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Raised ICP Management — FRCA Final MCQ

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ModerateNeuroanaesthesiaRaised ICP ManagementFRCA Final

An adult remains in the neurocritical care unit on day 4 after a severe traumatic brain injury. Intracranial pressure has been sustained at 28 mmHg for more than 10 minutes. Repeat CT shows diffuse cerebral swelling without an evacuable mass lesion. Head position, oxygenation, PaCO2, temperature, analgesia, sedation and cerebral perfusion pressure have been optimised. The external ventricular drain is patent and open to drainage, but intracranial pressure remains elevated. Renal function and serum sodium and osmolality do not preclude hyperosmolar treatment. What is the most appropriate next intervention?

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Correct answer: C — Administer bolus hyperosmolar therapy with mannitol or hypertonic saline

The correct answer is C. Sustained ICP of 28 mmHg despite physiological optimisation and effective CSF drainage requires escalation, and intermittent bolus hyperosmolar therapy is the appropriate next lower-risk intervention. Mannitol increases plasma osmolality and produces an osmotic gradient drawing water from brain parenchyma; hypertonic saline has a similar osmotic effect while tending to support intravascular volume and arterial pressure. Agent selection depends on sodium, osmolality, renal function and haemodynamics. Decompressive craniectomy and barbiturate coma carry substantial morbidity and are reserved for intracranial hypertension refractory to lower-tier treatment. Cooling to 33°C is not routine ICP therapy and risks coagulopathy, infection and arrhythmia. A BIS target below 20 is not a validated ICP-management endpoint and may cause unnecessary cardiovascular depression.

Reference: Royal College of Anaesthetists, Raising the Standards: RCoA quality improvement compendium, Neuroanaesthesia section 12.5, Management of raised intracranial pressure in severe traumatic brain injury, 2020. https://rcoa.ac.uk/media/15651