PAEDIATRIC ALTERED CONSCIOUS LEVEL GUIDELINE
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DELPHI PROCESS

Round one

11. Raised intracranial pressure

Statement 11a (Raised intracranial pressure recognition and initial management)

Intracranial pressure is related to cerebral perfusion pressure by the following equation:

Cerebral perfusion pressure = mean arterial pressure – intracranial pressure

% Agree	% Disagree	Result
93.9%	6.1%	Included

Position	Comments
PICU	It is CPP = mean BP – mean ICP
Neuro	This is an estimate of the CPP used in practice. It may not represent the CPP at the microvascular level.

Statement 11b

Raised intracranial pressure can be defined clinically by the presence of 2 or more of the following signs:

Reduced conscious level (being Unrousable or GCS < 9)

Abnormal pattern of respiration (hyperventilation, irregular ventilation or apnoeas)

Abnormal pupils (unilateral or bilateral dilated pupils or unreactive pupils)

Abnormal posture (decorticate or decerebrate posture or complete flaccidity)

Abnormal doll’s eye (oculocephalic) response or caloric (oculovestibular) response

% Agree	% Disagree	Result
83.3%	6.7%	Included

Position	Comments
Paed	Bradycardia and hypertension could be included ?
	There are other explanations for these findings
Neuro	These do not DEFINE ICP but certainly make it likely
ED P	Seems sensible, although I don’t know how many of the criteria you need
Neuro S	Several of the above could theoretically occur in brainstem ischaemia in the absence of raised ICP but this is unlikely in the paediatric age group
Endo	1. and one or more of the others
Paed	however not all signs may be present and clinical situation, eg trauma, may complicate picture
PICU	Abn of range of eye movement esp increase gaze may be more subtle early sign of raised ICP
Paed	caloric response not to be done by inexperienced doctors

Statement 11c

If raised intracranial pressure is suspected, then the child should undergo the following treatments:

(i) Position the patient’s head in the midline

% Agree	% Disagree	Result
86.7%	0%	Included

Position	Comments
ED P	May help, won’t cause harm!
ED	I’m not sure of the relevance of this – am I missing something? Isn’t that where we usually position the head??
Paed	Don’t know that but makes sense
PICU	may not always be easy to sustain

Statement 11c

If raised intracranial pressure is suspected, then the child should undergo the following treatments:

(ii) Angle the patient head up at 20 degrees above the horizontal

% Agree	% Disagree	Result
88.5%	0%	Included

Position	Comments
PICU	20-30 degrees
ED	If the child has sustained trauma, the spine should remain immobilised, ie the whole trolley should be at a slope of 20 degrees to the horizontal, not angled midway
ED	Outside my expertise and usually managed by PICU / Anaesthetists
PICU	10-30 deg advised from variety – difficult in active patient

(iii) Sedate, intubate and ventilate the patient to maintain the PaCO₂ between 4.0 and 5.0 kPa

% Agree	% Disagree	Result
64%	24%	Discussed in round 2

Position	Comments
Paed	Need lower co2
ED	I don’t know if there is a standard regarding sedating and ventilating.
Neuro	Not in all patients, certainly not in all suspected patients
Radiol	Yes but don’t know gas levels
Neuro S	4.0 – 4.5 would be my ideal
Endo	4.0-4.5?
Paed	BUT beware the DKA child with spontaneous pCO2 <2 – an increase to 4 precipitate coning
PICU	May be required. IC decision. PaCO2 4-4.5 initially

(iv) Sedate, intubate and ventilate the patient to maintain the PaCO₂ below 4.0 kPa

% Agree	% Disagree	Result
29.2%	66.7%	Excluded

Position	Comments
Paed	But should also define lower limit ? 3kPa to avoid people overdoing it
	hyperventilate only if other measures have failed to bring ICP down
Neuro	There is a danger of causing cerebral ischaemia
Neuro	not always necessary, do you want to measure the pressure first? Bolt?
Paed	Though this was too low now?
Neuro S	Too low risk ischaemia
Endo	?above 3.5 ie 3.5-4.5
Paed	BUT beware the DKA child with spontaneous pCO2 <2 – an increase to 4 precipitate coning
Paed	occasionally required acutely to reduce pressure

(v) the patient should be paralysed with muscle relaxing agents

% Agree	% Disagree	Result
60%	20%	Discussed in round 2

Position	Comments
PICU	only if tight control of C02 needed
Neuro	Depends on the situation; sometimes appropriate
Neuro	not always necessary
Neuro S	Not crucial initially
Endo	Need to observe movements if possible
Paed	in ICU setting
PICU	never routinely

-

(vi) Administer a dose of 1g / kg of intravenous mannitol

% Agree	% Disagree	Result
50%	19.2%	Discussed in round 2

Position	Comments
	depends on cause of raised ICP
Metab	0.5 Gm/kg IV
Neuro	Depends on response to other measures. Often appropriate, but certainly not always necessary
ED P	Not sure about dose (?0.5 g/kg) also some units prefer 3% saline
ED	If the child has an intracranial bleed amenable to surgical decompression and / or in consultation with a neurosurgical team
ED P	If proven, not just suspected
Neuro S	0.5g/kg probably adequate
Paed	D/W neurosurgeons
Paed	only if P.U.s
PICU	may be required but not automatically, often used with frusemide if given
Paed	I discuss with neurosurgeons/neurologists as various places have different policies
Neuro	If not in renal failure and intracerebral haematoma excluded; 0.25-0.5g may work just as well

(vii) Administer a dose of 5ml / kg of 3% sodium chloride (“hypertonic saline”)

% Agree	% Disagree	Result
25%	41.7%	Excluded

Position	Comments
PICU	if mannitol produced no response
Neuro	I don’t think the evidence base is strong enough to routinely recommend hypertonic saline
ED P	Cant remember dose
ED P	If proven, not just suspected
Paed	Never heard of it!
Neuro S	Not something I’ve seen used and don’t like the idea
Endo	Not in my experience
PICU	may be required. not usually both mannitol and 3% saline. duration of bolus if advised needs to be given. some would give over 60 mins other 180 mins

(viii) Maintenance fluid should be administered at 100% of normal

% Agree	% Disagree	Result
26.9%	50%	Discussed in round 2

Position	Comments
PICU	if normal saline used
Neuro	Depends upon the volume status of the child and the BP
Paed	it should be ideally 2/3 maintenance
ED	Depends on intravascular filling and hydration
ED P	May get SIADH
Neuro	Unless signs of being overloaded
Metab	Assuming shock has been treated by this stage…
Endo	If shock present?
PICU N	Yes, but need a lot more detail regarding why ICP raised
PICU	rarely 100% usual about 70%

Statement 11c

If raised intracranial pressure is suspected, then the child should undergo the following treatments:

(ix) Maintenance fluid should be administered at 70% of normal

% Agree	% Disagree	Result
68%	12%	Discussed in round 2

Position	Comments
	Occasinally less depenbding on other factors eg renal function
Neuro	Depends upon the volume status of the child and the BP
PICU N	need to maintain CPP therefore need to keep fluids at 100% initially
Paed	at maximum
Neuro S	Old fashioned
Endo	But supporting perfusion
PICU	usually

(x) Maintenance fluids should not be hypotonic

% Agree	% Disagree	Result
100%	0%	Included

Position	Comments
Neuro S	Ideally use saline/saline dex mix

(xi) Maintenance fluids should be 0.45% saline and dextrose (with 20 – 40mmol/l potassium if required) initially

% Agree	% Disagree	Result
34.8%	39.1%	Discussed in round 2

Position	Comments
PICU N	Need more patient details
Neuro	Depends upon the fluid status of the child

(xii) Maintenance fluids should be 0.9% saline (with 20 – 40mmol/l potassium if required) initially

% Agree	% Disagree	Result
62.5%	16.7%	Discussed in round 2

Position	Comments
PICU N	Need more patient details
Paed	Might need to add glucose especially for younger children
Neuro	monitor blood sugars, pending electrolyte results
ED	Depends on other local policies ie protocols for glucose/ stage of treatment reached

(xiii) Arrange for patient transfer to a paediatric intensive care unit

% Agree	% Disagree	Result
93.9%	3.0%	Included

Position	Comments
PICU N	If necessary - Need more details
Neuro	If intubated and ventilated yes
Endo	…with neurosurgical facility
Paed	Neurosugical centre with PICU
PICU	ideally

(xiv) Ensure the results of all the core investigations performed are reviewed, and consider further tests if the cause of the raised intracranial pressure is not diagnosed. (“core investigations performed” will be defined as the investigations agreed upon in Statement 7d; “further tests” will be defined as the investigations agreed upon in statements 7e)

% Agree	% Disagree	Result
100%	0%	Included

Position	Comments
PICU	time scale of results being available would help – with 30min reasonable

Statement 11d

Patients with suspected raised intracranial pressure should have invasive intracranial pressure monitoring performed if: (the mode of “invasive intracranial pressure monitoring” will be addressed later)

(i) the patient does not improve after initial intracranial pressure lowering measures have been implemented (“intracranial pressure lowering measures” will be defined by the treatments agreed upon in statement 11c)

% Agree	% Disagree	Result
63.6%	13.6%	Excluded

Position	Comments
Paed	Depends a little on availability
ED	seems appropriate but the evidence that monitoring alters outcome does not exist
Neuro	It very much depends on the cause of the raised ICP
ED P	This would be dealt with by centre we have referred to
ED P	If high suspicion
ED	Depends on cause
Endo	Ideally
PICU N	If severe enough – see neuro team
PICU	poor indication. no evidence to my knowledge

(ii) the patient has cerebral oedema on CT scan

% Agree	% Disagree	Result
35%	35%	Excluded

Position	Comments
Neuro	Depends on cause
ED P	This would be dealt with by centre we have referred to
Neuro	not if patient improves
PICU N	neuro team
Paed	Neurosurgeon
Neuro S	Depends on history/level of GCS/other scan findings eg GCS>10 with focal contusion and oedema may be best woken up to be assessed. Global oedema from asphyxia there may be no point in ICP monitoring a lethal brain injury
Endo	Not sure seeing it makes a difference
PICU	not an indication

(iii) the patient is hypertensive (a mean arterial pressure above the 95^th centile for age)

% Agree	% Disagree	Result
31.6%	42.1%	Excluded

Position	Comments
PICU	no
Endo	As CPP more difficult to assess
Paed	Neurosurgeon
ED P	Start antihypertensives
PICU N	neuro team
Neuro	not if patient improves
Neuro	I don’t think this is an important criterion for deciding on pressure monitoring

(iv) the patient has a raised plasma ammonia level

% Agree	% Disagree	Result
14.3%	42.9%	Excluded

Position	Comments
PICU N	neuro team
Neuro	dpends on the level…lower ammonia level first
Paed	?what
Neuro S	Depends on clinical condition
PICU	no

Statement 11e

(i) In the acute setting, the most appropriate method of monitoring intracranial pressure is by inserting :

(a) an intraventricular catheter

% Agree	% Disagree	Result
37.5%	62.5%	Excluded

Position	Comments
ED	I’m no expert but I think these are used
ED	allows access to CSF but is technically more difficult and risks further infection
Neuro	If the ventricles are dilated, it may be a reasonable approach
ED P	Would not be doing this
Neuro	Nice in theory – in practice expertise amongst junior neurosurgical staff (and indeed many consultants) minimal
Metab	Depends on the setting: this is what we have easiest access to, performed by either a general surgeon, or by a physician-neurologist
PICU	CATHETER THAT ALLOWS DRAINAGE OF CSF IS IDEAL
Neuro S	Invasive, infection risk, though accurate and allows therapeutic tapping of fluid
Neuro	Ventricle are often compressed making insertion difficult
PICU	may help esp if spaces drainable
Neuro	If the surgeon can get one in…

Statement 11e

(i) In the acute setting, the most appropriate method of monitoring intracranial pressure is by inserting :

(b) a subarachnoid screw or bolt

% Agree	% Disagree	Result
56.3%	31.3%	Excluded

Position	Comments
ED	depends on availability of kit and is technically easier
Metab	We don’t have easy access to neurosurgery, which isn’t on-site
PICU	AS CAN BE PERFORMED BY NEUROSURGEON OR INTENSIVIST ON PICU
Neuro	Parenchymal bolt
ED	I’m no expert but I think these are used
Endo	Only experience I have!
Neuro	No data
Neuro S	Old fashioned
PICU	“usual” method

(c) an epidural sensor

% Agree	% Disagree	Result
33.3%	50%	Excluded

Position	Comments
ED	potential risk of EDH if clotting is abnormal
Metab	Not available to us at this centre
Neuro	No data
Neuro S	But I think you mean subdural sensor as in Codman neurosensor (epidural placement is very inaccurate
PICU	not

(ii) In the acute setting, the choice of intracranial pressure monitoring device should be determined by the neurosurgeon performing the procedure

% Agree	% Disagree	Result
72%	0%	Excluded

Position	Comments
PICU	most in the UK now use intraparenchymal devices
Neuro	If he understands the physiology
Metab	In consultation with Paed neurol/intensivists and according to their individual experiences
Neuro S	Monitoring devices and compatibilities will vary from unit to unit
PICU	helped by guidelines!

Statement 11f

Patients with an intracranial pressure monitoring device in situ must also have invasive blood pressure monitoring to calculate the cerebral perfusion pressure

% Agree	% Disagree	Result
80%	0%	Included

Position	Comments
PICU	generally
Neuro S	In paediatric age range CPPs are less well researched than in adult
ED	Tho’ I have little experience of this I would support this
Neuro	This is good practice, but there is on going debate about whether ICP or perfusion pressure should be followed
Neuro	This is preferable but not essential
	seems sensible, but evidence that ICP monitoring effects outcome is awaited

Statement 11g

Cerebral perfusion pressure should be maintained above 60 mmHg with the PaCO₂ in the normal range

% Agree	% Disagree	Result
76.9%	0%	Included

Position	Comments
PICU N	For some patients PaCO2 at the lower end of normal is required to maintain stability
PICU	This value is age dependent
PICU	DEPENDS ON AGE OF CHILD
Neuro	The critical limits of CPP probably vary with age, but are unknown
Neuro	No data
Neuro	This is an appropriate level in older children but may be too high for younger children. It can be dangerous to drive the heart to hard and it may be better, in some circumstances to accept a lower perfusion pressure (say above 50). Ceratinly the Pa CO2 should be kept normal
Neuro S	Reasonable target for older kids. Bob Minns in Edinburgh (Royal Hosp for Sick Children – paed neurology) has recently looked at different targets for ages – I think 50, 55, 60 were the figures he came up with when I last heard him talk at European Soc for Paed Neurosurgery 2004
Metab	This sounds somewhat high to me – we found poor prognosis if <40 – other say norm=50. But best if can be >60
PICU	age dependent (local guide and 1^st guess = <1 yr 40; 1-3 yr 50; 3+ 60)

Statement 11h

To maintain an adequate cerebral perfusion pressure :

(i) inotropic support may be required

% Agree	% Disagree	Result
96.8%	0%	Included

Position	Comment
PICU	usual requirement = not inotrope but inoconstrictor (noradrenaline)

(ii) further doses of mannitol may be used

% Agree	% Disagree	Result
84%	0%	Included

Position	Comments
Neuro	Limited by osmality: a specialist (intensivist) decision
PICU N	but tend to be used just for crisis management
Paed	only once or twice?
Neuro S	Within limits – subsequent ones less effective
PICU	with careful monitoring

(iii) further doses of 3% saline may be used

% Agree	% Disagree	Result
69.2%	15.4%	Excluded

Position	Comments
Neuro	a specialist (intensivist) decision
PICU	especially by slow infusion to target Na/Osmol – 160/320

(iv) hypothermia should ideally be used in a controlled clinical trial setting only

% Agree	% Disagree	Result
88.9%	5.6%	Included

Position	Comments
	I don’t understand “controlled clinical trial setting”. Does this mean as part of a research investigation, or with careful clinical monitoring where everything else is controlled?
PICU	NO EVIDENCE THAT IMPROVES OUTCOME
PICU N	yes but realistically, evidence-base for use is poor
Neuro S	Mild hypothermia to 35 deg C
PICU	normothermia = current standard

(v) subtemporal decompression should ideally be used in a controlled clinical trial setting only

% Agree	% Disagree	Result
73.3%	20%	Excluded

Position	Comments
	I don’t understand “controlled clinical trial setting”. Does this mean as part of a research investigation, or with careful clinical monitoring where everything else is controlled?
Neuro S	Do you mean “decompressive craniectomy” (diagram explaining that subtemporal decompression is a small flap). Not good evidence for this
PICU	depends on local neuroSx
Neuro	Or a more complete decompression

(vi) deep barbiturate sedation should ideally be used in a controlled clinical trial setting only

% Agree	% Disagree	Result
37.5%	31.3%	Excluded

Position	Comments
	I don’t understand “controlled clinical trial setting”. Does this mean as part of a research investigation, or with careful clinical monitoring where everything else is controlled?
Metab	Widely used , safe in my experience
PICU	USED AT THE END OF ALGORHYTHM FOR TREATMENT OF RAISED ICP
Neuro	I think that the clinical experience with it is very considerable and I would be unhappy to proscribe it outside a trial
Neuro S	Clinically useful when all else failing
PICU	will usually follow 1^st/2^nd line management and needs eeg/cfam support