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Analgésie et sédation en réanimation pp 197–210Cite as

Sédation-analgésie du patient cérébrolésé

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Part of the book series: Le point sur ... ((POINT))

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En neuroréanimation, la sédation est bien plus qu’un traitement adjuvant permettant la tolérance de la VM et la tolérance des différents actes de la réanimation. Il s’agit en fait d’un véritable traitement, dont l’objectif est de réduire la consommation en oxygène du cerveau, déterminant essentiel de la balance énergétique cérébrale. C’est aussi un des moyens les plus efficaces pour faire baisser la PIC, qui est la résultante commune de nombreuses pathologies intracérébrales, qu’elles soient d’origine traumatique, vasculaire, métabolique ou infectieuse.

Chez les patients peu graves et neurologiquement stables, le midazolam ou le propofol associé à un opiacé (fentanyl, sufentanil, rémifentanil, morphine) peuvent être recommandés comme premier palier dans la gradation de l’intensité de la sédation. En cas d’HIC modérée à sévère non contrôlée par ce premier palier, une combinaison d’hypnotiques (midazolam plus propofol) associée à un opiacé (fentanyl, sufentanyl, rémifentanil) peut être préconisée. Le recours aux barbituriques se justifie en cas d’HIC réfractaire aux thérapeutiques précédentes ou en cas d’état de mal épileptique. L’adjonction d’une faible dose de thiopental (de 1 à 2 g /24 h) à l’association midazolam-propofol procure un effet maximal en induisant des burst suppressions. L’utilisation des curares se limitera aux situations de désadaptation du respirateur et à l’hypothermie modérée thérapeutique, et ce seulement en cas de frissons.

Le sevrage de la sédation nécessitera selon les cas le recours à la morphine, aux neuroleptiques (halopéridol, loxapine), aux alpha2-agonistes (clonidine), aux BZD, aux bêta-bloquants (avlocardyl, aténolol) ou aux antidépresseurs (sertraline) et plus rarement aux agents dopaminergiques (amantadine, bromocriptine). C’est une phase à risque de complications imposant une surveillance stricte.

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Authors and Affiliations

  1. Unité de neuro-anesthésie réanimation Département d’anesthésie-réanimation, Groupe hospitalier Pitié-Salpêtrière AP-HP et Université Pierre-et-Marie-Curie, 47-83, boulevard de l’Häpital, 75013, Paris, France

    L. Abdennour, T. Lescot & L. Puybasset

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Abdennour, L., Lescot, T., Puybasset, L. (2010). Sédation-analgésie du patient cérébrolésé. In: Analgésie et sédation en réanimation. Le point sur .... Springer, Paris. https://doi.org/10.1007/978-2-287-99029-8_14

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  • DOI: https://doi.org/10.1007/978-2-287-99029-8_14

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