Table 2.
ICE Protocol Treatment of Intracranial Pressure
| 1. Specific therapeutic interventions |
| a. After optimized sedation and analgesia, hyperventilation and hyperosmotic therapy should be started simultaneously if there is evidence of edema on CT, as indicated as following: |
| 1. Compressed peri-mesencephalic cisterns |
| 2. Midline shift |
| 3. Cortical sulcal compression/effacement |
| b. Mild hyperventilation |
| i. Maintain PaCO2 30-35 mm Hg (correcting for altitude) |
| c. Hyperosmolar/hypertonic therapy |
| i. Mannitol should be used first except in the following situations (HHH): |
| a. Arterial hypotension |
| b. Hypovolemia |
| c. Hyponatremia |
| 2. Hyperosmolar (mannitol) therapy guidelines and dosing |
| a. Plasma osmolarity or tonicity should be monitored at least every 12–24 h |
| i. Plasma osmolarity or tonicity should be calculated using the following formulae: |
| 1. Osmolarity = 2 * (Na) + (BUN/ 2.8) + (Glucose/18) |
| 2. Tonicity = 2 * (Na + K) + (Glucose/18) |
| ii. Hyperosmolar (mannitol) therapy should be suspended for plasma osmolarity >320 or tonicity >340 |
| b. Mannitol dosing regimen using 20% mannitol bolus: |
| i. 100 mL (20 g) IV every 3-4 h for the first 3 days, then |
| ii. 80 mL (16 g) IV every 3-4 h on Day 4, then |
| iii. 60 mL (12 g) IV every 3-4 h on Day 5, then |
| iv. 40 mL (8 g) IV every 3-4 h on Day 6 and suspend |
| 3. Hypertonic saline therapy guidelines and dosing |
| a. Hypertonic saline should only be used in cases of HHH as described above |
| b. Plasma osmolarity or tonicity and serum sodium should be monitored at least every 12-24 h |
| i. Plasma osmolarity or tonicity should be calculated using the following formulae: |
| 1. Osmolarity = 2 * (Na) + (BUN/ 2.8) + (Glucose/18) |
| 2. Tonicity = 2 * (Na + K) + (Glucose/18) |
| ii. Hypertonic saline therapy should be suspended for plasma osmolarity >360 or tonicity >380 or serum sodium >160 |
| c. Hypertonic saline dosing regimen using 5% NaCl solution bolus: |
| i. 80 mL normal saline (0.9% NaCl) +20 mL 20% NaCl = 100 mL 5% NaCl solution |
| ii. 100 mL IV every 4-12 h for 6 days then suspend |
| d. High dose IV barbiturates |
| i. Use after hyperventilation and hyperosmolar/hypertonic therapies |
| ii. Should be used if second CT shows evidence of compressed PMC |
| iii. Dosing: thiopental (pentothal) 2.5-4.0 mg/kg/h IV continuous infusion for 3 days (approximately 4-6 g/day) |
| iv. Hypotension must be avoided |
ICE, CT, computed tomography; PaCO2, partial pressure of carbon dioxide; BUN, blood urea nitrogen; IV, intravenous.