Clinical review: Critical care management of spontaneous intracerebral hemorrhage

Table 3 Stepwise treatment protocol for elevated intracranial pressure* in a monitored patient in the intensive care unit

1. Surgical decompression	Consider repeat CT scanning, and definitive surgical intervention or ventricular drainage
2. Sedation	Intravenous sedation to attain a motionless, quiet state
3. CPP optimization	Vasopressor infusion if CPP is <70 mmHg, or reduction of blood pressure if CPP is >110 mmHg (preferred agents are phenylephrine, vasopressin, nor-epinephrine)
4. Osmotherapy	Mannitol 0.25 to 1.5 g/kg IV or 0.5 to 2.0 ml/kg 23.4% hypertonic saline (repeat every 1 to 6 hours as needed)
5. Controlled hyperventilation	Target PaCO₂ levels of 26 to 30 mmHg
6. High dose pentobarbital therapy	Load with 5 to 20 mg/kg, infuse 1 to 4 mg/kg/h
7. Hypothermia	Cool core body temperature to 32 to 33°C

*Elevated intracranial pressure ≥20 mmHg. Adapted from Mayer SA, Chong J: Critical care management of increased intracranial pressure. J Int Care Med 2002, 17: 55–67. CPP, cerebral perfusion pressure; CT, computed tomography; IV, intravenous; PaCO₂ = arterial partial pressure of carbon dioxide.

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