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Volume-targeted therapy of increased intracranial pressure: the Lund concept unifies surgical and non-surgical treatments

Grände, Per-Olof LU ; Asgeirsson, Bogi LU and Nordström, Carl-Henrik LU (2002) In Acta Anaesthesiologica Scandinavica 46(8). p.929-941
Abstract
Opinions differ widely on the various treatment protocols for sustained increase in intracranial pressure (ICP). This review focuses on the physiological volume regulation of the intracranial compartments. Based on these mechanisms we describe a protocol called 'volume-targeted' ('Lund concept') for treatment of increased ICP. The driving force for transcapillary fluid exchange is determined by the balance between effective transcapillary hydrostatic and osmotic pressures. Fluid exchange across the intact blood-brain barrier (BBB) is counteracted by the low permeability to crystalloids (mainly Na+ and Cl-) combined with the high osmotic pressure (5500 mmHg) on both sides of the BBB. This contrasts to most other capillary regions where the... (More)
Opinions differ widely on the various treatment protocols for sustained increase in intracranial pressure (ICP). This review focuses on the physiological volume regulation of the intracranial compartments. Based on these mechanisms we describe a protocol called 'volume-targeted' ('Lund concept') for treatment of increased ICP. The driving force for transcapillary fluid exchange is determined by the balance between effective transcapillary hydrostatic and osmotic pressures. Fluid exchange across the intact blood-brain barrier (BBB) is counteracted by the low permeability to crystalloids (mainly Na+ and Cl-) combined with the high osmotic pressure (5500 mmHg) on both sides of the BBB. This contrasts to most other capillary regions where the osmotic pressure is mainly derived from the plasma proteins (approximately 25 mmHg). Accordingly, the level of the cerebral perfusion pressure (CPP) is of less importance under physiological conditions. In addition cerebral intracapillary hydrostatic pressure (and cerebral blood flow) is physiologically tightly autoregulated, and variations in systemic blood pressure are generally not transmitted to these capillaries. If the BBB is disrupted, transcapillary water transport will be determined by the differences in hydrostatic and colloid osmotic pressure between the intra- and extracapillary compartments. Under these pathological conditions, pressure autoregulation of cerebral blood flow is likely to be impaired and intracapillary hydrostatic pressure will depend on variations in systemic blood pressure. The volume-targeted 'Lund concept' can be summarized under four headings: (1) Reduction of stress response and cerebral energy metabolism; (2) reduction of capillary hydrostatic pressure; (3) maintenance of colloid osmotic pressure and control of fluid balance; and (4) reduction of cerebral blood volume. The efficacy of the protocol has been evaluated in experimental and clinical studies regarding the physiological and biochemical (utilizing intracerebral microdialysis) effects, and the clinical experiences have been favorable. (Less)
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author
organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
microdialysis, hydrostatic capillary pressure, formula, Starling, pressure, colloid osmotic, brain trauma, blood-brain barrier, brain edema
in
Acta Anaesthesiologica Scandinavica
volume
46
issue
8
pages
929 - 941
publisher
Wiley-Blackwell
external identifiers
  • wos:000177547900002
  • pmid:12190792
  • scopus:0036724462
ISSN
0001-5172
DOI
10.1034/j.1399-6576.2002.460802.x
language
English
LU publication?
yes
id
de7ec104-9eb9-41d3-b97b-0e7e3035d1a8 (old id 331168)
date added to LUP
2007-08-21 09:47:06
date last changed
2017-10-22 03:47:03
@article{de7ec104-9eb9-41d3-b97b-0e7e3035d1a8,
  abstract     = {Opinions differ widely on the various treatment protocols for sustained increase in intracranial pressure (ICP). This review focuses on the physiological volume regulation of the intracranial compartments. Based on these mechanisms we describe a protocol called 'volume-targeted' ('Lund concept') for treatment of increased ICP. The driving force for transcapillary fluid exchange is determined by the balance between effective transcapillary hydrostatic and osmotic pressures. Fluid exchange across the intact blood-brain barrier (BBB) is counteracted by the low permeability to crystalloids (mainly Na+ and Cl-) combined with the high osmotic pressure (5500 mmHg) on both sides of the BBB. This contrasts to most other capillary regions where the osmotic pressure is mainly derived from the plasma proteins (approximately 25 mmHg). Accordingly, the level of the cerebral perfusion pressure (CPP) is of less importance under physiological conditions. In addition cerebral intracapillary hydrostatic pressure (and cerebral blood flow) is physiologically tightly autoregulated, and variations in systemic blood pressure are generally not transmitted to these capillaries. If the BBB is disrupted, transcapillary water transport will be determined by the differences in hydrostatic and colloid osmotic pressure between the intra- and extracapillary compartments. Under these pathological conditions, pressure autoregulation of cerebral blood flow is likely to be impaired and intracapillary hydrostatic pressure will depend on variations in systemic blood pressure. The volume-targeted 'Lund concept' can be summarized under four headings: (1) Reduction of stress response and cerebral energy metabolism; (2) reduction of capillary hydrostatic pressure; (3) maintenance of colloid osmotic pressure and control of fluid balance; and (4) reduction of cerebral blood volume. The efficacy of the protocol has been evaluated in experimental and clinical studies regarding the physiological and biochemical (utilizing intracerebral microdialysis) effects, and the clinical experiences have been favorable.},
  author       = {Grände, Per-Olof and Asgeirsson, Bogi and Nordström, Carl-Henrik},
  issn         = {0001-5172},
  keyword      = {microdialysis,hydrostatic capillary pressure,formula,Starling,pressure,colloid osmotic,brain trauma,blood-brain barrier,brain edema},
  language     = {eng},
  number       = {8},
  pages        = {929--941},
  publisher    = {Wiley-Blackwell},
  series       = {Acta Anaesthesiologica Scandinavica},
  title        = {Volume-targeted therapy of increased intracranial pressure: the Lund concept unifies surgical and non-surgical treatments},
  url          = {http://dx.doi.org/10.1034/j.1399-6576.2002.460802.x},
  volume       = {46},
  year         = {2002},
}