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Nursing Interventions and Intracranial Pressure: A Literature Review

Nursing Interventions and Intracranial Pressure: A Literature Review. Laura Genzler, BSN, CCRN PhD Graduate Student, U of MN Abbott Northwestern Hospital. Objectives. Describe cerebral hemodynamics and the pathophysiology related to increased intracranial pressure (ICP)

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Nursing Interventions and Intracranial Pressure: A Literature Review

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  1. Nursing Interventions and Intracranial Pressure: A Literature Review Laura Genzler, BSN, CCRN PhD Graduate Student, U of MN Abbott Northwestern Hospital

  2. Objectives • Describe cerebral hemodynamics and the pathophysiology related to increased intracranial pressure (ICP) • Identify the impact of nursing interventions on ICP • Be able to integrate knowledge of how nursing interventions can impact ICP in patients with a neurologic diagnosis

  3. Prevalence & Cost Neurological Injury • STROKE • 4th leading cause of morbidity & mortality in U.S. • #1 cause severe long-term disability • $18.8 billion cost of care stroke survivors • $15.5 billion cost lost productivity & premature mortality • TRAUMATIC BRAIN INJURY • Major cause of morbidity and mortality in children and young adults • 70,000-90,000 people with permanent neurological impairment yearly • $40 billion yearly cost to society due to disability

  4. Intracranial Pressure • Monroe-Kellie Hypothesis: The skull is a rigid compartment and if the volume of one component rises another must decrease to maintain equilibrium • 80% Brain Parenchyma • 10% Cerebral Spinal Fluid (CSF) • 10% Cerebral Blood

  5. Cerebral Hemodynamics • Brain Parenchyma: minimal volume changes • CSF • Able to displace CSF from the ventricular system in brain to the lumbar cistern at the base of the spine • Able to  CSF reabsorption in the presence of ↑ intraventricular pressure • Able to  CSF production in the presence of ↑ intraventricular pressure

  6. Cerebral Hemodynamics • Cerebral Blood Flow (CBF) Autoregulation • Arterioles dilate or constrict in response to changes in the brain’s metabolic needs, systemic blood pressure or intracranial pressure. • The vessel diameter and the total cerebral blood volume both influence the pressure within the skull.

  7. Intracranial Compliance • Intracranial Compliance: • Ability of brain to tolerate increases in intracranial volume without a significant increase in intracranial pressure

  8. Intracranial (ICP) Monitoring • Bolt • Continuous • Ventriculostomy • Gold Standard • Drainage • Intermittent Cerebral Pulse Pressure (CPP)= MAP – ICP CPP>60-70 mm HG

  9. ICP Waveform

  10. Goal: Minimize Secondary Injury • Secondary Injury: Damage to the brain after the initial injury • Hypoxia • Hypercapnia/Hypocapnia • Hyperthermia • Hypoglycemia/Hyperglycemia • Anemia • Intracranial Hypertension • Vasospasms • Mass Effect

  11. Suctioning • Hyperventilation • PEEP • Pre-oxygenation • Cough/Suction • Open vs. Closed system suctioning (Campbell, 1991)

  12. Hyperventilation • ↑CO2= ↑CBF=↑cerebral blood volume =↑ICP (Hickey, 2009) • CO2 Potent Vasodilator • ↓CO2 can cause rapid vasoconstriction & ↓ICP • Aggressive hyperventilation (PaCO2 = 25 mm HG) can lead to ↓CBF to point of ischemia • Target level PaCO2 30-35 mm Hg: Transient impact • TBI patients have lowest CBF in 1st 24 hrs. Avoid PaCO2 < 35 mm Hg. • ↓O2 does not increase cerebral vasodilatation until ≤ 50 mm Hg • Pre-oxygenate before & after suctioning

  13. PEEP • Intrathoracic Pressure↑, ↑central venous pressure, ↑ ICP • Respiratory Rate & ambu bag synchronous • Ambu bag: Volume matters ( Campbell, 1991; Kerr, 1997)) • PEEP≤5 • ↑PEEP needed? • Monitor if ↓MAP as ↑PEEP = sign CPP influenced by PEEP

  14. Suctioning • Suction/Cough • Endotracheal Lidocaine (Billotti et al., 2008) • Small Sample n=41, Study Design Issues • Instilling lidocaine can initiate cough • Open vs. Closed Suctioning (Ugras, 2012) • Both methods ICP significant statistically > immediately post suction • ICP open suction > closed suction (p<.05) • All data points: B/4, immediate after, 5” & 15” post suction

  15. Ventilation • Hyper-oxygenate prior to suctioning • Keep suctioning time to 15 seconds or less • Space suctioning passes • Closed suction method over open • Lidocaine has potential to limit impact suctioning on ICP • Monitor for synchronous respirations on ventilator or ambu bag • Careful & limited hyperventilation

  16. Head Positioning • Keep head and neck midline with no forward, posterior or lateral flexion (Mitchell, Ozuna, & Lipe, 1981, sulllivan, 2000) • Promote venous drainage • Promote CSF flow • Use towels, pillows, soft collars: limit neck pressure

  17. Positioning • Repositioning (March, Mitchell, Grady, &, Winn, 1990; Hugo, 1990, Jones, 1994; Sullivan; 2000; Fan, 2004; KHckey, 2009) • Action causes ↑ICP • Hip Flexion • Intra-abdominal pressure • Head of Bed • Older studies: elevate HOB • TBI: HOB elevated preferred • Ischemic CVA • Lower head position? (Wosner et al, 2002) n=11 • Individualize & Monitor ( Ledwith et al.,2010) Absence of Monitor • HOB 30○ & knees slight elevated

  18. Positioning • Body Positions • Trendelenburg always contraindicated • Prone: ↑ intra abdominal & thoracic pressure, neck flexed • No single position reliably ↑PbtO2, ↓ ICP, ↑ CPP (Ledwith et al., 2012) • Lateral positions PbtO2 trended ↓ • Left lateral jugular vein anatomically smaller than R, easier to compress (Hugo, 1992) • No Universal Guidelines • Position impact Outcomes? • Individualize Care

  19. Interventions • Chest Percussion per Bed • May not impact ICP (Olson, 2009) • Oral Care • Does not seem to adversely impact ICP (Pendergast et al, 2009) • Mechanical or electric toothbrush (Pendergast, Hasell, Hallberg, 2011) • Touch/Talk ( Mitchell & Habermann, 1999; Treloar et al, 1991; Walker et al, 1997; Mitchell et al, 1985) • Non-procedure touch by nurse researcher • Touch & Talk by Family • Family Presence (Hendrickson, 1987; Hepworth, Hendrickson, Lopex, 1994) • Passive Range of Motion (Melhorn, 1997) • Other

  20. Clustered Care • Collective effect of multiple interventions can cause ↑BP, ↑CBF, & ↑ICP • Planned 10 minute rest periods did not significantly decrease ICP in clustered care (Bruya, 1981) • Clustered care-ICP longer to return to baseline (Bruya, 1981; Hugo, 1987; Snyder, 1983; rising 1983; Tsementzis, Harris & Loizou, 1982) • Older observational studies on interventions: clustered care confounder

  21. EtCO2 as a Measure of Physiologic Stress Response to Clustered Nursing Interventions in Mechanically Ventilated Neurological Patients (Genzler et al., 2013) Laura Genzler, BSN, RN & Sue Sendelbach, PhD, RN, CCNS Abbott Northwestern Hospital Pamela Jo Johnson, MPH, PhD & Neha Ghildayal, BSB Center for Healthcare Innovation, Allina Hospitals & Clinics Sarah Pangarakis, APRN BC, RN Methodist Hospital, Minneapolis, MN

  22. Background • Physiological stress increases metabolism and raises CO2 that acts as a vasodilator potentially increasing intracranial pressure (ICP) • Nurses cluster patient cares to allow for maximal rest among nursing interventions • Most nursing guidelines recommend clustering of nursing interventions to minimize patient stress

  23. Background • CO2 levels may be useful for monitoring changes in cerebral blood flow • Changes in end tidal carbon dioxide (EtCO2) level may help assess the number of cares a patient can tolerate before impacting cerebral blood flow

  24. Research Questions • Does clustering of nursing cares have a detrimental impact on neurological patients as measured by end tidal carbon dioxide (EtCO2)? • Does mean % change in EtCO2 differ significantly for those with clustered care compared with those without? • Are patients with clustered care significantly more likely than those without clustered care to exhibit a stress response?

  25. End Tidal Carbon Dioxide (EtCO2)

  26. Study Background • Human Subjects • Approved by the Allina Institutional Review Board • Time period of data collection • July 2009 through March 2010

  27. Methods • Study design • Prospective, descriptive, comparative design • Sample • Convenience sample of patients in the ICU with primary brain diagnosis such as stroke (ischemic or hemorrhagic), tumor, intracranial hemorrhage, subdural hematoma or subarachnoid hemorrhage • Mechanically ventilated <48 hours • Exclusion criteria: lung disorder (COPD, asthma, lung cancer, pneumonia, acute respiratory syndrome; non-English speaking, <18 years old; pregnant women

  28. Data Collection Methods • Patient characteristics from electronic health record • Sex, age, diagnosis • Clinical data from bedside monitors • Vital signs, EtCO2 • Study specific data collection form • Collected 4 to 6 times in a 24 hour period • Start/stop times of each nursing interaction • Types of nursing cares, vital signs, and EtCO2

  29. Key Measures • Dependent variable: Stress response • Defined as a 10% or more change in EtCO2 • Calculated % change (Δ) in EtCO2 from baseline • Δ5min = Pre-care to 5 minutes after starting • Δ10min = Pre-care to 10 minutes after starting • Δlast = Pre-care to end of nursing interaction • Δpost = Pre-care to 15 minutes after nursing interaction • Independent variable: Clustered cares • Defined as >6 cares in a single nursing interaction

  30. Analysis • Descriptive statistics • Characteristics of patients • Characteristics of nursing interactions • Mean changes in EtCO2 by clustering status • T-tests with unequal variance • Percent with stress response by clustering status • Chi-square (Fisher’s Exact) tests for categorical data

  31. Results and Discussion

  32. Results: Patient Characteristics (N = 15) • Gender • 7 males and 8 females • Age • Mean age = 54.3 years (SD = 21.7) • Range = 18 to 92 years • Diagnosis • 53.6% Bleed (n = 8) • 46.4% Tumor, status epilepticus, or multiple diagnoses (n = 7) • Nursing interactions per patient • Mean = 4.8 (SD = 0.83) • Range = 4 to 6

  33. Results: Nursing Interactions • 70 nursing interactions • 60 interactions with complete data • All analysis based on 60 with complete data • Cares per nursing interaction • Mean = 6.1 (SD = 1.5) • Range = 3 to 10 • Nursing interactions with clustered cares • 61.7% clustered cares • Length of nursing interactions • Mean = 32.8 minutes (SD = 15.6) • Range = 10 to 80 minutes

  34. Number of Cares per Interaction

  35. Types of cares most frequently performed during nursing interaction

  36. Results: Mean Change in EtCO2 • Mean % change in EtCO2 differed significantly for those with clustered care compared with not: • At 5 minutes in (6.7% versus 0.02%; p=0.001) • At end of interaction (5.5% versus 0.02%; p = 0.033)

  37. Results: Stress Response • Patients with clustered care were significantly more likely than those with low clustering to exhibit a stress response: • At 5 minutes in (24.3% versus 0%; p=0.01)

  38. Conclusions • Mechanically ventilated neurological patients who received >6 clustered cares experienced a higher mean change in EtCO2 compared to those who received <6 cares • Contrary to nursing guidelines that recommend clustered care to reduce stress, our findings suggest that providing fewer cares at one nursing interaction may minimize induced stress

  39. Limitations • Small sample size • Some substantial, clinically relevant differences were not statistically significant most likely due to sample size • Convenience sample • Subjects may not be representative of all mechanically ventilated neurological patients • Results may not be generalizable • Missing data • 10 interactions were eliminated due to incomplete data • Confounding variables • Analyses do not account for differences in interactions with clustered care and without clustered care • These differences may explain the changes in EtCO2 and the increased prevalence of stress response in the clustered care group

  40. Future Research • Further study with larger sample size • Neuro-diagnosis, GCS & APACHEIII • Identify which nursing cares cause more stress • Other measures of stress response • PbtO2 • SVO2

  41. Additional Intracranial Hypertension Factors • Pain • Noxious Stimuli • Tube manipulation • Painful procedures • Anxiety • Neurological Diagnosis & Baseline ICP • Increased Cerebral Metabolism • Arousal from sleep • REM phase of sleep • Seizure activity • Hyperthermia

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  43. References Hepworth, J T Hendrickson,S G Lopez, J. (1994). Time series analysis of physiological response during ICU visitation. Western Journal of Nursing Research, 16(6), 704-717. doi:10.1177/019394599401600608 Hickey, J. (2009). Intracranial pressure waveform analysis during rest and suctioning. Biological Research for Nursing, 11(2), 174-186. doi:10.1177/1099800409332902 Hugo M. (1987). Alleviating the effects of care on the intracranial pressure (ICP) of head injured patients by manipulating nursing care activities. Intensive Care Nursing, 3(2), 78-82. doi:10.1016/0266-612X(87)90029-0 Hugo, M. J. (1991). [The effect of various nursing procedures and of rest on the intracranial pressure of the head-injured patient].Curationis, 14(4), 1-3. doi:10.4102/curationis.v14i4.337 Hugo, M. (1992). Left or right, up or down: A case for positioning of unconscious head-injured patients.Curationis, 15(1), 1-7. doi:10.4102/curationis.v15i1.344 Jones, B. (1994). The effects of patient repositioning on intracranial pressure. Australian Journal of Advanced Nursing, 12(2), 32-39. Kerr, M. E. (1997). Effect of short-duration hyperventilation during endotracheal suctioning on intracranial pressure in severe head-injured adults. Nursing Research, 46(4), 195. doi:10.1097/00006199-199707000-00003 Ledwith, Mary Bloom, Stephanie Maloney Wilensky, Eileen Coyle, Bernadette Polomano,Rosemary Le Roux, Peter. (2010). Effect of body position on cerebral oxygenation and physiologic parameters in patients with acute neurological conditions. The Journal of Neuroscience Nursing, 42(5), 280-287. doi:10.1097/JNN.0b013e3181ecafd4 March, K Mitchell, P Grady,S Winn, R. (1990). Effect of backrest position on intracranial and cerebral perfusion pressures. The Journal of Neuroscience Nursing, 22(6), 375-381. doi:10.1097/01376517-199012000-00008 McNett, M. (2013). Evidence to guide nursing interventions for critically ill neurologically impaired patients with ICP monitoring. The Journal of Neuroscience Nursing, 45(3), 120-123. doi:10.1097/JNN.0b013e3182901f0a Mehlhorn, S. M. (1997). Effect of passive range of motion on intracranial pressure in neurosurgical patients. Journal of Critical Care, 11(4), 176-9.

  44. References Mitchell, P H Habermann Little, B Johnson, F VanInwegenScott,D Tyler, D. (1985). Critically ill children: The importance of touch in a high-technology environment. Nursing Administration Quarterly, 9(4), 38-46. doi:10.1097/00006216-198500940-00007 Mitchell, P H Ozuna, J Lipe,H P. (1981). Moving the patient in bed: Effects on intracranial pressure. Nursing Research, 30(4), 212-218. doi:10.1097/00006199-198107000-00006 Mitchell, P. H. H., B. (1999). Rethinking physiologic stability: Touch and intracranial pressure. Biological Research for Nursing, 1(1), 12-19. doi:10.1177/109980049900100103 Olson DM. (2009). Effect of mechanical chest percussion on intracranial pressure: A pilot study. American Journal of Critical Care, 18(4), 330-335. doi:10.4037/ajcc2009523 Prendergast V. (2009). Oral health, ventilator-associated pneumonia, and intracranial pressure in intubated patients in a neuroscience intensive care unit. American Journal of Critical Care, 18(4), 368-376. doi:10.4037/ajcc2009621 Prendergast V. (2011). Electric versus manual tooth brushing among neuroscience ICU patients: Is it safe?Neurocritical Care, 14(2), 281-286. doi:10.1007/s12028-011-9502-2 Price, Ann Collins,Timothy Gallagher, Alison. (2003). Nursing care of the acute head injury: A review of the evidence. Nursing in Critical Care, 8(3), 126-133. doi:10.1046/j.1478-5153.2003.00019.x Snyder, M. (1983). Relation of nursing activities to increases in intracranial pressure. Journal of Advanced Nursing, 8(4), 273-279. doi:10.1111/j.1365-2648.1983.tb00326.x Sullivan J. (2000). Positioning of patients with severe traumatic brain injury: Research-based practice. The Journal of Neuroscience Nursing, 32(4), 204-209. doi:10.1097/01376517-200008000-00003 Treloar, D M Nalli, B J Guin,P Gary, R. (1991). The effect of familiar and unfamiliar voice treatments on intracranial pressure in head-injured patients. The Journal of Neuroscience Nursing, 23(5), 295-299. doi:10.1097/01376517-199110000-00005 Ugras, G. (2012). The effects of open and closed endotracheal suctioning on intracranial pressure and cerebral perfusion pressure: A crossover, single-blind clinical trial. The Journal of Neuroscience Nursing, 44(6), E1. doi:10.1097/JNN.0b013e3182682f69

  45. References Walker, J S Eakes,G G Siebelink, E. (1998). The effects of familial voice interventions on comatose head-injured patients. Journal of Trauma Nursing, 5(2), 41-45. doi:10.1097/00043860-199804000-00006 Williams, A. C.,S M. (1993). Effects of neck position on intracranial pressure. American Journal of Critical Care, 2(1), 68-71. Winkelman, C. (2000). Effect of backrest position on intracranial and cerebral perfusion pressures in traumatically brain-injured adults. American Journal of Critical Care, 9(6), 373-80.

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