Does ICP monitoring make a difference in neurocritical care?

Abstract

Raised intracranial pressure and low cerebral perfusion pressure are associated with ischaemia and poor outcome after brain injury. Therefore, many management protocols target these variables. However, there are no randomized controlled trials that have demonstrated the effectiveness of intracranial pressure-guided care in severely head-injured patients. Observational studies of such therapy have yielded inconsistent results, ranging from decreased mortality to no effect or increased morbidity or mortality. A recent cohort study supports the notion that the possible benefits of intracranial pressure monitoring after traumatic brain injury are small - if present - and would exceed a number needed for the treatment of 16. Furthermore, intracranial pressure monitoring and aggressive management of intracranial pressure and cerebral perfusion pressure have been associated with increased lengths of stay in the neurocritical care unit, conceivable costs and possibly an increased rate of complications. Against this background, there is sufficient clinical equipoise to warrant an adequately powered randomized controlled trial to compare intracranial pressure-guided care with supportive critical care without intracranial pressure monitoring in patients with severe traumatic brain injury. However, the realization of such a trial is likely to be problematic for a number of reasons, not least of which the firmly held biases of many clinicians.

Editorial: Intracranial pressure monitoring for brain injury

“…Unfortunately, they did not clearly define AKI and their reference to that definition 4 does not provide one. The currently accepted definition of AKI 2,3 would not support their reported AKI incidences. Furthermore, lack of information as to daily fluid balance or fractional excretion of sodium make it difficult to believe that the group differences in the renal data that they present are not simply due to lack of volume replacement to balance iatrogenic diuresis.…”

“…6,3 Furthermore, a few studies have shown that ICP monitoring was associated with worsened survival. 2,7 So this assessment index is quite variable. However, differences in the monitoring site might have contributed to the problem.…”

Towards Non-Invasive Bedside Monitoring of Cerebral Blood Flow and Oxygen Metabolism in Brain-Injured Patients with Near-Infrared Spectroscopy

“…The Lund protocol advises a lower limit of 50 mm Hg to prevent complications while avoiding extremely low CBF (Asgeirsson et al, 1994). It has even been suggested that CPP/ICP therapy only increases therapy intensity without improving outcome (Cremer, 2008). Strictly adhering to targets can therefore give clinicians a false sense of security.…”

Evaluation of a novel noninvasive ICP monitoring device in patients undergoing invasive ICP monitoring: preliminary results

“…Invasive ICP monitoring coupled with the use of external ventricular drainage (EVD) is still considered the gold standard of ICP monitoring and is part of the standard patient management in the intensive care unit (ICU). 3,8,18,20,31,34 The invasive nature of this method and the methodology itself makes invasive ICP (I-ICP) monitoring both a potentially harmful and technically difficult technique. 17,23 The main concerns with using EVD include an associated high infection rate, which ranges from 3.4% to 32.2%; 7 the rate of malplacement of the ventricular catheter, which in one study was as high as 12.3%; 28 and the problem of technically inaccurate recordings due to calibration errors.…”