Presentation Cerebral Resuscitation

7/29/2019 Presentation Cerebral Resuscitation.

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ICU TUTORIAL BYSN FLORA &

SN SONI


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Brain volume 1400ml-1500ml (80%)Blood volume 150ml (10%)

CSF volume 150ml (10%)

According to MONRO-KELLIE HYPOTHESIS :Intracranial vault is an enclosed space. Whenthe volume of any of these componentsincreases, one or both of the othercomponents must decrease proportionally orthere will be an increase in ICP.


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Intracranial pressure (ICP) is the pressure that is produce bythe three component in the intracranial vault.

Normal ICP is less than15mmHg

Cerebral perfusion pressure (CPP)is a pressure at whichthe brain tissue is perfuse and is used to estimate anadequacy of cerebral blood flow.

CPP = MAP ICP. MAP = SBP+2DBP/3

Normal CPP is 60- 100mmHg.

IfCPP less than 60mmHg will cause hypoperfusion and

cerebral ischemia. IfCPP more than 150mmHg will disrupt the blood brain

barrier and cause hyperperfusion and potential for cerebraledema.


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Brain matterCerebral oedema due to trauma, meningitisSpace occupying lesion, eg. Tumour/ hematoma,

arteriovenous malformation

Cerebrospinal fluid

Hydrocephalus due to obstruction or reducedabsorption .

Cerebral blood volumeSevere hypertension

Increase cerebral blood flow eg. Hyperthermia,increased metabolic rate.

Vasodilatation due to hypoxia, hypercarbia, acidosis

Venous congestion


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Impaired cerebral

blood flowCerebral ischemia

Further increased

In ICPCerebral oedema

Originalcause of

raised ICP


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1. Compromised cerebral blood flow

2. Worsening cerebral insult and ischemia

(irreversible if prolonged)

3. Compensatory hypertension worsening

cerebral hemorrhage

4. Conning (brain matter push out fromforamen magnum

5. Death


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Symptom :

Headache Vomting

Photophobia

Decrease or absent of reflexes e.g cough gag, corneal reflex.

Sign : Neck stiffness

Reduced GCS

Focal neurology

Papilooedema

Cushings sign :increase SBP, widened pulse pressure,bradycardia, temp: hyperthermia, ICP >15mmHg, respiration:cheyne stokes ( tachypnoea slowly apnea)
http://www.medicinenet.com/encephalitis_and_meningitis/article.htmhttp://www.medicinenet.com/aches_pain_fever/article.htmhttp://www.medicinenet.com/headache/article.htm


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Cerebral resuscitation also known as cerebralprotection.

Cerebral resuscitation are measures taken to maintaina normal ICP of 5-15mmHg and as well protect thebrain from secondary brain injury.

Secondary brain injuries that occur after initial injuryexample as a result of hypoxemia/ hypovolemia/hypotension, hypocapnia/ hypercapnia, hyperthermia,

hypoglycemia, cerebral edema or cerebral ischemia.

This is to protect the brain from getting further insultand rise to further neurological deficit.


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Nursing interventions for cerebral resuscitation.

1. Maintain adequate oxygenation and ventilation.

2. Maintain proper head positioning.

3. Prevent valsalva maneuver

4. Suctioning.

5. Prevent unnecessary auditory stimuli.

6. Limit pain stimuli.

7. Prevent seizures.

8. Maintain normothermia.

9. Maintain euvolemia (adequate blood volume).

10. Blood pressure control.

11. Osmotic diuretic as prescribed.12. Decrease metabolic requirement of the brain.

13. Maintain normoglycemia .


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1. Maintain adequate oxygenation and ventilation.

Maintain patent airway by intubation andventilation if patient is unable to maintain patentairway or when GCS 8/15.

Monitor ABG to keep PaCO2 between 35-

45mmHg ; PaO2 80-100mmHg (>60mmHg) Rationale : PaCO2< 30mmHg will cause

vasoconstriction and lead to cerebral ischemia.

Rationale : PaCO2 >45mmHg will dilate the blood

vessel and will lead to cerebral edema. PaO2


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2. Maintain proper head positioning.

Elevate HOB to 30 degrees except inspine/cervical injury.

Maintain neutral alignment of head and neck .

Avoid overextension and over flexion of head. Ensure that trachy ties or cervical collar are not

too tight.

Avoid extreme hip flexion. Rationale : to promote venous return that can

reduce ICP.


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3. Prevent Valsalva Maneuver

Avoid Valsava maneuver e.g. constipation or

straining, coughing and muscle flexion.

Because it will increase the intra thoracic

pressure and intra abdominal pressure which

will increase intra cranial pressure.

Do log roll when turning patient.


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4. Suctioning.

Suctioning only when needed.

To Prevent Isometric Exercise- eg: give IV Fentanyl before suctioning or anyprocedure

Limit each suction episode to


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5. Prevent unnecessary auditory stimuli.

Maintain a quiet, relaxing environment

Decrease external stimuli in the room as light

or noise.

Limit visitors if appropriate and encourage

them talk quietly with patient and try to keep

conversation as non stressful as possible for

patient.

Minimize vigorous activity by assisting ADL.


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6. Limit pain stimuli

Use only those stimuli required to elicit aresponse during neurological assessment

Perform neurological assessment at specified

intervals Limit painful procedures e.g. insertion if IV lines.

Plan nursing care so patient have adequate rest.

Avoid tension on tubes- CBD Rationale : to prevent increase ICP


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7. Prevent seizures.

Administer anticonvulsant therapy to decreased the

cerebral metabolism.-Prophylactic anticonvulsant e.g. IV Phenytoin.

Calcium Antagonist ( Nimodipime )- for subarachnoid haemorrhage to reduce cerebralspasm

Treatment Of Epilepsyeg. Diazepam or Phenytoin- control seizures to reduce cerebral metabolic rate

Steroids eg. Dexamethasone

- for brain tumour- reduce cerebral oedema


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8. Maintain normothermia

monitor body temperature as required;4hourly

Administer antipyretic if temperature >37.5C.

Tepid sponging if temperature>38C

Avoid shivering rewarming blanket if temp.


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9. Maintain euvolemia (adequate blood volume).

Keep CVP 7-10mmhg

Monitor intake and output chart accurately

Administer isotonic fluid for infusion Avoid D5% as it will increase risk of cerebral

edema.

Administer blood and blood product if theresignificant blood loss/ hemorrhage.


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10. Blood pressure control

Hypotension is directly related to cerebral ischemia

Maintain MAP>90mmHg at all times with CPP>60 -150mmHg

Hypotension should be treated with fluid bolus (fluid challenge) orvasopressor e.g. infusion Noradrenaline to keep MAP>90mmHg.

Do not omit/ stop IV nimodipine simply. It is used to prevent braindamage caused by reduced blood flow to the brain resulting from

aneurysm, a dilated or ruptured blood vessel in the brain. Control of blood pressure will maintain an adequate cerebral

perfusion pressure (CPP)

CPP = MAP - ICP

If hypertension SBP> 170mmHg, titrate accordingly vasopressor.

Administer calcium channel blocker e.g T. Amlodipine to control Bp.


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11. Osmotic diuretic as prescribed

E.g mannitol 20% hypertonic saline 3 to 5 % IV

to pull fluid from the swollen brain into the

plasmadecrease intracranial volume, reduce

cerebral edeme and decrease ICP

Strict I/O charting, monitor for in crease water

& electrolyte imbalance.

osmotic diuretic ( Mannitol 20% )

loop diuretic ( Frusemide )


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12. Decrease metabolic requirement of the brain.

Sedation to reduce anxiety iv midazolam orpropofol

Keep GCS 2+T/15, Rikers sedation -3 for 24-

48hours for cerebral resuscitation. Analgesia to reduce pain e.g. morphine but

IV fentanyl is the best choice if patient is

hemodynamicaly unstable.

Rationale; anxiety, restlessness and pain will

increase metabolic demand and increase ICP


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13. Maintain Normoglycemia

Cerebral tissue need glucose for the source of

energy and about 20% is utilize by the cerebral.

Maintain blood glucose 4-6mmol/L and monitor

every 4hours.

Administer insulin accordingly to sliding scale

Rationale: maintain normal glucose levels to

avoids raising cerebral metabolism. If bloodglucose >7mmol/L will cause further cerebral

edema due to osmosis.


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Component of Triple H are:

HYPERVOLAEMICHPERTENSIVE

HEMODILUTION


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About 20% neuro patient experience vasospasmits

narrowing of blood vessels response to irritation fromblood accumulating in the subarachnoid space.

This makes it harder for nutrient and O2 to reach therest of the brain and if vasospasm persistent, it can

result in another strokes. This condition can be treated with Hypertension,

Hypervolemic, Hemodilutiontherapy commonlyknown as Triple H.

Triple H therapy is combines with intravenousmedication and large volume of intravenous fluids toelevate the BP, increase blood volume and thin theblood, driving blood flow through and around affectedvessels esp. in the cerebral.


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The fluids is used to achieve volume expansion

which is increase the volume status may

increases cardiac output, when the Bp isincrease thereby increasing cerebral blood

flow in the ischemic areas.

Patient hydration must be achieve andmaintain.


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Hypertension is achieved simply with volume

expansion when patient enough hydration, but

vasoactive drug eg. Dopamine/ Noradrenaline

may use to maintain a desire level of

hypertension to keep MAP >90 or SBP 140-

160mmHg.

So that increase of cerebral blood flow (CBF) andcerebral perfusion pressure (CPP) can be achieve.


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Hemodilution is the most controversial

component of triple H.

In hemodilution, must achieve a hematocrit of

30-35% , because is believe to be a reasonable to

compromise between O2 carrying capacity.

This treatment is maintance the high circulatingblood volume and increase perfusion pressure

and decrease blood viscosity in the cerebral.


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REFERENCE

1. Dennison R>D 2007. PASS CCRN, third edition chapter 7 : theneurologic system and disorder. by Elsiever Mosby.

2. Dessmon YH Tai Thomas WK Lew and Loo Shi. Bedside ICUHandbook 2nd edition. (2007)

3. Susan F. Wilson, RN, PhD, AORN, FND and Jean Foret Giddens, RN,

PhD, AORN, FND. Health Assesment for Nursing Practice andProtocol third edition (2009.)

4. www.medscape.Com/viewarticle/553110_2 : current and futuremedical theapies for cerebral resuscitation.-Neurosurgery focus2006 by J. Mocco,MD,Brad E. Zacharia, BS, Ricardo J. Komator,MD, E. Sander Connoly Jr., MD

5. allnurses nurses.com//triple-h-therapy-348846 : Triple H therapyneuro Intensive Care.


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EVERYONE HAS A ROLE IN MANAGING

PATIENT WITH RAISED ICP

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Presentation Cerebral Resuscitation