Effect of neuromuscular blockers and opiates on the cerebrovascular response to endotracheal suctioning in adults with severe head injuries

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

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

Initial Diagnosis and Management of Acutely Elevated Intracranial Pressure

Acutely elevated intracranial pressure (ICP) may have devastating effects on patient mortality and neurologic outcomes, yet its initial detection remains difficult because of the variety of manifestations that it can cause disease states it is associated with. Several treatment guidelines exist for specific disease processes such as trauma or ischemic stroke, but their recommendations may not apply to other causes. In the acute setting, management decisions must often be made before the underlying cause is known. In this review, we present an organized, evidence-based approach to the recognition and management of patients with suspected or confirmed elevated ICP in the first minutes to hours of resuscitation. We explore the utility of invasive and noninvasive methods of diagnosis, including history, physical examination, imaging, and ICP monitors. We synthesize various guidelines and expert recommendations and identify core management principles including noninvasive maneuvers, neuroprotective intubation and ventilation strategies, and pharmacologic therapies such as ketamine, lidocaine, corticosteroids, and the hyperosmolar agents mannitol and hypertonic saline. Although an in-depth discussion of the definitive management of each etiology is beyond the scope of this review, our goal is to provide an empirical approach to these time-sensitive, critical presentations in their initial stages.

High-Risk Airway Management in the Emergency Department: Diseases and Approaches, Part II

BACKGROUND

Successful airway management is critical to the practice of emergency medicine. Thus, emergency physicians must be ready to optimize and prepare for airway management in critically ill patients with a wide range of physiologic challenges. Challenges in airway management commonly encountered in the emergency department are discussed using a pearl and pitfall discussion in this second part of a 2-part series.

OBJECTIVE

This narrative review presents an evidence-based approach to airway and patient management during endotracheal intubation in challenging cases commonly encountered in the emergency department.

DISCUSSION

Adverse events during emergent airway management are common with postintubation cardiac arrest, reported in as many as 1 in 25 intubations. Many of these adverse events can be avoided by proper identification and understanding the underlying physiology, preparation, and postintubation management. Those with high-risk features including trauma, elevated intracranial pressure, upper gastrointestinal bleed, cardiac tamponade, aortic stenosis, morbid obesity, and pregnancy must be managed with airway expertise.

CONCLUSIONS

This narrative review discusses the pearls and pitfalls of commonly encountered physiologic high-risk intubations with a focus on the emergency clinician.

Opioids and cerebral physiology in the acute management of traumatic brain injury: a systematic review

BACKGROUND

Following traumatic brain injury (TBI), optimization of cerebral physiology is recommended to promote more favourable patient outcomes. Accompanying pain and agitation are commonly treated with sedative and analgesic agents, such as opioids. However, the impact of opioids on certain aspects of cerebral physiology is not well established.

OBJECTIVE

To conduct a systematic review of the evidence on the effect of opioids on cerebral physiology in TBI during acute care.

METHODS

A comprehensive literature search was conducted in five electronic databases for articles published in English up to November 2017. Studies were included if: (1) the study sample was human subjects with TBI; (2) the sample size was ≥3; (3) subjects were given an opioid during acute care; and (4) any measure of cerebral physiology was evaluated. Cerebral physiology measures were intracranial pressure (ICP), cerebral perfusion pressure (CPP), and mean arterial pressure (MAP). Subject and study characteristics, treatment protocol, and results were extracted from included studies. Randomized controlled trials were evaluated for methodological quality using the Physiotherapy Evidence Database tool. Levels of evidence were assigned using a modified Sackett scale.

RESULTS

In total, 22 studies met inclusion criteria, from which six different opioids were identified: morphine, fentanyl, sufentanil, remifentanil, alfentanil, and phenoperidine. The evidence for individual opioids demonstrated equally either: (1) no effect on ICP, CPP, or MAP; or (2) an increase in ICP with associated decreases in CPP and MAP. In general, opioids administered by infusion resulted in the former outcome, whereas those given in bolus form resulted in the latter. There were no significant differences when comparing different opioids, with the exception of one study that found fentanyl was associated with lower ICP and CPP than morphine and sufentanil. There were no consistent results when comparing opioids to other non-opioid medications.

CONCLUSION

Several studies have assessed the effect of opioids on cerebral physiology during the acute management of TBI, but there is considerable heterogeneity in terms of study methodology and findings. Opioids are beneficial in terms of analgesia and sedation, but bolus administration should be avoided to prevent additional or prolonged unfavourable alterations in cerebral physiology. Future studies should better elucidate the effects of different opioids as well as varying dosages in order to develop improved understanding as well as allow for tighter control of cerebral physiology.

ABBREVIATIONS

CPP: Cerebral Perfusion Pressure, GCS: Glasgow Coma Scale, ICP: Intracranial Pressure, MAP: Mean Arterial Pressure, PEDro: Physiotherapy Evidence Database, RCT: Randomized Controlled Trial, TBI: Traumatic Brain Injury.

Pathophysiology and Management of Intracranial Hypertension and Tissular Brain Hypoxia After Severe Traumatic Brain Injury: An Integrative Approach

Monitoring intracranial pressure in comatose patients with severe traumatic brain injury (TBI) is considered necessary by most experts. Acute intracranial hypertension (IHT), when severe and sustained, is a life-threatening complication that demands emergency treatment. Yet, secondary anoxic-ischemic injury after brain trauma can occur in the absence of IHT. In such cases, adding other monitoring modalities can alert clinicians when the patient is in a state of energy failure. This article reviews the mechanisms, diagnosis, and treatment of IHT and brain hypoxia after TBI, emphasizing the need to develop a physiologically integrative approach to the management of these complex situations.

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.

Clinical Practice and Risk Factors for Immediate Complications of Endotracheal Intubation by Intensive Care Unit Doctors in a Regional Hospital in Hong Kong

Background

Endotracheal intubation in critically ill patients is often challenging and is associated with a high complication rate. Intensive Care Unit (ICU) doctors are often responsible for emergency intubation but local data about their experience is lacking.

Objective

To describe the ICU team's practice of endotracheal intubation in critically ill patients in a regional hospital; to evaluate the incidence of immediate complications; and to identify risk factors for complications and predictors for successful intubation.

Design

Retrospective, observational study

Patients

All patients who received endotracheal intubation by the ICU team of the study centre between the 1st July 2013 and 31st December 2013.

Results

Complete data from 325 endotracheal intubations were analyzed. The commonest diagnosis was pneumonia (41.5%) and the mostly frequently cited indication for endotracheal intubation was respiratory failure (50.8%). Complications occurred in 25.5% of all intubations including 4 cases of cardiac arrest after the procedure. Haemodynamic alterations (hypotension and hypertension occurred in 9.2% and 7.4% respectively) were the most common complications. Overall, 96.6% of intubations were successful on the first two attempts. Logistic regression analyses showed that reduced mouth opening was a significant risk factor for immediate complications (odds ratio [OR] 15.98, 95% confidence interval [CI]: 2.71 to 94.41, P=0.006). Cormack-Lehane laryngoscope grading below 2b (OR 0.2, 95% CI: 0.07-0.59, P=0.003) and operator with more than 6 months of formal anaesthetic training (OR 7.06, 95% CI: 1.63 to 30.62, P=0.009) were independent predictors for successful intubation.

Conclusion

The ICU team achieves a high successful rate of emergency endotracheal intubation. High rates of anticipated and unanticipated difficult airway are encountered. Reduced mouth opening is a significant risk factor for complications occurrence. Cormack-Lehane laryngoscopic grading below 2b and intubation performer with more than 6 months of formal anaesthetic training are significant independent predictors for successful intubation. (Hong Kong j.emerg.med. 2016;23:135-144)

Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient

OBJECTIVE

To update the 2002 version of "Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient."

DESIGN

A Task Force comprising 17 members of the Society of Critical Medicine with particular expertise in the use of neuromuscular-blocking agents; a Grading of Recommendations Assessment, Development, and Evaluation expert; and a medical writer met via teleconference and three face-to-face meetings and communicated via e-mail to examine the evidence and develop these practice guidelines. Annually, all members completed conflict of interest statements; no conflicts were identified. This activity was funded by the Society for Critical Care Medicine, and no industry support was provided.

METHODS

Using the Grading of Recommendations Assessment, Development, and Evaluation system, the Grading of Recommendations Assessment, Development, and Evaluation expert on the Task Force created profiles for the evidence related to six of the 21 questions and assigned quality-of-evidence scores to these and the additional 15 questions for which insufficient evidence was available to create a profile. Task Force members reviewed this material and all available evidence and provided recommendations, suggestions, or good practice statements for these 21 questions.

RESULTS

The Task Force developed a single strong recommendation: we recommend scheduled eye care that includes lubricating drops or gel and eyelid closure for patients receiving continuous infusions of neuromuscular-blocking agents. The Task Force developed 10 weak recommendations. 1) We suggest that a neuromuscular-blocking agent be administered by continuous intravenous infusion early in the course of acute respiratory distress syndrome for patients with a PaO2/FIO2 less than 150. 2) We suggest against the routine administration of an neuromuscular-blocking agents to mechanically ventilated patients with status asthmaticus. 3) We suggest a trial of a neuromuscular-blocking agents in life-threatening situations associated with profound hypoxemia, respiratory acidosis, or hemodynamic compromise. 4) We suggest that neuromuscular-blocking agents may be used to manage overt shivering in therapeutic hypothermia. 5) We suggest that peripheral nerve stimulation with train-of-four monitoring may be a useful tool for monitoring the depth of neuromuscular blockade but only if it is incorporated into a more inclusive assessment of the patient that includes clinical assessment. 6) We suggest against the use of peripheral nerve stimulation with train of four alone for monitoring the depth of neuromuscular blockade in patients receiving continuous infusion of neuromuscular-blocking agents. 7) We suggest that patients receiving a continuous infusion of neuromuscular-blocking agent receive a structured physiotherapy regimen. 8) We suggest that clinicians target a blood glucose level of less than 180 mg/dL in patients receiving neuromuscular-blocking agents. 9) We suggest that clinicians not use actual body weight and instead use a consistent weight (ideal body weight or adjusted body weight) when calculating neuromuscular-blocking agents doses for obese patients. 10) We suggest that neuromuscular-blocking agents be discontinued at the end of life or when life support is withdrawn. In situations in which evidence was lacking or insufficient and the study results were equivocal or optimal clinical practice varies, the Task Force made no recommendations for nine of the topics. 1) We make no recommendation as to whether neuromuscular blockade is beneficial or harmful when used in patients with acute brain injury and raised intracranial pressure. 2) We make no recommendation on the routine use of neuromuscular-blocking agents for patients undergoing therapeutic hypothermia following cardiac arrest. 3) We make no recommendation on the use of peripheral nerve stimulation to monitor degree of block in patients undergoing therapeutic hypothermia. 4) We make no recommendation on the use of neuromuscular blockade to improve the accuracy of intravascular-volume assessment in mechanically ventilated patients. 5) We make no recommendation concerning the use of electroencephalogram-derived parameters as a measure of sedation during continuous administration of neuromuscular-blocking agents. 6) We make no recommendation regarding nutritional requirements specific to patients receiving infusions of neuromuscular-blocking agents. 7) We make no recommendation concerning the use of one measure of consistent weight over another when calculating neuromuscular-blocking agent doses in obese patients. 8) We make no recommendation on the use of neuromuscular-blocking agents in pregnant patients. 9) We make no recommendation on which muscle group should be monitored in patients with myasthenia gravis receiving neuromuscular-blocking agents. Finally, in situations in which evidence was lacking or insufficient but expert consensus was unanimous, the Task Force developed six good practice statements. 1) If peripheral nerve stimulation is used, optimal clinical practice suggests that it should be done in conjunction with assessment of other clinical findings (e.g., triggering of the ventilator and degree of shivering) to assess the degree of neuromuscular blockade in patients undergoing therapeutic hypothermia. 2) Optimal clinical practice suggests that a protocol should include guidance on neuromuscular-blocking agent administration in patients undergoing therapeutic hypothermia. 3) Optimal clinical practice suggests that analgesic and sedative drugs should be used prior to and during neuromuscular blockade, with the goal of achieving deep sedation. 4) Optimal clinical practice suggests that clinicians at the bedside implement measure to attenuate the risk of unintended extubation in patients receiving neuromuscular-blocking agents. 5) Optimal clinical practice suggests that a reduced dose of an neuromuscular-blocking agent be used for patients with myasthenia gravis and that the dose should be based on peripheral nerve stimulation with train-of-four monitoring. 6) Optimal clinical practice suggests that neuromuscular-blocking agents be discontinued prior to the clinical determination of brain death.

Acute effects of physiotherapeutic respiratory maneuvers in critically ill patients with craniocerebral trauma

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.

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

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.

Traumatic brain injury: A case-based review

BACKGROUND

Traumatic brain injuries are common and costly to hospital systems. Most of the guidelines on management of traumatic brain injuries are taken from the Brain Trauma Foundation Guidelines. This is a review of the current literature discussing the evolving practice of traumatic brain injury.

DATA SOURCES

A literature search using multiple databases was performed for articles published through September 2012 with concentration on meta-analyses, systematic reviews, and randomized controlled trials.

RESULTS

The focus of care should be to minimize secondary brain injury by surgically decompressing certain hematomas, maintain systolic blood pressure above 90 mmHg, oxygen saturations above 93%, euthermia, intracranial pressures below 20 mmHg, and cerebral perfusion pressure between 60-80 mmHg.

CONCLUSION

Much is still unknown about the management of traumatic brain injury. The current practice guidelines have not yet been sufficiently validated, however equipoise is a major issue when conducting randomized control trials among patients with traumatic brain injury.

Current therapeutic uses, pharmacology, and clinical considerations of neuromuscular blocking agents for critically ill adults

OBJECTIVE

To summarize literature describing use of neuromuscular blocking agents (NMBAs) for common critical care indications and provide a review of NMBA pharmacology, pharmacokinetics, dosing, drug interactions, monitoring, complications, and reversal.

DATA SOURCES

Searches of MEDLINE (1975-May 2011), EMBASE (1980-May 2011), and Cumulative Index to Nursing and Allied Health Literature (1981-May 2011) were conducted to identify observational and interventional studies evaluating the efficacy or safety of NMBAs for management of acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), status asthmaticus, elevated intracranial pressure (ICP), and therapeutic hypothermia.

STUDY SELECTION AND DATA EXTRACTION

We excluded case reports, animal- or laboratory-based studies, trials describing NMBA use during rapid sequence intubation or in the operating room, and studies published in languages other than English or French.

DATA SYNTHESIS

Clinical applications of NMBAs in intensive care include, but are not limited to, immobilizing patients for procedural interventions, decreasing oxygen consumption, facilitating mechanical ventilation, reducing intracranial pressure, preventing shivering, and management of tetanus. Recent data on ARDS demonstrated that early application of NMBAs improved adjusted 90-day survival for patients with severe lung injury. These results may lead to increased use of these drugs. While emerging data support the use of cisatracurium in select patients with ALI/ARDS, current literature does not support the use of one NMBA over another for other critical care indications. Cisatracurium may be kinetically preferred for patients with organ dysfunction. Close monitoring with peripheral nerve stimulation is recommended with sustained use of NMBAs to avoid drug accumulation and minimize the risk for adverse drug events. Reversal of paralysis is achieved by discontinuing therapy or, rarely, the use of anticholinesterases.

CONCLUSIONS

NMBAs are high-alert medications used to manage critically ill patients. New data are available regarding the use of these agents for treatment of ALI/ARDS and status asthmaticus, management of elevated ICP, and provision of therapeutic hypothermia after cardiac arrest. To improve outcomes and promote patient safety, intensive care unit team members should have a thorough knowledge of this class of medications.

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.

The effect of breath physiotherapeutic maneuvers on cerebral hemodynamics: a clinical trial

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.

[Intracranial pressure response during secretion aspiration after administration of a muscle relaxant]

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.

Respiratory care in spinal cord injury with associated traumatic brain injury: bridging the gap in critical care nursing interventions

Spinal cord injury (SCI) is a devastating and challenging condition. The events that lead to SCI, such as road traffic accidents, falls, sports and violence [Top. Spinal Cord Inj. Rehabil. 5 (1999) 83], are also the common aetiologies of traumatic brain injury (TBI). It's not surprising then, that 20-50% of those with cervical SCI have TBI [J. Trauma 46 (1999) 450]. The literature pertaining to the management of either injury in isolation is vast, but lacking where the two conditions are experienced together and require distinct adaptations to interventions. Consequently, a gap in the literature exists. This paper focuses on those patients with SCI of the cervical spine with associated head injury, and pay particular attention to respiratory difficulties, and presents interventions required to minimise and treat the effects of such pulmonary compromise.

Nursing care of the acute head injury: a review of the evidence

This article aims to review the current evidence in relation to acute head injury care. Head injuries are a frequent cause of death and disability in western society with the first 72 h being an important period for prevention of further brain damage. The underlying physiology behind head injury and intracranial pressure will be discussed. The monitoring of intracranial pressure and implications for practice will be addressed. The specialized nursing care and drug therapy management that is necessary for acute head injury patients will be highlighted. Recommendations for practice will be given.

Intracranial effects of endotracheal suctioning in the acute phase of head injury

In patients with head injury, endotracheal suctioning (ETS) is a potentially dangerous procedure, because it can increase intracranial pressure (ICP). The purpose of this prospective nonrandomized study was to evaluate the impact of ETS on intracranial dynamics in the acute phase of head injury. Seventeen patients with severe head injury (Glasgow Coma Score < or = 8, range 4-8), sedated and mechanically ventilated, were studied during the first week after trauma. Single-pass ETS maneuver (with a 16-French catheter, negative pressure of 100 mm Hg, and duration of less than 30 seconds) was performed 60 seconds after the FiO2 was increased to 100%. After ETS, FiO2 was maintained at 100% for another 30 seconds. Before and after ETS, arterial blood gases and jugular oxygen saturation (S(j)O2), ICP, and mean arterial pressure (MAP) were measured and cerebral perfusion pressure (CPP) was calculated. A total of 131 ETS episodes, which consisted of repeated assessment of each patient, were analyzed. Six patients in 20 cases coughed and/or moved during ETS because of inadequate sedation. After ETS, ICP increased from 20 +/- 12 to 22 +/- 13 mm Hg in well-sedated patients and from 15 +/- 9 to 28 +/- 9 mm Hg in patients who coughed and/or moved (mean change, 2 +/- 6 versus 13 +/- 6 mm Hg, P <.0001). CPP and S(j)O2 increased in well-sedated patients (from 78 +/- 16 to 83 +/- 19 mm Hg, and from 71 +/- 10 to 73 +/- 13%, respectively) and decreased in patients who reacted to ETS (from 79 +/- 14 to 72 +/- 14 mm Hg and from 69 +/- 7 to 66 +/- 9%, respectively), and the differences were significant (mean change, CPP: 5 +/- 14 versus -7 +/- 15 mm Hg, P =.003; (S(j)O2) 2 +/- 5 vs. -3 +/- 5%, P <.0001). In well-sedated patients, endotracheal suctioning caused an increase in ICP, CPP, and S j O 2 without evidence of ischemia. In contrast, in patients who coughed or moved in response to suctioning, there was a slight and significant decrease in CPP and S(j)O2. In the case of patients with head injuries who coughed or moved during endotracheal suctioning, we strongly suggest deepening the level of sedation before completing the procedure to reduce the risk of adverse effects.

Acute care management of severe traumatic brain injuries

Preservation or restoration of optimal neurologic function following traumatic brain injury (TBI) requires timely and aggressive therapeutic interventions. Effective diagnostic tools, together with an armamentarium of treatment modalities, have augmented the treatment strategies utilized today. In addition, the Guidelinesfor the Management of Severe Head Injury have established a standardized approach for the TBI patient. This article will provide current information regarding the resuscitation priorities, appropriate interventions, and pharmacological agents used in the treatment required by the complex nature of TBI. Also, a review of the occurrences associated with TBI will be discussed.

Effect of endotracheal suctioning on cerebral oxygenation in traumatic brain-injured patients

OBJECTIVE

In patients with severe head injuries, brain damage occurs not only from the primary trauma but also secondarily from a reduction in cerebral oxygenation as a result of brain swelling, ischemia, and elevated intracranial pressure (ICP). However, routine interventions designed to maintain oxygenation, such as endotracheal suctioning (ETS), also may negatively affect the cerebrovascular status by increasing the ICP. The purpose of this study was to determine whether ETS influences cerebral oxygenation in patients with traumatic brain injury.

DESIGN

Descriptive, prospective, with repeated assessments within each patient.

SETTING

Ten-bed trauma intensive care unit in a university Level I trauma center.

SUBJECTS

Nineteen patients who were 16 yrs or older, had acute head injury, a Glasgow Coma Scale score < or =8; external ventricular drain and arterial pressure devices in place, and were intubated and mechanically ventilated.

INTERVENTIONS

ETS protocol consisting of administration of four ventilator-delivered breaths at 135% of the patients' actual tidal volume, 100% F(IO)2, before and after suctioning with a standardized catheter at a 16-L flow rate.

MEASUREMENTS AND MAIN RESULTS

This study examined cerebrovascular responses as measured by the traditional measures of ICP and cerebral perfusion pressure, as well as middle cerebral artery velocity and jugular venous oxygen tension that occurred during ETS in head-injured adults. The results of this study show that both ICP and cerebral perfusion pressure are increased during ETS. In the majority of patients (84%), the ICP returned to baseline values within 2 mins.

CONCLUSIONS

The increase in jugular venous oxygen tension associated with increases in middle cerebral artery velocity and mean arterial pressure suggests that cerebral oxygen delivery was maintained during ETS. Cerebral changes associated with ETS using the described protocol are consistent with the preservation of cerebral oxygenation.