Multicenter evaluation of propofol for head-injured patients in Taiwan

The Impact of Sedative Choice on Intracranial and Systemic Physiology in Moderate to Severe Traumatic Brain Injury: A Scoping Review

Although sedative use is near-ubiquitous in the acute management of moderate to severe traumatic brain injury (m-sTBI), the evidence base for these agents is undefined. This review summarizes the evidence for analgosedative agent use in the intensive care unit management of m-sTBI. Clinical studies of sedative and analgosedative agents currently utilized in adult m-sTBI management (propofol, ketamine, benzodiazepines, opioids, and alpha-2 agonists) were identified and assessed for relevance and methodological quality. The primary outcome was the effect of the analgosedative agent on intracranial pressure (ICP). Secondary outcomes included intracranial hemodynamic and metabolic parameters, systemic hemodynamic parameters, measures of therapeutic intensity, and clinical outcomes. Of 594 articles identified, 61 met methodological review criteria, and 40 were included in the qualitative summary; of these, 33 were prospective studies, 18 were randomized controlled trials, and 8 were blinded. There was consistent evidence for the efficacy of sedative agents in the management of m-sTBI and raised ICP, but the overall quality of the evidence was poor, consisting of small studies (median sample size, 23.5) of variable methodological quality. Propofol and midazolam achieve the goals of sedation without notable differences in efficacy or safety, although high-dose propofol may disrupt cerebral autoregulation. Dexmedetomidine and propofol/ dexmedetomidine combination may cause clinically significant hypotension. Dexmedetomidine was effective to achieve a target sedation score. De novo opioid boluses were associated with increased ICP and reduced cerebral perfusion pressure. Ketamine bolus and infusions were not associated with increased ICP and may reduce the incidence of cortical spreading depolarization events. In conclusion, there is a paucity of high-quality evidence to inform the optimal use of analgosedative agents in the management of m-sTBI, inferring significant scope for further research.

Neurologic Assessment of the Neurocritical Care Patient

Sedation is a ubiquitous practice in ICUs and NCCUs. It has the benefit of reducing cerebral energy demands, but also precludes an accurate neurologic assessment. Because of this, sedation is intermittently stopped for the purposes of a neurologic assessment, which is termed a neurologic wake-up test (NWT). NWTs are considered to be the gold-standard in continued assessment of brain-injured patients under sedation. NWTs also produce an acute stress response that is accompanied by elevations in blood pressure, respiratory rate, heart rate, and ICP. Utilization of cerebral microdialysis and brain tissue oxygen monitoring in small cohorts of brain-injured patients suggests that this is not mirrored by alterations in cerebral metabolism, and seldom affects oxygenation. The hard contraindications for the NWT are preexisting intracranial hypertension, barbiturate treatment, status epilepticus, and hyperthermia. However, hemodynamic instability, sedative use for primary ICP control, and sedative use for severe agitation or respiratory distress are considered significant safety concerns. Despite ubiquitous recommendation, it is not clear if additional clinically relevant information is gleaned through its use, especially with the contemporaneous utilization of multimodality monitoring. Various monitoring modalities provide unique and pertinent information about neurologic function, however, their role in improving patient outcomes and guiding treatment plans has not been fully elucidated. There is a paucity of information pertaining to the optimal frequency of NWTs, and if it differs based on type of injury. Only one concrete recommendation was found in the literature, exemplifying the uncertainty surrounding its utility. The most common sedative used and recommended is propofol because of its rapid onset, short duration, and reduction of cerebral energy requirements. Dexmedetomidine may be employed to facilitate serial NWTs, and should always be used in the non-intubated patient or if propofol infusion syndrome (PRIS) develops. Midazolam is not recommended due to tissue accumulation and residual sedation confounding a reliable NWT. Thus, NWTs are well-tolerated in selected patients and remain recommended as the gold-standard for continued neuromonitoring. Predicated upon one expert panel, they should be performed at least one time per day. Propofol or dexmedetomidine are the main sedative choices, both enabling a rapid awakening and consistent NWT.

Effects of propofol sedation during the early postoperative period in hemorrhagic stroke patients

BACKGROUND

The early postoperative period is a critical time for patients after receiving a decompressive craniotomy. Prompt detection and early management of postoperative recurrent/residual hemorrhagic complications may dramatically improve clinical outcomes.

METHODS

The present cohort retrospective study involved 135 patients who received decompressive craniotomy and intensive care unit (ICU) supervision as life-saving measures. The purpose of the study was to evaluate the effects of propofol sedation on the clinical outcome during the ICU stay. The patients' demographic data, hemodynamic variables, the dose of propofol used during the first 48 hours after surgery, residual/recurrent blood clot volume after surgery, and neurologic and clinical outcomes were reviewed. The propofol dosages used for sedation were further divided into three categories: < 0.66, 0.66-3.33 and > 3.33 mg/kg/hr, based on the doses infused during the first 12 hours after surgery.

RESULTS

Our results indicated that the patients of the propofol-sedated group had a significantly smaller amount of residual/recurrent blood clot (p < 0.05) than did those of the non-sedated group. The 30-day mortality rate was significantly lower in the propofol-sedated group (p < 0.05) than in the non-sedated group. Among the propofol-sedated patients, those who received a dose of 0.66-3.33 mg/kg/hr in the first 12 hours after surgery achieved significantly improved clinical and neurologic outcomes than those who received either more than 3.33 mg/kg/hr or less than 0.66 mg/kg/hr of propofol.

CONCLUSION

Our results support the use of propofol sedation during the early postoperative period after craniotomy in hemorrhagic stroke patients, because it improved both neurologic and clinical outcomes. However, early postoperative use of propofol sedation at larger dosages warrants special attention.

Neurotrauma research in Taiwan

Because of the rapid industrial and economic growth, Taiwan and other developing countries have faced an enormous increase in the number of motorcycles, which has subsequently caused a rapid increase of the motorcycle-related traumatic brain injuries (TBI). In order to tackle this serious problem, stepwise approaches for TBI were implemented in Taiwan from 1991 to 2007. Step 1 was to do a nationwide TBI registry in order to identify the risk factors and determinants. We found that the major cause of TBI in Taiwan was motorcycle-related injury, and very few motorcyclists wore a helmet. Step 2 was to launch the implementation of the helmet use law on June 1, 1997. A rapid decline of TBI hospitalizations and deaths was demonstrated soon thereafter. Step 3 was to enroll into international collaborations with the Global Spine and Head Injury Prevention Project (Global SHIP Project) groups for TBI. The comparative results thus obtained could be used to develop prevention strategies for developing countries. Step 4 was to implement clinical researches for TBI, which included a Propofol study, hyperbaric oxygen therapy (HBOT), brain parenchymal oxygen (PbtO2) monitoring, etc. Step 5 was to develop guidelines for the management of severe TBI in Taiwan. Through a 2-year period of review, discussion, and integration, a 9-chapter guideline was published in June 2007. In summary, our experience and process for management of TBI in Taiwan can be used as a reference for other developing countries.