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Effects of Different Head-of-Bed Elevations and Body Positions on

Intracranial Pressure and Cerebral Perfusion Pressure in Neurosurgical
Patients

Article in Journal of Neuroscience Nursing · August 2018

DOI: 10.1097/jnn.0000000000000386

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 Volume 50 & Number 4 & August 2018 247

Effects of Different Head-of-Bed Elevations

and Body Positions on Intracranial Pressure
and Cerebral Perfusion Pressure in
Neurosurgical Patients
Gülay Altun Uğraz, Serpil Yüksel, Zeynep Temiz, Selin Eroğlu, Keziban yirin,
Yüksel Turan

ABSTRACT
Downloaded from https://journals.lww.com/jnnonline by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3/TxXCJJj86Hwc+4jv9ywjK85O1SeiGTAOnt7/GvmSN8= on 07/11/2018

Purpose: The aim of this study was to evaluate the effects of different head of bed (HOB) elevations and
body positions on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) and to identify safe
positions for neurosurgical patients with different Glasgow Coma Scale (GCS) scores. Methods: This study
with a quasi-experimental, prospective repeated measures is designed with control over the intervention
consisted of 30 patients hospitalized in the neurocritical care units (NCU). Patients’ HOB was elevated
(degree of 15,30,45) and the patients were at supine, left lateral and right lateral positions. ICP and CPP
were recorded for each patient. Results: It was found that ICP increased and CPP decreased at supine, left
and right lateral positions with different HOB elevations, which, however, did not reach statistical
significance. When patients with a GCS score of 3Y8 were at degree of 15 right and left lateral positions
and 45 right lateral position; and when patients with a GCS score of 13Y15 were positioned at degree of
15 left lateral, ICP and CPP changed significantly. Conclusion: The results of this study showed that
different positions the patients’ HOB (degree of 15,30,45) led to slight insignificant changes in ICP and
CPP; and these values were maintained within the ranges established by recent guidelines.

Keywords: body position, cerebral perfusion pressure, Glasgow coma scale, head of bed elevation,
intracranial pressure

INTRODUCTION ranges to reduce the risk for secondary brain injury in

It is important to maintain intracranial pressure (ICP)
and cerebral perfusion pressure (CPP) within normal
Questions or comments about this article may be directed to Gü
lay A. Uğraz, PhD, at carpediem0803@yahoo.com/gulay.altun@
yahoo.com. She is an Assistant Professor, The Department of
Surgical Nursing, School of Health, The University of Mersin,
Mersin, Turkey.
Gü lay A. Uğraz, PhD, is Assistant Professor, Department of
Surgical Nursing, The University of Mersin, Mersin, Turkey.
Serpil Yü ksel, PhD, is Assistant Professor, Department of Surgical
Nursing, The University of Necmettin Erbakan, Konya, Turkey.
Zeynep Temiz, PhD, is Assistant Professor, Department of Sur-
gical Nursing, The University of Artvin Ç oruh, Artvin, Turkey.
Selin Eroğlu, RN, is Nurse, Neurosurgery Intensive Care Unit, Cerrahpaza
Faculty of Medicine, The University of Istanbul, Istanbul, Turkey.
Keziban Sirin, RN, is Nurse, Cerrahpaza Faculty of Medicine, Depart-
ment of Neurosurgery, The University of Istanbul, Istanbul, Turkey.
Yüksel Turan, RN, is Nurse, Neurosurgery Intensive Care Unit, Cerrahpaza
Faculty of Medicine, The University of Istanbul, Istanbul, Turkey.
The authors declare no conflicts of interest.
Supplemental digital content is available for this article. Direct URL cita-
tions appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal’s Web site (www.jnnonline.com).
Copyright B 2018 American Association of Neuroscience Nurses
DOI: 10.1097/JNN.0000000000000386
neurosurgical patients.1 In neurocritical care units
(NCU), the head of bed (HOB) is elevated to reduce
ICP and maintain sufficient CPP;2Y8 different posi-
tions increase the quality of care, ensure comfort and
prevent pressure ulcers.2,3,9 Several studies demon-
strate the effects of different HOB elevations and
body positions on ICP and CPP.2,3,5,7,8 However, the
effects of lateral positioning and the degree of HOB
elevation are inconsistent. There are no studies in the
literature showing what impact different body posi-
tions have on patients’ ICP and CPP with different
Glasgow Coma Scale (GCS) scores. Considering
that lower GCS score is related to changes in the
autoregulation mechanism which enables brain to
adjust to the injury,10,11 identifying the positions in
which patients with different GCS scores are placed is
important for patient safety. This study evaluated the
effect of different HOB elevations and body positions
on ICP and CPP to identify safe positions for neuro-
surgical patients with different GCS scores.
METHODS
A quasi-experimental, prospective repeated measures
design with control over the intervention was used to

Copyright © 2018 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
248 Journal of Neuroscience Nursing
investigate the effects of different HOB elevations
and positioning on ICP and CPP in NCU patients.
Approval of Istanbul University Cerrahpasa Medical
School Ethics Committee (Number:83045809/18848;
Date:02.07.2013) and the patient written and verbal
consent was obtained. The sample size was calculated
taking the difference the between mean pre-and post-
positioning (right lateral position HOB 150) ICP
score averages (2.93) in the study by Ledwith et al.3
From a population of 46 patients undergoing external
ventricular drainage (EVD) and/or ICP monitoring
in the NCU of a university hospital in Istanbul between
August 2013 and December 2016, 30 patients were
enrolled to make explore for the difference ICP
averages between positions (power of 80% and an
alpha of 0.05).
Subjects were aged 18 years or older who had
undergone EVD and/or ICP monitoring, who had
intraarterial catheters and who were granted permis-
sion by a legally authorized representative. A total of
16 patients who were neurologically and hemody-
namically unstable, who could not tolerate a position
change (ICP925 mmHg for 5 minutes after position-
ing), who had no intraarterial catheters, who were
diagnosed with brain death or who had no or irregular
ICP waves were excluded from the study. Patients
undergoing craniotomy in the NCU where the study
was conducted were not included in the study. Because
the ICP values of the patients included in the study
were not 922 mmHg, drainage of the cerebrospinal
fluid (CSF) was performed via an EVD placed in the
lateral ventricule for the treatment of elevated ICP and
decreased CPP. In addition, standard ICP manage-
ment included the maintenance of optimal oxygena-
tion (intubatable if the GCS is e8), drug treatment
(sedative drugs, steroids, osmotic diuretics etc. according
to the health status of the patient) and nursing inter-
ventions to decrease ICP (positioning etc.).
A data colllection form was used to record ICP
and CPP values for each position. Intracranial pressure
[intraventricular catheter (pressure monitoring set,
BN0ak0Nlar, Istanbul,Turkey), was zeroed at the level
of external auditory canal (tragus) and head rotation
was avoided] and invasive blood pressure [radial
artery (Pressure monitoring set, BN0ak0Nlar, Istanbul,
Turkey), was zeroed at the level of the right atrium, its
position was not changed during all measurements]
were monitored on the bedside monitor (Infnitykappa,
Draeger, Germany). CPP was calculated as ICP minus
mean arterial pressure (MAP).3,12,13 Physicians could
prescribe CSF drainage to patients who had ICP moni-
toring via EVD; this prescribed drainage was generally
continous.
The HOB elevation was measured via goniometer.
Patients were observed in 9 different positions being
Copyright © 2018 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
Different HOB positions were
associated with statistically
insignificant changes in ICP and
CPP.
15-,30-,45- supine; 15-,30-,45- left lateral; 15-,30-,45-
right lateral. During patient positioning, extreme rotation
of the head, hyperextension and flexion of the neck,
and extreme flexion of the hip were avoided. Before
positioning the patients, EVD was clamped to prevent
excessive drainage and to ensure the ICP value was
not affected.12,14 Patients were given different body
positions (150 HOB supine, left lateral, right lateral;
300 HOB supine, left lateral, right lateral; 45 HOB
supine, left lateral, right lateral) at a 2-hour interval,
just like routine repositioning in the NCU. Patients
who had undergone surgery (mass excision n=5;
aneurysm clamping n=3; shunt revision n=1) were
positioned in a way that the surgery area would not
remain under pressure when they were transferred
to the NCU. ICP was monitored at the bedside for
15 minutes after each position change and CPP was
calculated according to the formula after EVD was
clamped. 14
Descriptive data were expressed in frequency,
percentage, mean and standard deviation. Repeated
measures variance analysis (ANOVA) was used for
the intercomparison of different HOB elevations and
body positions; and Kruskal Wallis test was used for
the difference evaluation in pre-and post-positioning
ICP and CPP values of the patients with different
GCS scores. GCS scores were classified as mild
(GCS 13Y15), moderate (GCS 9Y12), and severe
(GCS 3Y8).15A p value of G0.05 was considered sta-
tistically significant at a 95% confidence level.
RESULTS
Descriptive Characteristics
Demographic data are provided as Supplemental Digital
Content 1 (available at http://links.lww.com/JNN/A130).
The mean age of the patients was 52.8T17.0 years, most
of whom were female (60%, n=18). Patients were hos-
pitalized traumatic brain injury (n=13, 43.3%), subarac-
hnoid hemorrhage (N=7, 23.4%), and intracranial mass
(n=5, 16.7%). Of all patients, 33.3%(n=10) had a GCS
score of 3Y8; 26.7%(n=8) had a GCS score of 9Y11 and
40.0%(n=12) had a GCS score of 12Y15.
Supine position. After patients were in different
supine positions with HOB elevations, ICP increased
and CPP decreased compared to pre positioning values.
 Volume 50 & Number 4 & August 2018 249

However, the differences were not statistically signif-
icant (pG0.05; Table 1). It was found that supine po-
sitioning had no significant impact on ICP and CPP in
patients with different GCS scores (Supplemental Digital
Content 2, available at http://links.lww.com/JNN/A131).
Left lateral position. When patients were posi-
tioned at left lateral, ICP increased and CPP decreased
after HOB elevation of 150 and 300 compared to pre
positioning, whereas, ICP decreased and CPP increased
after HOB elevation of 450. This difference was not
statistically significant (pG0.05, Table 1). When pa-
tients were positioned at 150 left lateral position, ICP
increased significantly in patients with a GCS score
of 13Y15 (p=0.024). The CPP of patients with a GCS
score of 3Y8 decreased significantly compared to that
of patients with a GCS score of 9Y12 (p=0.034) in the
same position (Supplemental Digital Content 2, avail-
able at http://links.lww.com/JNN/A131).
Right lateral position. When patients were lying
in a right lateral position, ICP increased but CPP
decreased. This difference did not reach statistical
significance (pG0.05, Table 1). It was found that, at
150 right lateral position, ICP of patients with a GCS
score of 3Y8 increased significantly (p=0.040), whereas
CPP decreased significantly (p=0.007). In the right lateral
position where the HOB was elevated 450, CPP of pa-
tients with a GCS score of 9Y12 and 13Y15 decreased
significantly (p=0.018; Supplemental Digital Content 2,
available at http://links.lww.com/JNN/A131).
DISCUSSION
Different body positions and HOB elevations can
affect ICP and CPP in neurosurgical patients.2,3,16
On the other hand, there is no consensus on safe
positions for these patients in the literature.3,8,17
Supine Position
In this study, ICP increased and CPP decreased in the
supine position with different degrees of HOB
elevation, however, these values were not affected
by HOB elevation. Similar to this study, Blissitt et al.18
reported that HOB elevation (200,450) in the supine
position after subarachnoid hemorrhage decreased
ICP, but the changes in CPP were significant when it
was measured with a transducer at the phlebostatic
axis or at the level of the external auditory meatus.
In a meta-analysis aimed to determine an optimal
HOB degree (0,10,15,30,450) to decrease ICP in
post-craniotomy patients, HOB elevation of 300 or
400 were found to be optimal for decreasing ICP.17
However, this meta-analysis investigated only the
effects of HOB elevation on ICP and was limited to a
single position (supine) and therefore was unable to
evaluate its effects on CPP. However, patients are at
right and left lateral positions every two hours to
maintain skin integrity in the NCU. The effects of
these positions on ICP and CPP should also be
researched. Another study reported that HOB elevation
higher than 30o decreased both ICP and CPP.7 On the
other hand, in this study, patients’ ICP and CPP values
were not significantly affected in all supine positions
with different degrees of HOB elevation and were
maintained within normal range (ICPG22 mmHg;
CPP970 mmHg).1
Severe brain injury is known to influence auto-
regulation mechanism which enables brain adjust-
ment for the injury.10,11 We found no studies showing

TABLE 1. The Comparison of Pre- and Post-positioning ICP and CPP Values in Patients
ICP CPP
Pre- Post- Pre- Post-
Position and HOB positioning positioning Pa positioning positioning Pa
Supine 150 10.6 (6.3) 11.7 (7.5) 0.828 88.1 (16.4) 87.5 (18.1) 0.672
300 10.1 (5.1) 11.4 (8.0) 90.9 (16.5) 87.6 (17.7)
450 9.9 (5.2) 10.7 (6.7) 92.5 (19.1) 91.3 (18.4)
Left Lateral 150 10.9 (7.8) 11.8 (7.8) 0.374 85.8 (19.5) 84.6 (20.2) 0.224
300 11.3 (6.0) 11.6 (5.8) 91.1 (22.6) 86.2 (21.3)
450 12.7 (8.1) 12.0 (9.0) 87.1 (18.2) 87.5 (19.9)
Right 150 11.0 (6.1) 11.5 (7.2) 0.913 90.2 (20.6) 87.3 (20.1) 0.780
Lateral 300 10.6 (6.7) 11.5 (6.9) 90.5 (22.4) 88.9 (23.0)
450 11.0 (5.9) 11.5 (6.6) 91.7 (21.1) 88.3 (18.1)

Abbreviations: CPP, cerebral perfusion pressure; HOB, head of bed; ICP, intracranial pressure.
a
Data are given in mean (standard deviation); Analysis of variance was used for repeat measurement of pre and post-positioning
differences.

Copyright © 2018 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
250 Journal of Neuroscience Nursing
the effects of a given position in patients with dif-
ferent GCS scores. KPse and Hatipolglu,2 demon-
strated that the optimal cerebral blood flow (CBF)
required to maintain CPP could only be achieved
with 300 of HOB elevation in patients with a mean
GCS score of 14.7T0.7 who had undergone cranial
surgery. In a different study, 300 HOB elevation
reduced ICP and CPP values in patients with a GCS
score of 3Y8 whose autoregulation was not impaired.
The most dramatic decrease in ICP and CPP was
noted when the HOB was elevated from 00 to 600.4
Ng et al.5 reported that ICP was significantly lower,
but CPP was not significantly higher. in patients
with a closed head injury with a GCS score of 8.
Results from the current study indicated that supine
position with different HOB elevations (150,300,450)
did not affect ICP and CPP, and these positions were
safe for neurosurgical patients with different GCS
scores. These findings are consistent with the literature
data indicating that supine position with 300 of HOB is
safe. In this study, contrary to the literature data, the
effect of supine position with a 600of HOB was not
evaluated and CBF was not measured. The inability to
measure CBF at different positions and HOB eleva-
tions, different diagnoses of patients comprising the study
sample, and the inability to evaluate autoregulation of
the brain might explain the different results from the
literature were obtained.
Left and Right Lateral Positions
When patients were positioned at left and right
lateral sides with different HOB elevations, no
significant effect on ICP and CPP was noted and the
values were maintained within the range specified
in the most recent guideline.1 ICP increased signif-
icantly only in patients with a GCS score of 13Y15 at
150 left lateral position, and in those with a GCS
score of 3Y8 at 150 right lateral position.A previous
study investigating the effect of a given position on
CBF reported that the right and left lateral positions
were safe for patients with a mean GCS score of
14.7T0.7, however, the effect of these positions was
not evaluated in patients whose HOB were elevated
150 and 450and in those with lower GCS scores.2 In
another study, right and left lateral positions with
HOB elevation of 150 increased ICP significantly in
patients with a GCS score of 8 or less.3
In the present study, CPP of patients with a GCS
score of 3Y8 decreased significantly at 150 right and
left lateral positionsand the position which had the
least effect on CPP was 300 right lateral position in
these patients. Ledwith et al.3 indicate that CPP
reduced significantly at 300 left lateral position. This
inconsistency might have been caused by the fact that
pre-and post-positioning CPP values were compared in
Copyright © 2018 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
the aforementioned study whereas the difference be-
tween pre-and post-positioning CPP values were con-
sidered between the patients with different GCS scores.
In a world with rapidly growing technology and
ever-increasing availability of information, evidence-
based practices should be introduced on a wider clinical
area for the improvement of nursing care quality.
However, there are limited clinical studies2Y5,7,8,18 and
only 1 meta analysis17 investigating the effect of
HOB elevation and different positions on ICP and
CPP. The sample size varies between 10 and 38, and
all patients were not placed at the same position in
these studies. In addition, CBF was measured to
evaluate cerebral perfusion in some patients,2 whereas
only the measurement of ICP was investigated in
others.17 The inconsistency and differences among
the results of these studies, as in the current study,
indicates the need for further research on the subject.
There are several limitations in this study. First is
the attempt to evaluate cerebral perfusion by mea-
suring ICP and CPP values. However, depending
on whether autoregulatory capability was impaired,
optimal CPP values vary and affect patient results.1,19,20
One limitation of the study was the level of the
transducer used for the measurement of MAP and
calculation of CPP. Even though treatment and care
interventions are determined according to the CPP
value in neurosurgical patients, there is no evidence
indicating optimal location of the arterial transducer.
Although it was reported that MAP should be mea-
sured at the level of the tragus for neurologic targets,13
MAP was measured with the transducer placed at
the level of the phlebostatic axis in this study. It can
be suggested that the arterial transducer should be
placed at the level of the targus while measuring
MAP in future studies. Another limitation was that
the patients were grouped based on different GCS
scores and the effects of each position were evaluated
accordingly. However, the sample size might not be
sufficient despite similar numbers of patients in each
group, which indicates that further studies with higher
number of patients are warranted for the generalization
of the results.
CONCLUSION
The results of this study indicate that different posi-
tions in which the patients were placed led to changes
in ICP and CPP. However, these changes did not
reach statistical significance and these values were
maintained within the range specified in the most
recent guideline. In addition, there was a significant
ICP increase and a significant CPP decrease in
patients with different GCS scores particularly those
in left and right lateral positions with 150 of HOB

elevation, and those in right lateral position with 450
of HOB elevation. The significant changes in patients’
values also remained within the normal range specified,
which indicates that patients can be safely placed in
these positions but close monitoring is required. Given
that the autoregulation capability of the brain is impor-
tant for maintaining optimal cerebral perfusion, it can
be suggested that the autoregulation mechanism in
different patient groups with different GCS scores
should be evaluated and different positions should be
investigated in future studies.
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