Effect of intravenous midazolam on intracranial pressure during endotracheal suctioning in patients with severe head injury

Abstract

Background: Patients with severe traumatic brain injury (TBI) require elective ventilation and sedation to decrease intracranial pressure (ICP) and any increase in ICP may be detrimental for the outcome in these patients. Methods: This prospective study was done in a neurotrauma intensive care unit ( ICU )of a level 1 trauma centre in India over a one month period. All adult male patients with severe TBI on mechanical ventilation and monitored for ICP were included in this study. Baseline ICP was measured before starting endotracheal (ET) suctioning and serial readings were taken during and after ET suctioning. Patients were divided into two groups (control and intervention) with intervention group receiving intravenous bolus dose of 2 mg of midazolam before ET suction. Results: A total of 20 patients were enrolled during the study period. Both groups were well matched with regards to age and admission Glasgow coma scale (GCS). There were 10 patients in the midazolam group and 10 patients in the control group. The mean rise of ICP following ET suctioning in control group was found to be 24.1mm Hg ±11.1 as compared to 18.25 mm Hg ±-9.29 in the midazolam group ( P< 0.05). Conclusions: Significant rise in ICP from baseline occurs following ET suctioning in ventilated, severe TBI patients. Our study suggests that additional intravenous bolus of midazolam prior to suctioning may significantly reduce the rise in ICP and should be practiced by ICU nurses.

Keywords

Endotracheal suctioning - intracranial pressure - midazolam - severe traumatic brain injury

• REFERENCES

• 1 Heise T. Management of the multiple trauma patient with increased ICP. J Neurosurg Nurs 1983; 15: 201-4
• 2 Adelson PD, Bratton SL, Carney NA, Chesnut RM, du Coudray HE, Goldstein B. et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents. Chapter 9. Use of sedation and neuromuscular blockade in the treatment of severe pediatric traumatic brain injury. Pediatr Crit Care Med 2003; 4 (Suppl. 03) Suppl S34-7
• 3 Papazian L, Albanese J, Thirion X, Perrin G, Durbec O, Martin C. Effect of bolus doses of midazolam on intracranial pressure and cerebral perfusion pressure in patients with severe head injury. Br J Anaesth 1993; 71: 267-71
• 4 Cornell JE, Giffin JP, Lim K, Milhorat T, Stein S, Shwiry B. Intracranial pressure, mean arterial pressure and heart rate following midazolam or thiopental in humans with intra cranial masses. Anesthesiology 1982; 57: A323
• 5 Hanowell LH, Thurston JD, Behrman KH, Disbrow EA. Alfentanil administered prior to endotracheal suctioning reduces cerebral perfusion pressure. J Neurosurg Anesthesiol 1993; 5: 31-5
• 6 Fanconi S, Duc G. Intratracheal suctioning in sick preterm infants: Prevention of intracranial hypertension and cerebral hypoperfusion by muscle paralysis. Pediatrics 1987; 79: 538-43
• 7 Werba A, Weinstabl C, Petricek W, Plainer B, Spiss CK. Requisite muscle relaxation using vecuronium for tracheobronchial suction in neurosurgical intensive care patients. Anaesthesist 1991; 40: 328-31
• 8 Kerr ME, Sereika SM, Orndoff P, Weber B, Rudy EB, Marion D. et al. Effect of neuromuscular blockers and opiates on the cerebrovascular response to endotracheal suctioning in adults with severe head injuries. Am J Crit Care 1998; 7: 205-17
• 9 Tateishi A, Maekawa T, Takeshita H, Wakuta K. Diazepam and intracranial pressure. Anesthesiology 1981; 54: 335-7
• 10 Reves JG, Fragen RJ, Vinik HR, Greenblatt DJ. Midazolam: Pharmacology and uses. Anesthesiology 1985; 62: 310-24
• 11 Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF. et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013; 41: 263-306
• 12 Crutchfield JS, Narayan RK, Robertson CS, Michael LH. Evaluation of a fiberoptic intracranial pressure monitor. J Neurosurg 1990; 72: 482-7
• 13 Moss E, Powell D, Gibson RM, McDowall DG. Effect of etomidate on intracranial pressure and cerebral perfusion pressure. Br J Anaesth 1979; 51: 347-52
• 14 Wolff J. Cerebrovascular and metabolic effects of midazolam and flumazenil. Acta Anaesthesiol Scand Suppl 1990; 92: 75-7
• 15 Giffin JP, Cottrell JE, Shwiry B, Hartung J, Epstein J, Lim K. Intracranial pressure, mean arterial pressure, and heart rate following midazolam or thiopental in humans with brain tumors. Anesthesiology 1984; 60: 491-4
• 16 Chan KH, Miller JD, Dearden NM, Andrews PJ, Midgley S. The effect of changes in cerebral perfusion pressure upon middle cerebral artery blood flow velocity and jugular bulb venous oxygen saturation after severe brain injury. J Neurosurg 1992; 77: 55-61
• 17 Urwin SC, Menon DK. Comparative tolerability of sedative agents in head-injured adults. Drug Saf 2004; 27: 107-33
• 18 Skoglund K, Enblad P, Hillered L, Marklund N. The neurological wake-up test increases stress hormone levels in patients with severe traumatic brain injury. Crit Care Med 2012; 40: 216-22
• 19 Burry L, Rose L, McCullagh IJ, Fergusson DA, Ferguson ND, Mehta S. Daily sedation interruption versus no daily sedation interruption for critically ill adult patients requiring invasive mechanical ventilation. Cochrane Database Syst Rev 2014; 9 (07) DOI: CD009176.
• 20 Skoglund K, Enblad P, Marklund N. Effects of the neurological wake-up test on intracranial pressure and cerebral perfusion pressure in brain-injured patients. Neurocrit Care 2009; 11: 135-42
• 21 Heffernan DS, Inaba K, Arbabi S, Cotton BA. Sympathetic hyperactivity after traumatic brain injury and the role of beta-blocker therapy. J Trauma 2010; 69: 1602-9