Escalate and De-Escalate Therapies for Intracranial Pressure Control in Traumatic Brain Injury

Abstract

Severe traumatic brain injury (TBI) is frequently associated with an elevation of intracranial pressure (ICP), followed by cerebral perfusion pressure (CPP) reduction. Invasive monitoring of ICP is recommended to guide a step-by-step “staircase approach” which aims to normalize ICP values and reduce the risks of secondary damage. However, if such monitoring is not available clinical examination and radiological criteria should be used. A major concern is how to taper the therapies employed for ICP control. The aim of this manuscript is to review the criteria for escalating and withdrawing therapies in TBI patients. Each step of the staircase approach carries a risk of adverse effects related to the duration of treatment. Tapering of barbiturates should start once ICP control has been achieved for at least 24 h, although a period of 2–12 days is often required. Administration of hyperosmolar fluids should be avoided if ICP is normal. Sedation should be reduced after at least 24 h of controlled ICP to allow neurological examination. Removal of invasive ICP monitoring is suggested after 72 h of normal ICP. For patients who have undergone surgical decompression, cranioplasty represents the final step, and an earlier cranioplasty (15–90 days after decompression) seems to reduce the rate of infection, seizures, and hydrocephalus.

Novel Synthetic and Natural Therapies for Traumatic Brain Injury

“…One of the most fearful problems of TBI includes the evolution of intracranial hypertension (HICP). Irrespective of intracranial pressure (ICP) elevation, a “staircase approach” in severe TBI patients should be pursued [ 2 , 21 - 23 ]. We, therefore, consider as -tier zero- basic ICU interventions as endotracheal intubation followed by mechanical ventilation, head-up position (15-30°), analgesia and sedation, and normothermia, with the goal of maintaining a cerebral perfusion pressure (CPP) threshold of 60 mmHg, hemoglobin concentration of >7 g/dL, normal serum sodium, and peripheral oxygen saturation (SpO 2 ) of ≥ 94%.…”

“…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.…”

“…Once reached tier 3, barbiturate coma, mild hypothermia (35-36°C), hyperventilation (PaCO 2 goal of 30-32 mmHg), and secondary decompressive craniectomy may be opted. Further implementation includes an increase of a fraction of inspired oxygen up to 60% or partial pressure of oxygen up to 150 mmHg, CPP>70 mmHg, and a transfusion threshold of <9 g/dL in case of possible hypoxic damage [ 2 , 21 - 23 ].…”

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

“… 3) Barbiturates can decrease cerebral blood flow and volume, resulting in a reduction in the increased ICP. 4) However, according to the guidelines for the management of TBI, based on several clinical studies on barbiturates, high-dose barbiturate administration is only recommended (Level IIB) to control elevated ICP when hemodynamic stability is secured before and during barbiturate therapy. 5) On the other hand, thiamylal has been widely used for sedation in Japan 6 , 7) and could be used to control increased ICP if an appropriate protocol for thiamylal administration is established.…”

Effect of Mild Hypothermia after Craniotomy on the Function of Related Organs in Patients with Traumatic Brain Injury

“…Emergency Medicine International maintains normal cerebral perfusion pressure, and improves brain oxygenation and metabolism [13,14]. Mild hypothermia is considered as one of the most reliable physical therapy methods for patients with brain injury.…”