Cerebral Edema in Neurocritical Care Patients Clinical Practice Guidelines (NCS, 2020)

Neurocritical Care Society

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

May 29, 2020

Guidelines for the acute treatment of cerebral edema in neurocritical care patients were published in May 2020 by the Neurocritical Care Society (NCS).[1]

Treatment of cerebral edema in patients with subarachnoid hemorrhage (SAH)

Use of symptom-based bolus dosing of hypertonic sodium solutions rather than sodium target-based dosing is recommended for managing intracranial pressure (ICP) or cerebral edema in SAH patients.

Treatment of cerebral edema in patients with traumatic brain injury (TBI)

Use of hypertonic sodium solutions rather than mannitol is recommended for initial management of elevated ICP or cerebral edema in TBI patients.

Mannitol is an effective alternative in TBI patients in whom hypertonic sodium solutions are contraindicated.

It is not recommended to use hypertonic sodium solutions or mannitol in the pre-hospital setting to specifically improve neurological outcomes for TBI patients.

Treatment of cerebral edema in patients with acute ischemic stroke (AIS)

Use of either hypertonic sodium solutions or mannitol is recommended for initial management of ICP or cerebral edema in AIS patients.

Clinicians should consider administering hypertonic sodium solutions for managing ICP or cerebral edema in AIS patients who do not respond to mannitol.

It is not recommended to use prophylactic scheduled mannitol in AIS patients.

Treatment of cerebral edema in patients with intracerebral hemorrhage (ICH)

Use of hypertonic sodium solutions rather than mannitol is recommended for managing ICP or cerebral edema in ICH patients.

Use of either symptom-based bolus dosing or targeted sodium concentration is an appropriate hypertonic sodium solution strategy for managing ICP or cerebral edema in ICH patients.

It is not recommended to use corticosteroids to improve neurological outcome in ICH patients due to potential for increased mortality and infectious complications.

Treatment of cerebral edema in patients with bacterial meningitis

Use of IV dexamethasone 10 mg every 6 hours for 4 days is recommended for reducing neurological sequelae in patients with community-acquired bacterial meningitis.

Use of IV dexamethasone 0.15 mg/kg every 6 hours for 4 days is recommended as an alternative dose for bacterial meningitis patients with low weight or those who can’t take corticosteroids.

It is recommended to administer dexamethasone before or with the first dose of antibiotic in bacterial meningitis patients.

Use of corticosteroids for two weeks or more is recommended in patients with tuberculosis meningitis.

Treatment of cerebral edema in patients with hepatic encephalopathy

Use of either hypertonic sodium solutions or mannitol is recommended for managing ICP or cerebral edema in hepatic encephalopathy patients.

Hyperosmolar therapy safety and infusion

Use of osmolar gap rather than osmolarity thresholds during treatment with mannitol is recommended for monitoring risk of acute kidney injury (AKI).

Monitoring of renal function measures is recommended in patients receiving mannitol due to risk of AKI.

Severe hypernatremia and hyperchloremia during treatment with hypertonic sodium solutions should be avoided due to the association with AKI.

Routine monitoring of both sodium and chloride serum concentrations is recommended for assessing AKI risk related to elevated concentrations.

Monitoring of renal function is recommended in patients receiving hypertonic sodium solutions due to risk of AKI.

Nonpharmacologic treatment of cerebral edema and elevated ICP

Elevating the head of the bed to 30 degrees but no more than 45 degrees is recommended as a beneficial adjunct for reducing ICP.

Brief episodes of hyperventilation can be used in patients with acute elevations in ICP.

CSF diversion can be used as a beneficial adjunct for reducing ICP.

For more Clinical Practice Guidelines, go to Guidelines.

For more information, go to Intracranial Pressure Monitoring.

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