Nursing Report: Cerebral Oedema Management and Treatment Strategies

This report focuses on cerebral oedema in paediatric patients, a life-threatening condition characterized by fluid accumulation in the brain. It details various treatment strategies, including the use of IV Mannitol/3% hypertonic solution, elevation of the bed head, and the use of oxygen masks. The report provides descriptions, rationales, and evidence supporting each treatment, along with their goals, potential complications, and implications for nursing practice. Mannitol and hypertonic saline are discussed for their ability to reduce intracranial pressure, while bed head elevation is highlighted as a method to minimize venous outflow. The use of oxygen masks is also discussed for patients experiencing acute hypoxic respiratory failure. References from various medical journals and publications are included to support the information provided.

Running head: NURSING
Cerebral oedema in paediatric patients
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Cerebral Oedema
Cerebral oedema is a condition which is life threatening which develops from an
inflammatory reaction. In this condition there is an excess accumulation of fluid in the spaces
of brain. Its symptoms include vomiting, nausea, difficulty in vision, unconsciousness and in
extreme cases it may cause coma. In this condition the cerebrospinal fluid breaks down the
barrier and starts to accumulate in the brain. The alteration in the metabolism cause brain
cells to hold on the fluid the dilute the blood plasma causing the excessive water to
accumulate in the brain (Watts & Edge, 2014). The treatment of cerebral oedema includes
these following ways:
 Osmotherapy by Mannitol
 Diuretics used to decrease the fluid volume
 Corticosteroids for suppressing the immune system
 Using of hypertonic saline solution
 Elevation of bed head
 Surgical decompression.
Here in this assignment there is a description about two of those strategies and given point to
discuss about the treatments:
 A description, rationale and evidence to support the treatment strategy.
 Goals and complications of the treatment.
 Considerations and implications for nursing practice.
Treatment strategies for cerebral oedema

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1. Giving of IV Mannitol / 3%hypertomic solution to patient with Cerebral
Oedema before the happening of respiratory failure.
Description, rationale and evidence
The most fast and effective way to decreasing fluid from brain is osmotic
therapy. Mannitol is the most used osmotic agent which decreases intra cranial
pressure and increases CBF. Mannitol decreases the volume of brain by reducing the
fluid content of the brain. Mannitol also improves the cerebral perfusion by reducing
the viscosity and altering the red blood cell Rheology. It is also used to protect from
the effects of the biochemical injury (Scott, et al. 2013).
There are some evidences that proves that low dose of Mannitol is effective
which is having less chance of hyper-osmolar problems, that is caused by high-dose
therapy. At first 1.0g/kg dose of mannitol is given, later it was increased and 50g is
given after every 2-3 hours.
Goals and complications of the treatment
The use of mannitol is aimed for plasma osmolality along with the
maintenance of the volume of plasma. But prolonged use may cause an electrolyte
imbalance in the human body. If high doses of Mannitol is are infused in the patients
with renal failure then Mannitol if retained in the blood (Stokum, Gerzanich, &
Simard, 2016). This statement is proved by a study of 45 patients who were treated
with Mannitol for many days. It was found that only one patient was detected with
potassium more than normal and 22 patients developed hypokalemia that is potassium
content in serum low than the range (Garcia et al. 2014).
Implications of mannitol

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Mannitol decreases blood viscosity, CBF unchanged while Cerebral Blood
volume (CBV) and Intracranial Pressure (ICP) decrease. Mannitol also reduces ICP
by reducing cerebral parenchymal cell water, total effect takes 20-30min. Eventually
Mannitol enters Cerebrospinal Fluid (CSF) and increases ICP.
2. 3% hypertonic solution
Hypertonic saline is a solution contains sodium chloride (NaCl). The most
common preparations used are 2%, 3%, 5%, 7%, and 23% NaCl. HTS plays an
important role for the prevention and treatment of the effects of effects of brain
oedema (Doyle et al., 2001).
Goal and complications
The 3% HTS is mainly used for decreasing the intracranial pressure (ICP) by
releasing excess fluid from brain. It is further associated by inducing of osmotic
agents intravenously which increases the osmosis of serum. This results in the
shrinkage of brain that effectively reduces intracranial pressure. The continuous
infusion of 3% HTS can cause rebounding in oedema. It also causes the disruption of
blood-brain barrier which happens due to the shrinkage of the endothelial cells. The
continuous infusion of 7.5% saline solution leads to excessive neuron death
Implications
Blood is a hypertonic solution that contains higher sodium concentration
whether cerebral tissue, has a lower sodium concentration. The flow of excess water
from cerebral tissue set up an osmotic gradient from cerebral tissue to the blood.
Osmosis is cause by the movement of water through the concentration gradient
passively. In this process the water moves from lower level to the areas of higher
cncengtration (Feig & McCurdy, 1977).

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3. Elevation of bed head
Description, rationale and evidence
The elevation of the head of bed (HOB) to a semi-CBV recumbent position (at
least 30 degrees) is associated with a decreased incidence cerebral oedema. The
intervention is supported clinical guidelines, and the publications in the field accept
HOB elevation as an effective, low-cost, and low-risk intervention (Schallom et al.,
2015).
The elevation of bed head technique is the frequently used technique for
cerebral oedema it is used to minimize the venous outflow. Evidences show that with
the help of elevation of the bed head to 30°, there is a reduction in ICP without any
changes occurring in CPP or CBF. When the head is elevated the blood pressure from
the head is lowered which is the safest for most of the patients.
Goals and complications of the treatment
Elevation of the bed head technology is an effective method for reducing
oedema. Studies suggested that the semi horizontal position of lying decreases blood
pressure from the brain. The elevation of the bed head to 30° helps in improving the
jugular venous outflow and lowering the ICP. In the patients suffering from
hypovolaemia, this process will help in reducing the blood pressure and a complete
diminishing of cerebral perfusion pressure (DeCourcey et al., 2013).
It has been reviewed that nine RCTs and two studies to evaluate the role of
body positioning on the elevated bed head. There is a review which summarizes the
epidemiology, pathophysiology, and risk factors associated with cerebral oedema and
provide evidence-based recommendations for preventions. Review recommends the

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use of continuous backrest elevation of 30–45 degrees as an early prevention measure
for cerebral oedema in the emergency department.
Implications of bed head elevation
Head bed elevation might prevent the chances of spreading of infection in the
brain by elevating the head of the bed. The semi-recumbent position is the best
method to prevent the cerebral oedema in extremely ill adult patients who requires
mechanical support ventilation. It has been also investigated that 30° is the best angle
of elevation of bed head in a semi-recumbent position. There are evidences from eight
studies involving 759 participants demonstrated that a semi-recumbent (30º to 60º)
position reduced clinically suspected cerebral oedema by 25.7% when compared to a
0° to 10° supine position (Pool et al., 2015).
4. Oxygen mask
Description, rationale and evidence
A non-rebreathing mask is having three unidirectional valves. One valve is located on
each side of the mask to permit the ventilation of the exhaled gases. The third
unidirectional valve is situated between the mask and the reservoir bag and prevents
exhaled gases from entering the bag. Evidences show that, patients with acute hypoxic
respiratory failure were treated in the emergency department first with a non-
rebreathing mask.
Goals and complications
Its aim is to enable the delivery of high concentrations of oxygen and is
recommended for use in patients who are critically ill.
Complications

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Dry gas may have different side effects on the respiratory system. Breathing of
dry air cause excessive water loss by the nasal mucosa, which might reduce the nasal
mucoclliary clearance rate or adhesiveness of nasal mucus and/or slowing of ciliary
pulses.
Implications
During inspiration the use of the oxygen reservoir bag prevents the oxygen
loss which helps to increase the oxygen concentration. It is important to make sure
that the amount of oxygen flow rate is maintained so that oxygen reservoir bag does
not collapse during inspiration. Some non-rebreathing masks are made up of
elasticated ear loop bands. These masks are mainly used for trauma patients as they
don’t need to move the head.
References

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Nissenson, A. R., Weston, R. E., & Kleeman, C. R.. Mannitol. Western Journal of Medicine,
131(4), 277.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1271822/pdf/westjmed00242-
0017.pdf
Picetti, E., Iaccarino, C., & Servadei, F. (2017). Guidelines for the Management of Severe
Traumatic Brain Injury Fourth Edition. Neurosurgery, nyx086.
https://braintrauma.org/uploads/07/04/Guidelines_for_the_Management_of_Severe_T
raumatic.97250__2_.pdf
Peng, Y., Liu, X., Wang, A., & Han, R. (2014). The effect of mannitol on intraoperative brain
relaxation in patients undergoing supratentorial tumor surgery: study protocol for a
randomized controlled trial. Trials, 15(1), 165.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4018619/
Yildizdas, D., Altunbasak, S., Celik, U., & Herguner, O. (2016). Hypertonic saline treatment
in children with cerebral edema. Indian pediatrics, 43(9), 771-779.
http://medind.nic.in/ibv/t06/i9/ibvt06i9p771.pdf
Mangat, H. S., Chiu, Y. L., Gerber, L. M., Alimi, M., Ghajar, J., & Härtl, R. (2015).
Hypertonic saline reduces cumulative and daily intracranial pressure burdens after
severe traumatic brain injury. Journal of neurosurgery, 122(1), 202-210.
http://thejns.org/doi/pdf/10.3171/2014.10.JNS132545
Kukreti, V., Mohseni-Bod, H., & Drake, J. (2014). Management of raised intracranial
pressure in children with traumatic brain injury. Journal of pediatric neurosciences,
9(3), 207. http://medind.nic.in/icb/t10/i12/icbt10i12p1409.pdf

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Schallom, M., Dykeman, B., Metheny, N., Kirby, J., & Pierce, J. (2015). Head-of-bed
elevation and early outcomes of gastric reflux, aspiration and pressure ulcers: a
feasibility study. American Journal of Critical Care, 24(1), 57-66.
https://www.aacn.org/docs/cemedia/A152401.pdf
Shahriari, A., Khooshideh, M., & Heidari, M. (2014). Diseases treated with hyperbaric
oxygen therapy; a literature review. Medical Hypothesis, Discovery & Innovation
Interdisciplinary Sciences Journal, 1(1). file:///C:/Users/absas/Downloads/153-230-1-
SM.pdf