NEUROCRITICAL CARE

Raised Intracranial Pressure Syndrome: A Stepwise Approach

Swagata Tripathy1, Suma Rabab Ahmad2

A b s t r ac t
Raised intracranial pressure (rICP) syndrome is seen in various pathologies. Appropriate and systematic management is important for favourable
patient outcome. This review describes the stepwise approach to control the raised ICP in a tiered manner, with increasing aggressiveness. The
role of ICP measurement in the assessment of cerebral autoregulation and individualised management is discussed. Although a large amount
of research has been undertaken for the management of raised ICP, there still remain unanswered questions. This review tries to put together
the best evidence in a succinct manner.
Keywords: Complications, Cerebrospinal fluid, Hypertonic saline, Intracranial pressure, Management, Steroids
Indian Journal of Critical Care Medicine (2019): 10.5005/jp-journals-10071-23190

Introduction 1,2
Department of Anesthesia and Intensive Care, All India Institute of
Raised intracranial pressure (rICP) syndrome is a constellation of Medical Sciences, Bhubaneswar, Odisha, India
clinical symptoms and signs associated with a rise in intracranial Corresponding Author: Swagata Tripathy, Department of Anesthesia
pressure. Various pathologies may lead to a rise in intracranial and Intensive Care, All India Institute of Medical Sciences, Bhubaneswar,
pressure (ICP). The realm of management of raised ICP has Odisha, India, Phone: 8763400534, e-mail: tripathyswagata@gmail.
progressed over time with the development of new monitoring com
technology and treatment modalities. There is more clarity now How to cite this article: Tripathy S, Ahmad SR. Raised Intracranial
in the understanding of the management; however, there are still Pressure Syndrome: A Stepwise Approach. Indian J Crit Care Med
some gaps. Here we attempt to review the systematic approach to 2019;23(Suppl 2):S129–S135.
management of the rICP syndrome. Source of support: Nil
Conflict of interest: None
Pathophysiology of Raised ICP Syndrome
The Monro-Kellie doctrine originated from the first description
of ICP by Scottish anatomist Alexander Monro in 1783.1 He was
supported by his colleague George Kellie some years later. Harvey
Cushing, American neurosurgeon, in 1926, formulated the doctrine
as we know it today.2 He stated that with an intact skull, the volume
of the brain, blood, and cerebrospinal fluid (CSF) is constant. An
increase in one component will cause a decrease in one or both of
the other components. Thus, when there is a growing mass lesion
of the brain parenchyma there will be decrease of the CSF or the
blood (mainly venous) until the compensatory point is exceeded
where we get an elevated ICP3 (Fig. 1). Various causes enumerated
in Table 1 lead to rICP by increase of either one or all of the three
components namely brain, CSF or blood.4
Normal ICP is defined as the pressure inside the lateral ventricles
or lumbar subarachnoid space in supine position. It normally ranges
from <10–15 mm Hg in adults, 3–7 mm Hg in children and 1.5–6
mm Hg in term infants. Fig. 1: Cerebral volume–pressure curve showing the relationship
We use the Glasgow Coma Scale (GCS) and the Full Outline of between ICP and an increase in the intracranial component volume
UnResponsiveness (FOUR) score to monitor the consciousness of the
patient. The FOUR Score was developed for assessing consciousness Clinical clues are the mainstay for deciding the requirement
in intubated trauma patients in whom all the components of GCS for any imaging or intervention. However, at times these may be
cannot be assessed.5 It has a good correlation with GCS, shown to missed or appear late (Table 1). These clinical manifestations are
give better details of the neurological status in some studies6 and a consequence of two major derangements. Firstly rICP poses a
can be used in stroke and non-trauma coma also. It is an extensive danger to the patient in terms of decreased cerebral perfusion
17-point scale assessing four domains of neurological function: pressure (CPP) and the resultant tissue ischemia. Secondly the lesion
eye responses, motor responses, brainstem reflexes, and breathing itself can cause a shift in brain parenchyma manifested as cerebral
pattern. Any decrease in these scores are associated with worsening herniation syndromes (Fig. 2) causing irreversible brain damage
consciousness as well as ICP. and even death (Table 2).

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.
org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to
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 Raised Intracranial Pressure Syndrome: A Stepwise Approach

Table 1: Causes of raised intracranial pressure

Pathophysiology Causes
Focal brain oedema (localized mass lesion) Traumatic hematomas (extradural, subdural, intracerebral)
Neoplasms (gliomas, meningiomas, metastasis)
Ischemic or hemorrhagic stroke, abscess
Diffuse brain oedema Encephalitis, meningitis, diffuse head injury, seizures, encephalopathy (hepatic,
toxic, uremic or septic), hypoxemic ischemic encephalopathy, water intoxica-
tion, Reye’s syndrome
Disturbance of CSF circulation Obstructive hydrocephalus
Communicating hydrocephalus
Subarachnoid hemorrhage
Obstruction to major venous sinuses Depressed fractures overlying major venous sinuses.
Cerebral venous thrombosis
Vascular malformations Arteriovenous malformation
Idiopathic Benign intracranial hypertension

Table 2: Symptoms and signs of rICP

Headache
Nausea and vomiting
Systolic hypertension
Bradycardia Cushing’s triad
Irregular respiration, Cheyne-
stokes respiration
Decreased mental abilities
Confusion
Double vision
Pupils not reacting to light and
unequal pupils
Loss of consciousness and finally
coma as the pressure worsens.

G e n e r a l M a n ag e m e n t /T i e r Z e r o
Resuscitation: Airway, Breathing and Circulation
Airway
Proper and prompt management of airway, breathing and
7
Fig. 2: Herniation sites : 1. Subfalcine/Cingulate; 2. Central transtentorial; circulation prevents hypoxia, hypercapnia and hypotension.
3. Lateral transtentorial (Uncal); 4. Tonsillar; 5. Transcalvarial Hypoxia increases ICP by vasodilatation and cerebral edema.
Coughing or bucking during laryngoscopy and intubation can
cause further increse in the ICP. Hence sedatives should always be
Management of raised ICP
used before intubation even if the patient is unresponsive. Esmolol,
Increased ICP aggravates secondary brain injury. Secondary brain labetalol and lignocaine can also be used to blunt the hemodynamic
injury occurs within hours to days after the primary injury. The responses to laryngoscopy.
detrimental processes are cerebral ischemia, cerebral edema and
neurochemical interplay of excitatory neurotransmitters, free Ventilation
radicals’ formation, and increased levels of calcium and potassium Hypercarbia is a potent cerebral vasodilator causing increase in
intracellularly.8 The various treatment strategies for lowering ICP cerebral blood volume and ICP. Hence hypoventilation should be
should be started along with the treatment of the primary cause. avoided and normocapnia maintained.
Secondary brain injury is worsened with hypoxia and hypotension.
Most commonly the interventions are aimed at decreasing the Blood Pressure
cerebral blood volume and the fluid component of the brain tissue. Hypotension will decrease the cerebral perfusion pressure in a
Drainage of CSF or surgical removal of brain tissue are done in brain with impaired autoregulation. BTF guidelines recommend
selected cases. maintaining systolic blood pressure at ≥ 100 mm Hg for patients
Most of the evidence for management of rICP has been derived 50 to 69 years old or at ≥ 110 mm Hg or above for patients 15–49 or
from the published literature on traumatic brain injury (TBI), in >70 years old to decrease mortality and improve outcomes (Level III).
particular the Brain Trauma Foundation (BTF) guidelines, fourth Elevated blood pressure is seen commonly in patients with
edition published in 2017.9 rICP. This is a compensatory mechanism to maintain the CPP and it

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 Raised Intracranial Pressure Syndrome: A Stepwise Approach

Table 3: Comparison of different sedatives and supporting evidence

Sedative Advantages Cautions Literature
Propofol Recommended for the control of ICP High dose or prolonged infusion: First line sedative 15
(level IIb) Propofol infusion syndrome
Midazolam Safe in rICP Tachyphylaxis First line sedative 15
lowest incidence of spreading -Robin et al.: iv bolus of
depolarizations, a potentially midazolam prior to suctioning
modifiable secondary injury significant reduction in ICP 16
mechanism
Ketamine NMDA receptor antagonist Early case reports concluded Intraoperative administration of
neuroprotective effect inconclusive that it increases CSF secretion ketamine for craniotomy: 1 mg/
Used as an adjunct with other increases ICP kg Ketamine reduced ICP 18
sedatives: has shown to decrease ICP 17 Further RCTs required
Barbiturates Only for elevated ICP refractory to Prophylactic use against the Brain Trauma Foundation
maximum standard development of raised ICP: not guidelines9
medical and surgical treatment. recommended.
Hemodynamic stability is essential
Dexmedetomidine Sedation and analgesia without Hypotension, bradycardia, Aryan et al., neurosurgical
respiratory depression Agitation patients: safe and effective, mean
Patient is arousable, facilitates Further studies to establish its ICP decreased.19
neurological assessment dose and duration avoid loading dose, higher
Rapid distribution and elimination maintenance doses to ensure
properties adequate sedation
Inhaled sedatives: Emerging as sedative agent Flow metabolism uncoupling Subarachnoid hemorrhage
sevoflurane and isoflurane action without rICP: 0.8 % isoflurane
Acute cerebrovascular disease: significantly improved regional
sevoflurane was associated with a CBF with modest effect on ICP
significant increase in ICP 20 when compared with propofol 21
*NMDA: N-methyl-D-aspartate

is unwise to control it. However, when autoregulation is impaired, protective effects primarily by reducing cerebral metabolic rate
as in traumatic brain injury (TBI) this might increase the cerebral of oxygen consumption (CMRO2) and CBF which is tightly coupled
blood flow (CBF) and ICP. It is also carries a risk of causing intracranial to CMRO2.12
hemorrhage in certain conditions like hemorrhagic stroke or in Minimal periods of sedation interruption in patients with rICP
the postoperative neurosurgery patient. Systemic hypertension will prevent ICP spikes.13 There is no evidence that one sedative
usually resolves with sedation. For treatment antihypertensive agent is more efficacious than another for improvement of ICP
drugs such as sympatholytics: β-blockers (labetalol, esmolol) or (Table 3).14
centrally acting α -agonists (clonidine) can be used. Vasodilating Sedatives should be adequately supplemented with analgesics.
drugs, such as nitroprusside, and nitro-glycerine should be avoided Newer opioids like fentanyl are the primary analgesics. Large bolus
as these increase ICP. doses of opioids, however, have potentially deleterious effects on
ICP and CPP.14 Non-opioid analgesics help to minimize opioid use.
CPP Rarely, ICP control necessitates the use of neuromuscular blockade.
BTF recommends target CPP value for survival and favourable
outcomes between 60 mm Hg and 70 mm Hg, depending on the Facilitation of Cerebral Venous Drainage
autoregulatory status of the patient. Values above 70 carry a risk Head end of the bed should be kept elevated at 15–30 degrees
of acute respiratory distress syndrome9 (Level III). with the head in a neutral position to enhance cerebral venous
drainage and to promote the circulation of CSF from intracranial
Fluids to spinal compartment. Any tight circumferential tracheostomy or
A subgroup analysis of patients with TBI in the Saline vs. Albumin endotracheal tube ties or cervical collar may need adjustment to
Fluid Evaluation (SAFE) study found that mortality was higher in prevent internal jugular vein compression. Any rise in intrathoracic
patients resuscitated with albumin compared with saline, but the or intra-abdominal pressures can also interfere with venous
mechanism was unknown.10 Later it was propounded that the drainage.
most likely mechanism of increased mortality was the rICP during
the use of albumin in the first week.11 Hypo-osmolar fluids should Fever Control
be avoided. Hyponatremia should be corrected since it increases Fever increases metabolic rate by 10% to 13% per degree Celsius and
cerebral edema. is a potent vasodilator. It increases ICP. Fever should be controlled
by antipyretics and hydrotherapy.
Sedation and Analgesia
Sedation and analgesia in patients with rICP prevent coughing, Glucocorticoids
bucking and agitation, facilitates mechanical ventilation and Neurological deficit secondary to vasogenic oedema due to brain
suctioning as well as enables seizure control. It exerts cerebral tumors, abcesses or non-infectious neuroinflammations responds

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 Raised Intracranial Pressure Syndrome: A Stepwise Approach

well to steroid use as a temporising intervention. rICP, when present be given in continuous infusion. Serum sodium beyond 160 mEq/
decreases over the following 2–5 days. Intravenous dexamethasone dL is unlikely to provide any further benefit.
is commonly used, at a dose of 4 mg every 6 hours. Central line access is recommended. Frequent serum sodium
Steroids are contraindicated in treating raised ICP or for levels will need to be monitored prior to the next scheduled dose
improving outcome secondary to TBI or spontaneous hemorrhage to prevent osmotic demyelination due too rapid rise of serum
(Level I Evidence)7. Use of methylprednisolone for 48 hours in CRASH sodium if the patient had hyponatremia to begin with . Duration of
trial resulted in a significant increase in the risk of death. effect is 90 min to 4 hrs. Adverse effects include thrombophlebitis,
A non-contrast CT scan head should be performed when coagulation abnormality and hyperchloremic metabolic acidosis.
patient can be transported safely after Tier 0 management.22 If ICP is controlled with Tier 1 measures then consider repeating
CT scan to rule out any new processes.
Tier 1 Specific Therapy
Osmotic Therapy Tier 2
Hyperosmolar therapy has been regarded as the mainstay of If ICP is not controlled with Tier 1 medical interventions,
treatment of raised ICP. Hyperosmolar agents help to decrease ICP decompressive surgical options should be considered. If patient is
by effectively reducing brain water. It can be traced back to the not fit for surgery then other Tier 2 interventions should be applied.
publication of Weed and McKibben.23 However a Class I evidence Sedation depth can be increased by using agents like propofol.22
is still lacking.
Resection of Mass Lesions
Though mannitol is a time-tested agent, more recently,
hypertonic saline (HTS) formulations, have been investigated. In These are done to decrease the ICP and as a definitive therapy for
1988 Worthley et al. first found that HTS reduced rICP which was the lesions. Abscesses must be drained; acute epidural and subdural
refractory to mannitol.24 However, for acute elevations in ICP, either hematoma must be evacuated. Resection of intracerebral lesion
of the hyperosmolar therapy has shown equal efficacy in lowering (lobar/cerebellar hemorrhage) or brain parenchyma (eg: contusion)
ICP. For refractory intracranial hypertension, hypertonic saline may also aid in decompression. Tension pneumo-encephalous should
be preferred as concluded by a recent meta-analysis by Gu et al.25 be tapped.

Mannitol Cerebrospinal Fluid (CSF) Drainage

Mannitol is effective for control of raised ICP at doses of 0.25–1 g/kg CSF drainage by external ventricular drain (EVD) lowers ICP
body weight. Doses > 200g/day may cause acute renal failure (ARF). immediately by reducing intracranial volume. In a diffusely swollen
The serum osmolarity should be monitored and kept below 320 brain, sudden decompression may cause the ventricles to collapse.
mOsm/kg. A more reliable marker of serum mannitol level may be Continuous drainage of CSF by an EVD zeroed at the level of the
the osmolar gap (OG). midbrain (5–10 cm above the external auditory meatus) may be
Mannitol lowers the ICP 1–5 minutes after intravenous more beneficial in reducing the ICP than intermittent drainage.9
administration, and its peak effect is at 40 minutes. The duration of (Level III) Use of CSF drainage to lower ICP in patients with an initial
effect is 90 minutes – 6 hours. Mannitol will cause an initial plasma GCS <6 during the first 12 hours after TBI may be considered in the
expansion that will increase CBF. A damaged blood-brain barrier absence of coagulopathy.
(BBB) may worsen vasogenic oedema, however.
Mannitol is associated with many other complications. Decompressive Craniectomy (DC)
Hypotension with rapid administration (< 5min), rebound increase DC involves removal of a portion of the skull vault resulting
in ICP, volume overload and electrolyte imbalances (hypo/ in immediate decrease of the ICP. It is undertaken in patients
hypernatremia) and an early but transient decrease of serum with diffuse cerebral swelling due to TBI, meningoencephalitis,
bicarbonate and increases in serum potassium. Arterial hypotension stroke with brain edema and non-infectious neuro-inflammatory
(systolic blood pressure < 90 mm Hg) should be avoided.26 Mannitol conditions (eg: acute demyelinating encephalopathy). Usually a
use should be restricted prior to ICP monitoring in patients with decompressive hemicraniotomy (DHC) is done.
signs of transtentorial herniation.26 Reported complications of decompressive craniectomy include
Mannitol can be administered via a peripheral vein. An osmolar hydrocephalus, hemorrhagic swelling ipsilateral to the craniectomy
gap of 20 mmol/dl marks inadequate clearance of mannitol and will site, and subdural hygroma. A large frontotemporoparietal DC (not
increase the risk of rebound rise in ICP. Mannitol may need to be less than 12 x 15 cm or 15 cm diameter) is recommended over a small
warmed to dissolve crystals which precipitate in the bottle. frontotemporoparietal DC for reduced mortality and improved
neurologic outcomes in patients with severe TBI.9
Hypertonic saline (HTS) Although there is evidence of decrease in ICP with DC, several
Gaining popularity,27 it is available concentrations ranging from 3% studies have been performed to assess whether the benefits can
to 23.4%. It remains within the vascular compartment longer than be achieved in terms of good functional outcome or decrease in
mannitol and so is useful in treating the hypovolemic patient. It mortality.
has a better reflection coefficient than mannitol (agents with lower Cerebral oedema after massive malignant middle cerebral-
reflection coefficients have a greater risk of accumulating inside artery infarction (mMCAi) results in increased ICP. It often has
the brain) and tends to cross the BBB less. HTS can also be used to devastating consequences leading to brain herniation and death.
treat hyponatremia, which untreated can worsen brain oedema. A recent meta-analysis which included most large RCTs to date
Dose: Bolus dosing 3%: 2.5–5 mL/kg over 5–20 minutes, 5%: (Table 4) concluded that DC results in large reductions in mortality
2.5–5 mL/kg over 5–20 minutes, 7.5%: 1.5–2.5 mL/kg over 5–20 (RR 2.05, 95%CI 1.54–2.72; p < 0.00001). Surgery improved the
minutes, 23.4%: 30 mL over 10–20 minutes. Hypertonic saline may likelihood to survive with a mRS 0–3 (RR 1.58, 95%CI 1.02–2.46;

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 Raised Intracranial Pressure Syndrome: A Stepwise Approach

Table 4: Trials assessing the effect of decompressive craniectomy in massive malignant middle cerebral-artery infarction
Sl. No. Trials Year Conclusion
1 DECIMAL: Decompressive craniectomy in malignant MCA 2007 Absolute mortality reduction of 52% with DC, No significant
infarcts29 difference in functional outcomes.
2 DESTINY I: Decompressive surgery for the treatment of 2007 Mortality reduction from 88% to 47% with DC after 1 month.
malignant infarction of the MCA 30
3 HAMLET: Hemicraniectomy after MCA infarction with life- 2009 ARR 38% for fatality, but no difference in functional outcomes.
threatening edema trial 31
4 HeADDFIRST: Hemicraniectomy and Durotomy Upon 2014 Difference in mortality was not significant
Deterioration From Infarction-Related Swelling Trial32
5 DESTINY II: Decompressive surgery for the treatment of 2014 Significant reduction of severe disability.
malignant infarction of the MCA in elderly patients >60
years age33

Table 5: Evidence for the effect of decompressive craniectomy in patients with post-traumatic refractory intracranial hypertension
Sl. No. Trials Conclusion
1. DECRA study No benefit in terms of functional outcome at 6 months from
Limited by its restrictive eligibility criteria 34 bifrontal DC
2. RESCUE ICP: 35 Reduction of mortality by 22%
Randomised Evaluation of Surgery with Craniectomy for Higher rates of vegetative state, and severe disabilities than
Uncontrollable Elevation of ICP medical management
broader range of patients: more typical of those encountered Similar rates of moderate disability and good recovery with
in routine practice surgery than medical management.
published after BTF-IVth edition

p = 0.04).28 As the DESTINY II trial included elderly patients, age can Table 6: Contraindications of hyperventilation36
not be a criteria for exclusion of patients, although the functional Prophylactic
outcomes of this population is arguably worse than that of younger For first 24 hours of severe TBI when CBF often is reduced critically9
patients.
For prolonged periods (>4–6 hours)
The role of DC in patients with post-traumatic intracranial
hypertension that is refractory to medical management alone Without brain oxygenation monitoring
also remains unclear. Bifrontal DC is not recommended to improve Should not stop suddenly: risk of rebound rICP
outcomes as measured by the GOS-E score at 6 months post-
injury in severe TBI with diffuse injury (without mass lesions), and only with electroencephalographic monitoring. There is insufficient
with refractory ICP elevation. However, this procedure has been evidence to recommend levetiracetam compared with phenytoin
demonstrated to reduce ICP and ICU days (Level IIA) (Table 5). regarding efficacy in preventing early PTS and toxicity.

Hyperventilation Tier 3
Hyperventilation is recommended only as a temporizing measure They are the most aggressive measure to reduce ICP with most
for the reduction of elevated ICP in the setting of refractory serious adverse effects. Hence used only in refractory cases. Good
hypertension and for brief periods (<2 hours) in cases of cerebral quality evidence is sparse.
herniation or acute neurologic deterioration.9 Barbiturate coma: Barbiturates reduce ICP. The mechanism of
The effect of hyperventilation is almost immediate but lasts for ICP reduction by barbiturates is probably the result of a coupled
only 4–6 hours after which pH of the CSF rapidly equilibrates to the reduction in CBF and CMR. Pentobarbital is not preferred as it may
new PaCO2 level. As the CSF pH equilibrates, the cerebral arterioles result in hypotension needing vasopressor support. Thiopentone
dilate again. A goal of pCO2 30–35 mm Hg should be the target.22 is given in a loading dose of 5mg/kg over 30 minutes followed by
Prolonged prophylactic hyperventilation with PaCO2 of ≤25 mm Hg infusion of 1-5 mg/kg hour until the electroencephalogram shows
is not recommended by BTF ( Level IIB ) as there is a risk of cerebral a burst suppression pattern. During administration blood pressure
ischemia (Table 6). If hyperventilation is used, SjO2 (Jugular venous should be monitored as it can cause hypotension. Complications
oxygen) or BtpO2 (brain tissue oxygen) measurements are ideally of barbiturate coma include hypotension, hypokalemia, respiratory
recommended to monitor oxygen delivery. depression, infections due to immune suppression, and hepatic
and renal dysfunction.
Antiseizure Therapy
Therapeutic Hypothermia
Seizure activity will increase cerebral metabolic rate (CMR) and
CBF. CBF in excess of tissue demand leads to increased ICP. The Hypothermia reduces the CMR in a similar way as pentobarbital
latest BTF guidelines have recommended phenytoin to decrease coma. It also reduces the basal component of cellular metabolism
the incidence of early posttraumatic seizures (PTS), within 7 days along with suppression of electrical activity of brain.37 The evidence
of injury. Prophylactic use of phenytoin is not recommended for for benefit is stronger for post-cardiac arrest patients and for
preventing late PTS. In patients with severe TBI as well as with other neonatal hypoxic ischemia. There is a predictable decrease in ICP
causes of coma and rICP, seizures may be nonconvulsive, detected with the use of moderate hypothermia (target core temperature

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 Raised Intracranial Pressure Syndrome: A Stepwise Approach

32–34°C). There are various adverse effects of hypothermia such C o n c lu s i o n

as shivering, cardiac arrhythmias, electrolyte disturbances and
Timely recognition and management of rICP improves patient
sepsis. Rewarming should be done slowly to avoid rebound severe
outcomes when performed in a step wise manner and increasing
intracranial hypertension.
aggressiveness. Direct benefits on functional outcomes may
Recently, the large multicenter EUROTHERM trial randomized
be more apparent when the management is done in a more
patients with recent TBI and ICP refractory to tier one strategies,
individualized manner. Recent research and attempts are ongoing
to receive either therapeutic hypothermia for a minimum of 48
toward precision care of acute brain injury, of which ICP remains
hours plus standard care, or standard care alone. They found
an integral component.
that the two approaches were equivalent in reducing ICP, but the
intervention group paradoxically had a statistically significant
increase in the odds of poor functional outcome and mortality
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Indian Journal of Critical Care Medicine, June 2019;23 (Suppl 2) S135