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

Abstract

BACKGROUND: Intracranial hypertension occurs in response to routine procedures such as endotracheal suctioning in patients with severe head injuries. In some patients, the intracranial pressure does not immediately return to baseline levels. OBJECTIVES: To examine the effect of drug administration on cerebrovascular response to endotracheal suctioning in adults with severe head injuries. METHODS: Seventy-one subjects were divided into 3 groups: those who received no drugs, those treated with opiates only (morphine sulfate and fentanyl citrate), and those treated with a neuromuscular blocking agent (vecuronium bromide) plus opiates. A controlled protocol involving 2 sequences of endotracheal suctioning that included hyperoxygenation, hyperinflation, and suctioning was used for all subjects. Two-way repeated-measures analyses of variance were done with type of drug as the between-subject factor and phase of suctioning as the within-subject factor. Survival analysis was used to compare the return of intracranial pressure to baseline levels among the 3 groups. RESULTS: Changes in intracranial pressure were significantly smaller in subjects who received a neuromuscular blocking agent plus opiates than in subjects who did not receive any drugs or received opiates only. The greatest increase in intracranial pressure from baseline was in the first and second phases of suctioning. The 3 groups showed no significant difference in the return of intracranial pressure to baseline level. CONCLUSIONS: Neuromuscular blockers attenuate the increases in intracranial pressure that occur with endotracheal suctioning. It is not known whether control of procedurally induced elevations in intracranial pressure affects long-term outcomes in adults with severe head injuries.

The effect of nursing interventions on the intracranial pressure in paediatric traumatic brain injury

“…However, the physiological effects of many of these interventions are largely unknown, and research in paediatric intensive care (PIC) is extremely limited. There is some evidence to show that in adult intensive care, these care interventions can produce significant adverse effects in brain‐injured patients (Mitchell et al , 1981; Fisher et al , 1982; Parsons and Ouzts Shogan, 1984; Parsons and Wilson, 1984; Parsons et al , 1985; Garradd and Bullock, 1986; Lee, 1989; Ersson et al , 1990; Campbell , 1991; Rudy et al , 1991; Crosby and Parsons, 1992; Paratz and Burns, 1993; Jones, 1995; Brucia and Rudy, 1996; Kerr et al , 1998; Gemma et al , 2002). However, this evidence is inconclusive in relation to the effects of many essential nursing care interventions in head‐injured patients.…”

Endotracheal suctioning in children with severe traumatic brain injury: a literature review

“…Similarly, Kerr et al (1998) in a large experimental study of 71 head-injured adults comparing different drug treatment with ETS found that patients treated with no sedative drugs displayed the classic 'stair-step' ICP increase pattern with ETS, whereas those treated with opiates and neuromuscular blockade (no cough) showed a flat response to ETS, with little change in ICP, demonstrating the effectiveness of levels of sedation and paralysis on patient's response to ETS. So, two papers concluded that if patients cough during ETS then their ICP is more pronounced.…”

“…They found that ETS increased ICP, and this increase was more pronounced when sedation was inadequate (p < 0Á0001). Kerr et al (1998) specifically studied the effect of neuromuscular blockade and opiates on the cerebrovascular response to ETS in 71 severe head-injured adults using a quasi-experimental design (no randomization). These patients were divided into three groups: group 1, no drugs; group 2, opiates only and group 3, opiates + neuromuscular blockade.…”

“…Endotracheal suctioning (ETS) is an essential nursing activity in intensive care that is carried out to reduce morbidity associated with invasive ventilation. However, research has shown that ETS can have considerable negative impact on many physiological variables, including the ICP and cerebral perfusion pressure (CPP) of head-injured patients (Bruya, 1981;Fisher et al, 1982;Hugo, 1987;Hobdell et al, 1989;Campbell, 1991;Rudy et al, 1991;Crosby and Parsons, 1992;Paratz and Burns, 1993;Brucia and Rudy, 1996;Wainwright and Gould, 1996;Kerr et al, 1998;Gemma et al, 2002). Despite this, nearly half of all nursing interventions performed in these severely ill children (with brain injury) are suctioning related (Tume, 2007).…”

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

“…However, it is also important to prevent sudden drops in blood pressure and cerebral perfusion by giving too much sedation; therefore, a balance needs to be achieved (Hall, 1997). The use of neuromuscular blockade drugs, such as rocuronium or atracurium, may be given prior to ETS as they reduce the incidence of coughing which will cause a rise in ICP (Palmer, 2000;Kerr et al, 1998). Suctioning should be performed if clinically indicated, and interventions of preoxygenation and sedation are recommended.…”