Severe Pediatric Traumatic Brain Injury (TBI), PICU — Licox Monitoring — Clinical Pathway: Emergency, ICU and Inpatient

Traumatic Brain Injury (TBI) Clinical Pathway — Emergency Department and ICU

Licox Monitoring

The Licox can provide ICP, brain tissue oxygenation (PbtO2), and brain temperature values. This enables evaluation of cerebral oxygenation in addition to intracranial pressure monitoring.

Licox Monitoring Nursing Procedure – View Nursing Procedure

Cerebral Ischemia +/- Elevated ICP

If concern for cerebral ischemia (Brain PbtO2 ≤ 15), perform the following actions to resolve:

Perform “O2 Challenge” Test to Rule out Licox Malfunctioning

Adjust ventilator. Increase PaO2 by increasing FiO2 TRANSIENTLY to 100% and assess:

  • Pass: Increase in brain PbtO2 (i.e. the Licox is functioning).
  • Fail: No improvement in brain PbtO2. Decrease FiO2 back to 55% and contact Neurosurgery for possible Licox adjustment and CT scan.

If Patient Passes the O2 Challenge Test:

  1. Decrease FiO2 to the lowest level to maintain the PbtO2 ≥ 15 (max 55% FiO2 to avoid O2 toxicity)
  2. If lowest FiO2 = 55% and PbtO2 continues to drop, consider the following:
Indication Goals Interventions Mechanisms Comments
Cerebral Ischemia:
Brain PbtO2 ≤ 15
  • Lower ICP
 
  • Avoid hypotension
  • Increase cerebral perfusion pressure (CPP)
  • Consider 5-10 ml/kg IV NSS bolus
  • Start vasopressor infusion
  • Blood pressure regulation
  • Increase brain oxygen delivery (increase PbtO2)
  • Ventilator adjustments: increase PEEP and/or arterial CO2 to > 40
  • Transfuse pRBCs to
    Hgb ≥ 8 g/dL
  • Increase O2 carrying capacity/delivery
If target is to increase:
  • PEEP: may decrease venous return and increase ICP
  • paCO2: resultant cerebral vasodilation may increase ICP
Elevated ICP
ICP > 20
  • Lower ICP
 See Treating Elevated ICP – Escalation of Therapy