The effect of intensive care nursing interventions on the intracranial pressure in children with moderate to severe traumatic brain injury

Abstract

Objective The aim of this study was to examine the effects of selected routine nursing interventions - endotracheal suctioning and manual ventilation (ETSMV), log-rolling, eye care, mouth care and washing - on the intracranial pressure (ICP) in children with traumatic brain injury. Design Prospective observational study over three years. Setting Single tertiary paediatric intensive care unit in the North West of England. Patients Twenty five children with moderate to severe closed traumatic brain injury and intraparenchymal intracranial pressure monitoring in intensive care (2 -17 years of age). Interventions Routine nursing care interventions. Measurements and main results ICP measured one minute before the procedure, at the maximal value during the procedure and five minutes after the procedure was recorded for the purpose of this study. Time to recovery was also recorded, in minutes. A total of 25 measurements (the first one in each child) in the first 36 hours of the child's PICU admission were analysed. Both ETSMV and log-rolling were associated with clinically and statistically significant changes in ICP from baseline to maximal ICP (p=0.005) and maximal to 5-minute post ICP (p=0.001) for ETSMV and (p 15mmHg) showed higher maximal ICPs (but not ICP rise), suggesting a linear relationship between baseline and maximal ICP, although this was more pronounced during turning. One third of the children had not returned to their baseline ICP by 5 minutes after ETSMV, compared with 60% children after log-rolling. Neither eye care nor mouth care showed any clinically significant effects on ICP in these children, suggesting these procedures are not noxious and are tolerated very well. However, there was only a small number of washing episodes reported in this study therefore the observations are not conclusive. Conclusions Endotracheal suctioning and log-rolling in moderate to severe traumatic brain injured children can cause significant intracranial instability and should only be performed as required and with careful planning and execution. Eye and mouth care and washing appear to be well tolerated interventions and could be performed when necessary.