The Role of Neuromuscular Blockade in Patients with Traumatic Brain Injury: A Systematic Review

Abstract

Management of Traumatic Brain Injury (TBI) focuses on controlling intracranial pressure (ICP), while other treatments, such as the use of neuromuscular blocking agents (NMBAs), need scientific evidence. We conducted a systematic review to investigate the usefulness of NMBAs in the context of TBI and/or increased ICP. We searched MEDLINE and EMBASE databases up to January 31st 2014, including both clinical and experimental findings. We found a total of 34 articles, of which 22 were prospective clinical trials. No systematic review/meta-analyses were found. Seven studies evaluated NMBA boluses in preventing stimulation-related ICP surges: paralysis was effective during tracheal suctioning and physiotherapy but not during bronchoscopy. Fourteen small studies (8 to 25 patients) assessed the effect of NMBA boluses on ICP. Two studies showed an ICP increase by succinylcholine and one found a decrease in ICP after atracurium. No ICP changes were observed in the other studies. One prospective study confirmed that discontinuing paralysis increases energy expenditure. Two retrospective studies investigated mortality/morbidity: one found that early paralysis (continued for >12 h) was not beneficial and potentially associated with extra-cranial complications, while the second demonstrated a correlation between continuous infusion of NMBA and time spent with ICP > 20 mmHg. Eight animal studies were also retrieved. In most studies, NMBA bolus was beneficial in controlling ICP, especially when performing stimulating procedures. However, retrospective evidence found potential harm by continuous NMBA infusion. In the context of TBI patients, we discuss the potentially positive effects of paralysis with its negative ones. Well-conducted randomized controlled trials and/or large pharmaco-epidemiologic studies are warranted.

The Association Between Spontaneous Hyperventilation, Delayed Cerebral Ischemia, and Poor Neurological Outcome in Patients with Subarachnoid Hemorrhage

“…Sedation with opioids can also be effective, but may interfere with monitoring of the patient's neurological status [38,39]. The use of neuromuscular blockade is typically discouraged in critically ill neurological patients because it further compromises the ability to assess neurological status, and neuromuscular blockers significantly increase the risk of adverse effects such as ICU-acquired weakness [40,41]. Additional study is needed before either modality should be recommended to treat severe spontaneous hyperventilation in SAH.…”

Pediatric Traumatic Brain Injury: Characteristic Features, Diagnosis, and Management

“…Sanfilippo et al confirmed the lack of evidence on the effect of neuromuscular blockade on ICP and related outcomes in his recent systematic review. 65) …”

The critical care management of poor-grade subarachnoid haemorrhage

“…The initial approach to raised ICP includes head of bed elevation (between 30° and 45°) to optimise cerebral venous drainage, normoventilation (arterial partial pressure of carbon dioxide (PaCO 2 ): 35–40 mm Hg) [ 33 ], use of sedation and analgesia to achieve a calm and quiet state (Richmond Agitation Sedation Scale score of −5 or Sedation-Agitation Scale score of 1), and surgical intervention in the presence of mass-occupying lesions [ 34 ]. The use of neuromuscular blocking agents is sometimes applied to prevent ICP surges during tracheal suctioning and physiotherapy; however, the role of these drugs for ICP management is not well established, and some authors suggest that they may be more deleterious than beneficial [ 35 ]. If ICP remains elevated despite these interventions, a short course (less than 2 hours) of hyperventilation (PaCO 2 of 30–35 mm Hg) might be considered while new brain imaging is obtained and other interventions are planned and initiated [ 36 – 38 ].…”