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Sontakke NG, Sontakke MG, Rai NK. Artificial Airway Suctioning: A Systematic Review. Cureus 2023; 15:e42579. [PMID: 37641766 PMCID: PMC10460288 DOI: 10.7759/cureus.42579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 07/27/2023] [Indexed: 08/31/2023] Open
Abstract
Airway suctioning is routinely performed in the majority of care circumstances, including acute care, subacute care, home-based settings, and long-term care. Using an artificial airway to suction the patient allows for the mobilization and evacuation of secretions. When a patient can't independently remove all of the secretions from their respiratory tract, suction is used. This can occur when the body produces excessive secretion or it is not eliminated quickly enough, causing the respiratory system's upper and lower respiratory secretions to accumulate. Airway blockage and inadequate breathing may result from this. Ultimately, this leads to a shortage of oxygen and carbon dioxide from the air, both of which are necessary for ideal cellular activity. Artificial airway suctioning is one of the most crucial components of airway care and a core competency for medical professionals trying to ensure airway patency. Artificial airway suctioning is a standard treatment carried out every day globally and is frequently done in both outpatient and inpatient patients. Therefore, specialists must know the safest and most efficient ways to perform surgery and any potential side effects. In ventilated infants and children, the removal of obstructive secretions by endotracheal suctioning is frequently done. It is unknown how suctioning affects the mechanics of breathing. This study used a prospective observational clinical design to examine the immediate impact of airway resistance in endotracheal suctioning, tidal volume, and dynamic lung regulation in mechanically ventilated adult patients and mechanically ventilated pediatric patients. The preparation, process, and indications for intraoperative fusion treatment in various circumstances are covered in this systematic review.
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Affiliation(s)
- Nikhil G Sontakke
- Health Sciences, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Mayuri G Sontakke
- Accident and Trauma Care Technology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Naveen K Rai
- Biochemistry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Harrois A, Anstey JR, Deane AM, Craig S, Udy AA, McNamara R, Bellomo R. Effects of Routine Position Changes and Tracheal Suctioning on Intracranial Pressure in Traumatic Brain Injury Patients. J Neurotrauma 2020; 37:2227-2233. [PMID: 32403976 DOI: 10.1089/neu.2019.6873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Patient position change and tracheal suctioning are routine interventions in mechanically ventilated traumatic brain injury (TBI) patients. We sought to better understand the impact of these interventions on intracranial pressure (ICP) and cerebral hemodynamics. We conducted a prospective study in TBI patients requiring ICP monitoring. The timing of position changes and suctioning episodes were recorded with concurrent blood pressure and ICP measurements. We collected data on 460 patient position changes and 204 suctioning episodes over 2404 h in 18 ventilated patients (mean age 34 [13] years, median Glasgow Coma Score 4 [3-7]). We recorded 24 (20-31) positioning and 11 (6-18) suctioning episodes per patient, with 54% and 39% of position changes associated with ICP ≥22 mm Hg and cerebral perfusion pressure (CPP) <60 mm Hg, respectively, and 22% and 27% of suctioning episodes associated with an ICP ≥22 mm Hg and CPP <60 mm Hg. The median change in ICP was 11 (6-16) mm Hg after position changes and 3 (1-9) mm Hg after suctioning. Reduction in CPP to <60 mm Hg lasted ≥10 min in 17% of positioning and 11% of suctioning episodes. The baseline ICP and its amplitude were both predictive of a rise in ICP ≥22 mm Hg after positioning and suctioning episodes, whereas cerebral autoregulation was not. Baseline CPP was predictive of a decrease in CPP <60 mm Hg after both interventions. Increases in ICP and reductions in CPP are common following patient positioning and tracheal suctioning episodes. Frequently, these changes are substantial and sustained.
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Affiliation(s)
- Anatole Harrois
- Intensive Care Unit, Level 5, Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Anesthesia and Surgical Intensive Care, Paris Sud University, Orsay, France
| | - James R Anstey
- Intensive Care Unit, Level 5, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Adam M Deane
- Intensive Care Unit, Level 5, Royal Melbourne Hospital, Parkville, Victoria, Australia.,Center for Integrated Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Sally Craig
- Intensive Care Unit, Level 5, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Andrew A Udy
- Australian and New Zealand Intensive Care Research Center, Monash University, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Intensive Care Unit, the Alfred Hospital, Melbourne, Victoria, Australia
| | - Robert McNamara
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia, Australia.,Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Rinaldo Bellomo
- Intensive Care Unit, Level 5, Royal Melbourne Hospital, Parkville, Victoria, Australia.,Center for Integrated Critical Care, University of Melbourne, Melbourne, Victoria, Australia.,Australian and New Zealand Intensive Care Research Center, Monash University, Melbourne, Victoria, Australia.,Department of Intensive Care, Austin Health, Melbourne, Victoria, Australia
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Vinclair M, Schilte C, Roudaud F, Lavolaine J, Francony G, Bouzat P, Bosson JL, Payen JF. Using Pupillary Pain Index to Assess Nociception in Sedated Critically Ill Patients. Anesth Analg 2019; 129:1540-1546. [PMID: 31743173 DOI: 10.1213/ane.0000000000004173] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Pupillary reflex dilation is a reliable indicator of response to noxious stimulation. In a proof of concept study, we investigated the performance of pupillary pain index, a new score derived from pupillary reflex dilation measurements, to predict nociceptive response to endotracheal suctioning in sedated critically ill patients. METHODS Twenty brain-injured and 20 non-brain-injured patients were studied within 48 hours of admission (T1) in the intensive care unit and at 48-72 hours later (T2). Video-based pupillometer was used to determine pupillary reflex dilation during tetanic stimulation. The tetanic stimulation (100 Hz) was applied to the skin area innervated by the ulnar nerve and was stepwise increased from 10 to 60 mA until pupil size had increased by 13% compared to baseline. The maximum intensity value allowed the determination of a pupillary pain index score ranging from 1 (no nociception) to 9 (high nociception). The Behavioral Pain Scale response to endotracheal suctioning was measured thereafter. RESULTS Behavioral Pain Scale responses to endotracheal suctioning and pupillary pain index scores were positively correlated at T1 and T2 (both P < .01). After adjustments for repeated measurements and group of patients, the area under the receiver operating characteristic curve of pupillary pain index to predict Behavioral Pain Scale response to endotracheal suctioning was of 0.862 (95% CI, 0.714-0.954). In the combined set of patients, a pupillary pain index score of ≤4 could predict no nociceptive response to endotracheal suctioning with a sensitivity of 88% (95% CI, 68%-97%) and a specificity of 79% (95% CI, 66%-88%). By contrast with endotracheal suctioning, tetanic stimulation had no effect on intracranial pressure in the brain-injured group. CONCLUSIONS These results are a proof of concept. The nociceptive response to endotracheal suctioning could be accurately predicted using the determination of pupillary pain index score in sedated critically ill patients whether they have brain injury or not.
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Affiliation(s)
- Marc Vinclair
- From the Pôle Anesthésie Réanimation, Centre Hospitalier Universitaire Grenoble Alpes, F-38000, Grenoble, France
| | - Clotilde Schilte
- From the Pôle Anesthésie Réanimation, Centre Hospitalier Universitaire Grenoble Alpes, F-38000, Grenoble, France
| | - Florian Roudaud
- From the Pôle Anesthésie Réanimation, Centre Hospitalier Universitaire Grenoble Alpes, F-38000, Grenoble, France
| | - Julien Lavolaine
- From the Pôle Anesthésie Réanimation, Centre Hospitalier Universitaire Grenoble Alpes, F-38000, Grenoble, France
| | - Gilles Francony
- From the Pôle Anesthésie Réanimation, Centre Hospitalier Universitaire Grenoble Alpes, F-38000, Grenoble, France
| | - Pierre Bouzat
- From the Pôle Anesthésie Réanimation, Centre Hospitalier Universitaire Grenoble Alpes, F-38000, Grenoble, France
- Institut National de la Santé et de la Recherche Médicale, U1216, F-38000 Grenoble, France
- Université Grenoble Alpes, Grenoble Institut des Neurosciences, F-38000 Grenoble, France
| | - Jean-Luc Bosson
- Clinical Research Centre, Institut National de la Santé et de la Recherche Médicale 003, Centre Hospitalier Universitaire Grenoble Alpes, F-38000, Grenoble, France
- Université Grenoble Alpes, Centre National de la Recherche Scientifique-Mathématiques et Applications, Grenoble Unité Mixte de Recherche, 5525-ThEMAS, F-38000 Grenoble, France
| | - Jean-Francois Payen
- From the Pôle Anesthésie Réanimation, Centre Hospitalier Universitaire Grenoble Alpes, F-38000, Grenoble, France
- Institut National de la Santé et de la Recherche Médicale, U1216, F-38000 Grenoble, France
- Université Grenoble Alpes, Grenoble Institut des Neurosciences, F-38000 Grenoble, France
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Endotracheal Lidocaine Installation, Endotracheal Suction, and Intracranial Pressure in Patients With Traumatic Brain Injury-Assessing the Impact. Pediatr Crit Care Med 2019; 20:387-388. [PMID: 30950993 DOI: 10.1097/pcc.0000000000001848] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Does Tracheal Lidocaine Instillation Reduce Intracranial Pressure Changes After Tracheal Suctioning in Severe Head Trauma? A Prospective, Randomized Crossover Study. Pediatr Crit Care Med 2019; 20:365-371. [PMID: 30461578 DOI: 10.1097/pcc.0000000000001817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Tracheal suctioning is a routine procedure in mechanically ventilated children, however, in severe head-injured patients it can result in potential deleterious increase in intracranial pressure. We aimed to assess the effect of tracheal lidocaine administration on intracranial pressure during tracheal suctioning. DESIGN Prospective randomized controlled crossover study. SETTING PICU of a tertiary hospital. PATIENTS Eleven patients with severe head trauma (Glasgow Coma Scale score 4-8) INTERVENTIONS:: Lidocaine (1.5 mg/kg) or saline solution was endotracheally instilled before a standardized tracheal suctioning maneuver. Each patient received both treatments in a crossover design. Cerebral hemodynamic and systemic and ventilatory effects were assessed at four time points: in baseline (T0), within 2 minutes (T1), 5 minutes (T2), and 15 minutes after tracheal instillation (T3). The 2-minute time interval around tracheal suctioning was used to assess each treatment efficacy MEASUREMENTS AND MAIN RESULTS:: The time course of intracranial pressure was different throughout the study in both treatment groups, with a significant increase of intracranial pressure from 14.82 ± 3.48 to 23.27 ± 9.06 with lidocaine (p = 0.003) and from 14.73 ± 2.41 to 30.45 ± 13.14 with saline (p = 0.02). The mean variation in intracranial pressure immediately after tracheal suctioning was smaller with lidocaine instillation than saline (8.45 vs 15.72 mm Hg; p = 0.006). Patients treated with lidocaine returned to baseline intracranial pressure value at 5 minutes after tracheal suctioning whereas those receiving saline solution returned to baseline intracranial pressure value at 15 minutes. Although patients treated with lidocaine had no significant hemodynamic changes, patients receiving saline solution experienced a higher mean value of mean arterial pressure (99.36 vs 81.73 mm Hg; p = 0.004) at T1. CONCLUSIONS This preliminary study showed that tracheal lidocaine instillation can attenuate increase in intracranial pressure induced by tracheal suctioning and favor a faster return to the intracranial pressure baseline levels without significant hemodynamic and ventilatory changes.
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Physiotherapy in the neurotrauma intensive care unit: A scoping review. J Crit Care 2018; 48:390-406. [PMID: 30316038 DOI: 10.1016/j.jcrc.2018.09.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 09/20/2018] [Accepted: 09/30/2018] [Indexed: 11/20/2022]
Abstract
PURPOSE This scoping review summarizes the literature on the safety and effectiveness of physiotherapy interventions in patients with neurological and/or traumatic injuries in the intensive care unit (ICU), identifies literature gaps and provides recommendations for future research. MATERIALS AND METHODS We searched five databases from inception to June 2, 2018. We included published retrospective studies, case studies, observation and randomized controlled trials describing physiotherapy interventions in ICU patients with neurotrauma injuries. Two reviewers reviewed the databases and independently screened English articles for eligibility. Data extracted included purpose, study design, population (s), outcome measures, interventions and results. Thematic analysis and descriptive numerical summaries are presented by intervention type. RESULTS 12,846 titles were screened and 72 met the inclusion criteria. Most of the studies were observational studies (44 (61.1%)) and RCTs (14 (19.4%)). Early mobilization, electrical stimulation, range of motion, and chest physiotherapy techniques were the most common interventions in the literature. Physiotherapy interventions were found to be safe with few adverse events. CONCLUSIONS Gaps in the literature suggest that future studies require assessment of long term functional outcomes and quality of life, examination of homogenous populations and more robust methodologies including clinical trials and larger samples.
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Comparison of effect of dexmedetomidine and lidocaine on intracranial and systemic hemodynamic response to chest physiotherapy and tracheal suctioning in patients with severe traumatic brain injury. J Anesth 2018; 32:518-523. [PMID: 29725828 DOI: 10.1007/s00540-018-2505-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Accepted: 04/28/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE Chest physiotherapy and tracheal suction cause sympathetic stimulation and increase heart rate (HR), mean arterial pressure (MAP) and intracranial pressure (ICP) which may have deleterious effect in the head injured. We planned to compare the effect of intravenous dexmedetomidine and lidocaine on intracerebral and systemic hemodynamic response to chest physiotherapy (CP) and tracheal suctioning (TS) in patients with severe traumatic brain injury (sTBI). METHODS Prospective, randomized study in patients with sTBI, 18-60 years of age, undergoing mechanical ventilation and intraparenchymal ICP monitoring. Patients were randomized to receive either iv dexmedetomidine 0.5 mcg/kg (group I; n = 30) or iv lidocaine 2 mg/kg (group II; n = 30) over 10 min. After infusion of test drug, CP with vibrator and manual compression was performed for 2 min and TS was done over next 15-20 s. The hemodynamic response was recorded before, during and at interval of 1 min for 10 min after CP and TS. A 20% change in hemodynamic parameters was considered significant. RESULTS The baseline hemodynamic (HR, MAP), intracranial (ICP, CPP) and respiratory (SPO2, AWPpeak) parameters were normal and comparable in both the groups. After dexmedetomidine infusion, MAP and CPP decreased significantly from baseline value. In group II, there was no significant change in HR, MAP, ICP and CPP. At end of CP and TS, HR, MAP and CPP in group I was lower as compared to group II. During the 10-min observation period following CP and TS, MAP and CPP in group I remained significantly lower as compared to baseline and group II. There was no significant change in value of other measured parameters. CONCLUSIONS Both dexmedetomidine and lidocaine were effective to blunt rise in HR, MAP and ICP in response to CP and TS in patients with sTBI. However, intravenous dexmedetomidine caused significant decrease in MAP and CPP as compared to the baseline and lidocaine.
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Effects of Closed Endotracheal Suctioning on Systemic and Cerebral Oxygenation and Hemodynamics in Children. Pediatr Crit Care Med 2018; 19:e23-e30. [PMID: 29189639 DOI: 10.1097/pcc.0000000000001377] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the effects of closed endotracheal tube suctioning on systemic oxygen saturation, cerebral regional oxygen saturation, and somatic regional (renal) oxygen saturation and hemodynamic variables in children. DESIGN Prospective observational. SETTING A tertiary care PICU. SUBJECTS Children aged 0-18 years, requiring invasive mechanical ventilation and with an arterial line. INTERVENTIONS Closed endotracheal suction. MEASUREMENTS AND MAIN RESULTS The study included 19 sedated and intubated children, 0-18 years old. They were enrolled in an ongoing prospective observational study. We used near-infrared spectroscopy for cerebral regional oxygen saturation and somatic regional (renal) oxygen saturation. The timing of each closed endotracheal tube suctioning event was accurately identified from video recordings. We extracted systemic oxygen saturation, cerebral regional oxygen saturation, somatic regional (renal) oxygen saturation, heart rate, and systolic blood pressure and diastolic blood pressure for 5 minutes before and 5 minutes after each event and used these data for analysis. One-minute average values of these variables were used for repeated-measures analysis. We analyzed 287 endotracheal tube suctioning episodes in 19 children. Saline was instilled into the endotracheal tube during 61 episodes. The mean heart rate (107.0 ± 18.7 vs 110.2 ± 10.4; p < 0.05), mean arterial blood pressure (81.5 ± 16.1 vs 83.0 ± 15.6 mm Hg; p < 0.05), and the mean cerebral regional oxygen saturation (64.8 ± 8.3 vs 65.8 ± 8.3; p < 0.05) were increased after suctioning. The mean systemic oxygen saturation (96.9 ± 2.7 vs 96.7 ± 2.7; p = 0.013) was decreased, whereas the mean somatic regional (renal) oxygen saturation was not significantly different after endotracheal tube suctioning. Repeated-measures analysis revealed transient increases in heart rate, respiratory rate, systolic blood pressure, and diastolic blood pressure; a sustained increase in cerebral regional oxygen saturation; and transient decreases in systemic oxygen saturation and somatic regional (renal) oxygen saturation. Saline instillation did not affect oxygenation or hemodynamic variables. CONCLUSIONS Closed endotracheal tube suctioning in sedated children is associated with transient but clinically insignificant changes in heart rate, blood pressure, cerebral regional oxygen saturation, systemic oxygen saturation, and somatic regional (renal) oxygen saturation. Saline instillation during endotracheal tube suctioning had no adverse effects on systemic or cerebral oxygenation.
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Abou-Arab MH, Feiner JR, Spigset O, Heier T. Alfentanil during rapid sequence induction with thiopental 4 mg/kg and rocuronium 0.6 mg/kg: tracheal intubation conditions. Acta Anaesthesiol Scand 2015; 59:1278-86. [PMID: 26176994 DOI: 10.1111/aas.12584] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Revised: 06/19/2015] [Accepted: 06/22/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Opioids have become an integral part of anaesthesia induction. We aimed to determine the dose of alfentanil needed to obtain perfect tracheal intubation conditions during rapid sequence induction with standard doses of thiopental and rocuronium, where laryngoscopy was initiated 55 s after commencement of drug administration. The influence of covariates (sex, body weight, age, alfentanil plasma concentration at laryngoscopy) was tested. METHODS Eighty-four healthy individuals were randomly assigned to receive one of the seven assessor-blinded alfentanil doses (0, 10, 20, 30, 40, 50 and 60 μg/kg) in conjunction with thiopental 4 mg/kg and rocuronium 0.6 mg/kg. For drug administration, 15 s was allowed. Laryngoscopy was initiated 40 s after rocuronium and tracheal intubation concluded within 70 s after commencement of drug administration. Alfentanil doses associated with 50%, 90% and 95% probability of perfect intubation conditions were determined with logistic regression. Multiple logistic regressions were used to test the influence of covariates. The relationship between alfentanil dose and concentration at laryngoscopy was analysed with linear regression. The effects of covariates on plasma concentrations of alfentanil were tested with multiple linear regressions. RESULTS Perfect intubation conditions of 95% probability was obtained with 56 μg/kg (confidence intervals 44-68). None of the covariates were significant predictors of perfect intubation conditions. Alfentanil plasma concentration correlated with dose and increased with increasing body weight (1.7 ng/ml/kg). CONCLUSION Perfect intubation conditions during rapid sequence induction can be obtained with clinically relevant doses of alfentanil in most healthy patients anaesthetized with thiopental 4 mg/kg and rocuronium 0.6 mg/kg.
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Affiliation(s)
- M. H. Abou-Arab
- Department of Anesthesia; Division of Emergencies and Critical Care Medicine; Oslo University Hospital; Oslo Norway
| | - J. R. Feiner
- Department of Anesthesia and Perioperative Care; University of California; UCSF; San Francisco CA USA
| | - O. Spigset
- Department of Clinical Pharmacology; St. Olav University Hospital; Trondheim Norway
- Department of Laboratory Medicine, Children's and Women's Health; Norwegian University of Science and Technology; Trondheim Norway
| | - T. Heier
- Department of Anesthesia; Division of Emergencies and Critical Care Medicine; Oslo University Hospital and University of Oslo; Oslo Norway
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Damkliang J, Considine J, Kent B, Street M. Using an evidence-based care bundle to improve initial emergency nursing management of patients with severe traumatic brain injury. J Clin Nurs 2015; 24:3365-73. [DOI: 10.1111/jocn.12923] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Jintana Damkliang
- School of Nursing and Midwifery; Deakin University; Burwood Vic. Australia
- Faculty of Nursing; Prince of Songkla University; Songkhla Thailand
| | - Julie Considine
- Eastern Health - Deakin University Nursing & Midwifery Research Centre/Centre for Quality and Patient Safety Research; School of Nursing and Midwifery; Deakin University; Burwood Vic. Australia
| | - Bridie Kent
- School of Nursing and Midwifery; University of Plymouth; Plymouth UK
| | - Maryann Street
- Eastern Health - Deakin University Nursing & Midwifery Research Centre/Centre for Quality and Patient Safety Research; School of Nursing and Midwifery; Deakin University; Burwood Vic. Australia
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Damkliang J, Considine J, Kent B, Street M. Using an evidence-based care bundle to improve Thai emergency nurses' knowledge of care for patients with severe traumatic brain injury. Nurse Educ Pract 2015; 15:284-92. [DOI: 10.1016/j.nepr.2015.03.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 12/10/2014] [Accepted: 03/22/2015] [Indexed: 12/01/2022]
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Ferreira LL, Valenti VE, Vanderlei LCM. Chest physiotherapy on intracranial pressure of critically ill patients admitted to the intensive care unit: a systematic review. Rev Bras Ter Intensiva 2015; 25:327-33. [PMID: 24553515 PMCID: PMC4031870 DOI: 10.5935/0103-507x.20130055] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 11/18/2013] [Indexed: 12/03/2022] Open
Abstract
Objective To analyze the outcomes of increased or decreased intracranial pressure and/or the
decrease in cerebral perfusion pressure resulting from respiratory physiotherapy
on critically ill patients admitted to the intensive care unit. Methods Through a systematic review of the literature, clinical trials published between
2002 and 2012 were selected. The search involved the LILACS, SciELO, MedLine and
PEDro databases using the keywords "physical therapy", "physiotherapy",
"respiratory therapy" and "randomized controlled trials" combined with the keyword
"intracranial pressure". Results In total, five studies, including a total of 164 patients between 25 and 65 years
of age, reporting that respiratory physiotherapy maneuvers significantly increased
intracranial pressure without changing the cerebral perfusion pressure were
included. The articles addressed several techniques including vibration,
vibrocompression, tapping, postural drainage, and the endotracheal aspiration
maneuver. All patients required invasive mechanical ventilation. Conclusion Respiratory physiotherapy leads to increased intracranial pressure. Studies
suggest that there are no short-term hemodynamic or respiratory repercussions or
changes in the cerebral perfusion pressure. However, none of the studies evaluated
the clinical outcomes or ensured the safety of the maneuvers.
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Affiliation(s)
- Lucas Lima Ferreira
- Corresponding Author: Lucas Lima Ferreira, Avenida Salustiano Luis
Marques, 681/1, Zip code: 15300-000 - General Salgado (SP), Brazil. E-mail:
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Sönmez Düzkaya D, Kuğuoğlu S. Assessment of Pain During Endotracheal Suction In the Pediatric Intensive Care Unit. Pain Manag Nurs 2015; 16:11-9. [DOI: 10.1016/j.pmn.2014.02.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 02/22/2014] [Accepted: 02/25/2014] [Indexed: 11/28/2022]
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Caricato A, Tersali A, Pitoni S, De Waure C, Sandroni C, Bocci MG, Annetta MG, Pennisi MA, Antonelli M. Racemic ketamine in adult head injury patients: use in endotracheal suctioning. Crit Care 2013; 17:R267. [PMID: 24209387 PMCID: PMC4056626 DOI: 10.1186/cc13097] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 10/16/2013] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Endotracheal suctioning (ETS) is essential for patient care in an ICU but may represent a cause of cerebral secondary injury. Ketamine has been historically contraindicated for its use in head injury patients, since an increase of intracranial pressure (ICP) was reported; nevertheless, its use was recently suggested in neurosurgical patients. In this prospective observational study we investigated the effect of ETS on ICP, cerebral perfusion pressure (CPP), jugular oxygen saturation (SjO2) and cerebral blood flow velocity (mVMCA) before and after the administration of ketamine. METHODS In the control phase, ETS was performed on patients sedated with propofol and remifentanil in continuous infusion. If a cough was present, patients were assigned to the intervention phase, and 100 γ/kg/min of racemic ketamine for 10 minutes was added before ETS. RESULTS In the control group ETS stimulated the cough reflex, with a median cough score of 2 (interquartile range (IQR) 1 to 2). Furthermore, it caused an increase in mean arterial pressure (MAP) (from 89.0 ± 11.6 to 96.4 ± 13.1 mmHg; P <0.001), ICP (from 11.0 ± 6.7 to 18.5 ± 8.9 mmHg; P <0.001), SjO2 (from 82.3 ± 7.5 to 89.1 ± 5.4; P = 0.01) and mVMCA (from 76.8 ± 20.4 to 90.2 ± 30.2 cm/sec; P = 0.04). CPP did not vary with ETS. In the intervention group, no significant variation of MAP, CPP, mVMCA, and SjO2 were observed in any step; after ETS, ICP increased if compared with baseline (15.1 ± 9.4 vs. 11.0 ± 6.4 mmHg; P <0.05). Cough score was significantly reduced in comparison with controls (P <0.0001). CONCLUSIONS Ketamine did not induce any significant variation in cerebral and systemic parameters. After ETS, it maintained cerebral hemodynamics without changes in CPP, mVMCA and SjO2, and prevented cough reflex. Nevertheless, ketamine was not completely effective when used to control ICP increase after administration of 100 γ/kg/min for 10 minutes.
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Affiliation(s)
- Anselmo Caricato
- Institute of Anesthesiology and Intensive Care, Catholic University School of Medicine, Policlinico ‘A. Gemelli’, Rome, Italy
| | - Alessandra Tersali
- Institute of Anesthesiology and Intensive Care, Catholic University School of Medicine, Policlinico ‘A. Gemelli’, Rome, Italy
| | - Sara Pitoni
- Institute of Anesthesiology and Intensive Care, Catholic University School of Medicine, Policlinico ‘A. Gemelli’, Rome, Italy
| | - Chiara De Waure
- Institute of Hygiene, Catholic University School of Medicine, Policlinico ‘A. Gemelli’, Rome, Italy
| | - Claudio Sandroni
- Institute of Anesthesiology and Intensive Care, Catholic University School of Medicine, Policlinico ‘A. Gemelli’, Rome, Italy
| | - Maria Grazia Bocci
- Institute of Anesthesiology and Intensive Care, Catholic University School of Medicine, Policlinico ‘A. Gemelli’, Rome, Italy
| | - Maria Giuseppina Annetta
- Institute of Anesthesiology and Intensive Care, Catholic University School of Medicine, Policlinico ‘A. Gemelli’, Rome, Italy
| | - Mariano Alberto Pennisi
- Institute of Anesthesiology and Intensive Care, Catholic University School of Medicine, Policlinico ‘A. Gemelli’, Rome, Italy
| | - Massimo Antonelli
- Institute of Anesthesiology and Intensive Care, Catholic University School of Medicine, Policlinico ‘A. Gemelli’, Rome, Italy
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Cerqueira Neto MLD, Moura ÁV, Cerqueira TCF, Aquim EE, Reá-Neto Á, Oliveira MC, Silva Júnior WMD, Santana-Filho VJ, Scola RH. Acute effects of physiotherapeutic respiratory maneuvers in critically ill patients with craniocerebral trauma. Clinics (Sao Paulo) 2013; 68:1210-4. [PMID: 24141836 PMCID: PMC3782728 DOI: 10.6061/clinics/2013(09)06] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 03/05/2013] [Accepted: 04/22/2013] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To evaluate the effects of physiotherapeutic respiratory maneuvers on cerebral and cardiovascular hemodynamics and blood gas variables. METHOD A descriptive, longitudinal, prospective, nonrandomized clinical trial that included 20 critical patients with severe craniocerebral trauma who were receiving mechanical ventilation and who were admitted to the intensive care unit. Each patient was subjected to the physiotherapeutic maneuvers of vibrocompression and increased manual expiratory flow (5 minutes on each hemithorax), along with subsequent airway suctioning with prior instillation of saline solution, hyperinflation and hyperoxygenation. Variables related to cardiovascular and cerebral hemodynamics and blood gas variables were recorded after each vibrocompression, increased manual expiratory flow and airway suctioning maneuver and 10 minutes after the end of airway suctioning. RESULTS The hemodynamic and blood gas variables were maintained during vibrocompression and increased manual expiratory flow maneuvers; however, there were increases in mean arterial pressure, intracranial pressure, heart rate, pulmonary arterial pressure and pulmonary capillary pressure during airway suctioning. All of the values returned to baseline 10 minutes after the end of airway suctioning. CONCLUSION Respiratory physiotherapy can be safely performed on patients with severe craniocerebral trauma. Additional caution must be taken when performing airway suctioning because this technique alters cerebral and cardiovascular hemodynamics, even in sedated and paralyzed patients.
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Aerosolized lidocaine during invasive mechanical ventilation: in vitro characterization and clinical efficiency to prevent systemic and cerebral hemodynamic changes induced by endotracheal suctioning in head-injured patients. J Neurosurg Anesthesiol 2013; 25:8-15. [PMID: 22990390 DOI: 10.1097/ana.0b013e31826a75b1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In patients with severe brain injury, endotracheal suctioning (ETS) can increase intracranial pressure (ICP) and reduce cerebral perfusion pressure (CPP). The aim of this prospective, blinded clinical trial was to assess the effectiveness of aerosolized lidocaine to prevent increase of ICP induced by ETS in mechanically ventilated head-injured patients. METHODS First, we measured the particle size of aerosolized lidocaine produced by a vibrating plate nebulizer. Second, we measured the cerebral hemodynamic response to tracheal suctioning in patients in a neurosurgical intensive care unit with and without pretreatment of aerosolized lidocaine. RESULTS Particle size distribution of aerosolized lidocaine was suitable to reach the bronchotracheal target during mechanical ventilation. In 15 patients included in this study, aerosolized lidocaine by itself did not induce significant changes in ICP. ETS caused an increase in ICP (variation: 6±2 mm Hg, P<0.05) with a concomitant decrease in CPP (variation: 2±2 mm Hg, P<0.05) that was maximal at 1 minute after NaCl aerosolization. This was prevented by aerosolization of lidocaine (variation of ICP: 1±1 mm Hg, and CPP: -1±1 mm Hg, P<0.05). CONCLUSIONS Aerosolized lidocaine (2 mg/kg) can prevent ETS-induced increases in ICP, without modifying systemic and cerebral hemodynamics in deeply sedated patients.
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Genzler L, Johnson PJ, Ghildayal N, Pangarakis S, Sendelbach S. End-tidal carbon dioxide as a measure of stress response to clustered nursing interventions in neurologic patients. Am J Crit Care 2013; 22:239-45. [PMID: 23635933 DOI: 10.4037/ajcc2013109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Guidelines recommend rest periods between nursing interventions for patients with a neurologic diagnosis but do not specify a safe number of interventions. OBJECTIVES To examine the physiological stress response to clustered nursing interventions in neurologic patients receiving mechanical ventilation. METHODS Prospective, comparative, descriptive design to examine effects of clustered interventions (≥6 interventions in a single nursing interaction) versus nonclustered interventions on patients' stress. Stress response was defined as a 10% change in end-tidal carbon dioxide from before the interaction to (1) 5 and 10 minutes after the start of the interaction, (2) at the end of the interaction, and (3) 15 minutes after the interaction. RESULTS The mean percent change in end-tidal carbon dioxide at 5 minutes differed significantly between patients with clustered interventions and patients with nonclustered interventions (6.7% vs -0.2%; P = .001). Patients with clustered interventions were significantly more likely than patients with low clustering to exhibit a stress response at 5 minutes (24.3% vs 0%; P = .01). CONCLUSIONS Neurologic patients receiving mechanical ventilation who experienced 6 or more clustered nursing interventions showed a higher mean change in end-tidal carbon dioxide than did patients who received fewer than 6 clustered interventions. These findings suggest that providing fewer interventions during 1 nursing interaction may minimize induced stress in neurologic patients receiving mechanical ventilation.
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Affiliation(s)
- Laura Genzler
- Laura Genzler is a staff nurse in a medical/surgical/neurologic intensive care unit and Sue Sendelbach is director of nursing research at Abbott Northwestern Hospital, Minneapolis, Minnesota. Pamela Jo Johnson is an adjunct assistant professor and Neha Ghildayal is a research assistant in the School of Public Health at the University of Minnesota, Minneapolis. Sarah Pangarakis is a critical care clinical nurse specialist at Methodist Hospital, Minneapolis, Minnesota
| | - Pamela Jo Johnson
- Laura Genzler is a staff nurse in a medical/surgical/neurologic intensive care unit and Sue Sendelbach is director of nursing research at Abbott Northwestern Hospital, Minneapolis, Minnesota. Pamela Jo Johnson is an adjunct assistant professor and Neha Ghildayal is a research assistant in the School of Public Health at the University of Minnesota, Minneapolis. Sarah Pangarakis is a critical care clinical nurse specialist at Methodist Hospital, Minneapolis, Minnesota
| | - Neha Ghildayal
- Laura Genzler is a staff nurse in a medical/surgical/neurologic intensive care unit and Sue Sendelbach is director of nursing research at Abbott Northwestern Hospital, Minneapolis, Minnesota. Pamela Jo Johnson is an adjunct assistant professor and Neha Ghildayal is a research assistant in the School of Public Health at the University of Minnesota, Minneapolis. Sarah Pangarakis is a critical care clinical nurse specialist at Methodist Hospital, Minneapolis, Minnesota
| | - Sarah Pangarakis
- Laura Genzler is a staff nurse in a medical/surgical/neurologic intensive care unit and Sue Sendelbach is director of nursing research at Abbott Northwestern Hospital, Minneapolis, Minnesota. Pamela Jo Johnson is an adjunct assistant professor and Neha Ghildayal is a research assistant in the School of Public Health at the University of Minnesota, Minneapolis. Sarah Pangarakis is a critical care clinical nurse specialist at Methodist Hospital, Minneapolis, Minnesota
| | - Sue Sendelbach
- Laura Genzler is a staff nurse in a medical/surgical/neurologic intensive care unit and Sue Sendelbach is director of nursing research at Abbott Northwestern Hospital, Minneapolis, Minnesota. Pamela Jo Johnson is an adjunct assistant professor and Neha Ghildayal is a research assistant in the School of Public Health at the University of Minnesota, Minneapolis. Sarah Pangarakis is a critical care clinical nurse specialist at Methodist Hospital, Minneapolis, Minnesota
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Lang SS, Kofke WA, Stiefel MF. Monitoring and intraoperative management of elevated intracranial pressure and decompressive craniectomy. Anesthesiol Clin 2012; 30:289-310. [PMID: 22901611 DOI: 10.1016/j.anclin.2012.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Elevated intracranial pressure can be caused by a variety of underlying conditions. Several physiologic and pharmacologic factors have a significant impact on intracranial hypertension, mostly caused by changes on cerebral blood volume, flow, and oxygenation. There are many therapies that can be used to decrease intracranial pressure ranging from pharmacologic to the surgical decompressive removal of the calvarium. Special consideration is made for the anesthetic management of these patients perioperatively.
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Affiliation(s)
- Shih-Shan Lang
- Department of Neurosurgery, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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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
Neuroscience intensive care unit nurses routinely perform oral care on patients with intracranial pressure (ICP) monitoring. When the ICP is elevated or rises in response to oral care, this intervention may be withheld despite the lack of evidence linking the two. To appraise the best evidence for providing oral care to patients with ICP monitoring, articles published in English from 1978 to 2009 and indexed in CINHAL, PubMed/MEDLINE, Cochran Library, and BioSys were searched using the key terms ICP monitoring, intracranial hypertension, oral care, mouth care, hygiene, nursing interventions, nursing care, intensive care, and critical care. Reference lists of retrieved articles were reviewed for articles missed during the initial search. The search yielded 65 articles: 16 experimental or quasi-experimental studies, 24 descriptive studies, and 25 review articles. Of these, only four specifically tested or described the effect of oral care on ICP. There is a need for more knowledge about the effect of oral care on ICP so that evidence-based oral care practices in this patient population can be defined.
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Abstract
BACKGROUND Epidural hematoma (EDH) is a major traumatic brain injury and a potentially life-threatening condition, with the mortality rate in the young age group varying across studies. The aim of this analysis was to investigate the magnitude of traumatic EDH in young patients aged 0 year to 24 years in Queensland, Australia. METHODS Study patients presented to the emergency department of 14 public hospitals participating in the Queensland Trauma Registry during 2005 to 2007 and were diagnosed and admitted for treatment of EDH. Age group comparisons were performed for demographic, injury, treatment, operation details, and outcome-related variables. RESULTS We identified 224 young patients with traumatic EDH. The most frequent cause of injury was a fall in the 0 year to 9 years age groups and road traffic crash in those aged 10 years to 24 years. Almost 81% of the EDH cases were due to accidental injury, 17% due to assault, with the remainder due to self-harm and undetermined intent. Skull fracture was present in 75% of the study patients. Neurosurgical operations were performed on 40%. The overall Injury Severity Score adjusted in-hospital mortality rate was 4.8%. The odds of in-hospital mortality was 2.5 (95% confidence interval, 0.8-8.2) compared with older patients (25-64 years). CONCLUSIONS The results indicate that the Injury Severity Score adjusted in-hospital mortality rates for young patients with EDH were 4.8%. Given the limited information on morbidity resulting from EDH, further analysis to examine modifiable factors for better management and to evaluate survivor's long-term health outcomes via a longitudinal follow-up study is warranted.
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Tume LN, Baines PB, Lisboa PJG. The effect of nursing interventions on the intracranial pressure in paediatric traumatic brain injury. Nurs Crit Care 2011; 16:77-84. [PMID: 21299760 DOI: 10.1111/j.1478-5153.2010.00412.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
AIMS AND OBJECTIVES The aim of this research was to investigate the effect of five selected intensive care nursing interventions on the intracranial pressure (ICP) of moderate to severe traumatic brain-injured children in intensive care. BACKGROUND The physiological effects of many nursing interventions in paediatric intensive care (PIC) are not known. This results in the lack of an evidence base for many PIC nursing practices. DESIGN Prospective observational cohort study conducted over 3 years in a single tertiary referral paediatric intensive care unit (PICU) in the North West of England. METHODS Five selected commonly performed nursing interventions were studied: endotracheal suctioning and manual ventilation (ETSMV), turning via a log-rolling (LR) approach, eye care, oral care and washing. These were studied in the first 72 h after injury. RESULTS A total of 25 children with moderate to severe traumatic brain injury and intraparenchymal ICP monitoring in intensive care (aged 2-17 years) were enrolled. Both ETSMV and LR were associated with clinically and statistically significant changes in ICP from baseline to maximal ICP (p = 0·001 ETSMV; p = < 0·001 LR) and from maximal post-ICP (p = < 0·001 ETSMV; p = < 0.001 LR). Eye care, oral care or washing did not cause any clinically significant change in ICP from baseline. After decompressive craniectomy, none of the interventions caused significant changes in ICP. CONCLUSIONS Only two of the five nursing interventions, endotracheal suctioning and LR, caused intracranial hypertension in moderate to severe traumatic brain-injured children, and after craniectomy, no care interventions caused any significant change in ICP. RELEVANCE TO CLINICAL PRACTICE Knowledge about the physiological effects of many intensive care nursing interventions is lacking and this is magnified in paediatrics. This study provides a significant addition to the evidence base in this area and allows intensive care nurses to plan, implement and evaluate more effectively their nursing care for brain-injured children.
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Affiliation(s)
- Lyvonne N Tume
- PICU, Alder Hey Children's NHS Foundation Trust/Liverpool John Moores University, Liverpool, UK.
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Cerqueira-Neto MLD, Moura AV, Scola RH, Aquim EE, Rea-Neto A, Oliveira MC, Cerqueira TCF. The effect of breath physiotherapeutic maneuvers on cerebral hemodynamics: a clinical trial. ARQUIVOS DE NEURO-PSIQUIATRIA 2011; 68:567-72. [PMID: 20730311 DOI: 10.1590/s0004-282x2010000400017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2009] [Accepted: 02/17/2010] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To observe the repercussion of respiratory physiotherapy techniques on the mean arterial pressure (MBP), intracranial pressure (ICP), cerebral perfusion pressure (CPP), jugular venous oxygen pressure (PjvO2) and jugular venous oxygen saturation (SjvO2). METHOD The sample consisted of 20 patients with head trauma. The protocol consisted of physiotherapy techniques application of vibrocompression (VBC), expiratory flow increase (EFI) and suction. RESULTS The results show the maintenance on variables of cerebral hemodynamics during the techniques of VBC and EFI. However, in relation to suction, there was an increase of MBP, ICP, with maintenance of CPP, PjvO2 and SjvO2 and return to baseline of MBP and ICP 10 minutes after the end of suction. CONCLUSION The respiratory physiotherapy techniques (VBC, EFI) do not promote cerebral hemodynamic repercussion, unlike suction, in severe head injury patients, mechanically ventilated, sedated and paralyzed.
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Heluain P, Demailly A, Fourrier L, Soury-Lavergne A, Robriquet L. Les aspirations endotrachéales chez le patient intubé et ventilé. MEDECINE INTENSIVE REANIMATION 2011. [DOI: 10.1007/s13546-010-0142-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Allen F, Riopelle J, Sinha A. Case report: intracranial placement of a nasotracheal tube in a patient with Goldenhar syndrome associated with cribriform plate agenesis. Anesth Analg 2010; 112:198-200. [PMID: 20966441 DOI: 10.1213/ane.0b013e3181fca689] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We describe a case of inadvertent intracranial placement of a nasotracheal tube in a patient with an undiagnosed major congenital cranial anomaly (a variant of Goldenhar syndrome, which included absence of the cribriform plate). We believe that this is the first reported case in which this complication arose as a result of a congenital abnormality rather than traumatic or iatrogenic disruption of the skull base. We conclude that patients with known craniofacial abnormalities or associated syndromes scheduled for procedures involving planned nasotracheal intubation or nasogastric tube placement should undergo preoperative cranial imaging studies to verify an intact skull base.
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Affiliation(s)
- Frederick Allen
- Department of Anesthesiology, Hospital of University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104, 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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Skoglund K, Enblad P, Marklund N. Effects of the neurological wake-up test on intracranial pressure and cerebral perfusion pressure in brain-injured patients. Neurocrit Care 2009; 11:135-42. [PMID: 19644774 DOI: 10.1007/s12028-009-9255-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2009] [Accepted: 07/21/2009] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the effects of the neurological "wake-up test" (NWT), defined as interruption of continuous propofol sedation and evaluation of the patient's level of consciousness, on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in patients with severe subarachnoid hemorrhage (SAH) or traumatic brain injury (TBI). METHODS A total of 127 NWT procedures in 21 severely brain-injured adult patients with either TBI (n = 12) or SAH (n = 9) were evaluated. ICP and CPP levels prior to, during and after the NWT procedure were recorded. RESULTS During the NWT, ICP increased from 13.4 +/- 6 mmHg at baseline to 22.7 +/- 12 (P < 0.05) and the CPP increased from 75.6 +/- 11 to 79.1 +/- 21 mmHg (P < 0.05) in TBI patients. Eight patients showed a reduced CPP during the NWT due to increased ICP. In SAH patients, ICP increased from 10.6 +/- 5 to 16.8 +/- 8 mmHg (P < 0.05) and the CPP increased from 76.9 +/- 13 to 84.6 +/- 15 mmHg (P < 0.05). CONCLUSION When continuous propofol sedation was interrupted and NWT was performed in severely brain-injured patients, the mean ICP and CPP levels were modestly increased. A subset of patients showed more pronounced changes. To date, the role of the NWT in the neurointensive care of TBI and SAH patients is unclear. Although the NWT is safe in the majority of patients and may provide useful clinical information about the patient's level of consciousness, alternate monitoring methods are suggested in patients showing marked ICP and/or CPP changes during NWT.
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Affiliation(s)
- Karin Skoglund
- Department of Neuroscience, Neurosurgery, Uppsala University Hospital, 751 85 Uppsala, Sweden
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Routine nursing procedures--take care of the patient and the splanchnic circulation! Crit Care Med 2009; 37:751-2. [PMID: 19325369 DOI: 10.1097/ccm.0b013e318194d157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gholamzadeh S, Javadi M. Effect of endotracheal suctioning on intracranial pressure in severe head-injured patients. Crit Care 2009. [PMCID: PMC4083966 DOI: 10.1186/cc7244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Tume L, Jinks A. Endotracheal suctioning in children with severe traumatic brain injury: a literature review. Nurs Crit Care 2008; 13:232-40. [DOI: 10.1111/j.1478-5153.2008.00285.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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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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Using the Synergy Model as best practice in endotracheal tube suctioning of critically ill patients. Dimens Crit Care Nurs 2008; 27:10-5. [PMID: 18091626 DOI: 10.1097/01.dcc.0000304666.97336.46] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Endotracheal suctioning with normal saline is a common practice in intensive care units. This unit reviews research concerning this practice as well as the adverse effects of saline instillation. In addition, the role of the critical care nurse as it pertains to the synergy model when caring for these patients is highlighted.
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Kofke WA, Stiefel M. Monitoring and intraoperative management of elevated intracranial pressure and decompressive craniectomy. Anesthesiol Clin 2008; 25:579-603, x. [PMID: 17884709 DOI: 10.1016/j.anclin.2007.05.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There are numerous clinical scenarios wherein a critically ill patient may present with neurologic dysfunction. In a general sense these scenarios often involve ischemia, trauma, or neuroexcitation. Each of these may include a period of decreased cerebral perfusion pressure, usually due to elevated intracranial pressure (ICP), eventually compromising cerebral blood flow sufficiently to produce permanent neuronal loss, infarction, and possibly brain death. Elevated ICP is thus a common pathway for neural demise and it may arise from a variety of causes, many of which may result in a neurosurgical procedure intended to ameliorate the impact or etiology of elevated ICP.
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Affiliation(s)
- W Andrew Kofke
- Department of Anesthesia and Critical Care, University of Pennsylvania, 3400 Spruce St., Dulles 7, Philadelphia, PA 19104, USA.
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Endotracheal Lidocaine in Preventing Endotracheal Suctioning-induced Changes in Cerebral Hemodynamics in Patients with Severe Head Trauma. Neurocrit Care 2007; 8:241-6. [DOI: 10.1007/s12028-007-9012-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Tonner PH, Weiler N, Paris A, Scholz J. Sedation and analgesia in the intensive care unit. Curr Opin Anaesthesiol 2007; 16:113-21. [PMID: 17021449 DOI: 10.1097/00001503-200304000-00003] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Sedation and analgesia are important means of providing care for the critically ill patient. RECENT FINDINGS It is now clear that posttraumatic stress disorders resulting from an intensive care unit stay may be prevented by the right level of sedation. New drug developments but also recent findings in new ventilation strategies allow for a sedation management that is better tailored to an individual's need. Most importantly, regular definition of the appropriate level of sedation and analgesia as well as monitoring of the desired level will help to avoid over- and undersedation and may ultimately improve the outcome of the patient and reduce costs. SUMMARY Sedation and analgesia are now regarded as an integral part of treatment on the intensive care unit instead of being an unpleasant but necessary and minor issue. The importance of monitoring the level of sedation and analgesia has only recently been realized. It remains to be shown that new management strategies including an evaluation of the patient, planned interventions and the choice of drugs will further improve the care for the critically ill.
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Affiliation(s)
- Peter H Tonner
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Kiel, Kiel, Germany.
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Abstract
PURPOSE OF REVIEW Major complications after intracranial surgery occur in 13-27% of patients. These complications may have multiple causes, but a body of arguments suggests that the haemodynamic and metabolic changes of anaesthesia recovery may be responsible for intracranial complications. The aim of this review is to explain the rationale of this hypothesis and analyse the recent studies relevant to neuroanaesthesia recovery. RECENT FINDINGS Rapid recovery and extubation after intracranial tumour surgery is desirable in order to make an early diagnosis of intracranial complications. Since light pharmacological sedation may worsen a neurological deficit, short-acting anaesthetics are preferable intraoperatively. Extubation in the operating room, however, may be associated with agitation, increased oxygen consumption, catecholamine secretion, hypercapnia and systemic hypertension. This may exacerbate cerebral hyperaemia observed even during an uneventful recovery, leading to cerebral oedema or haemorrhage. SUMMARY Pain, hypothermia, hypercapnia, hypoxia, hypoosmolality, hypertension, and anaemia should be avoided during emergence. Early emergence is associated with minimal haemodynamic and metabolic changes. If there is any doubt as to whether the patient should be extubated in the operating room, a gradual emergence in the intensive care unit makes it possible to decide whether or not extubation can be performed safely.
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Affiliation(s)
- Nicolas J Bruder
- Department of Anaesthesiology and Intensive Care, La Timone University Hospital, Marseille, France.
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Fryman L, Murray L. Managing Acute Head Trauma in a Crowded Emergency Department. J Emerg Nurs 2007; 33:208-13. [PMID: 17517265 DOI: 10.1016/j.jen.2006.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Lisa Fryman
- University of Kentuky Medical Center, University of Knetucky, Lexington, KY 40536-0293, USA.
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Bernard SA. Paramedic intubation of patients with severe head injury: a review of current Australian practice and recommendations for change. Emerg Med Australas 2006; 18:221-8. [PMID: 16712531 DOI: 10.1111/j.1742-6723.2006.00850.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Secondary brain injury may occur early after severe traumatic brain injury due to hypoxia and/or hypotension. Prehospital care by ambulance paramedics has the goal of preventing and treating these complications and, thus, improving outcomes. In Australia, most ambulance services recommend paramedics attempt endotracheal intubation in patients with severe head injury. Even though most patients with severe head injury retain airway reflexes, most states do not allow the use of appropriate drugs to facilitate intubation. In contrast, recent evidence from trauma registries suggests that this approach may be associated with significantly worse outcomes compared with no intubation. Two states allow intubation facilitated by sedative (but not relaxant) drugs, but this has a low success rate and could worsen brain injury because of a decrease in cerebral perfusion pressure. For road-based paramedics, the role of rapid sequence intubation is uncertain. Given the risks of this procedure and the lack of proven benefit, this procedure should not be introduced without supportive evidence from randomised, controlled trials. In contrast, for safety reasons, comatose patients transported by helicopter should undergo rapid sequence intubation prior to flight. However, this is not authorised in most states, despite good supportive evidence that this can be safely and effectively undertaken by paramedics. Finally, there is evidence that inadvertent hyperventilation is associated with adverse outcome, yet only two ambulance services use waveform capnography in head injury patients who are intubated. Overall, current paramedic airway practice in most states of Australia is not supported by the evidence and is probably associated with worse patient outcomes after severe head injury. For road-based paramedics, rapid transport to hospital without intubation should be regarded as the current standard of care. Rapid sequence intubation should be limited to use within appropriate clinical trials, or patients transported by helicopter. For patients who are intubated, waveform capnography is essential to confirm tracheal placement and to prevent inadvertent hyperventilation.
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Affiliation(s)
- Stephen A Bernard
- Metropolitan Ambulance Service, and Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
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Chivite Fernández N, Martínez Oroz A, Marraco Bonmcompte M, Navarro García MA, Nuin ES, Gómez de Segura Nieva JL, Bermejo Fraile B. [Intracranial pressure response during secretion aspiration after administration of a muscle relaxant]. ENFERMERIA INTENSIVA 2005; 16:143-52. [PMID: 16324542 DOI: 10.1016/s1130-2399(05)73401-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED Aspiration of secretions is a usual nursing technique in patients undergoing mechanical ventilation that may be the cause of increased Intracranial Pressure (ICP). OBJECTIVE This study aims to evaluate the repercussion of a muscle relaxant on ICP with secretion aspiration. METHOD Clinical trial using the same patient as case and control, performing two endotracheal aspirations in each patients, on of them after administration of a muscle relaxant (Cis-Atracurium) and another no. The bolus administration of the relaxant in the first or second aspiration was done randomly. Thirteen patients with intraparenchymatous ICP measurement catheter were studied within the first 36 hours post-placement and with sedoanalgesia for a score of 6 on the Ramsay scale. ICP and CPP were measured before, during and after each aspiration. STATISTICAL METHOD SPSS 11.0 program was used. Data analysis by Student's t test for paired data. Statistical significance level accepted was 95%. RESULTS On comparing the cases in which muscle relaxant was administered with those in which it was not administered, statistically significant differences were found in the ICP and CCP values during secretion aspiration. CONCLUSIONS According to the data obtained in the study, a lower increase of ICP was observed during secretion aspiration in those cases in which muscle relaxant was administered prior to the aspiration.
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Leone M, Albanèse J, Viviand X, Garnier F, Bourgoin A, Barrau K, Martin C. The Effects of Remifentanil on Endotracheal Suctioning-Induced Increases in Intracranial Pressure in Head-Injured Patients. Anesth Analg 2004; 99:1193-1198. [PMID: 15385374 DOI: 10.1213/01.ane.0000132546.79769.91] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In patients with severe traumatic brain injury, bronchotracheal toilet may be accompanied by deleterious variations in intracranial pressure (ICP). To avoid these effects, IV opioids have been proposed. Twenty mechanically-ventilated patients received 3 ascending IV doses of remifentanil: dose 1 (1 microg/kg bolus, 0.25 microg/kg/min infusion); dose 2 (2 microg/kg bolus, 0.5 microg/kg/min infusion); and dose 3: (4 microg/kg bolus, 1 microg/kg/min infusion). Endotracheal suction was performed 20 min after the beginning of infusion to assess coughing. Heart rate, ICP, mean arterial blood pressure (MAP), cerebral perfusion pressure (CPP), middle cerebral artery mean flow velocity (V(MCA)), and bispectral index were monitored throughout the 30-min study period. Twelve, 15, and 19 patients receiving dose 1, 2, and 3, respectively, required vasopressors to maintain CPP >60 mm Hg. Suctioning resulted in coughing in 16, 15, and 5 patients receiving dose 1, 2, and 3, respectively. An increase in ICP, without change in V(MCA), corresponded to the reduction in MAP consistent with the preservation of autoregulation. Remifentanil used as a continuous infusion in head-injured patients is not an effective drug to block responses to suctioning.
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Affiliation(s)
- Marc Leone
- *Intensive Care Unit and Department of Anesthesiology and the †Department of Biostatistics and Epidemiology, Nord Hospital, Marseilles University Hospital System (AP-HM), Marseilles School of Medicine, Marseilles, France
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Bruder N, Ravussin P. Modifications hémodynamiques cérébrales et systémiques au moment du réveil en neurochirurgie. ACTA ACUST UNITED AC 2004; 23:410-6. [PMID: 15120789 DOI: 10.1016/j.annfar.2004.01.013] [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: 10/26/2022]
Abstract
Major complications after intracranial surgery occur in 13-27% of patients. Among multiple causes, haemodynamic and metabolic changes of anaesthesia recovery may be responsible for intracranial complications. Recovery from neurosurgical anaesthesia is followed by an increase in body oxygen consumption and catecholamines concentrations. However, in normothermic patients, theses changes are usually mild and not prevented by a 2-h recovery delay. Systemic hypertension is common after neurosurgery and a link between perioperative hypertension and intracranial haemorrhage has been established. The cerebral consequences of recovery associate cerebral hyperaemia and increased ICP in patients with a tight brain at the end of surgery. Cerebral hyperaemia may promote or exacerbate cerebral haemorrhage or oedema. This has been demonstrated in patients operated for subdural haematoma removal or undergoing carotid surgery. Prevention of hypothermia and pain are key factors to prevent metabolic changes. Beta-blockers seem to be suitable agents to obtain haemodynamic control in neurosurgical patients.
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Affiliation(s)
- N Bruder
- Département d'anesthésie-réanimation, CHU de la Timone, 13385 Marseille, France.
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Engelhard K, Reeker W, Kochs E, Werner C. Effect of remifentanil on intracranial pressure and cerebral blood flow velocity in patients with head trauma. Acta Anaesthesiol Scand 2004; 48:396-9. [PMID: 15025597 DOI: 10.1111/j.0001-5172.2004.00348.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Remifentanil, an ultra-short-acting opioid, is used as an on-top analgesic in head trauma patients during transient painful procedures, e.g. endotracheal suctioning, physiotherapy, on the intensive care unit. However, previous studies have shown that opioids may increase intracranial pressure and decrease cerebral blood flow. METHODS The present study investigates the effect of remifentanil on mean arterial blood pressure, intracranial pressure measured with intraparenchymal or epidural probes, and on cerebral blood flow velocity assessed by transcranial Doppler flowmetry in 20 head trauma patients sedated with propofol and sufentanil. Ventilation was adjusted for a target PaCO2 of 4.7-5.1 kPa. After baseline measurements a bolus of remifentanil (0.5 microg x kg(-1) i.v.) was administrated followed by a continuous infusion of remifentanil (0.25 microg x kg(-1) x min(-1) i.v.) for 20 min. RESULTS There was no change in mean arterial blood pressure, intracranial pressure, and cerebral blood flow velocity in response to remifentanil infusion over time. Statistical analysis was performed using the Wilcoxon Signed Rank test. CONCLUSIONS These data suggest that remifentanil can be used for on-top analgesia in head trauma patients without adverse effects on cerebrovascular haemodynamics, cerebral perfusion pressure or intracranial pressure.
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Affiliation(s)
- K Engelhard
- Klinik für Anaesthesiologie der Technischen Universität München, Klinikum rechts der Isar, Munich, Germany.
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Paul M, Dueck M, Kampe S, Petzke F, Ladra A. Intracranial placement of a nasotracheal tube after transnasal trans-sphenoidal surgery. Br J Anaesth 2003; 91:601-4. [PMID: 14504169 DOI: 10.1093/bja/aeg203] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Intracranial misplacement of a tracheal tube during attempted nasotracheal intubation is a rare, usually lethal complication. Such incidents are associated with fractures of the face and base of the skull. We report inadvertent intracranial placement of a nasotracheal tube in a patient who had 2 weeks previously undergone transnasal trans-sphenoidal surgery for a pituitary tumour. One should be aware that transnasal trans-sphenoidal surgery leaves a bony defect in the skull, which is susceptible to perforation by nasally introduced tubes.
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Affiliation(s)
- M Paul
- Department of Anaesthesiology, University of Cologne, Joseph-Stelzmann-Str 9, D-50931 Cologne, Germany.
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Abstract
PURPOSE OF REVIEW To evaluate the rationale and the pharmacologic options for sedating neurointensive care patients. RECENT FINDINGS Sedation is a fundamental element in the neurointensive care unit. Even if the sedative strategy in the neurointensive care unit shares the same general aims with intensive care, the characteristics of the patients in the neurointensive care unit pose other unique challenges and some specific indications. The primary aim of neurointensive care is to maintain adequate cerebral perfusion pressure, to control intracranial pressure, and to maintain an adequate mean arterial pressure. Reducing the brain's metabolic demand is an important treatment strategy, and analgesic and sedative agents are used to prevent undesirable increases in intracranial pressure. There are many different pharmacologic agents available, each with distinct advantages and disadvantages. SUMMARY The pharmacokinetic and pharmacologic effects of the available sedatives used in neurointensive care patients are reviewed.
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Affiliation(s)
- Giuseppe Citerio
- Dipartimento di Anestesia e Rianimazone, Nuovo Ospedale San Gerardo, Monza, Italy.
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Bruder N. [Anaesthesia for patients with intracranial hypertension due to cerebral oedema]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2003; 22:226-34. [PMID: 12747991 DOI: 10.1016/s0750-7658(03)00011-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The main objective for anaesthesia in patients with intracranial hypertension (ICH) is to maintain the cerebral perfusion pressure (CPP). Before the operation, the assessment of the level of intracranial pressure relies on the Glasgow coma score and the signs of ICH on the CT-scan. In the perioperative period, repeated transcranial Doppler examinations may help in determining the adequate CPP. Haemodynamic and respiratory complications are common after subarachnoid haemorrhage or head injury. Careful preoperative screening of the cardiovascular and respiratory system is mandatory before anaesthesia. There is no recommended anaesthetic technique for patients with ICH. Nitrous oxide should be avoided in patients with severe ICH or during emergency surgery. Theoretically, intravenous anaesthesia is a better choice than inhalation anesthesia because of the cerebral vasodilatation induced by inhalation agents. In the most severe cases thiopental is the only anaesthetic agent to consider. Treatment of hypovolaemia with fluid loading and the early use of vasoactive agents can be recommended to maintain CPP. Before intracranial surgery, large doses of mannitol have been demonstrated to improve neurological recovery in brain injured patients. The urinary losses due to the infusion of mannitol should be replaced with isotonic saline. Emergence and extubation are best performed in the intensive care unit under close systemic and cerebral haemodynamic control.
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Affiliation(s)
- N Bruder
- Département d'anesthésie-réanimation, centre hospitalier universitaire Timone, 13385 Marseille, France.
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