Increased ICP and traumatic brain injury

▪ ICP normal < 10 mmHg (↑ ICP → sustained pressure > 18 mmHg within subarachnoid space)
▪ Techniques to monitor ICP → intraventricular catheter (commonly used, can drain CSF), subdural or subarachnoid
bolts/catheters (no penetration through brain parenchym), epidural tranducer, brain intraparenchymalfiber-optic
device.
▪ Causes of ↑ ICP
↑ CSF volume ↑ blood volume ↑ brain tissue volume
Communicating hydrocephalus Intracerebral hemmorhage (aneurisma/AVM) Neoplasma
Obstructing/noncommunicating hydrocephalus Epidural/subdural hematom Cerebral edema
cysts
▪ Symptoms of ↑ ICP: headache, nausea, vomiting, papilledema, focal neurologic deficits, behavioral changes, altered
consciousness, decerebrate posturing, oculomotor nerve palsy, apnea.
▪ Cushing reflex (brain medullary ischemia) → systemic hypertension & reflex bradikardia
▪ CPP = MAP - ICP/CVP (whichever is higher)

▪ Intracranial elastance → variation of ICP with changes in intracranial volume

↑ CMRO2 → ↑ CBF (delay 1-2 min) ↑ PaCO2 (vasodilator) → ↑ CBF by 1-2 ml/100 g/min per mmHg
▪
↓ PaO2 (< 50 mmHg) → ↑ CBF MAP 50-150 mmHg → CBF constant
▪ Chronic hypertension → autoregulation curve shift to the right (higher MAP to perfuse the brain)
▪ Goal of anesthetic in ↑ ICP: ↓ CMRO2, intracranial volume, initiate seizure prophylaxis medications
▪ Preoperative medication: mild fluid restriction (1/3-1/2 daily intake), corticosteroid, seizure prophylaxis
▪ Thiopental & propofol → ↓ CBF & CMRO2.
Opioid (variable effect on CBF) → used to blunt sympathetic response during intubation (could induce hypoventilation
& ↑ PaCO2).
Lidocaine (0,5-1 mg/kg) → as adjuncts at induction (blunt sympathetic response)
Esmolol (short acting beta blocker) → ↓ systemic hypertension during laryngoscopy
▪ Intraoperative maneuvers: ↓ CSF, blood volume, total brain water content
○ CSF: ventriculostomy
○ Blood volume: hyperventilation (↓ PaCO2), anesthetic agent that ↓ CMRO2 (halogenated < 1 MAC; avoid nitrous
oxide), slight reverse tredelenburg
○ Brain water: mannitol (0,25-1,5 g/kg), furosemide (0,5-1 mg/kg), limit crystalloid
○ PEEP may elevate CVP & ICP
▪ Hyperventilation → ineffective for ↓ ICP after 24-48 hours. Avoid hyperventilation < 25-30 mmHg
▪ Avoid hypotonic crystalloid. NS superior to RL. Use hypertonic saline.. Colloidal solution (albumin, hetastarch) not
superior to isotonic crystalloid
▪ Volatile anesthetic → ↑ CBF, response CBF to PaCO2 preserved
↓↑→a•
Nondepolarizing NMD → no effect on ICP
Succinylcholine → generally not recommended, kecuali untuk high risk for aspiration
▪ Emergence from anesthesia → esmolol & labetalol, lidocaine
Tx to ↓ ICP Factors affecting CBF Agents to avoid in ↑ ICP
1. Head elevation 1. MAP & CPP 1. Ketamine & etomidate
2. Analgesia & anxiolysis 2. PaO2 2. Nitrous oxide
3. Osmotherapy (manitol/NS 3%) 3. PaCO2 3. Hypotonic IV fluids
▪ 4. Furosemid 4. CMRO2 4. Glucose containing IV fluids (hyperglikemia worsened neurologic)
5. CSF drainage 5. Inhalation agent
6. CTS (tumor related edema)
7. Avoid hypervolemia
8. Hyperventilation (PaCO2 30-35 mmHg)
9. Barbiturate come (phentobarbital)

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