The Effects of Remifentanil on Endotracheal Suctioning-Induced Increases in Intracranial Pressure in Head-Injured Patients

Abstract

In patients with severe traumatic brain injury, bronchotracheal toilet may be accompanied by deleterious variations in intracranial pressure (ICP). To avoid these effects, IV opioids have been proposed. Twenty mechanically-ventilated patients received 3 ascending IV doses of remifentanil: dose 1 (1 microg/kg bolus, 0.25 microg/kg/min infusion); dose 2 (2 microg/kg bolus, 0.5 microg/kg/min infusion); and dose 3: (4 microg/kg bolus, 1 microg/kg/min infusion). Endotracheal suction was performed 20 min after the beginning of infusion to assess coughing. Heart rate, ICP, mean arterial blood pressure (MAP), cerebral perfusion pressure (CPP), middle cerebral artery mean flow velocity (V(MCA)), and bispectral index were monitored throughout the 30-min study period. Twelve, 15, and 19 patients receiving dose 1, 2, and 3, respectively, required vasopressors to maintain CPP >60 mm Hg. Suctioning resulted in coughing in 16, 15, and 5 patients receiving dose 1, 2, and 3, respectively. An increase in ICP, without change in V(MCA), corresponded to the reduction in MAP consistent with the preservation of autoregulation. Remifentanil used as a continuous infusion in head-injured patients is not an effective drug to block responses to suctioning.

Temperature-controlled radiofrequency tonsil ablation for the treatment of halitosis

“…The rapid offset of action and short contextsensitive half-time of remifentanil, irrespective of the duration of the infusion, makes the drug a valuable opioid analgesic and sedative option [29][30][31]. Remifentanil in combination with low dose of midazolam provided less retching and gagging, decreased fear and anxiety, consequently improved surgical outcome with early recovery periods in our patients.…”

Endotracheal Lidocaine in Preventing Endotracheal Suctioning-induced Changes in Cerebral Hemodynamics in Patients with Severe Head Trauma

“…These adverse cerebral hemodynamic events can have catastrophic consequences, especially, when cerebral auto-regulation is lost because of head trauma [8,9]. Although several techniques or pharmacological agents have been proposed to prevent increased ICP during endotracheal suctioning in patients with severe head trauma, including hyperventilation [10], muscle relaxants [1] and topical, and systemic use of local anesthetics including lidocaine [1,11,12] and more recently infusion of the sedative opioid remifentanil [13], all have adverse effects that limit their clinical application. Hyperventilation, for example, abruptly reduces carbon dioxide tension, and thereby, reducing cerebral perfusion thus increasing the risk of cerebral ischemia [14] and causes hyperinflation thus worsening ICP [15].…”

“…The use of muscle relaxants lengthens patients' stay in the intensive care unit and increases the incidence of sepsis, pneumonia and neuropathy [16]. Sedation alters systemic and cerebral hemodynamics (possibly reducing CPP) and precludes neurological examination [13,17]. Earlier clinical trials did not resolve the clinical problem of endotracheal suctioninginduced changes in cerebral hemodynamics.…”

Remifentanil and Other Opioids

“…On the other hand, further assessments are still required before a sound position can be taken on the problem of acute tolerance or pain-free transition to recovery (Muellejans et al 2004). Furthermore, dosing schemes are still to be refined for fear no clinical benefit can be demonstrated (Leone et al 2004b). …”