Head Positioning for Intracranial Pressure Due to Brain Bleeds

Overseen By Hazard, M.D.

Age: 18+

Sex: Any

Trial Phase: Academic

Sponsor: Milton S. Hershey Medical Center

Disqualifiers: Pulmonary hypertension, Cirrhosis, Clinically unstable, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Approved in 1 Jurisdiction This treatment is already approved in other countries

Compensation: Varies

Number of Visits: Unknown

Duration: 10 days

15 Participants Needed

Trial Summary

What is the purpose of this trial?

The purpose of this study is to evaluate how pressure inside the skull responds to position changes in patients with brain bleeds.

Do I need to stop my current medications for this trial?

The trial protocol does not specify whether you need to stop taking your current medications.

What data supports the idea that Head Positioning for Intracranial Pressure Due to Brain Bleeds is an effective treatment?

The available research shows that elevating the head of the bed is a common practice for managing intracranial pressure in patients with brain injuries. For example, one study highlights that this position is standard for patients with severe traumatic brain injury, as it may help reduce pressure in the brain by improving blood flow and drainage. Another study indicates that while head elevation is standard, its effects on brain oxygen levels and circulation are still being explored. Overall, the research suggests that head positioning is widely used and believed to help manage brain pressure, although more data is needed to fully understand its benefits. ^{1 2 3 4 5}

What safety data exists for head positioning in managing intracranial pressure?

The safety data for head positioning, including head-of-bed elevation, in managing intracranial pressure is mixed. Studies indicate that elevating the head of the bed can reduce intracranial pressure, which is beneficial for patients with cerebral edema or at risk of intracranial hypertension. However, there are concerns that it may also decrease cerebral perfusion pressure, potentially leading to cerebral ischemia. The optimal head positioning should be individualized, taking into account both intracranial pressure and cerebral perfusion pressure measurements. Further research is needed to refine these practices and ensure patient safety. ^{2 4 6 7 8}

Is head positioning a promising treatment for managing intracranial pressure due to brain bleeds?

Yes, head positioning is a promising treatment for managing intracranial pressure from brain bleeds. Elevating the head of the bed can help reduce pressure in the brain by improving blood flow and oxygenation. This method is commonly used in patients with brain injuries to help manage pressure and improve recovery. ^{1 2 3 4 5}

Research Team

Cain Dudek, BS

Principal Investigator

Penn State Hershey Medical Center College of Medicine

Eligibility Criteria

This trial is for adults over 18 with a confirmed subarachnoid hemorrhage who have devices to monitor skull pressure and arterial blood pressure. They must be able to consent or have someone who can. Excluded are those prone while intubated, with severe heart failure, pulmonary hypertension, clinical instability, multiple IV meds for blood pressure, active resuscitation, or serious liver issues.

Inclusion Criteria

You have had bleeding in the space around your brain, confirmed by specific imaging tests.

I am 18 years old or older.

You have a device that measures pressure inside your head.

Exclusion Criteria

I am on a breathing machine and can be laid face down.

My heart's pumping ability is very low.

I have been diagnosed with high blood pressure in the lungs.

Timeline

Screening

Participants are screened for eligibility to participate in the trial

1-2 weeks

Treatment

Participants undergo positional changes to evaluate intracranial pressure response

10 days

Daily monitoring during hospitalization

Follow-up

Participants are monitored for safety and effectiveness after treatment

2 weeks

Treatment Details

Interventions

• Head-of-Bed Positioning

Trial Overview The study tests how different body positions affect intracranial pressure in patients with brain bleeds. Positions include lying flat (supine), semi-reclined sitting up slightly (semi-recumbent), and semi-reclined with legs bent.

Participant Groups

Group I: Positional Changes Experimental Treatment 3 Interventions

The patient will begin in a supine position with the head-of-bed (HOB) at zero (0) degrees. The patient will remain in this position for five (5) minutes while pressure data is collected every fifteen (15) seconds. Next, the HOB will be adjusted to thirty (30) degrees. The patient will remain in this position for five (5) minutes while pressure data is collected every fifteen (15) seconds. Lastly, the HOB will remain at thirty (30) degrees and the foot-of-bed (FOB) will be adjusted to place the patient's leg in a dependent position. The patient will remain in this position for five (5) minutes while pressure data is collected every fifteen (15) seconds.

Who Is Running the Clinical Trial?

Milton S. Hershey Medical Center

Lead Sponsor

Trials

515

Recruited

2,873,000+

Findings from Research

In a study of 20 acute ischemic stroke patients, lowering the head of the bed from 30 degrees to 0 degrees significantly increased mean flow velocity in the middle cerebral artery, suggesting improved blood flow to the affected brain tissue.

Lowering the head position did not increase resistance to blood flow, and some patients experienced immediate neurological improvement, indicating that adjusting head positioning could be a beneficial intervention in acute stroke management.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Heads down: flat positioning improves blood flow velocity in acute ischemic stroke. Wojner-Alexander, AW., Garami, Z., Chernyshev, OY., et al.[2016]

In a study of 136 patients, measuring cerebral perfusion pressure (CPP) with the arterial transducer positioned at the tragus resulted in significantly lower values compared to when it was positioned at the phlebostatic axis, regardless of the head-of-bed (HOB) elevation.

This finding suggests that the position of the arterial transducer can influence CPP readings, indicating that careful consideration of measurement techniques is crucial in managing patients at risk for intracranial hypertension.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

The Impact of Head-of-Bed Positioning and Transducer Location on Cerebral Perfusion Pressure Measurement. McNett, M., Livesay, S., Yeager, S., et al.[2019]

In a study of 18 pediatric patients with severe traumatic brain injury (TBI), the optimal head of bed (HOB) position for minimizing intracranial pressure (ICP) and maximizing cerebral perfusion pressure (CPP) was found to vary, indicating that a standard 30° elevation may not be suitable for all patients.

The research highlighted that individualized HOB positioning is crucial, as some patients showed better outcomes at different angles, including horizontal positioning, emphasizing the need for daily assessment of optimal HOB for each patient.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Head of bed elevation in pediatric patients with severe traumatic brain injury. Lang, SS., Valeri, A., Zhang, B., et al.[2022]

Implementing a standardized order for semirecumbent head-of-bed positioning in mechanically ventilated patients significantly increased the average angle of head positioning from 24 degrees to 35 degrees, reducing the risk of ventilator-associated pneumonia (VAP).

Following a provider education program, the percentage of patients positioned at greater than 45 degrees rose from 3% to 29%, demonstrating that both standardized orders and education can effectively maintain improved positioning practices over time.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Effect of standardized orders and provider education on head-of-bed positioning in mechanically ventilated patients. Helman, DL., Sherner, JH., Fitzpatrick, TM., et al.[2019]

In a study of 23 patients with severe acute brain injury, lowering the head position from 30° to 0° significantly increased intracranial pressure (ICP) by an average of 7.4 mm Hg, indicating a potential risk of elevated ICP in flat positions.

Conversely, brain oxygenation and circulation improved when the head was lowered from 30° to 0°, suggesting that individualized head positioning may be beneficial for optimizing brain oxygenation and blood flow in these patients.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Impact of Head-of-Bed Posture on Brain Oxygenation in Patients with Acute Brain Injury: A Prospective Cohort Study. Burnol, L., Payen, JF., Francony, G., et al.[2022]

Elevating the head of the bed to 45° in mechanically ventilated patients significantly reduces mean arterial pressure (MAP) and central venous oxygen saturation (ScvO2), indicating potential hemodynamic instability.

Factors such as the mode of mechanical ventilation and the dose of norepinephrine were found to significantly influence the risk of hypotension during head elevation, suggesting that patients may need to be positioned at a lower angle (20° to 30°) to maintain stability, especially early in their ICU stay.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

The effects of the semirecumbent position on hemodynamic status in patients on invasive mechanical ventilation: prospective randomized multivariable analysis. Göcze, I., Strenge, F., Zeman, F., et al.[2021]

Current nursing practice typically involves elevating the head of the bed (HOB) to 30 or 45 degrees for patients with cerebral edema, but new guidelines for managing intracranial hypertension suggest that this practice may need to be re-evaluated.

The article aims to critically assess existing research on the effects of HOB elevation on patients with intracranial hypertension and propose updated recommendations based on the latest critical pathway for treatment.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Positioning and intracranial hypertension: implications of the new critical pathway for nursing practice. Beitel, J.[2016]

Head elevation is a common nursing practice to reduce intracranial pressure (ICP) in patients with neurotrauma, but it can also risk causing intracranial hypertension and reduced blood flow to the brain (cerebral ischemia) due to lower cerebral perfusion pressure (CPP).

The review emphasizes the importance of monitoring both ICP and CPP when determining the optimal head position for individual patients, suggesting that personalized approaches are necessary for effective management of intracranial hemodynamics.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Management of intracranial hemodynamics in the adult: a research analysis of head positioning and recommendations for clinical practice and future research. Simmons, BJ.[2019]

References

1. United States pubmed.ncbi.nlm.nih.gov

Heads down: flat positioning improves blood flow velocity in acute ischemic stroke. [2016]

2. United States pubmed.ncbi.nlm.nih.gov

The Impact of Head-of-Bed Positioning and Transducer Location on Cerebral Perfusion Pressure Measurement. [2019]

3. United States pubmed.ncbi.nlm.nih.gov

Head of bed elevation in pediatric patients with severe traumatic brain injury. [2022]

4. United States pubmed.ncbi.nlm.nih.gov

Effect of standardized orders and provider education on head-of-bed positioning in mechanically ventilated patients. [2019]

5. United States pubmed.ncbi.nlm.nih.gov

Impact of Head-of-Bed Posture on Brain Oxygenation in Patients with Acute Brain Injury: A Prospective Cohort Study. [2022]

6. England pubmed.ncbi.nlm.nih.gov

The effects of the semirecumbent position on hemodynamic status in patients on invasive mechanical ventilation: prospective randomized multivariable analysis. [2021]

7. Canada pubmed.ncbi.nlm.nih.gov

Positioning and intracranial hypertension: implications of the new critical pathway for nursing practice. [2016]

8. United States pubmed.ncbi.nlm.nih.gov

Management of intracranial hemodynamics in the adult: a research analysis of head positioning and recommendations for clinical practice and future research. [2019]