Treatment of Increased Intracranial Pressure

The treatment of increased ICP involves a few standard procedures (,Table 26-7 ). Perhaps the easiest method for decreasing ICP is proper positioning of the patient and the avoidance of situations that can increase intrathoracic pressure. Placing the patient in an upright (or close to upright) position will lower ICP by promoting an increase in venous flow and will avoid compression of the jugular veins. Additionally, if high pressures associated with positive pressure ventilation are managed, increases in intracranial pressure can be reduced. The administration of intravenous mannitol or hyperventilation can quickly lower ICP in most patients, yet both procedures have possible adverse side effects and are not long lasting. Mannitol treatment may lead to dehydration or electrolyte imbalance as a result of its potent osmotic diuretic effect. The beneficial effects of hyperventilation are short lived because the body quickly compensates for the induced respiratory alkalosis by producing a metabolic acidosis. Theoretically, over-hyperventilation may also lead to significant vasoconstriction with associated cerebral ischemia. Corticosteroids are best used to treat increased ICP in the setting of vasogenic edema (see T.a.bie.,.2.6-5 ) such as occurs with brain tumors or abscesses and have little value in the setting of a patient with a stroke or head trauma. The management of blood pressure is also important in patients with an elevated ICP, because although lowering the systemic blood pressure can lower ICP, it may also lower CPP. Beta blockers or mixed beta and alpha blockers provide the best antihypertensive effects without causing significant cerebral vasodilatation that can lead to elevated ICP. Finally, in rare cases of hydrocephalus, direct drainage of CSF by ventriculostomy may be extremely useful.

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