Medical Pharmacology: Management of Intracranial Pressure

In management of intracranial hypertension, mannitol (Osmitrol) decreases ICP independent of the status of the blood-brain barrier
1. true
2. false
Mannitol (Osmitrol) and ICP reduction
1. may cause initial increase in ICP
2. in patients with reduced left ventricular capacity, loop diuretics may be more appropriate for lowering ICP
3. both
4. neither
Mechanisms responsible for ICP reduction caused by furosemide (Lasix) administration:
1. reduce cerebral edema by enhancing water transport
2. decreasing CSF production
3. systemic diuresis
4. A & C
5. A, B & C
Effectiveness in reducing ICP:
1. mannitol (Osmitrol) > furosemide (Lasix)
2. furosemide (Lasix) > mannitol (Osmitrol)
3. both about equal
Management of elevated ICP: furosemide (Lasix) + mannitol (Osmitrol)
1. more severe electrolyte balance and dehydration
2. more effective than mannitol (Osmitrol) alone in reducing intracranial pressure
3. both
4. neither
Intraoperative implications of of combination treatment (furosemide (Lasix) + mannitol (Osmitrol)) for ICP reduction
1. may require potassium replacement
2. requires careful monitoring electrolytes
3. both
4. pewter
Relatively rapid ICP reduction:
1. corticosteroids
2. mannitol (Osmitrol)
3. both
4. neither
ICP reduction: corticosteroids
1. blood-brain barrier repair
2. preoperative steroid administration may initially worsen neurological status before ICP reduction
3. brain dehydration
4. A & C
5. A, B & C
Complications of continual perioperative steroid administration:
1. hypoglycemia
2. GI bleeding
3. infection
4. B & C
5. A, B & C
Mainstay of ICP reduction:
1. chlorthalidone (Hygroton)
2. furosemide (Lasix)
3. hyperventilation
Hyperventilation and ICP reduction:
1. effective for both subacute and acute management
2. decreases CBF by cerebral vasodilation
3. effectiveness independent of cerebrovascular CO2 reactivity
Factor(s) which may impair cerebral vascular CO2 responsiveness:
1. cerebral ischemia
2. cerebral trauma
3. tumor presence
4. infection
5. all the above
Hyperventilation to reduce ICP & therapeutic concerns:
1. PaCO2 < 20 mm Hg: excessive cerebral vasodilation
2. hyperventilation + enflurane (Ethrane): increasing ICP
3. both
4. neither
Drugs which may reduce systemic blood-pressure in patients with elevated ICP but with limited/no effect on CBF or ICP
1. labetalol (Trandate, Normodyne)
2. esmolol (Brevibloc)
3. propranolol (Inderal)
4. A & C
5. A, B & C
Combined alpha and data-adrenergic blockade:
1. propranolol (Inderal)
2. esmolol (Brevibloc)
3. labetalol (Trandate, Normodyne)
4. metoprolol (Lopressor)
Succinylcholine (Anectine) and ICP
1. may increase ICP
2. not recommended for elective neurosurgery
3. both
4. neither
Succinylcholine (Anectine)-mediated increase in ICP may be blocked by a full, paralyzing vecuronium (Norcuron) dose
1. true
2. false
Best agent for rapid sequence tracheal intubation to achieve total paralysis:
1. pancuronium (Pavulon)
2. atracurium (Tracrium)
3. succinylcholine (Anectine)
4. tubocurarine
Vasolytic effects may cause an increase in ICP in patients with abnormal autoregulation:
1. doxacurium (Nuromax)
2. pipecuronium (Arduan)
3. vecuronium (Norcuron)
4. roncuronium (Zemuron)
5. pancuronium (Pavulon)
Succinylcholine (Anectine) should be avoided in hemiplegic/paraplegic patients because:
1. duration of action may be excessive
2. bradycardia may be difficult to manage
3. hyperkalemia may occur
4. renal excretion may be compromised
Nondepolarizing muscle relaxants least likely to increase ICP
1. d-tubocurarine
2. metocurine (Metubine Iodide)
3. atracurium (Tracrium)
4. mivacurium (Mivacron)
5. doxacurium (Nuromax)
Induction sequencein patients with elevated ICP: IV thiopental (Pentothal), fentanyl (Sublimaze), muscle relaxant.
1. reasonable
2. unreasonable
Most common opioid usedin anesthesia maintenance and patients with supratentorial tumors:
1. meperidine (Demerol)
2. fentanyl (Sublimaze)
3. morphine
4. pentazocine (Talwain)
5. propoxyphene (Darvon)
Most common volatile agent used in anesthesia maintenance in patients with supratentorial tumors
1. enflurane (Ethrane)
2. halothane (Fluothane)
3. isoflurane (Forane)
4. nitrous oxide
Alternative to nitrous oxide or higher isoflurane (Forane) concentrations (> 1%) for patients with high ICP or low intracranial compliance
1. opioid-thiopental (Pentothal)
2. propofol (Diprivan) + midazolam (Versed) or low-dose isoflurane (Forane)
3. both
4. neither
Anesthesia in patients with severe intracranial hypertension even after steroids, hyperventilation, and diuretic administration
1. isoflurane (Forane) + nitrous oxide
2. enflurane (Ethrane) + thiopental (Pentothal)
3. thiopental (Pentothal) + fentanyl (Sublimaze) boluses/infusion