Escalation therapy in severe traumatic brain injury: how long is intracranial pressure monitoring necessary?

Abstract

Traumatic brain injury frequently causes an elevation of intracranial pressure (ICP) that could lead to reduction of cerebral perfusion pressure and cause brain ischemia. Invasive ICP monitoring is recommended by international guidelines, in order to reduce the incidence of secondary brain injury; although rare, the complications related to ICP probes could be dependent on the duration of monitoring. The aim of this manuscript is to clarify the appropriate timing for removal and management of invasive ICP monitoring, in order to reduce the risk of related complications and guarantee adequate cerebral autoregulatory control. There is no universal consensus concerning the duration of invasive ICP monitoring and its related complications, although the pertinent literature seems to show that the longer is the monitoring maintenance, the higher is the risk of technical issues. Besides, upon 72 h of normal ICP values or less than 72 h if the first computed tomography scan is normal (none or minimal signs of injury) and the neurological exam is available (allowing to observe variations and possible occurrence of new-onset pathological response), the removal of invasive ICP monitoring can be justified. The availability of non-invasive monitoring systems should be considered to follow up patients' clinical course after invasive ICP probe removal or for substituting the invasive monitoring in case of contraindication to its placement. Recently, optic nerve sheath diameter and straight sinus systolic flow velocity evaluation through ultrasound methods showed a good correlation with ICP values, demonstrating their potential role in place of invasive monitoring or in the early weaning phase from the invasive ICP monitoring.

Impact of Intracranial Hypertension on Outcome of Severe Traumatic Brain Injury Pediatric Patients: A 15-Year Single Center Experience

“…Moreover, studies show that the implementation of evidence-based TBI treatment algorithms are associated with improved outcomes, highlighting the importance of future precise ICP-based guidelines in order to reduce practice disparity among TBI patients [ 39 ]. A low percentage (3.4%) of ICP monitoring-related hemorrhagic complications was found in the present study, similar to the published literature [ 34 , 40 ].…”

“…Even though extensive literature has recently been published, the potential benefit of invasive ICP monitoring still remains controversial, despite high percentages of IC-HTN in pediatric sTBI cases, or the generally accepted association between IC-HTN and worse neurologic outcomes [ 3 , 34 ]. The present study evaluated the influences of IC-HTN on the outcome of sTBI pediatric patients, and reports a high percentage of nearly 66% of children who were managed through ICP-guided protocols.…”

Novel Synthetic and Natural Therapies for Traumatic Brain Injury

“…Tiers -one to -three- includes the interventions suggested only in the case of HICP. Goals of tier 1 include CPP maintenance between 60-70 mmHg and partial pressure of carbon dioxide (PaCO 2 ) between 35 and 38 mmHg, eventually implementing analgesia and sedation, using an intermittent bolus of osmotic agents, placing external ventricular drainage to allow cerebrospinal fluid drainage [ 24 ], and implementing electroencephalographic monitoring and prophylactic anticonvulsants if the risk of seizures is deemed high [ 2 , 21 - 23 ]. Tier 2 is expected to implement tier 1 interventions as much as mild hypocapnia (32-35 mmHg), neuromuscular paralysis, inotropes or vasopressors to assess if cerebral autoregulation is intact.…”

Efficacy of a Novel Prophylactic Barbiturate Therapy for Severe Traumatic Brain Injuries: Step-down Infusion of a Barbiturate with Normothermia

“…It has been reported that one of the main determinants of poor outcome in patients with sTBI is an increased intracranial pressure (ICP), which can result from intracranial hemorrhage, brain edema, and obstructive hydrocephalus, among others. 1) Therefore, several interventions to control ICP and improve the outcome, including management of body temperature and barbiturate therapy, have been widely studied. 2) Barbiturates exert sedative and anesthetic effects by potentiating the action of γ-aminobutyric acid (GABA) at the GABA A receptor.…”