Intracranial Pressure Monitoring, Assisting in Placement and Care of

CLINICAL GUIDELINES

Placement of an intracranial pressure (ICP) monitor is a surgical procedure performed by a healthcare prescriber (physician, or nurse practitioner or physician assistant depending on state scope of practice regulations) and the removal of such a device is the responsibility of the healthcare prescriber. Informed consent to complete the procedure must be obtained (see Chapter 51).
The registered nurse (RN) is responsible for monitoring the child and system; monitoring takes place in an intensive care setting.
Sedation and pain management of the child with ICP monitoring are implemented on an individual basis according to the child’s diagnosis and unique healthcare needs.
The accuracy of the monitoring system is assessed at least once a shift by zero-balancing the ICP system, checking the status of system alarms, and frequently assessing the level of the transducer and device placement.

EQUIPMENT

SETUP AND PLACEMENT

Surgical examination light (if needed by healthcare prescriber)
Shaving device (electric razor with disposable blades or several disposable razors)
Sterile antiseptic prep swabs (e.g., povidone-iodine, chlorhexidine)
Sterile gowns, gloves, masks, and caps
Sterile drapes or towels
Lidocaine (xylocaine) local anesthetic (0.5% or 1%)
Sterile syringes (assortment of sizes: 3 and 5 mL, and tuberculin)
Needles (22- and 25-gauge)
Cranial drill and bit
Alcohol antiseptic
Scalpel
Sterile retractor
Forceps
Sterile scissors
Hemostats
Subarachnoid bolt, Silastic intraventricular catheter, or intraparenchymal catheter (institutional preference)
Suture material (usually 2-0 to 3-0 nylon/silk)
Gauze dressing
Sterile transparent dressing (if needed)
Gauze dressing roll (3-in)
Tape (1-in)
Preservative-free sterile normal saline for injection
Individual institution monitoring system and equipment (i.e., ICP module, monitor, transducer, cable, and hookup)
Level to check height of transducer
Sedation and pain medications (as ordered)
Antibiotics (as ordered)

CHILD AND FAMILY ASSESSMENT AND PREPARATION

Assess the child’s and the family’s cognitive level, readiness, and ability to process information.
Perform detailed baseline and ongoing neurologic assessments. Assess child for signs and symptoms of increased ICP, including altered or decreased level of consciousness, anxiety, restlessness, irritability, agitation, lethargy, confusion, drowsiness, headaches, seizures, posturing, inappropriate motor function or dysfunction, widened pulse pressure, bradycardia, altered respiratory pattern, and pupillary dysfunction. An infant may also display tense or bulging fontanels, separated cranial sutures, increased head circumference, projectile vomiting, highpitched “neuro” cry, or paralysis of upward gaze of the eyes (“sun-setting sign”).
Ensure that informed consent has been obtained and that the appropriate documents are signed and present in the child’s medical record. If the procedure is urgent, ensure that two physicians have signed the consent.
Reinforce the need for device placement, as appropriate, to both the child and the family.
Reinforce the healthcare prescriber’s explanation of the risks and benefits of monitoring.
Discuss with family the need to talk to the child and provide physical comfort, even while the child is sedated.

PROCEDURE
Setup for Bedside Insertion of ICP Monitoring by Healthcare Prescriber

Steps	Rationale/Points of Emphasis
1a Perform hand hygiene.	Reduces transmission of microorganisms.
1b Gather the necessary equipment, personnel, and supplies for device placement.	Assembly of all necessary equipment promotes efficient time management and provides an organized approach to the procedure. Note that two healthcare personnel will be needed to assist healthcare prescriber in placement of catheter device: one person positions and holds the child in place while assessing the child’s condition during the procedure and the other provides and gathers equipment as needed.
	caREminder
	This is a sterile procedure. All personnel should wear surgical caps and masks; reduce traffic in the patient area as much as possible during the procedure; shut the door to the room.
2 Obtain the following baseline data: Vital signs Level of consciousness Pupil response Skeletal motor function Sensory function Glasgow Coma Scale score (age appropriate)	Having baseline data facilitates identification of any acute changes in the child’s condition during and after the procedure. The earlier that signs and symptoms of brain injury are identified, the sooner treatment can begin to improve outcome.
3a Assess sedation and pain management needs of the child in collaboration with the healthcare prescriber. Administer sedation and pain management medications as ordered (see Chapter 7 ).	ICP placement is a painful procedure. The child’s comfort will be enhanced by administration of medications to sedate and manage pain.
3b The healthcare prescriber may elect to administer IV antibiotics to the child during preparation and after catheter insertion.	Antibiotic therapy may assist in preventing infections that may occur secondary to this invasive procedure.
4 Assemble ICP pressure monitoring system to interface with the monitor (i.e., ICP module, transducer, cable, and hookup) (Figure 52-1) and prepare catheter, if needed, per manufacturer’s instructions. Figure 52-1 Intracranial pressure monitoring equipment.	Ensures proper setup and facilitates procedure. Priming line avoids introducing air into the ventricular or subdural spaces. The preservative in saline may cause cortical necrosis.
5 Prepare sterile field and place instruments on field.	Maintains sterile field.
6 Don sterile attire.	Standard precautions for surgical sterile procedure.
7 Position the child for access by the healthcare prescriber and hold the child’s head securely in midline position throughout procedure, while maintaining sterile field.	Facilitates ease of access, and assists with catheter insertion.
8 Restrain the child’s limbs as necessary to ensure sterility of procedure.	Keeps the child from moving and possibly breaking sterile field required for catheter insertion.
9 Assist healthcare prescriber in identifying area on scalp for device placement. The left frontal/temporal scalp area is often the preferred access point. Follow institutional policy and procedure for ensuring preoperative verification process is completed, appropriate operative site is marked, and “time out” is completed before start of procedure.	Identifies access site. “Time-out” implements Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery.
10 Assist the healthcare prescriber in shaving the scalp and prepping the area with sterile antiseptic agent. Shave an area large enough to accommodate the transparent dressing that will be placed over the site at the end of the procedure, if used.	Visualizes insertion site; prevents hair from falling into and thereby contaminating sterile field. Transparent dressing will not secure well if attached to hair.
caREminder	KidKare Keep the child’s hair and place in a plastic bag. The family may wish to keep the child’s hair.
Do not use 2% chlorhexidine when potential contact with the meninges is present.
11 Assist the healthcare prescriber in draping head in sterile fashion.	Protects insertion site from contamination.
12 After injecting the subcutaneous lidocaine (xylocaine), the scalp and the skull are incised by the healthcare prescriber using the hand drill and scalpel.	Lidocaine anesthetizes the site. Allows for insertion of ICP bolt or catheter.
13 Using sterile technique assist the healthcare prescriber as needed throughout the procedure, and continually assess the child for changes in neurologic and vital sign status.	Ongoing monitoring of the child facilitates early detection of problems.
14 Once the catheter is in place (Figure 52-2), attach the monitor cable to the ICP device.	Provides interface between bedside monitor and the child’s ICP system.
15 When the ICP device is in place, assist in placing semipermeable transparent dressing over the catheter insertion site on the child’s scalp if used.	Protects the site from microorganisms.
16 Zero-balance the fiberoptic system with bedside monitoring system according to manufacturer’s instructions.	Allows waveform to be viewed with electrocardiogram and other pressure tracings. Zero-balancing and calibrating system provides more accurate measurements.
Figure 52-2 (A) Intraventricular catheter, (B) subdural catheter, and (C) intracranial bolt.
17 If requested by the healthcare prescriber, assist in dressing the entire scalp with gauze and gauze dressing.	Further protects the site from contamination or from accidental disconnection of device by the child.
18a Position the child in bed with the head of bed (HOB) up 30 degrees and head in a midline position to the rest of the body.	Flexion or rotation of the head or neck can obstruct venous return and increase ICP. Positioning the child so that the head of the bed is elevated 30 degrees promotes venous return.
18b Position the child and equipment to keep the ICP transducer at the foramen of Monro. Anatomically, the reference point is equivalent to the level of the tragus of the ear, external auditory meatus, or the outer canthus of the eye.	Transducer placement at a point above or below the anatomically correct position will result in false readings.
19 Dispose of equipment and waste in appropriate receptacles.	Standard precautions.
20 Remove gloves and perform hand hygiene.	Reduces transmission of microorganisms.