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Jeffcote T, Weir T, Anstey J, Mcnamara R, Bellomo R, Udy A. The Impact of Sedative Choice on Intracranial and Systemic Physiology in Moderate to Severe Traumatic Brain Injury: A Scoping Review. J Neurosurg Anesthesiol 2023; 35:265-273. [PMID: 35142704 DOI: 10.1097/ana.0000000000000836] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/06/2022] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Toby Jeffcote
- Department of Intensive Care Medicine, The Alfred Hospital
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, Vic
| | - Timothy Weir
- Department of Intensive Care Medicine, The Alfred Hospital
| | - James Anstey
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne
| | - Robert Mcnamara
- Department of Intensive Care, Royal Perth Hospital, Perth, WA, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care Medicine, The Austin Hospital
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne
- Department of Critical Care, University of Melbourne, Parkville
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, Vic
| | - Andrew Udy
- Department of Intensive Care Medicine, The Alfred Hospital
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, Vic
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Wang Y, Zhang G, Ding J. An obvious antinomy, superior sagittal sinus thrombosis in a patient with immune thrombocytopenia: Case report and a review of literatures. Medicine (Baltimore) 2023; 102:e33412. [PMID: 37000101 PMCID: PMC10063276 DOI: 10.1097/md.0000000000033412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 02/28/2023] [Accepted: 03/10/2023] [Indexed: 04/01/2023] Open
Abstract
RATIONALE Immune thrombocytopenia (ITP) is an autoimmune disease with an increased risk of bleeding. However, in recent years, it has been reported that patients with this hemorrhagic disease have the risk of thrombosis and embolism. PATIENT CONCERNS AND DIAGNOSIS The patient, in this case, was a young female who was diagnosed with ITP. When the platelet count was low, she had skin, mucosa, internal organs, and intracranial hemorrhage. In the process of ITP and hemostatic treatment, superior sagittal sinus thrombosis occurred when she was still bleeding. INTERVENTIONS She was given treatments for reducing intracranial pressure and controlling epilepsy. OUTCOMES And then the embolectomy operation failed. It was suggested in this case that ITP patients with severe thrombocytopenia and bleeding tendency also have a risk of having thrombotic disease. We reviewed literatures regarding the mechanism of the simultaneous occurrence of 2 antinomy diseases and cerebral venous thrombosis. LESSONS There are many factors for ITP patients to have thrombosis involving ITP itself, its treatment and the patients' constitution, medical history, and former medication. ITP is not only a hemorrhagic disease but also a thrombotic disease. Clinicians should be alert to the risk of thrombotic diseases in ITP treatment. Therefore thrombus monitoring and screening should be carried out, and early prevention or appropriate anticoagulant treatment should be selected, especially for patients with high risk.
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Affiliation(s)
- Yuhui Wang
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Ge Zhang
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jinggang Ding
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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Abstract
This article introduces the basic concepts of intracranial physiology and pressure dynamics. It also includes discussion of signs and symptoms and examination and radiographic findings of patients with acute cerebral herniation as a result of increased as well as decreased intracranial pressure. Current best practices regarding medical and surgical treatments and approaches to management of intracranial hypertension as well as future directions are reviewed. Lastly, there is discussion of some of the implications of critical medical illness (sepsis, liver failure, and renal failure) and treatments thereof on causation or worsening of cerebral edema, intracranial hypertension, and cerebral herniation.
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Affiliation(s)
- Aleksey Tadevosyan
- Department of Neurology, Tufts University School of Medicine, Beth Israel Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA.
| | - Joshua Kornbluth
- Department of Neurology, Tufts University School of Medicine, Tufts Medical Center, 800 Washington Street, Box#314, Boston, MA 02111, USA
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Froese L, Dian J, Batson C, Gomez A, Unger B, Zeiler FA. Cerebrovascular Response to Propofol, Fentanyl, and Midazolam in Moderate/Severe Traumatic Brain Injury: A Scoping Systematic Review of the Human and Animal Literature. Neurotrauma Rep 2020; 1:100-112. [PMID: 33251530 PMCID: PMC7685293 DOI: 10.1089/neur.2020.0040] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Intravenous propofol, fentanyl, and midazolam are utilized commonly in critical care for metabolic suppression and anesthesia. The impact of propofol, fentanyl, and midazolam on cerebrovasculature and cerebral blood flow (CBF) is unclear in traumatic brain injury (TBI) and may carry important implications, as care is shifting to focus on cerebrovascular reactivity monitoring/directed therapies. The aim of this study was to perform a scoping review of the literature on the cerebrovascular/CBF effects of propofol, fentanyl, and midazolam in human patients with moderate/severe TBI and animal models with TBI. A search of MEDLINE, BIOSIS, EMBASE, Global Health, SCOPUS, and the Cochrane Library from inception to May 2020 was performed. All articles were included pertaining to the administration of propofol, fentanyl, and midazolam, in which the impact on CBF/cerebral vasculature was recorded. We identified 14 studies: 8 that evaluated propofol, 5 that evaluated fentanyl, and 2 that evaluated midazolam. All studies suffered from significant limitations, including: small sample size, and heterogeneous design and measurement techniques. In general, there was no significant change seen in CBF/cerebrovascular response to administration of propofol, fentanyl, or midazolam during experiments where PCO2 and mean arterial pressure (MAP) were controlled. This review highlights the current knowledge gap surrounding the impact of commonly utilized sedative drugs in TBI care. This work supports the need for dedicated studies, both experimental and human-based, evaluating the impact of these drugs on CBF and cerebrovascular reactivity/response in TBI.
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Affiliation(s)
- Logan Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Joshua Dian
- Section of Neurosurgery, Department of Surgery, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Carleen Batson
- Department of Anatomy and Cell Science, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Anatomy and Cell Science, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Bertram Unger
- Section of Critical Care, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Frederick A Zeiler
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada.,Section of Neurosurgery, Department of Surgery, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Anatomy and Cell Science, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada.,Division of Anesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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5
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Contemporary Management of Increased Intraoperative Intracranial Pressure: Evidence-Based Anesthetic and Surgical Review. World Neurosurg 2019; 129:120-129. [PMID: 31158533 DOI: 10.1016/j.wneu.2019.05.224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 05/26/2019] [Accepted: 05/27/2019] [Indexed: 12/29/2022]
Abstract
Increased intracranial pressure (ICP) is frequently encountered in the neurosurgical setting. A multitude of tactics exists to reduce ICP, ranging from patient position and medications to cerebrospinal fluid diversion and surgical decompression. A vast amount of literature has been published regarding ICP management in the critical care setting, but studies specifically tailored toward the management of intraoperative acute increases in ICP or brain bulk are lacking. Compartmentalizing the intracranial space into blood, brain tissue, and cerebrospinal fluid and understanding the numerous techniques available to affect these individual compartments can guide the surgical team to quickly identify increased brain bulk and respond appropriately. Rapidly instituting measures for brain relaxation in the operating room is essential in optimizing patient outcomes. Knowledge of the efficacy, rapidity, feasibility, and risks of the various available interventions can aid the team to properly tailor their approach to each individual patient. In this article, we present the first evidence-based review of intraoperative management of ICP and brain bulk.
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Wiener J, McIntyre A, Janzen S, Mirkowski M, MacKenzie HM, Teasell R. Opioids and cerebral physiology in the acute management of traumatic brain injury: a systematic review. Brain Inj 2019; 33:559-566. [PMID: 30696281 DOI: 10.1080/02699052.2019.1574328] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Following traumatic brain injury (TBI), optimization of cerebral physiology is recommended to promote more favourable patient outcomes. Accompanying pain and agitation are commonly treated with sedative and analgesic agents, such as opioids. However, the impact of opioids on certain aspects of cerebral physiology is not well established. OBJECTIVE To conduct a systematic review of the evidence on the effect of opioids on cerebral physiology in TBI during acute care. METHODS A comprehensive literature search was conducted in five electronic databases for articles published in English up to November 2017. Studies were included if: (1) the study sample was human subjects with TBI; (2) the sample size was ≥3; (3) subjects were given an opioid during acute care; and (4) any measure of cerebral physiology was evaluated. Cerebral physiology measures were intracranial pressure (ICP), cerebral perfusion pressure (CPP), and mean arterial pressure (MAP). Subject and study characteristics, treatment protocol, and results were extracted from included studies. Randomized controlled trials were evaluated for methodological quality using the Physiotherapy Evidence Database tool. Levels of evidence were assigned using a modified Sackett scale. RESULTS In total, 22 studies met inclusion criteria, from which six different opioids were identified: morphine, fentanyl, sufentanil, remifentanil, alfentanil, and phenoperidine. The evidence for individual opioids demonstrated equally either: (1) no effect on ICP, CPP, or MAP; or (2) an increase in ICP with associated decreases in CPP and MAP. In general, opioids administered by infusion resulted in the former outcome, whereas those given in bolus form resulted in the latter. There were no significant differences when comparing different opioids, with the exception of one study that found fentanyl was associated with lower ICP and CPP than morphine and sufentanil. There were no consistent results when comparing opioids to other non-opioid medications. CONCLUSION Several studies have assessed the effect of opioids on cerebral physiology during the acute management of TBI, but there is considerable heterogeneity in terms of study methodology and findings. Opioids are beneficial in terms of analgesia and sedation, but bolus administration should be avoided to prevent additional or prolonged unfavourable alterations in cerebral physiology. Future studies should better elucidate the effects of different opioids as well as varying dosages in order to develop improved understanding as well as allow for tighter control of cerebral physiology. ABBREVIATIONS CPP: Cerebral Perfusion Pressure, GCS: Glasgow Coma Scale, ICP: Intracranial Pressure, MAP: Mean Arterial Pressure, PEDro: Physiotherapy Evidence Database, RCT: Randomized Controlled Trial, TBI: Traumatic Brain Injury.
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Affiliation(s)
- Joshua Wiener
- a Parkwood Institute Research , Lawson Health Research Institute,Parkwood Institute , London , Ontario , Canada
| | - Amanda McIntyre
- a Parkwood Institute Research , Lawson Health Research Institute,Parkwood Institute , London , Ontario , Canada
| | - Shannon Janzen
- a Parkwood Institute Research , Lawson Health Research Institute,Parkwood Institute , London , Ontario , Canada
| | - Magdalena Mirkowski
- a Parkwood Institute Research , Lawson Health Research Institute,Parkwood Institute , London , Ontario , Canada
| | - Heather M MacKenzie
- a Parkwood Institute Research , Lawson Health Research Institute,Parkwood Institute , London , Ontario , Canada.,b Parkwood Institute , St. Joseph's Health Care London , London , Ontario , Canada.,c Schulich School of Medicine and Dentistry , University of Western , London , Ontario , Canada
| | - Robert Teasell
- a Parkwood Institute Research , Lawson Health Research Institute,Parkwood Institute , London , Ontario , Canada.,b Parkwood Institute , St. Joseph's Health Care London , London , Ontario , Canada.,c Schulich School of Medicine and Dentistry , University of Western , London , Ontario , Canada
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7
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Geeraerts T, Velly L, Abdennour L, Asehnoune K, Audibert G, Bouzat P, Bruder N, Carrillon R, Cottenceau V, Cotton F, Courtil-Teyssedre S, Dahyot-Fizelier C, Dailler F, David JS, Engrand N, Fletcher D, Francony G, Gergelé L, Ichai C, Javouhey É, Leblanc PE, Lieutaud T, Meyer P, Mirek S, Orliaguet G, Proust F, Quintard H, Ract C, Srairi M, Tazarourte K, Vigué B, Payen JF. Management of severe traumatic brain injury (first 24hours). Anaesth Crit Care Pain Med 2017; 37:171-186. [PMID: 29288841 DOI: 10.1016/j.accpm.2017.12.001] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The latest French Guidelines for the management in the first 24hours of patients with severe traumatic brain injury (TBI) were published in 1998. Due to recent changes (intracerebral monitoring, cerebral perfusion pressure management, treatment of raised intracranial pressure), an update was required. Our objective has been to specify the significant developments since 1998. These guidelines were conducted by a group of experts for the French Society of Anesthesia and Intensive Care Medicine (Société francaise d'anesthésie et de réanimation [SFAR]) in partnership with the Association de neuro-anesthésie-réanimation de langue française (ANARLF), The French Society of Emergency Medicine (Société française de médecine d'urgence (SFMU), the Société française de neurochirurgie (SFN), the Groupe francophone de réanimation et d'urgences pédiatriques (GFRUP) and the Association des anesthésistes-réanimateurs pédiatriques d'expression française (ADARPEF). The method used to elaborate these guidelines was the Grade® method. After two Delphi rounds, 32 recommendations were formally developed by the experts focusing on the evaluation the initial severity of traumatic brain injury, the modalities of prehospital management, imaging strategies, indications for neurosurgical interventions, sedation and analgesia, indications and modalities of cerebral monitoring, medical management of raised intracranial pressure, management of multiple trauma with severe traumatic brain injury, detection and prevention of post-traumatic epilepsia, biological homeostasis (osmolarity, glycaemia, adrenal axis) and paediatric specificities.
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Affiliation(s)
- Thomas Geeraerts
- Pôle anesthésie-réanimation, Inserm, UMR 1214, Toulouse neuroimaging center, ToNIC, université Toulouse 3-Paul Sabatier, CHU de Toulouse, 31059 Toulouse, France.
| | - Lionel Velly
- Service d'anesthésie-réanimation, Aix-Marseille université, CHU Timone, Assistance publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Lamine Abdennour
- Département d'anesthésie-réanimation, groupe hospitalier Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Karim Asehnoune
- Service d'anesthésie et de réanimation chirurgicale, Hôtel-Dieu, CHU de Nantes, 44093 Nantes cedex 1, France
| | - Gérard Audibert
- Département d'anesthésie-réanimation, hôpital Central, CHU de Nancy, 54000 Nancy, France
| | - Pierre Bouzat
- Pôle anesthésie-réanimation, CHU Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - Nicolas Bruder
- Service d'anesthésie-réanimation, Aix-Marseille université, CHU Timone, Assistance publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Romain Carrillon
- Service d'anesthésie-réanimation, hôpital neurologique Pierre-Wertheimer, groupement hospitalier Est, hospices civils de Lyon, 69677 Bron, France
| | - Vincent Cottenceau
- Service de réanimation chirurgicale et traumatologique, SAR 1, hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | - François Cotton
- Service d'imagerie, centre hospitalier Lyon Sud, hospices civils de Lyon, 69495 Pierre-Bénite cedex, France
| | - Sonia Courtil-Teyssedre
- Service de réanimation pédiatrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, 69677 Bron, France
| | | | - Frédéric Dailler
- Service d'anesthésie-réanimation, hôpital neurologique Pierre-Wertheimer, groupement hospitalier Est, hospices civils de Lyon, 69677 Bron, France
| | - Jean-Stéphane David
- Service d'anesthésie réanimation, centre hospitalier Lyon Sud, hospices civils de Lyon, 69495 Pierre-Bénite, France
| | - Nicolas Engrand
- Service d'anesthésie-réanimation, Fondation ophtalmologique Adolphe de Rothschild, 75940 Paris cedex 19, France
| | - Dominique Fletcher
- Service d'anesthésie réanimation chirurgicale, hôpital Raymond-Poincaré, université de Versailles Saint-Quentin, AP-HP, Garches, France
| | - Gilles Francony
- Pôle anesthésie-réanimation, CHU Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - Laurent Gergelé
- Département d'anesthésie-réanimation, CHU de Saint-Étienne, 42055 Saint-Étienne, France
| | - Carole Ichai
- Service de réanimation médicochirurgicale, UMR 7275, CNRS, Sophia Antipolis, hôpital Pasteur, CHU de Nice, 06000 Nice, France
| | - Étienne Javouhey
- Service de réanimation pédiatrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, 69677 Bron, France
| | - Pierre-Etienne Leblanc
- Département d'anesthésie-réanimation, hôpital de Bicêtre, hôpitaux universitaires Paris-Sud, AP-HP, Le Kremlin-Bicêtre, France; Équipe TIGER, CNRS 1072-Inserm 5288, service d'anesthésie, centre hospitalier de Bourg en Bresse, centre de recherche en neurosciences, Lyon, France
| | - Thomas Lieutaud
- UMRESTTE, UMR-T9405, IFSTTAR, université Claude-Bernard de Lyon, Lyon, France; Service d'anesthésie-réanimation, hôpital universitaire Necker-Enfants-Malades, université Paris Descartes, AP-HP, Paris, France
| | - Philippe Meyer
- EA 08 Paris-Descartes, service de pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte, 75743 Paris cedex 15, France
| | - Sébastien Mirek
- Service d'anesthésie-réanimation, CHU de Dijon, Dijon, France
| | - Gilles Orliaguet
- EA 08 Paris-Descartes, service de pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte, 75743 Paris cedex 15, France
| | - François Proust
- Service de neurochirurgie, hôpital Hautepierre, CHU de Strasbourg, 67098 Strasbourg, France
| | - Hervé Quintard
- Service de réanimation médicochirurgicale, UMR 7275, CNRS, Sophia Antipolis, hôpital Pasteur, CHU de Nice, 06000 Nice, France
| | - Catherine Ract
- Département d'anesthésie-réanimation, hôpital de Bicêtre, hôpitaux universitaires Paris-Sud, AP-HP, Le Kremlin-Bicêtre, France; Équipe TIGER, CNRS 1072-Inserm 5288, service d'anesthésie, centre hospitalier de Bourg en Bresse, centre de recherche en neurosciences, Lyon, France
| | - Mohamed Srairi
- Pôle anesthésie-réanimation, Inserm, UMR 1214, Toulouse neuroimaging center, ToNIC, université Toulouse 3-Paul Sabatier, CHU de Toulouse, 31059 Toulouse, France
| | - Karim Tazarourte
- SAMU/SMUR, service des urgences, hospices civils de Lyon, hôpital Édouard-Herriot, 69437 Lyon cedex 03, France
| | - Bernard Vigué
- Département d'anesthésie-réanimation, hôpital de Bicêtre, hôpitaux universitaires Paris-Sud, AP-HP, Le Kremlin-Bicêtre, France; Équipe TIGER, CNRS 1072-Inserm 5288, service d'anesthésie, centre hospitalier de Bourg en Bresse, centre de recherche en neurosciences, Lyon, France
| | - Jean-François Payen
- Pôle anesthésie-réanimation, CHU Grenoble-Alpes, 38043 Grenoble cedex 9, France
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Alnemari AM, Krafcik BM, Mansour TR, Gaudin D. A Comparison of Pharmacologic Therapeutic Agents Used for the Reduction of Intracranial Pressure After Traumatic Brain Injury. World Neurosurg 2017; 106:509-528. [PMID: 28712906 DOI: 10.1016/j.wneu.2017.07.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 07/01/2017] [Accepted: 07/05/2017] [Indexed: 12/15/2022]
Abstract
OBJECTIVE In neurotrauma care, a better understanding of treatments after traumatic brain injury (TBI) has led to a significant decrease in morbidity and mortality in this population. TBI represents a significant medical problem, and complications after TBI are associated with the initial injury and postevent intracranial processes such as increased intracranial pressure and brain edema. Consequently, appropriate therapeutic interventions are required to reduce brain tissue damage and improve cerebral perfusion. We present a contemporary review of literature on the use of pharmacologic therapies to reduce intracranial pressure after TBI and a comparison of their efficacy. METHODS This review was conducted by PubMed query. Only studies discussing pharmacologic management of patients after TBI were included. This review includes prospective and retrospective studies and includes randomized controlled trials as well as cohort, case-control, observational, and database studies. Systematic literature reviews, meta-analyses, and studies that considered conditions other than TBI or pediatric populations were not included. RESULTS Review of the literature describing the current pharmacologic treatment for intracranial hypertension after TBI most often discussed the use of hyperosmolar agents such as hypertonic saline and mannitol, sedatives such as fentanyl and propofol, benzodiazepines, and barbiturates. Hypertonic saline is associated with faster resolution of intracranial hypertension and restoration of optimal cerebral hemodynamics, although these advantages did not translate into long-term benefits in morbidity or mortality. In patients refractory to treatment with hyperosmolar therapy, induction of a barbiturate coma can reduce intracranial pressure, although requires close monitoring to prevent adverse events. CONCLUSIONS Current research suggests that the use of hypertonic saline after TBI is the best option for immediate decrease in intracranial pressure. A better understanding of the efficacy of each treatment option can help to direct treatment algorithms during the critical early hours of trauma care and continue to improve morbidity and mortality after TBI.
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Affiliation(s)
- Ahmed M Alnemari
- Division of Neurological Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Brianna M Krafcik
- Division of Neurological Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Tarek R Mansour
- Division of Neurological Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Daniel Gaudin
- Division of Neurological Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA.
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9
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Ragland J, Lee K. Critical Care Management and Monitoring of Intracranial Pressure. JOURNAL OF NEUROCRITICAL CARE 2016. [DOI: 10.18700/jnc.160101] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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10
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Abstract
Elevated intracranial pressure (ICP) is a primary cause of morbidity and mortality for many neurologic disorders. The relationship between ICP and brain volume is influenced by autoregulatory processes that can become dysfunctional. As a result, neurologic damage can occur by systemic and intracranial insults such as ischemia and excitatory amino acids. Therefore, survival is dependent on optimizing ICP and cerebral perfusion pressure. Treatment of intracranial hypertension requires intensive monitoring and aggressive therapy. Intracranial pressure monitoring techniques such as intraventricular catheters are useful for determining ICP elevations before changes in vital signs and neurologic status. Therapeutic modalities, generally aimed at reducing cerebral blood volume, brain tissue, and cerebrospinal fluid (CSF) volume, include nonpharmacologic (CSF removal, controlled hyperventilation, and elevating the patient’s head) and pharmacologic management. Mannitol and sedation are first-line agents used to lower ICP. Barbiturate coma may be beneficial in patients with elevated ICP refractory to conventional treatment. The use of prophylactic antiseizure therapy and optimal nutrition prevents significant complication. Currently, investigations are directed at discovering useful neuroprotective agents that prevent secondary neurologic injury.
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Affiliation(s)
- Beth A. Vanderheyden
- Department of Pharmacy Services, University of Maryland Medical Center, 22 S. Greene Street, Baltimore, MD 21201,
| | - Brian D. Buck
- Department of Pharmacy Services, University of Maryland Medical Center, 22 S. Greene Street, Baltimore, MD 21201,
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11
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Abstract
Increased intracranial pressure (ICP) is a pathologic state common to a variety of serious neurologic conditions, all of which are characterized by the addition of volume to the intracranial vault. Hence all ICP therapies are directed toward reducing intracranial volume. Elevated ICP can lead to brain damage or death by two principle mechanisms: (1) global hypoxic-ischemic injury, which results from reduction of cerebral perfusion pressure (CPP) and cerebral blood flow, and (2) mechanical compression, displacement, and herniation of brain tissue, which results from mass effect associated with compartmentalized ICP gradients. In unmonitored patients with acute neurologic deterioration, head elevation (30 degrees), hyperventilation (pCO2 26-30 mmHg), and mannitol (1.0-1.5 g/kg) can lower ICP within minutes. Fluid-coupled ventricular catheters and intraparenchymal pressure transducers are the most accurate and reliable devices for measuring ICP in the intensive care unit (ICU) setting. In a monitored patient, treatment of critical ICP elevation (>20 mmHg) should proceed in the following steps: (1) consideration of repeat computed tomography (CT) scanning or consideration of definitive neurosurgical intervention, (2) intravenous sedation to attain a quiet, motionless state, (3) optimization of CPP to levels between 70 and 110 mmHg, (4) osmotherapy with mannitol or hypertonic saline, (5) hyperventilation (pCO2 26-30 mmHg), (6) high-dose pentobarbital therapy, and (7) systemic cooling to attain moderate hypothermia (32-33°C). Placement of an ICP monitor and use of a stepwise treatment algorithm are both essential for managing ICP effectively in the ICU setting.
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Affiliation(s)
- Stephan A. Mayer
- Division of Critical Care Neurology, Departments of Neurology, Neurosurgery, College of Physicians and Surgeons, Columbia University, New York, NY,
| | - Ji Y. Chong
- Division of Critical Care Neurology, Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY
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Oddo M, Crippa IA, Mehta S, Menon D, Payen JF, Taccone FS, Citerio G. Optimizing sedation in patients with acute brain injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:128. [PMID: 27145814 PMCID: PMC4857238 DOI: 10.1186/s13054-016-1294-5] [Citation(s) in RCA: 149] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Daily interruption of sedative therapy and limitation of deep sedation have been shown in several randomized trials to reduce the duration of mechanical ventilation and hospital length of stay, and to improve the outcome of critically ill patients. However, patients with severe acute brain injury (ABI; including subjects with coma after traumatic brain injury, ischaemic/haemorrhagic stroke, cardiac arrest, status epilepticus) were excluded from these studies. Therefore, whether the new paradigm of minimal sedation can be translated to the neuro-ICU (NICU) is unclear. In patients with ABI, sedation has ‘general’ indications (control of anxiety, pain, discomfort, agitation, facilitation of mechanical ventilation) and ‘neuro-specific’ indications (reduction of cerebral metabolic demand, improved brain tolerance to ischaemia). Sedation also is an essential therapeutic component of intracranial pressure therapy, targeted temperature management and seizure control. Given the lack of large trials which have evaluated clinically relevant endpoints, sedative selection depends on the effect of each agent on cerebral and systemic haemodynamics. Titration and withdrawal of sedation in the NICU setting has to be balanced between the risk that interrupting sedation might exacerbate brain injury (e.g. intracranial pressure elevation) and the potential benefits of enhanced neurological function and reduced complications. In this review, we provide a concise summary of cerebral physiologic effects of sedatives and analgesics, the advantages/disadvantages of each agent, the comparative effects of standard sedatives (propofol and midazolam) and the emerging role of alternative drugs (ketamine). We suggest a pragmatic approach for the use of sedation-analgesia in the NICU, focusing on some practical aspects, including optimal titration and management of sedation withdrawal according to ABI severity.
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Affiliation(s)
- Mauro Oddo
- Department of Intensive Care Medicine, CHUV-University Hospital, CH-1011, Lausanne, Switzerland. .,Faculty of Biology and Medicine, University of Lausanne, Rue du Bugnon 21, CH-1011, Lausanne, Switzerland.
| | - Ilaria Alice Crippa
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Neurointensive Care, Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy.,Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Sangeeta Mehta
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, Mount Sinai Hospital, University of Toronto, 600 University Ave #18-216, Toronto, M5G 1X5, Canada
| | - David Menon
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 2QQ, UK
| | - Jean-Francois Payen
- Department of Anesthesiology and Intensive Care, Hôpital Michallon, Grenoble University Hospital, F-38043, Grenoble, France
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Neurointensive Care, Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
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Effectiveness of Pharmacological Therapies for Intracranial Hypertension in Children With Severe Traumatic Brain Injury--Results From an Automated Data Collection System Time-Synched to Drug Administration. Pediatr Crit Care Med 2016; 17:236-45. [PMID: 26673840 PMCID: PMC4779724 DOI: 10.1097/pcc.0000000000000610] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe acute cerebral hemodynamic effects of medications commonly used to treat intracranial hypertension in children with traumatic brain injury. Currently, data supporting the efficacy of these medications are insufficient. DESIGN In this prospective observational study, intracranial hypertension (intracranial pressure ≥ 20 mm Hg for > 5 min) was treated by clinical protocol. Administration times of medications for intracranial hypertension (fentanyl, 3% hypertonic saline, mannitol, and pentobarbital) were prospectively recorded and synchronized with an automated database that collected intracranial pressure and cerebral perfusion pressure every 5 seconds. Intracranial pressure crises confounded by external stimulation or mechanical ventilator adjustments were excluded. Mean intracranial pressure and cerebral perfusion pressure from epochs following drug administration were compared with baseline values using Kruskal-Wallis analysis of variance and Dunn test. Frailty modeling was used to analyze the time to intracranial pressure crisis resolution. Mixed-effect models compared intracranial pressure and cerebral perfusion pressure 5 minutes after the medication versus baseline and rates of treatment failure. SETTING A tertiary care children's hospital. PATIENTS Children with severe traumatic brain injury (Glasgow Coma Scale score ≤ 8). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We analyzed 196 doses of fentanyl, hypertonic saline, mannitol, and pentobarbital administered to 16 children (median: 12 doses per patient). Overall, intracranial pressure significantly decreased following the administration of fentanyl, hypertonic saline, and pentobarbital. After controlling for administration of multiple medications, intracranial pressure was decreased following hypertonic saline and pentobarbital administration; cerebral perfusion pressure was decreased following fentanyl and was increased following hypertonic saline administration. After adjusting for significant covariates (including age, Glasgow Coma Scale score, and intracranial pressure), hypertonic saline was associated with a two-fold faster resolution of intracranial hypertension than either fentanyl or pentobarbital. Fentanyl was significantly associated with the most frequent treatment failure. CONCLUSIONS Intracranial pressure decreased after multiple drug administrations, but hypertonic saline may warrant consideration as the first-line drug for treating intracranial hypertension, as it was associated with the most favorable cerebral hemodynamics and fastest resolution of intracranial hypertension.
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Abstract
Maintenance of adequate oxygenation is a mainstay of intensive care, however, recommendations on the safety, accuracy, and the potential clinical utility of invasive and non-invasive tools to monitor brain and systemic oxygenation in neurocritical care are lacking. A literature search was conducted for English language articles describing bedside brain and systemic oxygen monitoring in neurocritical care patients from 1980 to August 2013. Imaging techniques e.g., PET are not considered. A total of 281 studies were included, the majority described patients with traumatic brain injury (TBI). All tools for oxygen monitoring are safe. Parenchymal brain oxygen (PbtO2) monitoring is accurate to detect brain hypoxia, and it is recommended to titrate individual targets of cerebral perfusion pressure (CPP), ventilator parameters (PaCO2, PaO2), and transfusion, and to manage intracranial hypertension, in combination with ICP monitoring. SjvO2 is less accurate than PbtO2. Given limited data, NIRS is not recommended at present for adult patients who require neurocritical care. Systemic monitoring of oxygen (PaO2, SaO2, SpO2) and CO2 (PaCO2, end-tidal CO2) is recommended in patients who require neurocritical care.
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Abstract
OPINION STATEMENT Pediatric severe traumatic brain injury continues to be a major cause of disability and death. Rapid initial airway and hemodynamic stabilization is critical, followed by the need for immediate recognition of intracranial pathology that requires neurosurgical intervention. Intracranial hypertension and cerebral hypoperfusion have been recognized as major insults after trauma and management should be directed at preventing both. Sedation with opioids, moderate hyperventilation to arterial carbon dioxide level of 35-40 mmHg, hyperosmolar therapy with 3 % saline or mannitol, normothermia, and cerebrospinal fluid drainage continue to be the cornerstones of initial management of intracranial hypertension (intracranial pressure >20 mmHg). Refractory intracranial hypertension is treated with high-dose barbiturate therapy to achieve medical burst suppression on electroencephalography and decompressive craniectomy. In addition, those children require antiepileptic medications for seizure prophylaxis, adequate nutritional management, and early physical therapy and rehabilitation referrals. Most of the evidence for care of children with brain injury comes from center-specific practice and experience rather than objective data. This lack of evidence provides the ground for ongoing research; nevertheless, outcomes after traumatic brain injury continue to show improvement.
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Affiliation(s)
- Haifa Mtaweh
- Department of Critical Care Medicine, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada,
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16
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Colton K, Yang S, Hu PF, Chen HH, Bonds B, Stansbury LG, Scalea TM, Stein DM. Pharmacologic Treatment Reduces Pressure Times Time Dose and Relative Duration of Intracranial Hypertension. J Intensive Care Med 2014; 31:263-9. [PMID: 25320157 DOI: 10.1177/0885066614555692] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 09/18/2014] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Past work has shown the importance of the "pressure times time dose" (PTD) of intracranial hypertension (intracranial pressure [ICP] > 19 mm Hg) in predicting outcome after severe traumatic brain injury. We used automated data collection to measure the effect of common medications on the duration and dose of intracranial hypertension. METHODS Patients >17 years old, admitted and requiring ICP monitoring between 2008 and 2010 at a single, large urban tertiary care facility, were retrospectively enrolled. Timing and dose of ICP-directed therapy were recorded from paper and electronic medical records. The ICP data were collected automatically at 6-second intervals and averaged over 5 minutes. The percentage of time of intracranial hypertension (PTI) and PTD (mm Hg h) were calculated. RESULTS A total of 98 patients with 664 treatment instances were identified. Baseline PTD ranged from 27 (before administration of propofol and fentanyl) to 150 mm Hg h (before mannitol). A "small" dose of hypertonic saline (HTS; ≤250 mL 3%) reduced PTD by 38% in the first hour and 37% in the second hour and reduced the time with ICP >19 by 38% and 39% after 1 and 2 hours, respectively. A "large" dose of HTS reduced PTD by 40% in the first hour and 63% in the second (PTI reduction of 36% and 50%, respectively). An increased dose of propofol or fentanyl infusion failed to decrease PTD but reduced PTI between 14% (propofol alone) and 30% (combined increase in propofol and fentanyl, after 2 hours). Barbiturates failed to decrease PTD but decreased PTI by 30% up to 2 hours after administration. All reductions reported are significantly changed from baseline, P < .05. CONCLUSION Baseline PTD values before drug administration reflects varied patient criticality, with much higher values seen before the use of mannitol or barbiturates. Treatment with HTS reduced PTD and PTI burden significantly more than escalation of sedation or pain management, and this effect remained significant at 2 hours after administration.
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Affiliation(s)
- Katharine Colton
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA Duke University School of Medicine, Durham, NC, USA
| | - S Yang
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - P F Hu
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - H H Chen
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - B Bonds
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - L G Stansbury
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - T M Scalea
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - D M Stein
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine and R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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Colton K, Yang S, Hu PF, Chen HH, Bonds B, Scalea TM, Stein DM. Intracranial pressure response after pharmacologic treatment of intracranial hypertension. J Trauma Acute Care Surg 2014; 77:47-53; discussion 53. [PMID: 24977754 DOI: 10.1097/ta.0000000000000270] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The accepted treatment of increased intracranial pressure (ICP) in patients experiencing severe traumatic brain injury is multimodal and algorithmic, obscuring individual effects of treatment. Using continuous vital signs monitoring, we sought to measure treatment effect and ascertain the accuracy of manual data recording. METHODS Patients older than 17 years, admitted and requiring ICP monitoring between 2008 and 2010 at a high-volume urban trauma center, were retrospectively evaluated. Timing and dose of ICP-directed therapy were recorded from paper and electronic medical records. ICP data were collected automatically at 6-second intervals and from manual charts. A statistical mixed model was applied to all data to account for multiple sampling. RESULTS A total of 117 patients met inclusion criteria; 450 treatments were administered when nursing records indicate an ICP greater than 20 mm Hg, while 968 treatments were given when ICP was greater than 20 mm Hg by automated data. Pharmacologic treatments identified include hypertonic saline (HTS), mannitol, barbiturates, and dose escalations of propofol or fentanyl infusions. Treatment with HTS resulted in the largest ICP decrease of the treatments examined, with a 1-hour ICP reduction of 8.8/9.9 mm Hg (for a small/large dose) according to manual data and a reduction of 3.0/2.4 mm Hg according to automated data. Propofol and fentanyl escalations resulted in smaller but significant ICP reductions. Mannitol (n = 8) resulted in statistically insignificant trends down in the first hour but rebounded by the second hour after administration. The average ICP in the hour before medication administration was higher for barbiturates (27 mm Hg) and mannitol (32 mm Hg) than for the other interventions (18-19 mm Hg). CONCLUSION ICP fell after administration of HTS, mannitol, or barbiturates and showed continued improvement after 2 hours. ICP fell initially after treatment with short-acting propofol and fentanyl but trended back up after 2 hours. Manually recorded data consistently overestimated treatment effectiveness. Automated data collection gives a more accurate assessment of patient status and responsiveness to treatment. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Affiliation(s)
- Katharine Colton
- From the Shock Trauma Anesthesia Research Organized Research Center (K.C., S.Y., P.F.H., H.H.C., B.B., T.M.S., D.M.S.), University of Maryland School of Medicine; and R Adams Cowley Shock Trauma Center (K.C., S.Y., P.F.H., H.H.C., B.B., T.M.S., D.M.S.), Baltimore, Maryland; and Duke University School of Medicine (K.C.), Durham, North Carolina
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Voils SA, Human T, Brophy GM. Adverse neurologic effects of medications commonly used in the intensive care unit. Crit Care Clin 2014; 30:795-811. [PMID: 25257742 DOI: 10.1016/j.ccc.2014.06.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Adverse drug effects often complicate the care of critically ill patients. Therefore, each patient's medical history, maintenance medication, and new therapies administered in the intensive care unit must be evaluated to prevent unwanted neurologic adverse effects. Optimization of pharmacotherapy in critically ill patients can be achieved by considering the need to reinitiate home medications, and avoiding drugs that can decrease the seizure threshold, increase sedation and cognitive deficits, induce delirium, increase intracranial pressure, or induce fever. Avoiding medication-induced neurologic adverse effects is essential in critically ill patients, especially those with neurologic injury.
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Affiliation(s)
- Stacy A Voils
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, 1225 Center Drive, HPNP Building, Room 3315, PO Box 100486, Gainesville, FL 32610-0486, USA
| | - Theresa Human
- Barnes-Jewish Hospital, Washington University in St. Louis, St. Louis, MO 63110, USA
| | - Gretchen M Brophy
- Departments of Pharmacotherapy & Outcomes Science and Neurosurgery, Medical College of Virginia Campus, Virginia Commonwealth University, 410 North, 12th Street, Richmond, VA 23298-0533, USA.
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Abstract
Acute ischemic stroke is the fourth leading cause of death and the leading cause of disability in the United States. Stroke is a medical emergency. The development of stroke systems of care has changed the way practitioners view and treat this devastating disease. Ample evidence has shown that patients presenting early and receiving intravenous thrombolytic therapy have the best chance for significant improvement in functional outcome, particularly if they are transported to specialized stroke centers. Early detection and management of medical and neurologic complications is key at preventing further brain damage in patients with acute ischemic stroke.
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Affiliation(s)
- Nelson J Maldonado
- Division of Vascular Neurology and Neurocritical Care, Department of Neurology, Baylor College of Medicine, One Baylor Plaza, MS NB302, Houston, TX 77030, USA
| | - Syed O Kazmi
- Division of Vascular Neurology and Neurocritical Care, Department of Neurology, Baylor College of Medicine, One Baylor Plaza, MS NB302, Houston, TX 77030, USA
| | - Jose Ignacio Suarez
- Division of Vascular Neurology and Neurocritical Care, Department of Neurology, Baylor College of Medicine, One Baylor Plaza, MS NB302, Houston, TX 77030, USA.
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20
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DiFazio J, Fletcher DJ. Updates in the management of the small animal patient with neurologic trauma. Vet Clin North Am Small Anim Pract 2013; 43:915-40. [PMID: 23747266 DOI: 10.1016/j.cvsm.2013.03.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Neurologic trauma, encompassing traumatic brain injury (TBI) and acute spinal cord injury (SCI), is a cause of significant morbidity and mortality in veterinary patients. Acute SCIs occurring secondary to trauma are also common. Essential to the management of TBI and SCI is a thorough understanding of the pathophysiology of the primary and secondary injury that occurs following trauma. This article reviews the pathophysiology of this primary and secondary injury, as well as recommendations regarding clinical assessment, diagnostics, pharmacologic and nonpharmacologic therapy, and prognosis.
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Affiliation(s)
- Jillian DiFazio
- Section of Emergency and Critical Care, Cornell University Hospital for Animals, Upper Tower Road, Ithaca, NY 14853, USA
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Chang LC, Raty SR, Ortiz J, Bailard NS, Mathew SJ. The emerging use of ketamine for anesthesia and sedation in traumatic brain injuries. CNS Neurosci Ther 2013; 19:390-5. [PMID: 23480625 DOI: 10.1111/cns.12077] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Revised: 01/15/2013] [Accepted: 01/26/2013] [Indexed: 01/02/2023] Open
Abstract
Traditionally, the use of ketamine for patients with traumatic brain injuries is contraindicated due to the concern of increasing intracranial pressure (ICP). These concerns, however, originated from early studies and case reports that were inadequately controlled and designed. Recently, the concern of using ketamine in these patients has been challenged by a number of published studies demonstrating that the use of ketamine was safe in these patients. This article reviews the current literature in regards to using ketamine in patients with traumatic brain injuries in different clinical settings associated with anesthesia, as well as reviews the potential mechanisms underlying the neuroprotective effects of ketamine. Studies examining the use of ketamine for induction, maintenance, and sedation in patients with TBI have had promising results. The use of ketamine in a controlled ventilation setting and in combination with other sedative agents has demonstrated no increase in ICP. The role of ketamine as a neuroprotective agent in humans remains inconclusive and adequately powered; randomized controlled trials performed in patients undergoing surgery for traumatic brain injury are necessary.
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Affiliation(s)
- Lee C Chang
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX 77030, USA.
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Hocker SE, Fogelson J, Rabinstein AA. Refractory intracranial hypertension due to fentanyl administration following closed head injury. Front Neurol 2013; 4:3. [PMID: 23372564 PMCID: PMC3556561 DOI: 10.3389/fneur.2013.00003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Accepted: 01/08/2013] [Indexed: 11/13/2022] Open
Abstract
Background: Although the effects of opioids on intracranial pressure (ICP) have long been a subject of controversy, they are frequently administered to patients with severe head trauma. We present a patient with an uncommon paradoxical response to opioids. Case Report: A patient with refractory intracranial hypertension after closed head injury was managed with standard medical therapy with only transient decreases in the ICP. Only after discontinuation of opiates did the ICP become manageable without metabolic suppression and rescue osmotic therapy, implicating opiates as the etiology of refractory intracranial hypertension in this patient. Conclusion: Clinicians should consider opioids as a contributing factor in malignant intracranial hypertension when findings on neuroimaging do not explain persistent and refractory intracranial hypertension.
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Affiliation(s)
- Sara E Hocker
- Division of Critical Care Neurology, Mayo Clinic Rochester, MN, USA
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23
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Burns JD, Green DM, Metivier K, DeFusco C. Intensive Care Management of Acute Ischemic Stroke. Emerg Med Clin North Am 2012; 30:713-44. [DOI: 10.1016/j.emc.2012.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Bhalla T, Dewhirst E, Sawardekar A, Dairo O, Tobias JD. Perioperative management of the pediatric patient with traumatic brain injury. Paediatr Anaesth 2012; 22:627-40. [PMID: 22502728 DOI: 10.1111/j.1460-9592.2012.03842.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
TBI and its sequelae remain a major healthcare issue throughout the world. With an improved understanding of the pathophysiology of TBI, refinements of monitoring technology, and ongoing research to determine optimal care, the prognosis of TBI continues to improve. In 2003, the Society of Critical Care Medicine published guidelines for the acute management of severe TBI in infants, children, and adolescents. As pediatric anesthesiologists are frequently involved in the perioperative management of such patients including their stabilization in the emergency department, familiarity with these guidelines is necessary to limit preventable secondary damage related to physiologic disturbances. This manuscript reviews the current evidence-based medicine regarding the care of pediatric patients with TBI as it relates to the perioperative care of such patients. The issues reviewed include those related to initial stabilization, airway management, intra-operative mechanical ventilation, hemodynamic support, administration of blood and blood products, positioning, and choice of anesthetic technique. The literature is reviewed regarding fluid management, glucose control, hyperosmolar therapy, therapeutic hypothermia, and corticosteroids. Whenever possible, management recommendations are provided.
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Affiliation(s)
- Tarun Bhalla
- Departments of Anesthesiology, Nationwide Children's Hospital and the Ohio State University, Columbus, OH, USA
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Vahedi K, Proust F, Geeraerts T. [Experts' recommendations for stroke management in intensive care: intracranial hypertension]. Rev Neurol (Paris) 2012; 168:501-11. [PMID: 22571966 DOI: 10.1016/j.neurol.2011.07.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Revised: 04/29/2011] [Accepted: 07/19/2011] [Indexed: 11/20/2022]
Abstract
This article aims to describe the arguments underlying the experts' recommendations for management of stroke patients in the intensive unit, focusing on intracranial hypertension. This article describes the pathophysiology, diagnostic methods and therapeutic options for intracranial hypertension after stroke, including medical and surgical management.
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Affiliation(s)
- K Vahedi
- Service de neurologie, hôpital Lariboisière, 2 rue Ambroise-Paré, Paris, France
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26
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Freysz M. [Sedation and analgesia in emergency structure. Which sedation and/or analgesia for the patient presenting neurological injury?]. ACTA ACUST UNITED AC 2012; 31:332-8. [PMID: 22436602 DOI: 10.1016/j.annfar.2012.01.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- M Freysz
- Département de médecine d'urgence, université de Bourgogne, CHU de Dijon, 3, rue du Faubourg-Raines, BP 77908, 21079 Dijon cedex, France.
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Abstract
Administering analgesics, sedatives and antipsychotics is challenging in the Neurological Intensive Care Unit (NICU). We reviewed this literature and our current practice to better inform the critical care practitioner and to identify gaps for future research. We electronically searched observational, intervention and outcome studies addressing sedation, analgesia and delirium in the NICU, and their bibliographies. Practice patterns were assessed in three critical care units with specialized neurological care in Montreal. Bedside pain assessment tools are psychometrically validated in the neuro-critically ill but sedation and delirium tools are not. Rigorous pain and sedation assessments appear feasible; delirium screening has not been tested. Publications addressing outcomes and responses to pharmacologic treatment lack consistency, rigor or both. In daily practice, pharmacologic management varies greatly. Clearly, little information exists on analgesia, sedation and delirium in the NICU. Systematic evaluation of pain improves outcome. No evidence-based therapeutic recommendations can be proffered.
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Sedation for critically ill adults with severe traumatic brain injury: a systematic review of randomized controlled trials. Crit Care Med 2012; 39:2743-51. [PMID: 22094498 DOI: 10.1097/ccm.0b013e318228236f] [Citation(s) in RCA: 111] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
OBJECTIVES To summarize randomized controlled trials on the effects of sedative agents on neurologic outcome, mortality, intracranial pressure, cerebral perfusion pressure, and adverse drug events in critically ill adults with severe traumatic brain injury. DATA SOURCES PubMed, MEDLINE, EMBASE, the Cochrane Database, Google Scholar, two clinical trials registries, personal files, and reference lists of included articles. STUDY SELECTION Randomized controlled trials of propofol, ketamine, etomidate, and agents from the opioid, benzodiazepine, α-2 agonist, and antipsychotic drug classes for management of adult intensive care unit patients with severe traumatic brain injury. DATA EXTRACTION In duplicate and independently, two investigators extracted data and evaluated methodologic quality and results. DATA SYNTHESIS Among 1,892 citations, 13 randomized controlled trials enrolling 380 patients met inclusion criteria. Long-term sedation (≥24 hrs) was addressed in six studies, whereas a bolus dose, short infusion, or doubling of plasma drug concentration was investigated in remaining trials. Most trials did not describe baseline traumatic brain injury prognostic factors or important cointerventions. Eight trials possibly or definitely concealed allocation and six were blinded. Insufficient data exist regarding the effects of sedative agents on neurologic outcome or mortality. Although their effects are likely transient, bolus doses of opioids may increase intracranial pressure and decrease cerebral perfusion pressure. In one study, a long-term infusion of propofol vs. morphine was associated with a reduced requirement for intracranial pressure-lowering cointerventions and a lower intracranial pressure on the third day. Trials of propofol vs. midazolam and ketamine vs. sufentanil found no difference between agents in intracranial pressure and cerebral perfusion pressure. CONCLUSIONS This systematic review found no convincing evidence that one sedative agent is more efficacious than another for improvement of patient-centered outcomes, intracranial pressure, or cerebral perfusion pressure in critically ill adults with severe traumatic brain injury. High bolus doses of opioids, however, have potentially deleterious effects on intracranial pressure and cerebral perfusion pressure. Adequately powered, high-quality, randomized controlled trials are urgently warranted.
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Sedating the injured brain: searching for the "ideal" pharmacological recipe. Crit Care Med 2011; 39:2780-2. [PMID: 22094517 DOI: 10.1097/ccm.0b013e31822d28a6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Opioid analgesics have an established role in the management of postoperative pain and cancer pain, and are gaining acceptance for the management of moderate to severe chronic noncancer pain, most notably chronic low back pain and osteoarthritis, that does not respond to other interventions. Many patients with chronic pain have co-morbid medical conditions that may complicate opioid therapy. Selecting the appropriate opioid requires knowledge of how individual opioids differ with respect to metabolism and interaction with concurrent medications, as well as the reasons why specific medical conditions may influence their efficacy and tolerability. Polypharmacy is a common complicating condition in the elderly and in patients with psychiatric illness, cancer, cardiovascular disease, diabetes mellitus or other chronic illnesses. Polypharmacy, though often necessary for patients with multiple medical conditions, also multiplies the risk of drug interactions. Pharmacokinetic drug interactions can increase or reduce exposure to the opioid or concurrent medications, reducing efficacy and/or tolerability and increasing toxicity. Pharmacodynamic interactions can enhance the depressive effects of opioids, compromising safety. Patients with impaired renal or hepatic function may have difficulty clearing or metabolizing opioids and concurrent medications, leading to increased risk of adverse events. Patients with cardiovascular, cerebrovascular or respiratory disease (including smokers of >/=2 packs/day with no other diagnosis) may be more susceptible to respiratory depression, bradycardia and hypotension with any opioid, and a few specific opioids pose additional risks. Patients with cerebrovascular disease, dementia, brain injury or psychiatric illness are more susceptible to opioid effects on the CNS, which can include euphoria, cognitive impairment and sedation. Appropriate opioid selection may mitigate these effects. Even in older patients, addiction, abuse and misdirection of prescribed opioids are of concern. Higher risk exists for patients with psychiatric illness, history of substance abuse, and identifiable substance abuse risk factors. Screening for abuse potential and vigilant patient monitoring should be routine. Opioids differ in their ability to produce euphoria, based on opioid receptor agonism, but substance abusers may be more influenced by availability, familiarity and cost factors. Consequently, opioid selection has limited influence on abuse potential but can facilitate ease of monitoring. This review provides an overview of opioid use in medically complicated patients and recommendations on how to optimize analgesia while avoiding adverse events and drug interactions in the clinical setting. Articles cited in this review were identified via a search of EMBASE and PubMed. Articles selected for inclusion discussed characteristics of specific opioids and general physiological aspects of opioid therapy in important patient populations.
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Affiliation(s)
- Howard Smith
- Department of Anesthesiology, Albany Medical College, Albany, New York, USA
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Meyer MJ, Megyesi J, Meythaler J, Murie-Fernandez M, Aubut JA, Foley N, Salter K, Bayley M, Marshall S, Teasell R. Acute management of acquired brain injury part II: an evidence-based review of pharmacological interventions. Brain Inj 2010; 24:706-21. [PMID: 20376996 DOI: 10.3109/02699051003692126] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PRIMARY OBJECTIVE To review the research literature on pharmacological interventions used in the acute phase of acquired brain injury (ABI) to manage ICP and improve neural recovery. MAIN OUTCOMES A literature search of multiple databases (CINAHL, EMBASE, MEDLINE and PSYCHINFO) and hand searched articles covering the years 1980-2008 was performed. Peer reviewed articles were assessed for methodological quality using the PEDro scoring system for randomized controlled trials (RCTs) and the Downs and Black tool for RCTs and non-randomized trials. Levels of evidence were assigned and recommendations were made. RESULTS In total, 11 pharmacological interventions used in the acute management of ABI were evaluated. These included propofol, barbiturates, opioids, midazolam, mannitol, hypertonic saline, corticosteroids, progesterone, bradykinin antagonists, dimethyl sulphoxide and cannabinoids. Of these interventions, corticosteroids were found to be contraindicated and cannabinoids were reported as ineffective. The other nine interventions demonstrated some benefit for treatment of acute ABI. However, rarely did these benefits result in improved long-term patient outcomes. CONCLUSIONS Substantial research has been devoted to evaluating the use of pharmacological interventions in the acute management of ABI. However, much of this research has focused on the application of individual interventions in small single-site trials. Future research will need to establish larger patient samples to evaluate the benefits of combined interventions within specific patient populations.
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Affiliation(s)
- Matthew J Meyer
- Aging, Rehabilitation and Geriatric Care Program, Lawson Health Research Institute, London, Ontario, Canada
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32
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Makii JM, Mirski MA, Lewin JJ. Sedation and Analgesia in Critically Ill Neurologic Patients. J Pharm Pract 2010; 23:455-69. [DOI: 10.1177/0897190010372339] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Critically ill neurologic patients can pose a challenge when it comes to providing sedation and analgesia, primarily with the balance of maintaining sedation to provide patient comfort while still allowing a neurological examination. Determination of the optimal agent requires assessment and understanding of the underlying requirement for sedation: provision of analgesia, anxiolysis, or treatment of delirium. Pharmacological options exist that can affect individual or multiple underlying sedation requirements. Numerous evaluation tools exist to monitor the efficacy of sedation as well as help clinicians titrate agents to predefined goals; these tools allow the safe administration of drugs that can otherwise have serious adverse effects. Sedation regimens must ultimately be individualized to each patient to account for differences in pharmacokinetics and dynamics of the various agents, and this is particularly true in sedating neurologically injured patients. The agents frequently used to provide sedation and analgesia in the critically ill neurologic patient will be reviewed.
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Affiliation(s)
- Jason M. Makii
- Department of Pharmacy Services, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Marek A. Mirski
- Department of Anesthesiology and Critical Care Medicine, Division of Neuroanesthesia/Neurosciences Critical Care, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - John J. Lewin
- Department of Pharmacy, The Johns Hopkins Medical Institution, Baltimore, MD, USA
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[Sedation in neurointensive care unit]. ACTA ACUST UNITED AC 2010; 28:1015-9. [PMID: 19945245 DOI: 10.1016/j.annfar.2009.10.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2009] [Accepted: 10/06/2009] [Indexed: 11/22/2022]
Abstract
The objectives for using sedation in neurointensive care unit (neuroICU) are somewhat different from those used for patients without severe brain injuries. One goal is to clinically reassess the neurological function following the initial brain insult in order to define subsequent strategies for diagnosis and treatment. Another goal is to prevent severely injured brain from additional aggravation of cerebral blood perfusion and intracranial pressure. Depending on these situations is the choice of sedatives and analgesics: short-term agents, e.g., remifentanil, if a timely neurological reassessment is required, long-term agents, e.g., midazolam and sufentanil, as part of the treatment for elevated intracranial pressure. In that situation, a multimodal monitoring is needed to overcome the lack of clinical monitoring, including repeated measurements of intracranial pressure, blood flow velocities (transcranial Doppler), cerebral oxygenation (brain tissue oxygen tension), and brain imaging. The ultimate stop of neurosedation can distinguish between no consciousness and an alteration of arousing in brain-injured patients. During this period, an elevation of intracranial pressure is usual, and should not always result in reintroducing the neurosedation.
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Martin J, Heymann A, Bäsell K, Baron R, Biniek R, Bürkle H, Dall P, Dictus C, Eggers V, Eichler I, Engelmann L, Garten L, Hartl W, Haase U, Huth R, Kessler P, Kleinschmidt S, Koppert W, Kretz FJ, Laubenthal H, Marggraf G, Meiser A, Neugebauer E, Neuhaus U, Putensen C, Quintel M, Reske A, Roth B, Scholz J, Schröder S, Schreiter D, Schüttler J, Schwarzmann G, Stingele R, Tonner P, Tränkle P, Treede RD, Trupkovic T, Tryba M, Wappler F, Waydhas C, Spies C. Evidence and consensus-based German guidelines for the management of analgesia, sedation and delirium in intensive care--short version. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2010; 8:Doc02. [PMID: 20200655 PMCID: PMC2830566 DOI: 10.3205/000091] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Indexed: 12/28/2022]
Abstract
Targeted monitoring of analgesia, sedation and delirium, as well as their appropriate management in critically ill patients is a standard of care in intensive care medicine. With the undisputed advantages of goal-oriented therapy established, there was a need to develop our own guidelines on analgesia and sedation in intensive care in Germany and these were published as 2(nd) Generation Guidelines in 2005. Through the dissemination of these guidelines in 2006, use of monitoring was shown to have improved from 8 to 51% and the use of protocol-based approaches increased to 46% (from 21%). Between 2006-2009, the existing guidelines from the DGAI (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin) and DIVI (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) were developed into 3(rd) Generation Guidelines for the securing and optimization of quality of analgesia, sedation and delirium management in the intensive care unit (ICU). In collaboration with another 10 professional societies, the literature has been reviewed using the criteria of the Oxford Center of Evidence Based Medicine. Using data from 671 reference works, text, diagrams and recommendations were drawn up. In the recommendations, Grade "A" (very strong recommendation), Grade "B" (strong recommendation) and Grade "0" (open recommendation) were agreed. As a result of this process we now have an interdisciplinary and consensus-based set of 3(rd) Generation Guidelines that take into account all critically illness patient populations. The use of protocols for analgesia, sedation and treatment of delirium are repeatedly demonstrated. These guidelines offer treatment recommendations for the ICU team. The implementation of scores and protocols into routine ICU practice is necessary for their success.
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Affiliation(s)
- Jörg Martin
- Department of Anesthesiology and Operative Intensive Care, Klinik am Eichert, Göppingen, Germany
| | - Anja Heymann
- Department of Anesthesiology and Operative Intensive Care, Charité Campus Virchow, Berlin, Germany
| | | | - Ralf Baron
- Department of Neurology, Christian-Albrechts University, Kiel, Germany
| | - Rolf Biniek
- Department of Neurology, LVR-Klinik Bonn, Germany
| | - Hartmut Bürkle
- Clinic for Anaesthesiology and Operative Intensive Care and Pain Clinic of Memmingen, Germany
| | | | | | - Verena Eggers
- Department of Anesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Ingolf Eichler
- Department of Cardiac and Vascular Surgery, Klinikum Dortmund GgmbH, Germany
| | - Lothar Engelmann
- Department of Internal Medicine and Intensive Care Medicine, University of Leipzig, Germany
| | - Lars Garten
- Department of Neonatology, Charité University Medicine Berlin, Germany
| | - Wolfgang Hartl
- Department of Surgery Grosshadern, University of Munich, Germany
| | - Ulrike Haase
- Department of Anesthesiology and Intensive Care Medicine, Charité Campus Mitte, Berlin, Germany
| | - Ralf Huth
- University Children's Hospital of Mainz, Germany
| | - Paul Kessler
- Department of Anesthesiology and Intensive Care Medicine, Orthopedic University Hospital, Frankfurt, Germany
| | - Stefan Kleinschmidt
- Department of Anesthesiology, Intensive Care Medicine and Pain Management, BG Trauma Clinic Ludwigshafen, Germany
| | - Wolfgang Koppert
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Germany
| | - Franz-Josef Kretz
- Olgahospital, Department of Anesthesiology and Operative Intensive Care, Stuttgart, Germany
| | | | - Guenter Marggraf
- West German Heart Center Essen, Department of Thoracic and Cardiovascular Surgery, University Hospital Essen, Germany
| | - Andreas Meiser
- Department of Anesthesiology, Intensive Care and Pain, Saarland University Hospital, Homburg, Germany
| | - Edmund Neugebauer
- IFOM - Institute for Research in Operative Medicine, Institute for Surgical Research, Private University of Witten/ Herdecke GmbH, Köln, Germany
| | - Ulrike Neuhaus
- Department of Anesthesiology and Operative Intensive Care, Charité Campus Virchow, Berlin, Germany
| | - Christian Putensen
- Anesthesiology and Operative Intensive Care, University of Bonn, Germany
| | | | - Alexander Reske
- Department of Anesthesiology and Intensive Care, Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | - Bernard Roth
- Department of General Pediatrics, Cologne, Germany
| | - Jens Scholz
- Department of Anesthesiology and Surgical Intensive Care, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Stefan Schröder
- Department of Psychiatry and Psychotherapy, CMM Hospital Guestrow, Germany
| | - Dierk Schreiter
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Dresden, Germany
| | | | | | - Robert Stingele
- Department of Neurology, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Peter Tonner
- Department of Anesthesiology and Intensive Care Medicine, Emergency Medicine Hospital Links der Weser GmbH, Bremen, Germany
| | - Philip Tränkle
- Department of Internal Medicine, Division III, ICU 3IS, Tübingen, Germany
| | - Rolf Detlef Treede
- Department of Neurophysiology, Center for Biomedicine and Medical Technology Mannheim (CBTM), Germany
| | - Tomislav Trupkovic
- Department of Anesthesiology, Intensive Care Medicine and Pain Management, BG Trauma Clinic Ludwigshafen, Germany
| | - Michael Tryba
- Anesthesiology and Operative Intensive Care, Klinikum Kassel, Germany
| | - Frank Wappler
- Department of Anesthesiology and Operative Intensive Care, Hospital Cologne-Merheim, University of Witten/ Herdecke, Cologne, Germany
| | | | - Claudia Spies
- Department of Anesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
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Abstract
Raised intracranial pressure (ICP) is a life threatening condition that is common to many neurological and non-neurological illnesses. Unless recognized and treated early it may cause secondary brain injury due to reduced cerebral perfusion pressure (CPP), and progress to brain herniation and death. Management of raised ICP includes care of airway, ventilation and oxygenation, adequate sedation and analgesia, neutral neck position, head end elevation by 20 degrees-30 degrees, and short-term hyperventilation (to achieve PCO(2) 32-35 mm Hg) and hyperosmolar therapy (mannitol or hypertonic saline) in critically raised ICP. Barbiturate coma, moderate hypothermia and surgical decompression may be helpful in refractory cases. Therapies aimed directly at keeping ICP <20 mmHg have resulted in improved survival and neurological outcome. Emerging evidence suggests that cerebral perfusion pressure targeted therapy may offer better outcome than ICP targeted therapies.
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36
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Abstract
Stroke is the third leading cause of death and the leading cause of disability in the United States. This article summarizes the management of acute ischemic stroke, including conventional and novel therapies. The article provides an overview of the initial management, diagnostic work-up, treatment options, and supportive measures that need to be considered in the acute phase of ischemic stroke.
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Affiliation(s)
- Anna Finley Caulfield
- Department of Neurology and Neurological Sciences, Neurocritical Care Program, Stanford Stroke Center, Stanford University School of Medicine, Palo Alto, CA 94304, USA.
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37
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Abstract
Effective management of intracranial hypertension involves meticulous avoidance of factors that precipitate or aggravate increased intracranial pressure. When intracranial pressure becomes elevated, it is important to rule out new mass lesions that should be surgically evacuated. Medical management of increased intracranial pressure should include sedation, drainage of cerebrospinal fluid, and osmotherapy with either mannitol or hypertonic saline. For intracranial hypertension refractory to initial medical management, barbiturate coma, hypothermia, or decompressive craniectomy should be considered. Steroids are not indicated and may be harmful in the treatment of intracranial hypertension resulting from traumatic brain injury.
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Affiliation(s)
- Leonardo Rangel-Castillo
- Department of Neurosurgery, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
| | - Shankar Gopinath
- Department of Neurosurgery, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
| | - Claudia S. Robertson
- Department of Neurosurgery, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
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38
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Ladanyi S, Elliott D. Traumatic brain injury: an integrated clinical case presentation and literature review part II: the continuum of care. Aust Crit Care 2008; 21:141-53. [PMID: 18387814 DOI: 10.1016/j.aucc.2008.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2007] [Revised: 01/30/2008] [Accepted: 02/07/2008] [Indexed: 01/15/2023] Open
Abstract
The following paper continues the presentation of a case scenario outlining the assessment, interventions and outcome of a person who sustained multiple trauma with a focus on traumatic brain injury (TBI). Part I explored assessment and initial management of the patient from pre-hospital care through to the emergency department and operating theatre. Part II describes the intensive care period as an integral component of the continuum of care. Key issues in the case are presented sequentially with relevant theory integrated and applied to the clinical case throughout the discussion with a focus on the complex physiological, psychological, and spiritual needs of the patient and their family.
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Affiliation(s)
- Suzy Ladanyi
- Faculty of Nursing, Midwifery and Health, University of Technology, Sydney, NSW, Australia.
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39
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Celis-Rodríguez E, Besso J, Birchenall C, de la Cal M, Carrillo R, Castorena G, Ceraso D, Dueñas C, Gil F, Jiménez E, Meza J, Muñoz M, Pacheco C, Pálizas F, Pinilla D, Raffán F, Raimondi N, Rubiano S, Suárez M, Ugarte S. Guía de práctica clínica basada en la evidencia para el manejo de la sedo-analgesia en el paciente adulto críticamente enfermo. Med Intensiva 2007; 31:428-71. [DOI: 10.1016/s0210-5691(07)74853-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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40
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Schmittner MD, Vajkoczy SL, Horn P, Bertsch T, Quintel M, Vajkoczy P, Muench E. Effects of Fentanyl and S(+)-ketamine on Cerebral Hemodynamics, Gastrointestinal Motility, and Need of Vasopressors in Patients With Intracranial Pathologies. J Neurosurg Anesthesiol 2007; 19:257-62. [PMID: 17893578 DOI: 10.1097/ana.0b013e31811f3feb] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In neurosurgical patients, opioids are administered to prevent secondary cerebral damage. Complications often related to the administration of opioids are a decrease in blood pressure affording the use of vasopressors and intestinal atonia. One alternative approach to opioids is the application of S(+)-ketamine. However, owing to a suspected elevation of intracranial pressure (ICP), the administration of S(+)-ketamine has questioned for a long time. The aim of the present study was to evaluate ICP, gastrointestinal motility, and catecholamine consumption in neurosurgical patients undergoing 2 different protocols of anesthesia using fentanyl or S(+)-ketamine. Twenty-four patients sustaining traumatic brain injury or aneurysmal subarachnoid hemorrhage received methohexitone plus either fentanyl or S(+)-ketamine to establish a comparable level of sedation. To reach an adequate cerebral perfusion pressure (CPP), the norepinephrine dosage was adapted successively. Enteral nutrition and gastrointestinal stimulation were started directly after admission on the critical care unit. ICP, CPP, and norepinephrine dosage were recorded over 5 days and also the time intervals to full enteral nutrition and first defecation. There was no difference regarding ICP, CPP, and the time period until full enteral nutrition or first defecation between both groups. Patients who underwent analgesia with S(+)-ketamine showed a trend to a lower demand of norepinephrine compared with the fentanyl group. Our results indicate that S(+)-ketamine does not increase ICP and that its use in neurosurgical patients should not be discouraged on the basis of ICP-related concerns.
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Affiliation(s)
- Marc D Schmittner
- Department of Anesthesiology and Critical Care Medicine, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
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41
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Chiu WT, Lin TJ, Lin JW, Huang SJ, Chang CK, Chen HY. Multicenter evaluation of propofol for head-injured patients in Taiwan. ACTA ACUST UNITED AC 2007; 66 Suppl 2:S37-42. [PMID: 17071254 DOI: 10.1016/j.surneu.2006.08.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2006] [Accepted: 08/21/2006] [Indexed: 11/26/2022]
Abstract
BACKGROUND The present study was a multicenter, retrospective study which aimed to evaluate the efficacy of propofol, a new choice of pharmacotherapy in head-injured patients. METHODS Head-injured patients admitted to 3 hospitals during the period from January 2003 to December 2004 were included in this clinical trial. Data on patients' demographics, laboratory data, GCS score, ICP, CPP, concurrent medications, and therapeutic outcomes were collected. RESULTS Among the 104 patients included, only 44 were given propofol. The average age was 40.8 +/- 22 years for all patients, with 41.91 +/- 20.41 and 43.48 +/- 23.19 years for the propofol group and nonpropofol group, respectively (P=.097). There was no significant difference in baseline GCS score between the 2 groups (5.86 +/- 1.84 vs 5.66 +/- 1.59, P=.729). Mean ICP for the first 3 days in the ICU was 17.23 +/- 9.0 mm Hg in the propofol group and 33.19 +/- 32.56 in the nonpropofol group, respectively (P=.017). Mean CPP for the first 5 days in the ICU was 71.10 +/- 15.32 mm Hg in the propofol group and 43.20 +/- 29.92 mm Hg in the nonpropofol group (P<.001). A higher survival rate was found in the propofol group (81.8% vs 46.7%, P<.001). CONCLUSIONS The present study demonstrated that propofol improved the outcome in recovery phase of head-injured patients.
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Affiliation(s)
- Wen-Ta Chiu
- Department of Neurosurgery, Taipei Medical University-Wanfang Hospital, Taipei Medical University, Taipei 116, Taiwan
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42
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Abstract
Stroke is the third leading cause of death and the leading cause of disability in the United States. This article summarizes the critical care of acute ischemic stroke, including conventional and novel therapies. The article provided an overview of the initial management, diagnostic workup, treatment options, and supportive measures that need to be considered in the acute phase of ischemic stroke.
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Affiliation(s)
- Anna Finley Caulfield
- Department of Neurology and Neurological Sciences, Neurocritical Care Program, Stanford Stroke Center, Stanford University School of Medicine, Palo Alto, CA 94304, USA.
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43
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Abstract
Effective treatment of intracranial hypertension involves meticulous avoidance of factors that precipitate or aggravate increased intracranial pressure. When intracranial pressure becomes elevated, it is important to rule out new mass lesions that should be surgically evacuated. medical management of increased intracranial pressure should include sedation and paralysis, drainage of cerebrospinal fluid, and osmotherapy with either mannitol or hypertonic saline. For intracranial hypertension refractory to initial medical management, barbiturate coma, hypothermia, or decompressive craniectomy should be considered. Steroids are not indicated and may be harmful in the treatment of intracranial hypertension resulting from traumatic brain injury.
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Affiliation(s)
- Leonardo Rangel-Castillo
- Research Assistant, Department of Neurosurgery, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
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44
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Vavilala MS, Muangman S, Waitayawinyu P, Roscigno C, Jaffe K, Mitchell P, Kirkness C, Zimmerman JJ, Ellenbogen R, Lam AM. Neurointensive care; impaired cerebral autoregulation in infants and young children early after inflicted traumatic brain injury: a preliminary report. J Neurotrauma 2007; 24:87-96. [PMID: 17263672 DOI: 10.1089/neu.2006.0058] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The objective of this report is to describe cerebral autoregulation after severe inflicted pediatric traumatic brain injury (iTBI). We examined cerebral autoregulation of both cerebral hemispheres (mean autoregulatory index; ARI) in children <5 years with Glasgow Coma Scale (GCS) score of <9 and no evidence of brain death within the first 48 h of pediatric intensive care unit (PICU) admission. Discharge and 6-month Glasgow Outcome Scale (GOS) scores were collected. GOS of <4 reflected poor outcome. All three iTBI and all seven noninflicted TBI (nTBI) patients had admission GCS score of <9. Eight of 10 patients had Autoregulatory Index (ARI) of <0.4 (impaired cerebral autoregulation) of at least one hemisphere. All children with iTBI had poor outcome, and none had intact cerebral autoregulation in both hemispheres. Children with nTBI had better overall outcome than those with iTBI. Two of the children with nTBI had intact autoregulation in both hemispheres and good outcome. Two of the three children with iTBI had differential effects on autoregulation between hemispheres despite bilateral injury. These are, to our knowledge, the first data on cerebral blood flow autoregulation in the unique setting of iTBI and provide a rationale for further study of their relationship to outcome and effects of therapy.
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Affiliation(s)
- Monica S Vavilala
- Department of Anesthesiology, University of Washington, Harborview Medical Center, 325 Ninth Avenue, Seattle, WA 98104, USA.
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45
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Leone M, Visintini P, Alliez JR, Albanèse J. Quelle sédation pour la prévention et le traitement de l'agression cérébrale secondaire ? ACTA ACUST UNITED AC 2006; 25:852-7. [PMID: 16713168 DOI: 10.1016/j.annfar.2006.03.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The aim of sedation and analgesia is to prevent secondary brain insult. The goals of sedation are the prevention and treatment of intracranial hypertension and systemic disorders. In such situation, the use of sedative and analgesic therapy should respect the rate of cerebral blood flow/cerebral oxygen consumption coupling while preserving cerebral perfusion pressure and decreasing the intracranial pressure. This treatment should have an analgesic and myorelaxing action with short and predictable time of action. The optimal agent with all these characteristics does not exist, but the combination of several pharmacological compounds may reach this goal. Benzodiazepines are the most frequently agents used. In most of cases they are associated with analgesics like opioids or ketamine. Opioids are the basis of analgesia because they do not produce brain haemodynamic alterations if arterial pressure is maintained. Ketamine, which use in this indication is matter of debate, has the advantage to maintain haemodynamics. Ketamine has no side effects on brain haemodynamics when used in combination with propofol or midazolam. Because of their side effects on haemodynamics and immune response, barbituric are no longer used as long term sedative agents. However, they are still recommended in cases of refractory intracranial hypertension. Propofol remains the optimal sedative agent because of its short duration action although its use is restricted because it is an expensive drug. Its use is recommended for short time sedation with or without opioids. The use of neuromuscular blockers should be focused on the patients with an intracranial hypertension refractory to standard treatment. The presence of brain damage in patients makes difficult to assess the level of sedation. One should avoid over sedation, which increases morbidity by prolongation of the duration of mechanical ventilation.
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Affiliation(s)
- M Leone
- Département d'Anesthésie-Réanimation et centre de Traumatologie, Hôpital Nord, 13915 Marseille cedex 20, France
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46
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Beydon L, Audibert G, Berré J, Boulard G, Gabrillargues J, Bruder N, Hans P, Puybasset L, Ravussin P, de Kersaint-Gilly A, Ter Minassian A, Dufour H, Lejeune JP, Proust F, Bonafé A. [Pain management in severe subarachnoid haemorrhage]. ACTA ACUST UNITED AC 2005; 24:782-6. [PMID: 15922538 DOI: 10.1016/j.annfar.2005.04.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- L Beydon
- Département d'anesthésie-réanimation chirurgicale, CHU, 4, rue Larrey, 49933 Angers cedex 01, France.
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Bruder N, Ravussin P, Hans P, Berré J, Puybasset L, Audibert G, Boulard G, Beydon L, Ter Minassian A, Dufour H, Bonafé A, Gabrillargues J, Lejeune JP, Proust F, de Kersaint-Gilly A. Anesthésie pour le traitement des hémorragies méningées graves par rupture d'anévrisme. ACTA ACUST UNITED AC 2005; 24:775-81. [PMID: 15922545 DOI: 10.1016/j.annfar.2005.03.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- N Bruder
- Département d'anesthésie-réanimation, CHU de la Timone-Adultes, 264, rue Saint-Pierre, 13385 Marseille cedex 05, France.
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Bourgoin A, Albanèse J, Léone M, Sampol-Manos E, Viviand X, Martin C. Effects of sufentanil or ketamine administered in target-controlled infusion on the cerebral hemodynamics of severely brain-injured patients*. Crit Care Med 2005; 33:1109-13. [PMID: 15891344 DOI: 10.1097/01.ccm.0000162491.26292.98] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The manual injection of a bolus of opioid in patients with brain injury induces an increase in intracranial pressure related to a decrease in mean arterial pressure. Such an effect has not been observed with the use of ketamine. The use of target-controlled infusion would minimize or suppress this adverse effect of opioid. This study evaluated the effects of an increase in plasma concentrations of sufentanil or ketamine administered by target-controlled infusion on cerebral hemodynamics. DESIGN Prospective, randomized study. SETTING Intensive care unit in a trauma center. PATIENTS Thirty patients with severe traumatic brain injury. INTERVENTIONS Patients were assigned to receive sedation consisting of sufentanil-midazolam or ketamine-midazolam using target-controlled infusion. Twenty-four hours after the onset of sedation, the target concentrations of sufentanil or ketamine were doubled for 15 mins. Blood samples were collected to determine the actual plasma concentration of sufentanil and ketamine, before and 15 mins after concentration change. MEASUREMENTS AND MAIN RESULTS The baseline values of intracranial pressure and cerebral perfusion pressure were similar in both groups. The two-fold increase in drug concentrations did not involve a significant change for intracranial pressure, cerebral perfusion pressure, and mean velocity of middle cerebral artery in both the ketamine and the sufentanil groups. The measured plasma concentrations of sufentanil and ketamine were 0.4 +/- 0.2 ng/mL and 2.6 +/- 2.2 mug/mL, respectively, before the increase in concentrations and 0.7 +/- 0.4 ng/mL and 5.5 +/- 3.8 mug/mL after. CONCLUSIONS The present study shows that the increase in sufentanil or ketamine plasma concentrations using a target-controlled infusion is not associated with adverse effects on cerebral hemodynamics in patients with severe brain injury. The use of target-controlled infusion could be of interest in the management of severely brain-injured patients. However, there is a need for specific pharmacokinetic models designed for intensive care unit patients.
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Affiliation(s)
- Aurélie Bourgoin
- Department of Anesthesiology and Intensive Care and Trauma Center, Nord Hospital, France
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Audibert G, Steinmann G, Charpentier C, Mertes PM. Réunion de neuroanesthésie-réanimation. Prise en charge anesthésique du patient en hypertension intracrânienne aiguë. ACTA ACUST UNITED AC 2005; 24:492-501. [PMID: 15885971 DOI: 10.1016/j.annfar.2005.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Transcranial Doppler and, if possible, measurement of intracranial pressure (ICP) allow preoperative diagnosis of acute intracranial hypertension (ICH) after brain trauma. The main goal of the anaesthesiologist is to prevent the occurrence of secondary brain injuries and to avoid cerebral ischaemia. Treatment of high ICP is mainly achieved with osmotherapy. High-dose mannitol administration (1.4 to 2 g/kg given in bolus doses) may be considered a better option than conventional doses, especially before emergency evacuation of a cerebral mass lesion. Hypertonic saline seems as effective as mannitol without rebound effect and without diuresis increase. Haemostasis should be normalized before neurosurgery and invasive blood pressure monitoring is mandatory. For anaesthesia induction, thiopental or etomidate may be used. In case of ICH, halogenated and nitrous oxide should be avoided. Until the dura is open, mean arterial pressure should be maintained around 90 mmHg (or cerebral perfusion pressure around 70 mmHg). If a long-lasting (several hours) extracranial surgery is necessary, ICP should be monitored and treatment of ICH should have been instituted before.
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MESH Headings
- Acute Disease
- Anesthesia, General/methods
- Blood Pressure
- Brain Injuries/complications
- Brain Injuries/surgery
- Brain Ischemia/etiology
- Brain Ischemia/prevention & control
- Case Management
- Combined Modality Therapy
- Comorbidity
- Contraindications
- Diuretics, Osmotic/administration & dosage
- Diuretics, Osmotic/therapeutic use
- Etomidate
- Humans
- Hyperventilation
- Intracranial Hypertension/complications
- Intracranial Hypertension/diagnostic imaging
- Intracranial Hypertension/drug therapy
- Intracranial Hypertension/surgery
- Jugular Veins
- Mannitol/administration & dosage
- Mannitol/therapeutic use
- Monitoring, Intraoperative
- Monitoring, Physiologic
- Nitrous Oxide
- Oxygen/blood
- Preoperative Care
- Saline Solution, Hypertonic/administration & dosage
- Saline Solution, Hypertonic/therapeutic use
- Thiopental
- Tomography, X-Ray Computed
- Ultrasonography, Doppler, Transcranial
- Wounds and Injuries/surgery
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Affiliation(s)
- G Audibert
- Département d'anesthésie-réanimation, hôpital central, CHU de Nancy, 54000 Nancy, France.
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50
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Olsen KS, Juul N, Cold GE. Effect of alfentanil on intracranial pressure during propofol-fentanyl anesthesia for craniotomy. A randomized prospective dose-response study. Acta Anaesthesiol Scand 2005; 49:445-52. [PMID: 15777290 DOI: 10.1111/j.1399-6576.2005.00648.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The effect of alfentanil on intracranial pressure (ICP) in patients with supratentorial cerebral tumors has only been sparsely examined and with somewhat contradictory results. METHODS Thirty-one patients were anesthetized with propofol and fentanyl. After removal of the bone flap a bolus-dose of alfentanil 10 (group 1), 20 (group 2), or 30 microg kg(-1) (group 3) was administered followed by an infusion of 10, 20, or 30 microg.kg(-1).h(-1) to patients in groups 1, 2, and 3, respectively. A control group received no alfentanil. Subdural ICP, mean arterial blood pressure (MAP), and cerebral perfusion pressure (CPP) were monitored and arterial and jugular bulb blood were sampled before and every minute for 5 min after the bolus administration of alfentanil and again after 5 min of hyperventilation to be able to calculate cerebral arterio-venous oxygen content difference (AVDO2) and carbon dioxide reactivity (CO2-reactivity). RESULTS No changes in subdural ICP or AVDO2 from alfentanil in the study period were observed within the groups. However, alfentanil decreased MAP and CPP. The maximum CPP decrease (mean value of each group) was 4 mmHg, 8 mmHg, and 18 mmHg in groups 1, 2, and 3, respectively. There was no difference between groups as regards the CO2-reactivity. CONCLUSION We conclude that administration of alfentanil to propofol-fentanyl anesthetized patients with supratentorial cerebral tumors decreases MAP and CPP in a dose-related way, but does not influence subdural ICP, AVDO2 or the CO2-reactivity.
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Affiliation(s)
- K S Olsen
- Department of Anesthesia and Intensive Care, Glostrup Hospital, University of Copenhagen, Denmark.
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