Sedation in Traumatic Brain Injury

Several different classes of sedative agents are used in the management of patients with traumatic brain injury (TBI). These agents are used at induction of anaesthesia, to maintain sedation, to reduce elevated intracranial pressure, to terminate seizure activity and facilitate ventilation. The intent of their use is to prevent secondary brain injury by facilitating and optimising ventilation, reducing cerebral metabolic rate and reducing intracranial pressure. There is limited evidence available as to the best choice of sedative agents in TBI, with each agent having specific advantages and disadvantages. This review discusses these agents and offers evidence-based guidance as to the appropriate context in which each agent may be used. Propofol, benzodiazepines, narcotics, barbiturates, etomidate, ketamine, and dexmedetomidine are reviewed and compared.

[1]  M. Pinaud,et al.  Effects of propofol on cerebral hemodynamics and metabolism in patients with brain trauma. , 1990, Anesthesiology.

[2]  Xavier Morandi,et al.  Cerebral microdialysis effects of propofol versus midazolam in severe traumatic brain injury. , 2012, Journal of neurotrauma.

[3]  Dickson Ir.  Letter: Osteogenesis imperfecta. , 1976 .

[4]  J. Sánchez-Izquierdo Riera,et al.  Midazolam and 2% propofol in long-term sedation of traumatized critically ill patients: efficacy and safety comparison. , 2000, Critical care medicine.

[5]  A. Pirat,et al.  Is pancreatitis a complication of propofol infusion? , 1999, European journal of anaesthesiology.

[6]  R. Weeks,et al.  Ketamine in neurosurgical procedures. , 1971, Lancet.

[7]  M. Steinfath,et al.  Clinical Pharmacokinetics of Alfentanil, Fentanyl and Sufentanil , 1996, Clinical pharmacokinetics.

[8]  Barry Dixon,et al.  Propofol infusion syndrome , 2006, Forensic science, medicine, and pathology.

[9]  C. Kalkman,et al.  Update on the propofol infusion syndrome in ICU management of patients with head injury , 2008, Current opinion in anaesthesiology.

[10]  M. Norenberg,et al.  Trauma-Induced Cell Swelling in Cultured Astrocytes , 2008, Journal of neuropathology and experimental neurology.

[11]  I. Roberts,et al.  Barbiturates for acute traumatic brain injury. , 2012, The Cochrane database of systematic reviews.

[12]  David J. Hermann,et al.  The Pharmacokinetics of the New Short‐acting Opioid Remifentanil (GI87084B) in Healthy Adult Male Volunteers , 1993, Anesthesiology.

[13]  D. Zygun,et al.  Sedation for critically ill adults with severe traumatic brain injury: A systematic review of randomized controlled trials* , 2011, Critical care medicine.

[14]  Jack Chen,et al.  Prevalence of Delirium with Dexmedetomidine Compared with Morphine Based Therapy after Cardiac Surgery: A Randomized Controlled Trial (DEXmedetomidine COmpared to Morphine-DEXCOM Study) , 2009, Anesthesiology.

[15]  S. Forman.  Clinical and Molecular Pharmacology of Etomidate , 2011, Anesthesiology.

[16]  B Matta,et al.  Severe head injury in the United Kingdom and Ireland: a survey of practice and implications for management. , 1996, Critical care medicine.

[17]  D. Linton,et al.  Midazolam‐induced benzodiazepine withdrawal syndrome , 1991, Anaesthesia.

[18]  J. Gibbs,et al.  The effect of intravenous ketamine on cerebrospinal fluid pressure. , 1972, British journal of anaesthesia.

[19]  N. T. Smith,et al.  Seizures during opioid anesthetic induction--are they opioid-induced rigidity? , 1989, Anesthesiology.

[20]  R. Gibson,et al.  Effect of etomidate on intracranial pressure and cerebral perfusion pressure. , 1979, British journal of anaesthesia.

[21]  D. Rhoney,et al.  Use of sedative and analgesic agents in neurotrauma patients: Effects on cerebral physiology , 2001, Neurological research.

[22]  M A Foulkes,et al.  The role of secondary brain injury in determining outcome from severe head injury. , 1993, The Journal of trauma.

[23]  C. Ames,et al.  Safety and efficacy of dexmedetomidine in neurosurgical patients , 2006, Brain injury.

[24]  M. Slevin,et al.  Morphine intoxication in renal failure; the role of morphine-6-glucuronide. , 1986, British medical journal.

[25]  L. Nace,et al.  Risk factors of relative adrenocortical deficiency in intensive care patients needing mechanical ventilation , 2005, Intensive Care Medicine.

[26]  D. Coppel,et al.  Propofol infusion for sedation of patients with head injury in intensive care , 1989, Anaesthesia.

[27]  H. Huikuri,et al.  Induced Brugada-Type Electrocardiogram, a Sign for Imminent Malignant Arrhythmias , 2008, Circulation.

[28]  I. Egerod,et al.  Effect of an analgo-sedation protocol for neurointensive patients: a two-phase interventional non-randomized pilot study , 2010, Critical care.

[29]  R. Tovell,et al.  ANESTHESIA FOR ELECTROCONVULSIVE THERAPY , 1954, Anesthesiology.

[30]  G. Ramsay,et al.  The Role of the α2-Adrenoceptor Agonist Dexmedetomidine in Postsurgical Sedation in the Intensive Care Unit , 2003 .

[31]  R. Kirby,et al.  Cardiovascular and Pulmonary Responses following Etomidate Induction of Anesthesia in Patients with Demonstrated Cardiac Disease , 1979, Anesthesia and analgesia.

[32]  M. O'sullivan,et al.  Effect of midazolam versus propofol sedation on markers of neurological injury and outcome after isolated severe head injury: a pilot study. , 2007, Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine.

[33]  I. Ledingham,et al.  Mortality amongst multiple trauma patients admitted to an intensive therapy unit , 1983, Anaesthesia.

[34]  E. Hall,et al.  Mitochondrial protection after traumatic brain injury by scavenging lipid peroxyl radicals , 2010, Journal of neurochemistry.

[35]  P. Miller,et al.  Myth: Ketamine should not be used as an induction agent for intubation in patients with head injury. , 2010, CJEM.

[36]  A. Morandi,et al.  Delirium in the intensive care unit: a review. , 2011, Neurologic clinics.

[37]  M. Fearnside,et al.  The Westmead Head Injury Project outcome in severe head injury. A comparative analysis of pre-hospital, clinical and CT variables. , 1993, British journal of neurosurgery.

[38]  P. Safar,et al.  Rapid Induction/Intubation for Prevention of Gastric‐Content Aspiration , 1970, Anesthesia and analgesia.

[39]  J. Granry,et al.  Thiopental Pharmacokinetics under Conditions of Long‐term Infusion , 1985, Anesthesiology.

[40]  J. Guilburd,et al.  Effectiveness of ketamine in decreasing intracranial pressure in children with intracranial hypertension. , 2009, Journal of neurosurgery. Pediatrics.

[41]  A. Kirkham,et al.  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] , 2004, Critical care.

[42]  U Klotz,et al.  Midazolam kinetics , 1981, Clinical pharmacology and therapeutics.

[43]  X. Viviand,et al.  Effects of sufentanil or ketamine administered in target-controlled infusion on the cerebral hemodynamics of severely brain-injured patients* , 2005, Critical care medicine.

[44]  BryanP. Hodkinson,et al.  PROPROFOL AND THE ELECTROENCEPHALOGRAM , 1987, The Lancet.

[45]  D. Menon,et al.  Comparative Tolerability of Sedative Agents in Head-Injured Adults , 2004, Drug safety.

[46]  Charles Antzelevitch.  Brugada syndrome. , 2006, Pacing and clinical electrophysiology : PACE.

[47]  S. Roberts,et al.  Growth of Staphylococcus aureus in Diprivan and Intralipid: implications on the pathogenesis of infections. , 1999, Anesthesiology.

[48]  S. Carley,et al.  Propofol for resistant status epilepticus , 2002 .

[49]  U. Illievich,et al.  Electroencephalographic burst suppression by propofol infusion in humans: hemodynamic consequences. , 1993, Anesthesia and analgesia.

[50]  R. Tempelhoff,et al.  Intracranial pressure during induction of anaesthesia and tracheal intubation with etomidate-induced EEG burst suppression , 1992, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[51]  D K Menon,et al.  Survey of intensive care of severely head injured patients in the United Kingdom , 1996, BMJ.

[52]  M. Roizen.  Dexmedetomidine vs Midazolam for Sedation of Critically Ill Patients: A Randomized Trial , 2010 .

[53]  K. Bledsoe,et al.  Evaluating the Use of Dexmedetomidine in Neurocritical Care Patients , 2010, Neurocritical care.

[54]  Shahab Khan,et al.  Precipitation of thiopental with muscle relaxants: a potential hazard , 2011, JRSM short reports.

[55]  C. Kalkman,et al.  Long-term propofol infusion and cardiac failure in adult head-injured patients , 2001, The Lancet.

[56]  K. Mackway-Jones.  Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary , 2000, Emergency Medicine Journal.

[57]  J. Ghajar,et al.  In Reply: Guidelines for the Management of Severe Traumatic Brain Injury: 2020 Update of the Decompressive Craniectomy Recommendations. , 2020, Neurosurgery.

[58]  M. Maze,et al.  Open Access Research , 2022 .

[59]  M. Ghoneim,et al.  Pharmacokinetics of Etomidate, a New Intravenous Anesthetic , 1978, Anesthesiology.

[60]  T J Gallagher,et al.  Comparison of propofol and midazolam for sedation in intensive care unit patients. , 1995, Critical care medicine.

[61]  J. Michenfelder,et al.  Cerebral effects of high-dose midazolam and subsequent reversal with Ro 15-1788 in dogs. , 1988, Anesthesiology.

[62]  M. J. Sutherland,et al.  Propofol and Seizures , 1994, Anaesthesia and intensive care.

[63]  L. Papazian,et al.  Effect of bolus doses of midazolam on intracranial pressure and cerebral perfusion pressure in patients with severe head injury. , 1993, British journal of anaesthesia.

[64]  R. Dittus,et al.  Prevalence and risk factors for development of delirium in surgical and trauma intensive care unit patients. , 2008, The Journal of trauma.

[65]  Susan S. Margulies,et al.  Inflicted Childhood Neurotrauma: New Insight into The Detection, Pathobiology, Prevention, and Treatment of Our Youngest Patients with Traumatic Brain Injury , 2007 .

[66]  W. Ziai,et al.  Target-controlled infusion for sedation of traumatic brain-injured patients: role uncertain. , 2005, Critical care medicine.

[67]  B. Nossaman,et al.  Dexmedetomidine: a review of clinical applications , 2008, Current opinion in anaesthesiology.

[68]  H. Shapiro,et al.  Ketamine anaesthesia in patients with intracranial pathology. , 1972, British journal of anaesthesia.

[69]  R. Sheth,et al.  Refractory status epilepticus , 1998, Neurology.