Managing ICP in Traumatic Brain Injury

David Menon discusses the complex and fraught world of managing traumatic brain injury (TBI) in the ICU. In particular, David discusses the management of intracranial pressure and cerebral perfusion pressure in these patients. Although the Brain Trauma Foundation provides guidelines for the management of severe TBI, including targets for ICP and CCP, there is no Level 1 recommendation for the use of any intervention to modulate ICP/CCP. General principles remain simple in theory, if not in practice. David describes good basic intensive care, which he describes as doing lots of little things well. The main focuses should be maintaining blood pressure high enough to get oxygen to brain, optimising oxygenation and modulating carbon dioxide. This is in combination with other modalities such as hypertonic saline, cooling people, and using metabolic suppression. The trouble lies in the fact that there is no evidence base for second line therapy. In fact, some of these therapies have been shown to cause harm. When considering a therapy, it boils down to this - is the disease desperate enough and have the benefits and risks of therapy been weighed up. When controlling ICP, the indications for treatment are different so acceptance of iatrogenic risk must also change. Therefore, ICP treatments must be calibrated using a risk benefit ratio. For instance, utilising hyperventilation to decrease intracranial pressure can be a useful lever to pull. However, going too hard can reduce the cerebral blood flow to a detrimental point. The point here is to use it briefly, to make time for another less potentially harmful intervention. Similarly, when considering CCP, targets and protocols use population averages. No single optimal CCP exists across all patients. So, clinicians need a rationale way to titrate treatment to physiology. David suggests using graded thresholds to escalate treatment in an individualised way. Underlying these principles is good detection and minimisations of treatment harm. Underlying all of these principles is a grounding in the data and the utilisation of this data to effectively communicate with families. By doing this you can deliver the treatment and aim for the outcomes deemed most acceptable by the patient and their loved ones.

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