Principles of management of meningitis with raised intracranial pressure

see protocol

The main objective in managing patients with RICP is to maintain oxygen and nutrient delivery to the brain. Call for senior help and Paediatric Intensive Care immediately if there are signs of RICP.

• Patients with GCS < 8 or drop of 3 points in last hour, or fluctuating level of consciousness should have their airway secured by tracheal intubation and mechanical ventilation.
• Optimise ventilation to ensure normocapnia and avoid hypoxia. Cautious fluid resuscitation. Maintenance of circulating volume and adequate blood pressure is the goal. Overaggressive fluid resuscitation will exacerbate cerebral oedema. Only patients with shock require aggressive fluid resuscitation to ensure cerebral perfusion. Patients without shock require close monitoring and judicious fluid replacement depending on heart rate, blood pressure, urine output and metabolic acidosis.

Do not rely on capillary refill time to guide fluid management as this may be falsely prolonged in patients with raised ICP. Rely instead on the other markers of organ perfusion and circulatory status as described.

Consider the use of mannitol or hypertonic saline for acute changes in ICP as suggested by pupillary changes or sudden onset hypertension and bradycardia.

Nurse patient in head-up position, 20-30 degrees from horizontal. Avoid inserting central venous lines into the internal jugular vein as this impedes venous drainage of the head and the insertion of the line may exacerbate the raised intracranial pressure.