Use of Sedation/Analgesia In Treatment of Severe Traumatic Brain Injury

1. Use of Sedation/Analgesia In Treatment of Severe Traumatic Brain Injury Ri 吳 岫/VS 韓吟宜

2. Overview • Why? • For emergency intubation • For management including control of ICP in the ICU Pediatr Crit Care Med 2003 Vol. 4, No. 3

3. Benefit • Maintain the airway, catheters and other monitors • Facilitate patient transport • Mitigating secondary damage • Free form pain and stress • Anticonvulsant and anti-emetic actions • Prevention of shivering, and mitigation of the long-term psychological trauma of pain and stress. Pediatr Crit Care Med 2003 Vol. 4, No. 3

4. Painful or noxious stimuli or stress can.. • 2 to 3-fold increase in cerebral metabolic rate for oxygen • Increase cerebral blood volume and ICP • A randomized study of drugs for preventing increases in intracranial pressure during endotracheal suctioning Anesthesiology 1982; 57:242-244 • Effect of endotracheal suctioning on cerebral oxygenation in traumatic brain-injured patients. Crit Care Med 1999; 27:2776-2781 • Sympathetic tone↑ hypertension and bleeding from operation sites Pediatr Crit Care Med 2003 Vol. 4, No. 3

5. Adverse Effect • ↓Arterial BP •  cerebral vasodilation & exacerbate increase in cerebral blood volume and ICP. • More likely to occur in patient with underlying hypovolemia. Pediatr Crit Care Med 2003 Vol. 4, No. 3 Crit Care Med 2005 Vol. 33, No. 6

6. Current concepts • It is unaccepatable to allow pain on the argument that analgesic medicaitons may prevent a reliable neurologic evaluation. • There is no real preference for one analgesic agent over another. • Secondary to excessive doses of a sedative/analgesic should be avoided and is more likely to occur in patient with underlying hypovolemia.

7. Ideal sedative for patients with severe TBI • Rapid in onset & offset • Easily titrated to effect • Well-defined metabolism • Neither accumulates nor has active metabolites • Exhibits anticonvulsant actions • No adverse cardiovascular or immune actions • Lacks drug-drug interactions • Preserving the neurological examination Sedative and neuromuscular blocking drug use in critically ill patient with head injuries. New Horiz 1995; 3:456-468 Pediatr Crit Care Med 2003 Vol. 4, No. 3

8. Control of elevated ICP:  Barbiturates Thiopental Pentobarbital Early resuscitation:  Benzodiazepines Diazepam Midazolam lorazepam Opioids Fentanyl Ketamine Propofol Combination Ketamine-midazolam Ketamine-sufentanil Choices Crit Care Med 2005 Vol. 33, No. 6 Pediatr Crit Care Med 2003 Vol. 4, No. 3

9. Barbiturates • No randomized controlled trials assessing the effects of barbiturate therapy on outcome. • ↓ICP by • ↓ cerebral metabolic rate for oxygen  • ↓CBF, ↓cerebral blood volume • ↓Free-radical-mediate cell injury Crit Care Med 2005 Vol. 33, No. 6

10. Barbiturates • Can induce hypotension • ± pulmonary artery catheter to better assess the relative needs of fluids and inotropic agents. • Aim: profound barbiturate-induced coma • clinically no response to stimuli, no cough, and • burst suppression is seen if under EEG control. • Blood levels should not be the primary target. Crit Care Med 2005 Vol. 33, No. 6

11. Crit Care Med 2005 Vol. 33, No. 6

12. Ketamine is best avoided as it may increase ICP • ketamine-midazolam or detamine-sufentaninl have recently been shown to be comparable in maintaining ICP and CPP in patients with severe head injury receiving mechanical ventilation. Crit Care Med 2005 Vol. 33, No. 6

13. Propofol may be preferred • Rapid offset, facilitating serial neurologic evaluations. • Watch propofol-induced hypotension • Morphine or fentanyl are appropriate analgesics. • Watch hypercapnia or hypotension. Crit Care Med 2005 Vol. 33, No. 6

14. Thank You