Cerebral Oedema In Paediatric Patients: Treatment Strategies

Cerebral Oedema

Discuss about the Cerebral Oedema in Paediatric Patients.

Cerebral oedema is a condition which is life threatening which develops from an inflammatory reaction. In this condition there is an excess accumulation of fluid in the spaces of brain. Its symptoms include vomiting, nausea, difficulty in vision, unconsciousness and in extreme cases it may cause coma. In this condition the cerebrospinal fluid breaks down the barrier and starts to accumulate in the brain. The alteration in the metabolism cause brain cells to hold on the fluid the dilute the blood plasma causing the excessive water to accumulate in the brain (Watts & Edge, 2014). The treatment of cerebral oedema includes these following ways:

• Osmotherapy by Mannitol
• Diuretics used to decrease the fluid volume
• Corticosteroids for suppressing the immune system
• Using of hypertonic saline solution
• Elevation of bed head
• Surgical decompression.

Here in this assignment there is a description about two of those strategies and given point to discuss about the treatments:

• A description, rationale and evidence to support the treatment strategy.
• Goals and complications of the treatment.
• Considerations and implications for nursing practice

Giving of IV Mannitol / 3%hypertomic solution to patient with Cerebral Oedema before the happening of respiratory failure.

Description, rationale and evidence

The most fast and effective way to decreasing fluid from brain is osmotic therapy. Mannitol is the most used osmotic agent which decreases intra cranial pressure and increases CBF. Mannitol decreases the volume of brain by reducing the fluid content of the brain. Mannitol also improves the cerebral perfusion by reducing the viscosity and altering the red blood cell Rheology. It is also used to protect from the effects of the biochemical injury (Scott, et al. 2013).

There are some evidences that proves that low dose of Mannitol is effective which is having less chance of hyper-osmolar problems, that is caused by high-dose therapy. At first 1.0g/kg dose of mannitol is given, later it was increased and 50g is given after every 2-3 hours.

Goals and complications of the treatment

The use of mannitol is aimed for plasma osmolality along with the maintenance of the volume of plasma. But prolonged use may cause an electrolyte imbalance in the human body. If high doses of Mannitol is are infused in the patients with renal failure then Mannitol if retained in the blood (Stokum, Gerzanich, & Simard, 2016).  This statement is proved by a study of 45 patients who were treated with Mannitol for many days. It was found that only one patient was detected with potassium more than normal and 22 patients developed hypokalemia that is potassium content in serum low than the range (Garcia et al. 2014).

Implications of mannitol

Treatment strategies for cerebral oedema

Mannitol decreases blood viscosity, CBF unchanged while Cerebral Blood volume (CBV) and Intracranial Pressure (ICP) decrease. Mannitol also reduces ICP by reducing cerebral parenchymal cell water, total effect takes 20-30min. Eventually Mannitol enters Cerebrospinal Fluid (CSF) and increases ICP.

3% hypertonic solution

Hypertonic saline is a solution contains sodium chloride (NaCl). The most common preparations used are 2%, 3%, 5%, 7%, and 23% NaCl. HTS plays an important role for the prevention and treatment of the effects of effects of brain oedema (Doyle et al., 2001).

Goal and complications

The 3% HTS is mainly used for decreasing the intracranial pressure (ICP) by releasing excess fluid from brain. It is further associated by inducing of osmotic agents intravenously which increases the osmosis of serum. This results in the shrinkage of brain that effectively reduces intracranial pressure. The continuous infusion of 3% HTS can cause rebounding in oedema. It also causes the disruption of blood-brain barrier which happens due to the shrinkage of the endothelial cells. The continuous infusion of 7.5% saline solution leads to excessive neuron death

Implications

Blood is a hypertonic solution that contains higher sodium concentration whether cerebral tissue, has a lower sodium concentration. The flow of excess water from cerebral tissue set up an osmotic gradient from cerebral tissue to the blood. Osmosis is cause by the movement of water through the concentration gradient passively. In this process the water moves from lower level to the areas of higher cncengtration (Feig & McCurdy, 1977).

Elevation of bed head

Description, rationale and evidence

The elevation of the head of bed (HOB) to a semi-CBV recumbent position (at least 30 degrees) is associated with a decreased incidence cerebral oedema. The intervention is supported clinical guidelines, and the publications in the field accept HOB elevation as an effective, low-cost, and low-risk intervention (Schallom et al., 2015).

The elevation of bed head technique is the frequently used technique for cerebral oedema it is used to minimize the venous outflow. Evidences show that with the help of elevation of the bed head to 30°, there is a reduction in ICP without any changes occurring in CPP or CBF. When the head is elevated the blood pressure from the head is lowered which is the safest for most of the patients.

Goals and complications of the treatment

Elevation of the bed head technology is an effective method for reducing oedema. Studies suggested that the semi horizontal position of lying decreases blood pressure from the brain. The elevation of the bed head to 30° helps in improving the jugular venous outflow and lowering the ICP. In the patients suffering from hypovolaemia, this process will help in reducing the blood pressure and a complete diminishing of cerebral perfusion pressure (DeCourcey et al., 2013).

IV Mannitol

It has been reviewed that nine RCTs and two studies to evaluate the role of body positioning on the elevated bed head. There is a review which summarizes the epidemiology, pathophysiology, and risk factors associated with cerebral oedema and provide evidence-based recommendations for preventions. Review recommends the use of continuous backrest elevation of 30–45 degrees as an early prevention measure for cerebral oedema in the emergency department.

Implications of bed head elevation

Head bed elevation might prevent the chances of spreading of infection in the brain by elevating the head of the bed. The semi-recumbent position is the best method to prevent the cerebral oedema in extremely ill adult patients who requires mechanical support ventilation. It has been also investigated that 30° is the best angle of elevation of bed head in a semi-recumbent position. There are evidences from eight studies involving 759 participants demonstrated that a semi-recumbent (30º to 60º) position reduced clinically suspected cerebral oedema by 25.7% when compared to a 0° to 10° supine position (Pool et al., 2015).

Oxygen mask

Description, rationale and evidence

A non-rebreathing mask is having three unidirectional valves. One valve is located on each side of the mask to permit the ventilation of the exhaled gases. The third unidirectional valve is situated between the mask and the reservoir bag and prevents exhaled gases from entering the bag. Evidences show that, patients with acute hypoxic respiratory failure were treated in the emergency department first with a non-rebreathing mask.

Goals and complications

Its aim is to enable the delivery of high concentrations of oxygen and is recommended for use in patients who are critically ill.

Complications

Dry gas may have different side effects on the respiratory system. Breathing of dry air cause excessive water loss by the nasal mucosa, which might reduce the nasal mucoclliary clearance rate or adhesiveness of nasal mucus and/or slowing of ciliary pulses.

Implications

During inspiration the use of the oxygen reservoir bag prevents the oxygen loss which helps to increase the oxygen concentration. It is important to make sure that the amount of oxygen flow rate is maintained so that oxygen reservoir bag does not collapse during inspiration. Some non-rebreathing masks are made up of elasticated ear loop bands. These masks are mainly used for trauma patients as they don’t need to move the head

References

Nissenson, A. R., Weston, R. E., & Kleeman, C. R.. Mannitol. Western Journal of Medicine, 131(4), 277.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1271822/pdf/westjmed00242-0017.pdf

Picetti, E., Iaccarino, C., & Servadei, F. (2017). Guidelines for the Management of Severe Traumatic Brain Injury Fourth Edition. Neurosurgery, nyx086. https://braintrauma.org/uploads/07/04/Guidelines_for_the_Management_of_Severe_Traumatic.97250__2_.pdf

Peng, Y., Liu, X., Wang, A., & Han, R. (2014). The effect of mannitol on intraoperative brain relaxation in patients undergoing supratentorial tumor surgery: study protocol for a randomized controlled trial. Trials, 15(1), 165.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4018619/

Yildizdas, D., Altunbasak, S., Celik, U., & Herguner, O. (2016). Hypertonic saline treatment in children with cerebral edema. Indian pediatrics, 43(9), 771-779.  https://medind.nic.in/ibv/t06/i9/ibvt06i9p771.pdf

Mangat, H. S., Chiu, Y. L., Gerber, L. M., Alimi, M., Ghajar, J., & Härtl, R. (2015). Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury. Journal of neurosurgery, 122(1), 202-210. https://thejns.org/doi/pdf/10.3171/2014.10.JNS132545

Kukreti, V., Mohseni-Bod, H., & Drake, J. (2014). Management of raised intracranial pressure in children with traumatic brain injury. Journal of pediatric neurosciences, 9(3), 207. https://medind.nic.in/icb/t10/i12/icbt10i12p1409.pdf

Schallom, M., Dykeman, B., Metheny, N., Kirby, J., & Pierce, J. (2015). Head-of-bed elevation and early outcomes of gastric reflux, aspiration and pressure ulcers: a feasibility study. American Journal of Critical Care, 24(1), 57-66. https://www.aacn.org/docs/cemedia/A152401.pdf

Shahriari, A., Khooshideh, M., & Heidari, M. (2014). Diseases treated with hyperbaric oxygen therapy; a literature review. Medical Hypothesis, Discovery & Innovation Interdisciplinary Sciences Journal, 1(1). file:///C:/Users/absas/Downloads/153-230-1-SM.pdf