Standardized management of intracranial pressure: a preliminary clinical trial

To test a standardized protocol for management of intracranial pressure (ICP) after severe head injury (i.e., traumatic brain injury), consistent with published guidelines.

We compared prospective use of a standardized protocol for ICP management in 12 patients with severe head injuries and retrospective ICP management using preprinted hospital orders in combination with ad hoc physician orders in 12 historical control patients with severe head injuries. With the standardized protocol, flow-chart decision logic diagrams were applied at patient bedside by critical care practitioners, with nursing shift review.

ICP and its variation during the first 6 intensive care unit days was less for the standardized protocol- than for the preprinted order-managed group (p <0.001), indicating better process control with the standardized protocol. ICP exceeded 25 mm Hg for less time for the standardized protocol group (182 hours; 15+/-23 hours/patient) than for prescribed order group (429 hours; 36+/-28 hours/patient) (p = 0.03). On average, ICP exceeded 20 mm Hg for 2.3 days for the standardized protocol-managed group and for 4.7 days for the prescribed order-managed group. Cerebral perfusion pressure was significantly greater and its variation less for the standardized protocol- than for the preprinted order-managed group. Fewer interventions were made for ICP management for the standardized protocol- than for the preprinted order-managed patients (601 vs. 876), suggesting more effective nursing time using the standardized protocol.

ICP management was more consistent, and intracranial hypertension was better controlled, in patients managed according to a standardized, data-driven protocol for escalation and weaning of therapies in response to immediate patient needs. We recommend computerized implementation and a randomized clinical trial to compare the protocol with prescribed orders.