Preventing intracranial pressure fluctuation in severe traumatic brain injury during hemodialysis

Abstract

Background: Past studies have observed rises in intracranial pressure (ICP) during hemodialysis (HD) in the neurosurgical patient. This phenomenon may cause secondary brain injury and further compromise the patients' recovery. While continuous renal replacement modalities can theoretically be more beneficial for the brain-injured patient, this option is often not available due to limited resources. Modified prescriptions of intermittent HD may be the more easily accessible method. The purpose of this study is to clarify whether a less aggressive HD regimen in patients with severe traumatic brain injury (TBI) will prevent ICP fluctuation during HD. Patients and Methods: We present a single center experience with the enrollment of nine uremic patients with severe TBI who underwent decompressive surgery with ICP monitoring via external ventricular drain (EVD) between January 2003 and December 2006. These patients were divided into two groups based on different HD methods. In Group A, four patients received standard intermittent HD every other day, and in Group B, five patients received a modified, daily dialysis procedure that cut the amount of fluid removed per session and the dialysate flow rate by half. Results: All patients in both groups experienced an increased ICP during HD, but milder ICP changes were found in all five patients (P < 0.05) who had received the modified procedure (Group B). All patients in Group A had expired, but there were only two mortalities in Group B. Conclusion: ICP fluctuation may be minimalized by altering the HD protocol. A less aggressive HD procedure is recommended for uremic patients with severe TBI.