1. Changes in ICP following response checking and suctioning in Neurosurgical intensive care unit (NSICU) Anjusha T ,Deepak Agrawal Department of Neurosurgery JPN Apex Trauma Centre, AIIMS, New Delhi

2. BACKGROUND OF THE STUDY Presence of intracranial hypertension after traumatic brain injury (TBI) affects patient’s outcome Patients with head injury require elective ventilation and sedation to decrease ICP and any increase in ICP (even for brief period) may be detrimental

3. BACKGROUND Cont…. ICP cannot be reliably estimated from any specific clinical features or CT findings and must actually be measured. So ICP data from electronic monitoring equipment are usually calculated and recorded hourly in the clinical chart by trained nurses Normal ICP ranges from 1-15mm Hg

4. ICP MONITORING METHODS There are mainly three ways for measuring ICP By using intraventricular catheter Subarachnoid screw or bolt Epidural sensor CODMAN Parenchymal Monitoring system (Electronic)

5. ICP MONITORING DEVICES Codman monitor

6. RATIONALE FOR STUDY Nursing care activities and environmental stimuli have the potential to challenge the cerebrovascular system and capacity to increase the ICP

7. RATIONALE FOR STUDY positioning, coughing, straining, valsalva maneuver, response checking and invasive procedures like venipuncture and suctioning may result in sustained increase in ICP. Among these endotracheal suctioning plays a major role in a significant increase in ICP

8. AIMS & OBJECTIVES To monitor the variations in ICP during GCS response checking To monitor the variations in ICP during suctioning To assess the time duration to return to the baseline ICP, in both the cases To compare the variation in ICP during response checking and suctioning

9. METHODOLOGY Study Design : Prospective observational Study Sampling Technique : Convenience Sampling Setting : NSICU,JPNA Trauma Centre Inclusion Criteria : Ventilated severe head injury patients with ICP monitoring in NSICU Monitoring : Using intraparenchymal Codman catheter

11. It was followed by response checking using supra orbital pain stimuli & peak ICP as well as time to return to the baseline was noted.

12. In the same way the ICP was assessed while doing oro-tracheal suctioning.

14. Mean variation in ICP during response checking–6.19mmHg (67% increase from baseline) Mean variation in ICP during suctioning-19.61mmHg (168% increase from baseline) OBSERVATIONS

15. Mean duration of raised ICP with response checking 9.76 seconds Mean duration of raised ICP with suctioning 26.56 seconds OBSERVATIONS

16. Patient 1 Graph showing change in ICP with time during response checking

17. Patient 1 Graph showing change in ICP with time during suctioning

18. STATISTICAL ANALYSIS A paired T test was done Change in ICP during response checking was highly significant [p<0.001] Change in ICP during suctioning was also very highly significant [p<0.001]

19. CONCLUSIONS There is a wide fluctuation of ICP following response checking and suctioning. Significant rise in ICP occurs with GCS response checking as well as suctioning

20. CONCLUSIONS This rise in ICP and time to return to baseline are significantly higher during suctioning compared to response checking. Our study suggests that extra-sedation may be warranted prior to suctioning to prevent the rise in ICP.

21. THANK YOU