Upright patient positioning in the management of intracranial hypertension

Kenning, James A.; Toutant, Steven M.; Saunders, Richard L.

doi:10.1016/0090-3019(81)90037-9

Cited by 88 publications

(56 citation statements)

References 22 publications

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“…However, 13 patients showed lower ICPPA values at 0°position. The 30°head-up position is often used intuitively, and it was shown to be associated with low ICP and improved cerebral oxygenation in several studies [13,16,23,29,33,34,40,53]. However, all these studies also showed a considerable individual variability in terms of the optimum level of head elevation.…”

Section: Head Elevation and Cerebral Hemodynamicsmentioning

confidence: 95%

“…The ideal head position for patients with head injury has been debated in recent years. In critically ill patients with acute brain injury and associated intracranial hypertension, elevation of the head is clinically used to effect a reduction in the ICP [2,23,40]. A high ICP may lead to further brain damage by promoting ischemia, causing subsequent brain shift herniation.…”

Section: Head Elevation and Cerebral Hemodynamicsmentioning

confidence: 99%

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Intracranial pressure pulse amplitude during changes in head elevation: a new parameter for determining optimum cerebral perfusion pressure?

2009

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Objective During short-term postural changes, the factors determining the amplitude of intracranial pulse pressure (ICPPA) remain constant, except for cerebrovascular resistance (CVR). Therefore, it may be possible to draw conclusions from the ICPPA onto the cerebrovascular resistance (CVR) and thus the relative change in cerebral perfusion pressure (CPP). Methods Age, sex, disease, Glasgow Coma Scale score, placement of ventricular drain, blood gas analysis, and parameters of airway management were prospectively recorded in 40 patients. The changes in intracranial pressure (ICP), CPP, mean arterial pressure (MAP), and ICPPA at head elevations of 0°, 30°, and 60°were measured and analyzed online. Status of cerebrovascular autoregulation was checked using the pressure-reactivity index (PRx). Results Altogether 36 subjects fulfilled the study conditions. Three patients had positive PRx indicating disturbed autoregulation and were excluded. Thus, 33 were left for analysis (18 females and 15 males). All of them were sedated and mechanically ventilated with Glasgow Coma scores ranging from 3-8. During change in head elevation from 0°to 60°, we found a significant (p<0.05) improvement of the ICP, an increase of the ICCPA, a reduction of the MAP, and a decrease in the CPP. Increasing ICPPA was linked to decreasing CPP (0°to 60°, r=−0.42, p<0.05).Conclusions Head elevation is an important part of the ICP and CPP therapy in neurointensive care. When searching for the patient-specific optimum upper body position, ICPPA may provide additional information. Providing that the cerebral autoregulation is intact, the lowest ICPPA of a patient corresponds to the individual upper body position with the highest CPP.

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Section: Head Elevation and Cerebral Hemodynamicsmentioning

confidence: 95%

Section: Head Elevation and Cerebral Hemodynamicsmentioning

confidence: 99%

Intracranial pressure pulse amplitude during changes in head elevation: a new parameter for determining optimum cerebral perfusion pressure?

2009

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“…Most studies in neurosurgical patient collectives agree that moderate head elevation decreases ICP in patients with head trauma. [1][2][3]5,6,9,11 However, in head trauma patients, head elevation also decreases CPP because of a marked decrease in MAP. 3,4 Some authors have examined CBF in relation to body position.…”

Section: Discussionmentioning

confidence: 99%

“…For patients with head trauma, it is generally agreed that moderate (15°to 45°) head elevation significantly reduces ICP, whereas head elevation Ͼ45°may be dangerous because of a critical decrease in cerebral perfusion pressure (CPP). [1][2][3][4][5][6] However, in these patients, even moderate head elevation may compromise CPP. 3,4 Until now, for patients with ischemic stroke, the question of optimal body position has not been addressed in systematic studies.…”

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confidence: 99%

Effects of Body Position on Intracranial Pressure and Cerebral Perfusion in Patients With Large Hemispheric Stroke

Schwarz

Georgiadis

Aschoff

et al. 2002

Stroke

187

139

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Background and Purpose-The purpose of this study was to prospectively evaluate the effects of body position in patients with large supratentorial stroke. Methods-We performed 43 monitoring sessions in 18 patients with acute complete or subtotal middle cerebral artery (MCA) territory stroke. Intracranial pressure (ICP) was monitored with a parenchymal probe. Mean arterial blood pressure, ICP, and MCA peak mean flow velocity (V m MCA) were continuously recorded. Patients with acute ICP crises were excluded. After baseline values at a 0°supine position were attained, the backrest was elevated in 2 steps of 5 minutes each to 15°and 30°and then returned to 0°. Results-Baseline mean arterial pressure was 90.0Ϯ1.6 mm Hg and fell to 82.7Ϯ1.7 mm Hg at 15°and 76.1Ϯ1.6 mm Hg at 30°backrest elevation (PϽ0.0001). ICP decreased from 13.0Ϯ0.9 to 12.0Ϯ0.9 mm Hg at 15°a nd 11.4Ϯ0.9 mm Hg at 30°backrest elevation (PϽ0.0001). As a result, cerebral perfusion pressure decreased from a baseline value of 77.0Ϯ1.8 to 70.0Ϯ1.8 mm Hg at 15°and 64.7Ϯ1.7 mm Hg at 30°backrest elevation (PϽ0.0001). V m MCA was already higher on the affected side during baseline measurements. V m MCA decreased from 72.8Ϯ11.3 cm/s at 0°to 67.2Ϯ9.7 cm/s at 15°and 61.2Ϯ8.9 cm/s at 30°on the affected and from 49.9Ϯ3.7 cm/s at 0°to 47.7Ϯ3.6 cm/s at 15°and 46.2Ϯ2.2 cm/s at 30°on the contralateral side (PϽ0.0001). Conclusions-In patients with large hemispheric stroke without an acute ICP crisis, cerebral perfusion pressure was maximal in the horizontal position although ICP was usually at its highest point. If adequate cerebral perfusion pressure is considered more desirable than the absolute level of ICP, the horizontal position is optimal for these patients.

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“…The arterial: venous blood volume ratio is *0.3 [52] and capillary blood volume is considered negligible [53]. In healthy subjects, the effect of posture on intracranial physiology has been studied using magnetic resonance imaging (MRI) [ [55]. Further, hypercapnia can induce vasodilatation and increase arterial blood volume without necessarily a change in venous blood volume [56].…”

Section: Cerebral Blood Volumementioning

confidence: 99%

Effects of Positioning on Cerebral Oxygenation

Soeding

2013

Curr Anesthesiol Rep

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Postural change during anesthesia has a complex effect on the systemic and cerebral circulations which can potentially decrease cerebral blood flow and oxygenation. Cerebral oximetry is emerging as a monitor of cerebral perfusion with widespread application in many types of surgery. The technology is based on the differential absorption of oxygenated and deoxygenated hemoglobin to near-infrared light. However, the dynamic coupling that exists between cerebral arterial, venous and cerebrospinal fluid volumes may influence oximetric readings during postural change. Interpretation of cerebral oxygen saturation measurement must account for these changes in cerebral physiology if monitoring is to predict neurological outcome.

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Upright patient positioning in the management of intracranial hypertension

Cited by 88 publications

References 22 publications

Intracranial pressure pulse amplitude during changes in head elevation: a new parameter for determining optimum cerebral perfusion pressure?

Intracranial pressure pulse amplitude during changes in head elevation: a new parameter for determining optimum cerebral perfusion pressure?

Effects of Body Position on Intracranial Pressure and Cerebral Perfusion in Patients With Large Hemispheric Stroke

Effects of Positioning on Cerebral Oxygenation

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