Infectious complications and duration of intracranial pressure monitoring

We studied 65 children with acute brain injury to determine how the risk of infectious complications changed with duration of intracranial pressure (ICP) monitoring. More than half of the 72 monitors inserted in these patients were in place at least 7 days (range 1 to 28). Nine infections occurred on days 2 through 11. The overall risk was 1.5 infections per 100 monitor-days. After day 6 the risk of subsequent infection diminished, as did the percent of monitors which subsequently became infected. The declining risk of infection over time suggests that infection is introduced at the time of monitor insertion. These findings justify a protocol in which a single ICP monitoring device is used as long as necessary, with reinsertion of a new monitor only if a malfunction occurs, or if daily surveillance cultures demonstrate an infection. Routine reinsertion of a new monitor might increase risk by unnecessarily re-exposing the patient to contamination at the time of insertion.     

Intracranial pressure monitoring: Gold standard and recent innovations

Intracranial pressure monitoring (ICP) is based on the doctrine proposed by Monroe and Kellie centuries ago. With the advancement of technology and science, various invasive and non-invasive modalities of monitoring ICP continue to be developed. An ideal monitor to track ICP should be easy to use, accurate, reliable, reproducible, inexpensive and should not be associated with infection or haemorrhagic complications. Although the transducers connected to the extra ventricular drainage continue to be Gold Standard, its association with the likelihood of infection and haemorrhage have led to the search for alternate non-invasive methods of monitoring ICP. While Camino transducers, Strain gauge micro transducer based ICP monitoring devices and the Spiegelberg ICP monitor are the emerging technology in invasive ICP monitoring, optic nerve sheath diameter measurement, venous opthalmodynamometry, tympanic membrane displacement, tissue resonance analysis, tonometry, acoustoelasticity, distortion-product oto-acoustic emissions, trans cranial doppler, electro encephalogram, near infra-red spectroscopy, pupillometry, anterior fontanelle pressure monitoring, skull elasticity, jugular bulb monitoring, visual evoked response and radiological based assessment of ICP are the non-invasive methods which are assessed against the gold standard.     

Management of External Ventricular Drains During Intrahospital Transport for Radiographic Imaging

Critically ill patients with brain injury often need intracranial pressure (ICP) monitoring. The two most common methods of ICP monitoring are via an external ventricular drain (EVD) catheter and via an intraparenchymal fiberoptic catheter. In addition to ICP monitoring, an EVD has the additional advantage of being able to treat hydrocephalus or lower elevated ICP by cerebrospinal fluid drainage. In addition to ICP monitoring, frequent radiographic imaging is also considered to be a fundamental component of neurological multimodal monitoring. As such, patients with EVDs often require intrahospital transport for advanced imaging. There are currently no national or international standards guiding intrahospital transport to and from the radiology suite. We use a fictional case to describe practice patterns and variations that may improve care of the patient with EVDs during transport to radiology. The fundamentals for ICP monitoring are highlighted, and an emphasis is placed on clear and concise communication.     

Comparison of nurse and computer recording of ICP in head injured patients

The importance of intracranial pressure monitoring in management and study of the head-injured patient is clearly recognized by the clinician responsible for intensive care. However, in many institutions studies requiring quantitative measures of ICP in head-injured patients are limited by lack of sophisticated computer monitoring equipment. In this study we tested the ability of the nurse to describe ICP course by manual record and compared these results with an on-line computerized ICP monitoring system. The nurse recorded a single "end-hour" value of ICP from the bedside monitor while the computer averaged 720 data samples of ICP during the hour. Our results obtained from five head-injured patients undergoing ICP monitoring showed 55% of the 347 data points had a difference in ICP of 0.01 to 3.0 mm Hg and 38% differed between 3.01 and 6 mm Hg. In comparison, 84% of nurse observations were within 6 mm Hg. Comparison of the temporal course of nurse and computer ICP values combined with the frequency distribution of error data indicates the nurse "end-hour" value is a reasonable estimate of the patient's mean ICP for the entire hour as measured by the computer. Nurses can now ask questions regarding various aspects of a patient's ICP course and compare data with other groups as long as the method of data collection is defined in the same manner.     

Intracranial pressure monitoring and assessing intracranial compliance in brain injury

Caring for the patient with a brain injury is a dynamic process with the goal of providing therapy to prevent secondary injury. Until practitioners have a better understanding of the pathophysiology of ischemia and the response of therapies for treating increased ICP, they must use the tools that exist. ICP monitoring gives a rough index of the relationships and the response of the intracranial contents to changes in volume that may produce increases in pressure and further damage. Understanding the information supplied by ICP monitoring is imperative to successful management of increased ICP.     

Intraoperative non invasive intracranial pressure monitoring during pneumoperitoneum: a case report and a review of the published cases and case report series

Non-invasive measurement of ICP (nICP) can be warranted in patients at risk for developing increased ICP during pneumoperitoneum (PP). Our aim was to assess available data on the application of nICP monitoring during these procedures and to present a patient assessed with an innovative combination of noninvasive tools. Literature review of nICP assessment during PP did not find any studies comparing different methods intraprocedurally and only few studies of any nICP monitoring were available: transcranial Doppler (TCD) studies used the pulsatility index (PI) as an estimator of ICP and failed to detect a significant ICP increase during PP, whereas two out of three optic nerve sheath diameter (ONSD) studies detected a statistically significant ICP increase. In the case study, we describe a 52 year old man with a high grade thalamic glioma who underwent urgent laparoscopic cholecystectomy. Considering the high intraoperative risk of developing intracranial hypertension, he was monitored through parallel ONSD ultrasound measurement and TCD derived formulae (flow velocity diastolic formula, FVdnICP, and PI). ONSD and FVdnICP methods indicated a significant ICP increase during PP, whereas PI was not significantly increased. Our experience, combined with the literature review, seems to suggest that PI might not detect ICP changes in this context, however we indicate a possible interest of nICP monitoring during PP by means of ONSD and of TCD derived FVdNICP, especially for patients at risk for increased ICP.     

Investigation of an outbreak of nosocomial infection due to methicillin-resistant Staphylococcus aureus (MRSA) in the surgical ward of Tokyo Metropolitan Fuchu Hospital

Our hospital, a 756-bed non-teaching general hospital, acts as a tertiary ambulatory center and has an 89-bed surgical ward. The present study is concerned with how the presence of an infection control practitioner (ICP) affects the results of infection control. Methicillin-resistant Staphylococcus aureus (MRSA) nosocomial infections (according to the definitions of nosocomial infections) of the Centers for Disease Control and Prevention in the surgical ward were retrospectively studied in two periods: from February 1989 to June 1990 and from January 1992 to December 1994. Infection control procedures were established in November 1989 when the surgical ward was transferred to a new building. An ICP was present from November 1989 to June 1990, and from July 1993 to December 1994 and supervised infection control so that the infection control procedures were uniformly practiced by all staff in the surgical ward. After the appointment of the ICP, the infection rate per 100 admissions decreased from 3.2 to 1.2 (P < 0.05) in the first period and from 2.5 to 1.7 in the second period. After the appointment of the ICP, the infection rate per 1000 patient days decreased from 1.11 to 0.49 in the first period and from 1.00 to 0.67 in the second period. Hospital stay periods for patients with the same enterotoxin and coagulase types overlapped in 16 patients in the absence of the ICP and in 4 patients in the presence of the ICP, respectively, in the first period. The present study suggested that infection rates decreased in the presence of an ICP. Received: July 13, 1998 / Accepted: December 21, 1998     

Intracranial pressure monitoring and case mix-adjusted mortality in intracranial hemorrhage

OBJECTIVE: Intracranial pressure (ICP) monitoring is frequently used in intensive care treatment of patients with intracranial hemorrhage. Data demonstrating an improved outcome from this intervention are lacking. We analyzed standardized mortality ratios in patients with and without ICP monitoring to determine its efficacy. DESIGN: A nonrandomized study of case records of consecutively admitted intensive care unit (ICU) patients with intracranial hemorrhage. SETTING: General and medical ICU of a 900-bed tertiary-care hospital. PATIENTS: A total of 225 patients with intracranial hemorrhage (mainly nontraumatic) admitted consecutively between April 1997 and March 2000. MEASUREMENTS: Simplified Acute Physiology Score (SAPS) II, diagnosis, age, sex, use of ICP monitoring, and in-hospital mortality rates were collected from the hospital's ICU database. Expected mortality was provided by means of SAPS II. Standardized mortality ratios were calculated and compared in 119 patients with ICP monitoring and 106 patients without ICP monitoring. MAIN RESULTS: The case mix-adjusted hospital mortality in the group with ICP monitoring was in the expected range (standardized mortality ratio, 1.09 [95% confidence interval (CI), 0.87-1.31]). Patients without ICP monitoring had a significantly higher standardized mortality ratio than expected (1.26 [95% CI, 1.06-1.46]). CONCLUSIONS: A beneficial effect of ICP monitoring in patients with intracranial hemorrhage may be reflected in an improved standardized mortality ratio.     

Analysis of intracranial pressure

Methods for the acquisition and analysis of intracranial pressure (ICP) signals are reviewed from clinical and technical perspectives. The clinical importance of ICP monitoring is presented, and methods for ICP transduction are briefly discussed. These methods include intraventricular catheters, subarachnoid screws, epidural techniques, and the new fiberoptic ICP measurement systems. Approaches to the visual analysis of the ICP waveform are presented, with special emphasis on the relationship between the ICP waveform and the arterial blood pressure signal. Methods of computer-based ICP analysis are also reviewed, including histogram and systems analysis methods. Methods to predict ICP pressure rises and to estimate intracranial compliance are also discussed. Finally, ICP monitoring is reviewed from the point of view of patient outcome. It is concluded that advanced ICP waveform analysis methods warrant further clinical evaluation to demonstrate their clinical usefulness.     

Analysis of intracranial pressure

Methods for the acquisition and analysis of intracranial pressure (ICP) signals are reviewed from clinical and technical perspectives. The clinical importance of ICP monitoring is presented, and methods for ICP transduction are briefly discussed. These methods include intraventricular catheters, subarachnoid screws, epidural techniques, and the new fiberoptic ICP measurement systems. Approaches to the visual analysis of the ICP waveform are presented, with special emphasis on the relationship between the ICP waveform and the arterial blood pressure signal. Methods of computer-based ICP analysis are also reviewed, including histogram and systems analysis methods. Methods to predict ICP pressure rises and to estimate intracranial compliance are also discussed. Finally, ICP monitoring is reviewed from the point of view of patient outcome. It is concluded that advanced ICP waveform analysis methods warrant further clinical evaluation to demonstrate their clinical usefulness.     

Head trauma: comparison of infection rates for different methods of intracranial pressure monitoring

This article describes a study comparing the rates of infection for three different methods of intracranial pressure (ICP) monitoring. Case summaries of infected patients are presented. Maintenance of sterile technique by medical and nursing staff caring for the monitoring system is emphasized.     

Monitoring of intracranial pressure in patients with severe traumatic brain injury: an Austrian prospective multicenter study

OBJECTIVE: The goals of this study were to elucidate reasons why patients did or did not receive intracranial pressure (ICP) monitoring and to describe factors influencing hospital mortality after severe traumatic brain injury (TBI). DESIGN: Prospective multicenter cohort study. PATIENTS AND PARTICIPANTS: 88,274 patients consecutively admitted to 32 medical, surgical and mixed Austrian ICUs between 1998 and 2004. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: 1,856 patients (2.1% of all ICU admissions) exhibited severe TBI (GCS < 9); of these, 1,031 (56%) had ICP monitoring. The "worst" and the "best" cases were both less likely to receive ICP monitoring. Younger patients, female patients, and patients with isolated TBI were more likely to receive ICP monitoring. Compared with large centers ICP was monitored more frequently [odds ratio (OR) 3.09, CI 2.42-3.94] in medium-sized centers. The 20% of patients with the highest likelihood to receive ICP monitoring were monitored in 91% of cases, and had the lowest hospital mortality (31%, OR 0.78, CI 0.37-1.64). Multivariate analysis revealed that severity of illness, TBI severity, isolated TBI, and the number of cases treated per year were associated with hospital outcome. Compared with the large centers, ORs for hospital mortality were 1.85 (CI 1.42-2.40) for patients from medium-sized centers and 1.91 (CI 1.24-2.93) for patients from small centers. CONCLUSIONS: ICP monitoring may possibly have some beneficial effects, but this needs further evaluation. Patients with severe TBI should be admitted to experienced centers with high patient volumes since this might improve hospital mortality rates.     

超声测量视神经鞘直径预测颅内压增高的围手术期应用进展

视神经鞘(ONS)是颅内硬脑膜的直接延续,内有横梁式的蛛网膜下腔。当患者颅内压(ICP)升高时,脑脊液会经蛛网膜滤出使视神经鞘增宽,因此可以用视神经鞘直径(ONSD)预测ICP增高。目前,围手术期ICP监测手段较少,超声测量ONSD预测ICP的技术因具有无创、床旁、快速等优势在临床上被广泛应用,将该技术应用于围术期患者中可以提供术中ICP监测。本文就ICP监测现状、ONSD与ICP的关系、ONSD预测ICP增高的临界值及ONSD预测围术期ICP增高的应用前景作一综述,以期为围手术期应用超声测量ONSD预测ICP增高提供支持。     

Intracranial pressure monitoring: technical imperatives

Intracranial pressure (ICP) monitoring provides extremely important information that is helpful in detecting intracranial hypertension and guiding therapeutic interventions that attempt to control this pathologic condition. This article reviews the purpose and rationale for monitoring ICP. Commonly used ICP monitoring systems are described, including their advantages, limitations, and nursing implications. This article also explains how to interpret ICP, ICP waveforms, and cerebral perfusion pressure. In addition, it addresses the application of data retrieved from ICP monitoring to clinical nursing practice and implications for nursing research.     

无创颅内压监测

无创颅内压监测是神经危重症研究的重要方面,有助于指导疾病诊治,同时避免传统有创监测的风险和不足。目前无创颅内压监测主要通过脑血流监测、颅内压间接传导检测、神经电生理监测、脑代谢监测等方法实现,本质是检测颅内压变化引起的间接表现,如脑血流、组织结构形态、神经元电活动的改变。目前这些方法均无法准确可靠地测量颅内压,更理想的无创监测手段还需要进一步探索。     

颅内压监测在颅脑损伤患者中的应用与护理

目的探讨经颅内引流管行颅内压（ICP）监测对颅脑损伤疾病治疗的应用价值与护理。方法对2009年2月至2011年1月入住ICU的因颅脑损伤已行颅内引流术的患者,在常规监护、治疗基础上,在颅内引流管外侧端接三通管,行ICP监测。对ICP〉2.0 kPa者予加强脱水,ICP〈0.5 kPa者提高引流袋水平,减少脱水剂用量及使用时间。结果共53例患者行ICP监测,死亡6例,死亡率11.32%;较同期未行ICP监测病例死亡率26.53%明显下降。监测结果及表现图谱与病程发展相符。结论颅脑损伤术后患者经颅内引流管行ICP监测操作简便,达到ICP监测技术要求,具有明显的临床意义。     

重型颅脑损伤头CT图像计分与颅内压及预后的关系

目的明确头CT图像计分与重型颅脑损伤患者颅内压及其预后的关系。方法重型颅脑损伤患者96例,于入院时即行颅内压监测,并于伤后24小时行头CT平扫,测量CT图像并计分,于伤后3个月对每例患者行格拉斯哥预后评分(GOS),将CT图像计分分别与ICP数值、GOS对照、比较,以进一步明确头CT图像计分与颅内压及预后的关系。结果头CT图像计分越高,颅内压升高越明显,患者预后越差,生存质量越低。结论头CT图像计分能较好地估计颅内压,并可指导治疗,判断预后。     

Ocular sonography in patients with raised intracranial pressure: the papilloedema revisited

Invasive devices are recommended for the early detection of raised intracranial pressure (ICP) after severe traumatic brain injury. Owing to contraindication or local issues, however, invasive ICP monitoring is not always possible. Moreover, a significant proportion of moderate traumatic brain injury patients (managed without invasive ICP) will develop raised ICP. Reliable noninvasive ICP techniques are therefore needed. Soldatos and colleagues report the usefulness of ocular sonography in the diagnosis of raised ICP. Focusing on cerebrospinal fluid accumulation around the retrobulbar optic nerve, they show interesting results for the optic nerve sheath diameter in the diagnosis of raised ICP. If confirmed by further studies, and despite important limitations related to sonography, this technique could serve as a screening test in patients at risk for raised ICP, when invasive monitoring is not possible or is not clearly recommended.     

Jugular bulb catheterization does not increase intracranial pressure

Cerebral venous monitoring through jugular bulb catheterization (JBC) allows assessment of global oxygen delivery adequacy. Because of concern that venous obstruction by catheterization may cause or exacerbate intracranial hypertension, physicians are reluctant to puncture this vessel in brain-injured patients. We evaluated the impact of JBC on intracranial pressure (ICP). 37 consecutive pediatric patients with jugular bulb catheters and ICP monitoring were studied. ICP was monitored in 28 patients during JBC. Also immediately after JBC and daily thereafter the contralateral, ipsilateral, and bilateral jugular veins were compressed in all 37 patients to assess patency of these vessels. Change in ICP was noted. If ICP increased more than 5 torr, compression was stopped. Preinsertion ICP was 17.3±5.1 and postinsertion 17.2±5.1 torr. The maximum rise in ICP was 2 torr in a single patient while 6 others had a decrease in ICP. 120 compression tests were performed. Compression ipsilateral to the catheter caused the ICP to rise from 16.0±4.3 to 18.4±4.4 torr, and in contralateral compression 15.9±4.2 to 17.0±4.4. Neither the duration of catheterization nor the precompression ICP correlated with the rise in ICP. These data revealed no evidence of jugular venous obstruction in the catheterized vessel. We conclude that JBC can be performed in patients without aggravating and elevated ICP.This study was made possible by a generous grant from the Christopher C. Tackett, Jr. Memorial Research fund