Standardized management of intracranial pressure: a preliminary clinical trial.

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

Minimum discard volume from arterial catheters to obtain coagulation studies free of heparin effect.

With the use of the canine experimental model, the accuracy and reliability of coagulation test results were compared between arterial samples and samples obtained by venipuncture. The age of the catheter, the concentration of the heparinized flush solution, and the minimum discard volume were evaluated to obtain coagulation study results free of heparin effect. Thirty-seven paired samples of PT, aPTT, and TT were obtained. Analyses revealed no significant difference in test results between new lines and 7-day-old lines, nor between heparin concentrations of 1 unit/ml, 2 units/ml, or 4 units/ml. A minimum discard volume of five times the dead space (measured from catheter tip to sampling proximal stopcock) resulted in accurate and reliable PT, aPTT, and TT test results from the arterial catheters.