I'm interested in people's opinions on BP targets in ICH. Let's use an example. Gentleman in his mid 50s. Unknown PMHx. BP 220/100 o/a GCS 7 (M4) I+V to facilitate scan which shows ICH with hydrocephalus. Going to theatre for an EVD. What are your BP target, and upper and lower limits. - ThreadSky

leedsmedic.bsky.social • 55 days ago

I'm interested in people's opinions on BP targets in ICH. Let's use an example.

Gentleman in his mid 50s.
Unknown PMHx.
BP 220/100 o/a
GCS 7 (M4)
I+V to facilitate scan which shows ICH with hydrocephalus.
Going to theatre for an EVD.

What are your BP target, and upper and lower limits.

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leedsmedic.bsky.social•55 days ago

Let me know if there is anything else you would want to know to make a decision.

#ansky #neurosky #neuroicu

lotusgav.bsky.social•54 days ago

Most guidelines say keep it >110 eg https://static1.squarespace.com/static/63e696a90a26c23e4c021cee/t/640b5e6092ce39234e78f788/1678466657059/Management_of_Severe_TBI_ExecSmry_4th_Edition.pdf

leedsmedic.bsky.social•54 days ago

And would you have an upper limit?

lotusgav.bsky.social•54 days ago

The neurosurgeons and IR docs seem to like 160 but that doesn’t make physiological sense for CPP. But it’s their patient so I do what they ask🤷

anaesthom.bsky.social•54 days ago

TBI is different!

lotusgav.bsky.social•54 days ago

Sure but gotta start somewhere- they also recommend ICP monitoring in TBI - you can work out CPP and MAP targets off that then

anaesthom.bsky.social•55 days ago

There’s not much high quality evidence.

Ultimately <160sys but if starting at 220 as in your example I’d try to get there gently, not in one big immediate drop.

Defo >140sys.

leedsmedic.bsky.social•54 days ago

That's very similar to my practice, agree there is a paucity of evidence.

I was talking with a trainee about this as we had two ICHs in theatre at different stages of their presentation which triggered the question.

I'll post my current thinking with working in a day or so!

bobfunn.bsky.social•54 days ago

you guys steer ☸️ the brain using the systolic? I was taught that mean BP was the bees’ knees.

But that was back in the day when we 🦕 did retrograde jugular venous cannulation(!)

anaesthom.bsky.social•54 days ago

Mostly convention! And because we can’t monitor ICP and thus CCP during the course of surgery.

I suppose it makes sense in terms of maximal vessel wall stress in the context of vascular pathology too.

leedsmedic.bsky.social•54 days ago

Yeah, I think mean is the figure to use for estimatingcerebral perfusion, but sBP is likely the better marker / driver for rebleeds of haematoma expansion

bobfunn.bsky.social•54 days ago

reminds me of the nephrologists during kidney transplant surgery insisting on a sBP of >120 or whatever, and anaesthetists hammering on about the flow.

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