Cerebrovascular response of closed head-injured patients to a standardized endotracheal tube suctioning and manual hyperventilation procedure

Does Tracheal Lidocaine Instillation Reduce Intracranial Pressure Changes After Tracheal Suctioning in Severe Head Trauma? A Prospective, Randomized Crossover Study

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.

Effects of Closed Endotracheal Suctioning on Systemic and Cerebral Oxygenation and Hemodynamics in Children

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.

The effect of oral care on intracranial pressure in critically ill adults

A major goal in the care of patients with neurological problems is to prevent or minimize episodes of increased intracranial pressure (ICP). Elevations in ICP in response to nursing interventions have been acknowledged since the 1960s when ICP monitoring was first introduced in the clinical setting. Until recently, few studies have specifically examined the effect of oral care on ICP, and oral care and other hygiene measures were combined or not specified, prohibiting a direct interpretation of the influence of oral care alone on ICP. The purpose of this study was to describe the relationship between routine oral care interventions and the changes in ICP specifically focusing on the effect of intensity and duration of this intervention. Twenty-three patients with a clinical condition requiring ICP monitoring were enrolled over a 12-month period. Oral care provided by neuroscience intensive care nurses was observed and videotaped. Characteristics of the intervention were documented including products used, patient positioning, and duration of the intervention. A 1-5 subjective scale was used to score intensity of oral care. Wrist actigraphy data were collected from the nurses to provide an objective measure of intensity. Patient physiologic data were collected at 12-second epochs 5 minutes before, during, and 5 minutes after oral care. The mixed-effect repeated measures analysis of variance model indicated that there was a statistically significant increase in ICP in response to oral care (p = .0031). There was, however, no clinically significant effect on ICP. This study provides evidence that oral care is safe to perform in patients in the absence of preexisting elevated ICP.

The effect of oral care on intracranial pressure: a review of the literature

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.

The effect of nursing interventions on the intracranial pressure in paediatric traumatic brain injury

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.

Judgments of critical care nurses about risk for secondary brain injury

BACKGROUND

Interdisciplinary care for patients with traumatic brain injury focuses on treating the primary brain injury and limiting further brain damage from secondary injury. Intensive care unit nurses have an integral role in preventing secondary brain injury; however, little is known about factors that influence nurses' judgments about risk for secondary brain injury.

OBJECTIVE

To investigate which physiological and situational variables influence judgments of intensive care unit nurses about patients' risk for secondary brain injury, management solely with nursing interventions, and management by consulting another member of the health care team.

METHODS

A multiple segment factorial survey design was used. Vignettes reflecting the complexity of real-life scenarios were randomly generated by using different values of each independent variable. Surveys containing the vignettes were sent to nurses at 2 level I trauma centers. Multiple regression was used to determine which variables influenced judgments about secondary brain injury.

RESULTS

Judgments about risk for secondary brain injury were influenced by a patient's oxygen saturation, intracranial pressure, cerebral perfusion pressure, mechanism of injury, and primary diagnosis, as well as by nursing shift. Judgments about interventions were influenced by a patient's oxygen saturation, intracranial pressure, and cerebral perfusion pressure and by nursing shift. The initial judgments made by nurses were the most significant variable predictive of follow-up judgments.

CONCLUSIONS

Nurses need standardized, evidence-based content for management of secondary brain injury in critically ill patients with traumatic brain injury.

A prospective, randomized study of ventilator-associated pneumonia in patients using a closed vs. open suction system

The objective of this study was to verify the incidence of nosocomial pneumonia in intubated and extended mechanically ventilated patients having endotracheal suctioning by an open vs. closed suction method aiming to decrease nosocomial pneumonia. Twenty-four (51.1%) patients received open-tracheal suction and 23 (48.9%) received closed-tracheal suction. The inclusion criteria were: surgical and medical patients older than 13 years, undergoing mechanical ventilation for more than 48 hours. Additional data were gathered using the Acute Physiology and Chronic Health Evaluation II, and details on smoking, alcoholism, diabetes mellitus, renal failure, previous lung disease, and previous use of antibiotics, steroids, H2 antagonists and antacids. Among the 24 patients having open-tracheal suction, 11 developed nosocomial pneumonia while of the 23 patients undergoing closed-tracheal suction, seven developed infection (P = 0.278). Risk factors for nosocomial pneumonia were not significantly different between the two groups. In the final logistical regression model the following variables remained: groups (open and closed) [odds ratio (OR) = 0.014; confidence interval (CI) = 0.001-0.416; P = 0.014] and use of prior antibiotics (OR = 2.297; CI = 1.244-4.242; P = 0.008). Use of a closed suction system did not decrease the incidence of nosocomial pneumonia when compared with the open system. The exogenous risk factors were the most important for acquiring this infection.

[Endotrachael aspiration protocol in patients with serious cranial trauma. study of neurophysiological variables]

Aspiration of tracheobronchial secretions can cause noxious effects on neurophysiological variables. Different studies that refer to aspiration of secretions in Serious Cranial Trauma use hyperinsuflation and hyperoxygenation to minimize its repercussion on Intracranial Pressure and thus try to not contribute to the secondary lesion. After reviewing these studies, a protocol of tracheobronchial secretion aspiration was performed in our ICU in patients with serious cranial trauma subjected to mechanical ventilation in order to assess the effect of the aspiration of secretions in the neurophysiological variables following homogeneous and standardized guidelines. Neurological, hemodynamic, oxygenation and ventilation variables were analyzed before, during and after aspiration of secretions. When the results were compared before and during this, we observed a decrease in the Intracranial Pressure with increase of Cerebral Perfusion Pressure (due to increase of Mean Blood Pressure), maintaining the levels of PaCO2 and jugular saturation of O2, with an increase in the airway pressures. After finishing the aspiration process, all the affected values recovered. It is concluded that the aspiration of tracheobronchial secretions in patients with Severe Cranial Trauma, after standardized hyperinsuflation and hyperoxygenation, does not alter the hydrodynamics or brain use of O2.

Manual hyperinflation: consistency and modification of the technique by physiotherapists

BACKGROUND AND PURPOSE

The present study aimed to evaluate the consistency with which physiotherapists apply manual hyperinflation to a test lung using the Air-Viva-2 or Mapleson-B resuscitation circuit, and their ability to modify the technique as pulmonary characteristics change.

METHOD

A quasi-experimental, randomized, repeated-measures design was used to study 16 volunteer physiotherapists performing manual hyperinflation to a test lung simulating three clinical situations. Each subject applied manual hyperinflation to the test lung for each simulation three times in one day using the resuscitation circuit that they would normally use in their clinical practice. Eight subjects used the Air-Viva-2 circuit and eight used the Mapleson-B circuit. Measurements of tidal volume (Vp), peak airway pressure (Paw) and fraction of delivered oxygen (FDO2) were recorded during each testing period. Inflation rate and minute volume were calculated.

RESULTS

As compliance decreased and airway resistance increased, VT decreased and Paw increased. Of the eight subjects using the Air-Viva-2 circuit, only three subjects delivered greater than 0.80 FDO2. All subjects using the Mapleson-B circuit delivered greater than 0.85 FDO2.

CONCLUSIONS

Subjects demonstrated good consistency in the application of manual hyperinflation for all three simulations and modified their technique appropriately as simulated pulmonary characteristics changed.

[Incidence of ventilator-associated pneumonia in patients using open-suction systems and closed-suction systems: a prospective study -- preliminary data]

This a randomized clinical trial in which 20 patients were prospectively evaluated for the incidence of ventilator-associated pneumonia (VAP), of whom 12 received endotracheal suctioning by an open-suction method and 8 by a closed-suction method. Differences in the incidence of VAP was not significantly different (p = 0.4) between closed and open suctioning. Differences in Acute Physiology and Chronic Health Evaluation II, duration of entubation, and the use of steroids were all not significant. All patients in the study used H2 antagonist and a nasogastric tube. Proceeding with the study will involve a sample increase with a possible change in the results.

Management of raised intracranial pressure in children

Children suffer a significant number of head injuries as a result of their high activity levels, immature developmental skills and increased head-to-body mass ratio. Primary brain injury is irreversible, but secondary insults can be limited. Central to this is the management of raised intracranial pressure (ICP). The pathophysiology of head injury can explain some of the causes of raised ICP. Monitoring of ICP is important and this is closely linked to the maintenance of an adequate cerebral perfusion pressure and the importance of normovolaemia. Other interventions that have been shown to limit rises in ICP are appropriate use of positioning, mechanical ventilation and drug therapy. Less common therapies include jugular venous bulb oxygen saturation monitoring and the use of trometamol (THAM). Most nursing interventions do not actively reduce ICP, but they are central to its management. Reducing stimuli, avoiding cluster care, manual hyperinflation and limiting routine endotracheal suction may prevent an accumulative rise in ICP. Based on this literature review, it is possible to divide these interventions into first and second tier treatments, as shown in the protocol. Much of the suggested management will occur simultaneously, but it is important to assess the child's own response to each intervention and thus tailor treatment to minimize secondary brain injury.

The standard of suction for patients undergoing endotracheal intubation

The purpose of this study was to determine whether using a standard method of endotracheal suctioning, to ensure consistent use of available knowledge, had any impact on patient care. Using experimental study design, the results of two different methods of suctioning in a cardiovascular surgery intensive care unit were compared. One method was the suctioning procedure applied by the nurses working in the intensive care unit. The other one, standard suctioning procedure, was developed based on the related literature and applied to the patients assigned to the experimental group by the researcher herself. Mean arterial blood pressure (MAP), heart rate (HR), and arterial blood gases (ABGs) were measured before the procedure, immediately after, 5 and 15 minutes after the procedures for both control and experimental group. The majority of the nurses suctioning the control group did not evaluate the ABGs after endotracheal suctioning, none of these patients was given oxygen both before and after the suctioning, and suctioning took longer time than recommended. To compare the results of the two different methods, the values of MAP, HR, PO2 (arterial oxygenation), PCO2 (arterial carbondioxide), and HCO3- (hydrogen carbonate) 15 minutes after the procedure were used, and the differences between the two methods were statistically significant (P < 0.05).

Safety and feasibility of continuous infusion of remifentanil in the neurosurgical intensive care unit

OBJECTIVE

Remifentanil is a selective mu-opioid agonist with a context-sensitive half-time of 3 to 5 minutes, independent of dose or administration duration. Other desirable effects include decreased cerebral metabolism and intracranial pressure (ICP) with minimal cerebral perfusion pressure changes. We present six cases illustrating indications for the use of remifentanil in the neurosurgical intensive care unit.

METHODS

Patients received bolus doses of remifentanil of 0.05 to 1.0 microg/kg, followed by continuous infusions of 0.03 to 0.26 microg/kg/min, titrated to effect. When infusions were discontinued for neurological examinations, another bolus dose preceded infusion reinstitution. Indications for the use of remifentanil included mean arterial pressure and cerebral perfusion pressure decreases with the use of other agents (e.g., codeine or propofol) for ICP control, elevated ICP that was refractory to propofol/mannitol treatment, agitation that was unresponsive to standard therapies, and coughing that caused ICP increases after subarachnoid hemorrhage.

RESULTS

Three patients experienced spontaneous intracranial bleeding (two cases of subarachnoid hemorrhage and one case of intraventricular hemorrhage), and three patients exhibited severe traumatic subdural hemorrhage. All patients recovered from the effects of remifentanil within 3 minutes after discontinuation of infusion, which allowed frequent rapid neurological assessments. Procedures for pulmonary toilet (i.e., endotracheal suctioning, postural drainage, and bronchoscopy) were performed without deleterious ICP increases or mean arterial pressure or cerebral perfusion pressure decreases during remifentanil infusions.

CONCLUSION

The ultrashort duration of action of remifentanil allowed easy performance of frequent neurological examinations in the neurosurgical intensive care unit. No patient experienced deleterious hemodynamic or neurological effects as a result of remifentanil use.

Patient management in head injury care: a nursing perspective

Through a review of the literature, this article provides a consideration of nursing responsibilities and nursing care in the management of patients with head injuries. A brief review of the pathophysiology of head injury is followed by a description of intracranial pressure (ICP) monitoring and cerebral perfusion pressure (CPP) measurement, using the Camino fibreoptic catheter and monitor, with exploration of pulse and trend waveforms and their significance in assessing cerebral compliance. Jugular venous bulb saturation (SjO2) monitoring adds another dimension to the assessment of neurological damage by demonstrating cerebral tissue perfusion and cerebral metabolic rate, and this is also discussed. After identification of assessment as a crucial part of the nursing role, aspects of nursing care of head-injured patients are discussed. The discussion of respiratory support measures includes the controversial use of hyperventilation in reducing ICP, the prevention of hypoxia, the risk of respiratory complications, the use of suctioning and turning to prevent these and the problems associated with these nursing care measures. Other aspects of care are also considered, including careful positioning and temperature control, and the benefits of mild hypothermia.

Effect of short-duration hyperventilation during endotracheal suctioning on intracranial pressure in severe head-injured adults

A repeated measures randomized within-group design was used to determine the effectiveness of controlled short-duration hyperventilation (HV) in blunting the increase of intracranial pressure (ICP) during endotracheal suctioning (ETS). A multimodal continuous real-time computerized data acquisition procedure was used to compare the effects of two HV ETS protocols on ICP, arterial pressure, cerebral perfusion pressure (CPP), heart rate, and arterial oxygen saturation in severe head-injured adult patients. The results indicated that short-duration HV for 1 minute, which decreases the PaCO2, reduced ETS-induced elevations in ICP while maintaining CPP. However, it is not clear whether short-duration HV is neuroprotective, particularly in ischemic regions of the brain. Therefore, before a change in practice is implemented on the use of short-duration HV as a prophylactic treatment against ETS-induced elevations in ICP, additional questions on cerebral oxygen delivery and uptake need to be answered.

Endotracheal suctioning in adults with severe head injury: literature review

Endotracheal suctioning is a routine but potentially dangerous nursing procedure. The research literature documenting approaches to minimising the complications of endotracheal suctioning in adults with severe head injuries is reviewed. Hyperoxygenation, hyperventilation, hyperinflation, normal saline instillation and the effects of endotracheal suctioning on intracranial pressure and cerebral perfusion pressure are examined. Recommendations for an evidence-based endotracheal suctioning protocol are made.

The effect of suction catheter insertion and tracheal stimulation in adults with severe brain injury

OBJECTIVE

To determine the effect of suction catheter insertion and tracheal stimulation on cerebrovascular and systemic vascular status in adults with severe traumatic brain injury.

DESIGN

Quasi-experimental, within-subject design.

SETTING

Two university-affiliated critical care units.

SUBJECTS

Thirty intubated and mechanically ventilated adults with severe brain injury. The participants' average age was 31 +/- 15 years.

OUTCOME MEASURES

Mean intracranial pressure (MICP), mean arterial pressure (MAP), cerebral perfusion pressure (CPP), and heart rate (HR) were measured.

INTERVENTION

Endotracheal suction catheter insertion with tracheal stimulation was performed.

RESULTS

Suction catheter insertion and tracheal stimulation, isolated from other components of the suctioning procedure, significantly increased MICP, MAP, and CPP. HR was not significantly increased. During the application of negative pressure for actual suctioning, MICP and HR significantly increased, whereas MAP and CPP did not significantly change compared with catheter insertion.

CONCLUSION

Tracheal stimulation during suction catheter insertion initiates both cerebrovascular and systemic vascular responses during the suctioning procedure. Study findings suggest that a potentially productive direction for intervention research is to identify ways to minimize airway stimulation during the suctioning procedure.

A national survey of endotracheal suctioning techniques in the pediatric population

OBJECTIVE

To examine the current suctioning practices nationally of experienced pediatric intensive care unit (PICU) nurses.

DESIGN

A written survey method was used for this descriptive study.

POPULATION

All PICUs in the 92 hospitals listed in the 1991 National Association of Children's Hospitals and Related Institutions directory.

PARTICIPANTS

Staff nurses with more than 3 years experience were requested to complete the questionnaire in relation to their endotracheal suctioning practices of PICU patients.

RESULTS

The questionnaire was returned by 80 (90%) PICUs. A wide range of suctioning techniques were used. Most respondents reported hyperoxygenation, hyperventilation, and/or hyperinflation of the patient's respiratory system before suctioning. Nursing judgment and the patient's clinical condition were used to determine when a suctioning procedure was needed. Most respondents (71%) indicated inserting the suction catheter until resistance was met. Normal saline-solution irrigant was used by all but one respondent. A manual resuscitation bag was used routinely during suctioning. Eighty percent of respondents reported that few patients displayed an adverse response to the suctioning procedure.

RECOMMENDATIONS

The study should be replicated with direct observations of actual PICU suctioning practices. Suctioning techniques should be examined in relation to specific groups of PICU patients. Further research is needed to determine the optimal practice for rates of hyperventilation, percentage of oxygen increase during hyperoxygenation, and pressure increase during hyperinflation.

Rapid-sequence intubation in head trauma

Elevated intracranial pressure commonly is associated with severe head injury. Emergency airway management technique in the patient who has sustained severe head injury must optimize conditions for intubation, minimize the adverse effects of intubation, and permit rapid and effective management of the elevated intracranial pressure. Disturbances in autoregulation make the injured brain particularly susceptible to the adverse effects of alterations of systemic blood pressure. Airway manipulation without adequate pharmacologic support can cause precipitous changes in systemic hemodynamic parameters. This article reviews the physiologic and pathologic relationship among airway management, systemic hemodynamic parameters, and intracranial pressure. Specific recommendations for the use of neuromuscular blocking agents, anesthetic induction agents, and adjunctive medications are provided.