Comparative Efficacy and Safety of Sedative Agents in Severe Traumatic Brain Injury

  • D. J. Roberts
  • D. A. Zygun
Part of the Annual Update in Intensive Care and Emergency Medicine book series (AUICEM, volume 2012)

Abstract

Sedative agents are commonly used to manage adults in the intensive care unit (ICU) with severe traumatic brain injury (TBI) [1–3]. These drugs prevent or treat agitation, permit manipulation of artificial ventilation, and induce and maintain anxiolysis and amnesia [1–3]. Moreover, sedative agents may diminish cerebral metabolic rate and, through flow-metabolism coupling, reduce brain blood flow, intracranial blood volume, and ultimately intracranial pressure (ICP) [4]. Boluses or infusions of sedatives possibly also reduce the prolonged and marked increases in ICP produced by endotracheal suctioning or bronchoscopy [3, 5]. Unfortunately, however, sedative agents may also lower mean arterial pressure (MAP), hinder the neurological examination, and prolong the length of ventilatory support or ICU stay [3]. This chapter reviews regulation of brain blood flow and metabolic rate in TBI, relevant sedative neuropharmacology, and the comparative efficacy and safety of propofol, ketamine, etomidate, and agents from the opioid, benzodiazepine, α2-agonist (i.e., clonidine and dexmedetomidine), and antipsychotic drug classes for management of adults in the ICU with severe TBI.

Keywords

Intensive Care Unit Stay Cerebral Perfusion Pressure Severe Traumatic Brain Injury Severe Head Injury Sedative Agent 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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References

  1. 1.
    Jeevaratnam DR, Menon DK (1996) Survey of intensive care of severely head injured patients in the United Kingdom. BMJ 312: 944–947PubMedCrossRefGoogle Scholar
  2. 2.
    Matta B, Menon D (1996) Severe head injury in the United Kingdom and Ireland: a survey of practice and implications for management. Crit Care Med 24: 1743–1748PubMedCrossRefGoogle Scholar
  3. 3.
    Roberts DJ, Hall RI, Kramer AH, Robertson HL, Gallagher CN, Zygun DA (2011) Sedation for critically ill adults with severe traumatic brain injury: a systematic review of randomized controlled trials. Crit Care Med 39: 2743–2751PubMedCrossRefGoogle Scholar
  4. 4.
    Urwin SC, Menon DK (2004) Comparative tolerability of sedative agents in head-injured adults. Drug Saf 27: 107–133PubMedCrossRefGoogle Scholar
  5. 5.
    Kerr ME, Sereika SM, Orndoff P, et al (1998) Effect of neuromuscular blockers and opiates on the cerebrovascular response to endotracheal suctioning in adults with severe head injuries. Am J Crit Care 7: 205–217PubMedGoogle Scholar
  6. 6.
    Kramer AH, Zygun DA (2009) Anemia and red blood cell transfusion in neurocritical care. Crit Care 13: R89PubMedCrossRefGoogle Scholar
  7. 7.
    Coles JP, Cunningham AS, Salvador R, et al (2009) Early metabolic characteristics of lesion and nonlesion tissue after head injury. J Cereb Blood Flow Metab 29: 965–975PubMedCrossRefGoogle Scholar
  8. 8.
    Citerio G, Cormio M (2003) Sedation in neurointensive care: advances in understanding and practice. Curr Opin Crit Care 9: 120–126PubMedCrossRefGoogle Scholar
  9. 9.
    Oertel M, Kelly DF, Lee JH, et al (2002) Efficacy of hyperventilation, blood pressure elevation, and metabolic suppression therapy in controlling intracranial pressure after head injury. J Neurosurg 97: 1045–1053PubMedCrossRefGoogle Scholar
  10. 10.
    Karabinis A, Mandragos K, Stergiopoulos S, et al (2004) Safety and efficacy of analgesia-based sedation with remifentanil versus standard hypnotic-based regimens in intensive care unit patients with brain injuries: a randomised, controlled trial [ISRCTN50308308]. Crit Care 8: R268–R280PubMedCrossRefGoogle Scholar
  11. 11.
    Chiolero RL, Ravussin P, Anderes JP, Ledermann P, de Tribolet N (1988) The effects of midazolam reversal by RO 15–1788 on cerebral perfusion pressure in patients with severe head injury. Intensive Care Med 14: 196–200PubMedCrossRefGoogle Scholar
  12. 12.
    McCall M, Jeejeebhoy K, Penchars P, Moulton R (2003) Effect of neuromuscular blockade on energy expenditure in patients with severe head injury. JPEN J Parenter Enteral Nutr 27: 27–35PubMedCrossRefGoogle Scholar
  13. 13.
    Huang SJ, Shieh JS, Fu M, Kao MC (2006) Fuzzy logic control for intracranial pressure via continuous propofol sedation in a neurosurgical intensive care unit. Med Eng Phys 28: 639–647PubMedCrossRefGoogle Scholar
  14. 14.
    Bullock R, Stewart L, Rafferty C, Teasdale GM (1993) Continuous monitoring of jugular bulb oxygen saturation and the effect of drugs acting on cerebral metabolism. Acta Neurochir Suppl (Wien) 59: 113–118Google Scholar
  15. 15.
    Steiner LA, Johnston AJ, Chatfield DA, et al (2003) The effects of large-dose propofol on cerebrovascular pressure autoregulation in head-injured patients. Anesth Analg 97: 572–576PubMedCrossRefGoogle Scholar
  16. 16.
    Payen D, Quintin L, Plaisance P, Chiron B, Lhoste F (1990) Head injury: clonidine decreases plasma catecholamines. Crit Care Med 18: 392–395PubMedCrossRefGoogle Scholar
  17. 17.
    White PF, Schlobohm RM, Pitts LH, Lindauer JM (1982) A randomized study of drugs for preventing increases in intracranial pressure during endotracheal suctioning. Anesthesiology 57: 242–244PubMedCrossRefGoogle Scholar
  18. 18.
    Dearden NM, McDowall DG (1985) Comparison of etomidate and althesin in the reduction of increased intracranial pressure after head injury. Br J Anaesth 57: 361–368PubMedCrossRefGoogle Scholar
  19. 19.
    Sperry RJ, Bailey PL, Reichman MV, Peterson JC, Petersen PB, Pace NL (1992) Fentanyl and sufentanil increase intracranial pressure in head trauma patients. Anesthesiology 77: 416–420PubMedCrossRefGoogle Scholar
  20. 20.
    Levy ML, Aranda M, Zelman V, Giannotta SL (1995) Propylene glycol toxicity following continuous etomidate infusion for the control of refractory cerebral edema. Neurosurgery 37: 363–369PubMedCrossRefGoogle Scholar
  21. 21.
    Lauer KK, Connolly LA, Schmeling WT (1997) Opioid sedation does not alter intracranial pressure in head injured patients. Can J Anaesth 44: 929–933PubMedCrossRefGoogle Scholar
  22. 22.
    Sanchez-Izquierdo-Riera JA, Caballero-Cubedo RE, Perez-Vela JL, Ambros-Checa A, Cantalapiedra-Santiago JA, Alted-Lopez E (1998) Propofol versus midazolam: safety and efficacy for sedating the severe trauma patient. Anesth Analg 86: 1219–1224PubMedGoogle Scholar
  23. 23.
    Albanese J, Viviand X, Potie F, Rey M, Alliez B, Martin C (1999) Sufentanil, fentanyl, and alfentanil in head trauma patients: a study on cerebral hemodynamics. Crit Care Med 27: 407–411PubMedCrossRefGoogle Scholar
  24. 24.
    Kelly DF, Goodale DB, Williams J, et al (1999) Propofol in the treatment of moderate and severe head injury: a randomized, prospective double-blinded pilot trial. J Neurosurg 90: 1042–1052PubMedCrossRefGoogle Scholar
  25. 25.
    de Nadal M, Munar F, Poca MA, Sahuquillo J, Garnacho A, Rossello J (2000) Cerebral hemodynamic effects of morphine and fentanyl in patients with severe head injury: absence of correlation to cerebral autoregulation. Anesthesiology 92: 11–19PubMedCrossRefGoogle Scholar
  26. 26.
    Sandiumenge Camps A, Sanchez-Izquierdo Riera JA, Toral Vazquez D, Sa Borges M, Peinado Rodriguez J, Alted Lopez E (2000) Midazolam and 2 % propofol in long-term sedation of traumatized critically ill patients: efficacy and safety comparison. Crit Care Med 28: 3612–3619PubMedCrossRefGoogle Scholar
  27. 27.
    Bourgoin A, Albanese J, Wereszczynski N, Caharbit M, Vialet R, Martin C (2003) Safety of sedation with ketamine in severe head injury patients: comparison with sufentanil. Crit Care Med 31: 711–717PubMedCrossRefGoogle Scholar
  28. 28.
    Bourgoin A, Albanese J, Leone M, Sampol-Manos E, Viviand X, Martin C (2005) Effects of sufentanil or ketamine administered in target-controlled infusion on the cerebral hemodynamics of severely brain-injured patients. Crit Care Med 33: 1109–1113PubMedCrossRefGoogle Scholar
  29. 29.
    Ghori KA, Harmon DC, Elashaal A, et al (2007) Effect of midazolam versus propofol sedation on markers of neurological injury and outcome after isolated severe head injury: a pilot study. Crit Care Resusc 9: 166–171PubMedGoogle Scholar
  30. 30.
    McArthur CJ, Gin T, McLaren IM, Critchley JA, Oh TE (1995) Gastric emptying following brain injury: effects of choice of sedation and intracranial pressure. Intensive Care Med 21: 573–576PubMedCrossRefGoogle Scholar
  31. 31.
    Schmittner MD, Vajkoczy SL, Horn P, et al (2007) Effects of fentanyl and S(+)-ketamine on cerebral hemodynamics, gastrointestinal motility, and need of vasopressors in patients with intracranial pathologies: a pilot study. J Neurosurg Anesthesiol 19: 257–262PubMedCrossRefGoogle Scholar
  32. 32.
    Kolenda H, Gremmelt A, Rading S, Braun U, Markakis E (1996) Ketamine for analgosedative therapy in intensive care treatment of head-injured patients. Acta Neurochir (Wien) 138: 1193–1199CrossRefGoogle Scholar
  33. 33.
    Albanese J, Durbec O, Viviand X, Potie F, Alliez B, Martin C (1993) Sufentanil increases intracranial pressure in patients with head trauma. Anesthesiology 79: 493–497PubMedCrossRefGoogle Scholar
  34. 34.
    Scholz J, Bause H, Schulz M, et al (1994) Pharmacokinetics and effects on intracranial pressure of sufentanil in head trauma patients. Br J Clin Pharmacol 38: 369–372PubMedCrossRefGoogle Scholar
  35. 35.
    Tipps LB, Coplin WM, Murry KR, Rhoney DH (2000) Safety and feasibility of continuous infusion of remifentanil in the neurosurgical intensive care unit. Neurosurgery 46: 596–601PubMedCrossRefGoogle Scholar
  36. 36.
    Engelhard K, Reeker W, Kochs E, Werner C (2004) Effect of remifentanil on intracranial pressure and cerebral blood flow velocity in patients with head trauma. Acta Anaesthesiol Scand 48: 396–399PubMedCrossRefGoogle Scholar
  37. 37.
    Herregods L, Verbeke J, Rolly G, Colardyn F (1988) Effect of propofol on elevated intracranial pressure. Preliminary results. Anaesthesia 43 Suppl: 107–109PubMedCrossRefGoogle Scholar
  38. 38.
    Farling PA, Johnston JR, Coppel DL (1989) Propofol infusion for sedation of patients with head injury in intensive care. A preliminary report. Anaesthesia 44: 222–226CrossRefGoogle Scholar
  39. 39.
    Stewart L, Bullock R, Rafferty C, Fitch W, Teasdale GM (1994) Propofol sedation in severe head injury fails to control high ICP, but reduces brain metabolism. Acta Neurochir Suppl (Wien) 60: 544–546Google Scholar
  40. 40.
    Cohn BF, Rejger V, Hagenouw-Taal JC, Voormolen JH (1983) Results of a feasibility trial to achieve total immobilization of patients in a neurosurgical intensive care unit with etomidate. Anaesthesia 38 Suppl: 47–50PubMedCrossRefGoogle Scholar
  41. 41.
    Prior JG, Hinds CJ, Williams J, Prior PF (1983) The use of etomidate in the management of severe head injury. Intensive Care Med 9: 313–320PubMedCrossRefGoogle Scholar
  42. 42.
    Bingham RM, Procaccio F, Prior PF, Hinds CJ (1985) Cerebral electrical activity influences the effects of etomidate on cerebral perfusion pressure in traumatic coma. Br J Anaesth 57: 843–848PubMedCrossRefGoogle Scholar
  43. 43.
    Papazian L, Albanese J, Thirion X, Perrin G, Durbec O, Martin C (1993) Effect of bolus doses of midazolam on intracranial pressure and cerebral perfusion pressure in patients with severe head injury. Br J Anaesth 71: 267–271PubMedCrossRefGoogle Scholar
  44. 44.
    ter Minassian A, Beydon L, Decq P, Bonnet F (1997) Changes in cerebral hemodynamics after a single dose of clonidine in severely head-injured patients. Anesth Analg 84: 127–132PubMedGoogle Scholar
  45. 45.
    Albanese J, Arnaud S, Rey M, Thomachot L, Alliez B, Martin C (1997) Ketamine decreases intracranial pressure and electroencephalographic activity in traumatic brain injury patients during propofol sedation. Anesthesiology 87: 1328–1334PubMedCrossRefGoogle Scholar
  46. 46.
    Lescot T, Pereira AR, Abdennour L, et al (2007) Effect of loxapine on electrical brain activity, intracranial pressure, and middle cerebral artery flow velocity in traumatic braininjured patients. Neurocrit Care 7: 124–127PubMedCrossRefGoogle Scholar
  47. 47.
    Roberts DJ, Goralski KB, Renton KW, et al (2009) Effect of acute inflammatory brain injury on accumulation of morphine and morphine 3-and 6-glucuronide in the human brain. Crit Care Med 37: 2767–2774PubMedCrossRefGoogle Scholar
  48. 48.
    Roberts I, Schierhout G, Alderson P (1998) Absence of evidence for the effectiveness of five interventions routinely used in the intensive care management of severe head injury: a systematic review. J Neurol Neurosurg Psychiatry 65: 729–733PubMedCrossRefGoogle Scholar
  49. 49.
    Cremer OL, Moons KG, Bouman EA, Kruijswijk JE, de Smet AM, Kalkman CJ (2001) Long-term propofol infusion and cardiac failure in adult head-injured patients. Lancet 357: 117–118PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  • D. J. Roberts
  • D. A. Zygun

There are no affiliations available

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