Leveling art line to tragus for cpp??? - page 2

by jimmy_hat

Hello all. I am taking a class that stated in a sitting/semi-fowlers patient that we have concerns with CPP, we should level the art line at the tragus (or where every you would level your ICP monitor). I have never done that... Read More


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    Talked with the AACN. They tell me that the art line shoudl be leveled at the phleb axis no matter what the patient position. This is also the position and number to be used for CPP. I have a couple emails to a couple different organizations including braintrauma.org and The Society of Neurosurgical Anesthesia and Critical Care (SNACC). I will see if their answers are the same. I doubt they are as the anesthesia texts say otherwise. Feel free to chime in. I would love to hear of a Neruo ICU that levels the ART line transducer at the tragus for calculations of CPP.
    Jimmy
    IckuRN likes this.
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    since the tragus is higher than the phlebostatic axis (depending on HOB), I suspect you would have a really ugly blood pressure if it's leveled there. sounds like it would result in lots of false treating for imaginary hypotension. I only have 8 weeks of neurosurgical ICU as a new grad under my belt though but this is what my preceptors have said. Id also like to hear what others say about this.
    experienceawareness likes this.
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    I work in a large and respected academic hospital in SICU which takes all neuro and trauma patients, and we always level the ICP transducer and a-line transducer at external auditory canal (EAC). We actually have the two transducers clicked together so wherever you level them they are at the same level.
    I'm really intrigued by your question because I have never even questioned it. Everybody else is at phlebostatic axis except neuro pt. with bolt or ventric. I am always careful to use the bed's inclinometer and keep HOB at exactly 30 to avoid falsely affecting the measurements.
    With our method, the ICP and MAP are together so no matter how you level them, the CPP is going to be the same. i.e. if you level too high MAP will be lowered but so will ICP, so CPP will be about the same. But it will definately be a lower CPP than the one you get by leveling the a-line lower. What CPP do you treat for? We only treat to keep CPP>60 in most patients. (And 7.5% for any ICP >20). If it's a patient they want to be hypertensive for perfusion they will just order MAP 80-110 or whatever.
    It seems like this is the type of answer you are looking for, what bedside nurses in other NICUs do.
    IckuRN likes this.
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    Interesting. Thanks for the reply. That is what i was looking for. I have been unable to identify a unit NICU or SICU that actually does this until now. Like i had said before. I contacted the AACN and they said no one does this and did not understand my concern or really what my question was. I doubt the person was a specialist but she was CCRN (not that it means a lot). I would be happy to give you her name and contact info.

    What CPP do you treat for? We only treat to keep CPP>60 in most patients. (And 7.5% for any ICP >20)
    We would treat to the same CPP. greater than 60 or 65. Depended on the case. That was the CPP calculated with the MAP at the phleb axis and ICP leveled at the EAC. I have worked at a few different ICUs as a traveler and have never seen what you describe. I only learned about this in my current CRNA education. I am considering calling some of my contacts at Hopkins and seeing what they do there. Just kind of busy these days.
    We would use NEO to elevate the MAP to obtain that CPP. We had some pretty high BPs in attempt to obtain the CPP. What did you mean about the 7.5%? I do not understand your reference.

    I like you never thought of asking about this. Now I am finding different info. Europe already noted that they have a problem with this, but they did not come to a solution. I imagine if we did a survey here, we would see much the same info. I have a feeling about 30-40% of the hospitals level the art line to the EAC with the rest at the phleb axis. I think this is a pretty major confusion if someone wants to take the wheel and run with it.
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    idonotgiveout,
    I wanted to PM you but it seems that neither of us the ability. I was wondering where you worked. Email me if you do not mind.
    Last edit by jimmy_hat on Apr 28, '10
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    About 7.5%, I was referring to hypertonic saline which we use for ICP >20, I assume everybody does this? Or do you use mannitol or something? So, for CPP of 60 all we need is MAP of 60-80 depending on closed ICP, and if CPP is low d/t high ICP we of course treat ICP first with 7.5%. Even leveled at EAC it is usually not terribly hard to keep a MAP of 60 to 80 with just phenylephrine. Sometimes we have to add another pressor because of either propofol or if the patient just happens to be very sick. But that's not really a huge problem either since most of these patients have a central line anyway just in case they need 7.5%.

    On a semi-unrelated note, do you monitor with your ventrics open all the time and just close each hour to check ICP? Just curious.
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    I emailed you.
    lol at the addy.
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    We used both mannitol and hypertonic. We would also hyperventilate to fight spikes in ICP. BP is not our first choice but we often end up there when their sodium and serum osmolarity limit our ability to give the hypertonics or mannitol. It has been a couple years since I have done neuro. When I left they were thinking about chilling the patients heads, but I never saw it. I honestly can not remember what % saline we used. I want to say it was 5%. I will not swear to it.
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    Quote from IDoNotGiveOut
    On a semi-unrelated note, do you monitor with your ventrics open all the time and just close each hour to check ICP? Just curious.
    At the insistence of the neurointerventionalist, we check ICP hourly. At another hospital I've worked at they did continuous monitoring w/ continuous drainage by turning the stopcock completely up so that the monitor and drain are open simultaneously.
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    Yeah, we have the monitor and drain open simultaneously, but that's the open ICP, and then we close it and the closed ICP is the "real" one. As you know they're way way different. The reason I asked is because one of the nurses I work with said some places monitor it closed all the time and open hourly for drainage, the opposite of what we do. So I'm just wondering if others do it this way or they do it like we do.


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