANIOTOMY

HYPOTHERMIATO TARGET 35 °C

HYPERVENTILATION (HV)TO pCO2 30-35 mm Hg

BOLUS OSMOTHERAPYTO SERUM OSMS <320

SEDATION to RASS -4 to -5(Quiet, Motionless State)

TARGET CPP 50-70 mm Hg

CSF DRAINAGE and/orRESCUE CRANIOTOMY


MMM-GUIDED HV<30 mm Hg and/or THAM

BOLUS OSMOTHERAPYTO SERUM OSMS >320

PARALYSIS and/orBARBITURATES

MMM-GUIDEDCPP OPTIMIZATION

5HYPERVENTILATION (HV)

TO pCO2 30-35 mm Hg

1

SECOND TIER

6 HYPOTHERMIATO TARGET 35 °C

4 BOLUS OSMOTHERAPYTO SERUM OSMS <320

3 SEDATION to RASS -4 to -5(Quiet, Motionless State)

2 TARGET CPP 50-70 mm Hg


Advance

first-tier ICP

interventions

in stepwise

fashion to

avoid missing

essential steps

THIRD TIER



MMM-GUIDED HV<30 mm Hg or THAM




Advance

second-tier ICP

interventions

as needed

to fit

available

resources and

the clinical

situation

THIRD TIER



MMM-GUIDED HV<30 mm Hg or THAM




Three very bad

options for a

very bad

situation:

medically

refractory ICP!

What About the Latest Trials?

BEST-TRIP TRIAL

BEST-TRIP TRIAL

• 324 patients 13 years of age or older with severe TBI in Bolivia or Ecuador

– Protocol treating ICP based on ICP monitoring

– Protocol for treating ICP based on standing therapy, imaging and clinical examination

• Six-month mortality was 39% in the pressure-monitoring group and 41% in the imaging–clinical examination group (P = 0.60).

• Median length of stay in the ICU was similar in the two groups

BEST-TRIP TRIAL

• Number of days of brain-specific treatments (e.g., administration of hyperosmolar fluids and the use of hyperventilation) in the ICU was higher in the imaging–clinical examination group than in the pressure-monitoring group (4.8 vs. 3.4, P = 0.002).

• Serious adverse events was similar in the two groups.

BEST-TRIP

• Conclusion

For patients with severe traumatic brain injury, care focused on maintaining monitored intracranial pressure at 20 mm Hg or less was not shown to be superior to care based on imaging and clinical examination.

Survival at 14 days MUCH

better with ICP

monitoring!

Survival at 14 days better with ICP monitoring

Aneurysmal SAH with associated suddural hematoma

and bilateral motor posturing

DECRA

• 155 TBI patients

– Early bifrontal craniectomy vfersus standard care

• Surgical group had

– Lower ICPs

– Fewer ICP interventions

– Fewer ICU days

– WORSE outcomes despite similar mortality

DEAD FULL

RECOVERY

Communicating

hydrocephalus is

an almost

universal finding

in patients after

hemicraniectomy

EUROTHERM 3235

• 387 severe TBI patients

– Randomization trigger: firstepisode of ICP >20 mm Hg

• Hypothermia group

– Died more

– Less likely to survive with good outcome

• 26% vs 37%

– Cause of this worse outcome is unclear

RESCUEicp Trial

Conclusion

• When the going gets tough, when ICP is medically refractory, easy options are hard to find

• All three THIRD TIER options likely cause harm when performed early without a trial of ICU care

– Prophylactic barbiturate coma

– Straight to the OR for hemicraniectomy

– Cool to 32-35 C° at the first sign of ICP elevation

• My preference for definitive salvage intervention when ICU care is failing go to the OR

RESCUEicp Trial• 408 severe TBI patients

– Age 18-65

– Randomization trigger: Medically refractory ICP >25 mm Hg for 1-12 hours

– Time to randomization >72 hours after injury in 45%

• Hemicraniectomy group

– Absolute 22% reduction in mortality

– Better ICP control: 5 vs 17 hours with ICP >25 mm Hg

– More complications (mostly surgical related): 16% vs 9%

RESCUEicp Trial:

Craniectomy vs Barbiturates

Rescue Hemicraniectomy

Creates a 22% chance of converting death to survival in

a vegetative state or with severe disability

1

6

5

4

3

2

SECOND TIER


HYPERVENTILATION (HV)TO pCO2 30-35 mm Hg

BOLUS OSMOTHERAPYTO SERUM OSMS <320

SEDATION to RASS -4 to -5(Quiet, Motionless State)

TARGET CPP 50-70 mm Hg


Advance

first-tier ICP

interventions

in stepwise

fashion to

avoid missing

essential steps

1

6

5

4

3

2

SECOND TIER

HYPOTHERMIA to 35 °COption: TARGET 33° C

HYPERVENTILATION (HV)Option: MMM-Guided HV <30

BOLUS OSMOTHERAPYOption: PUSH OSMS >320

SEDATION to RASS -4 to -5Option: ADD PARALYTICS

TARGET CPP to 50-70 mm HgOption: MMM-TARGETED CPP


Ultimately,

once you

realize that

you are losing

the battle,

there is really

only one

effective third

tier therapy

for ICP: pop

the lid!


THIRD TIER

Neurocritical Care Societywww.neurocriticalcare.org

Neuro-ICU: Day 1 - Critical Care Canada · ICP A Stepwise Approach Stephan A. Mayer, MD Professor,...

Documents

Transcript of Neuro-ICU: Day 1 - Critical Care Canada · ICP A Stepwise Approach Stephan A. Mayer, MD Professor,...