Standardized management of intracranial pressure: A preliminary clinical trial

Objective: To test a standardized protocol for management of intracranial p ressure (ICP) after severe head injury (i,e,, traumatic brain injury), cons istent with published guidelines. Methods: We compared prospective use of a standardized protocol for ICP man agement in 12 patients with severe head injuries and retrospective ICP mana gement using preprinted hospital orders in combination with ad hoc physicia n 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 revie w. Results: ICP and its variation during the first 6 intensive care unit days was less for the standardized protocol- than for the preprinted order-manag ed group (p <0.001), indicating better process control with the standardize d protocol. ICP exceeded 25 mm Hg for less time for the standardized protoc ol group (182 hours; 15 +/- 23 hours/patient) than for prescribed order gro up (429 hours; 36 +/- 28 hours/patient) (p = 0.03). On average, ICP exceede d 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 pressu re was significantly greater and its variation less for the standardized pr otocol- than for the preprinted order-managed group, Fewer interventions we re made for ICP management for the standardized protocol-than for the prepr inted order-managed patients (601 vs. 876), suggesting more effective nursi ng time using the standardized protocol. Conclusion: ICP management was more consistent, and intracranial hypertensi on 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 ra ndomized clinical trial to compare the protocol with prescribed orders.