effect of intravenous midazolam on icp during endotracheal suctioning in severe head injured...

EFFECT OF INTRAVENOUS MIDAZOLAM ON ICP DURING ENDOTRACHEAL SUCTIONING IN

SEVERE HEAD INJURED PATIENTS

Anjusha T ,Deepak AgrawalDepartment of Neurosurgery

JPN Apex Trauma Centre, AIIMS, New Delhi

BACKGROUND OF THE STUDY

Presence of intracranial hypertension after traumatic brain injury

(TBI) affects patient’s outcome

Patients with head injury require elective ventilation and sedation

to decrease ICP and any increase in ICP (even for brief period)

may be detrimental

PILOT STUDYAs a precursor to the present study a pilot study

was done to assess changes in ICP following response checking & endotracheal suctioning

Pertinent data of the pilot study is presented as background to our present study

PROCEDURE (PILOT STUDY)

- At first the baseline ICP was recorded.

- It was followed by response checking using supra orbital pain stimuli & peak ICP as well as time to return to the baseline was noted.

- In the same way the ICP was assessed while doing oro-tracheal suctioning.

- The variation in ICP in both cases as well as the duration of change was noted

OBSERVATIONS (PILOT STUDY)

The total no. of patients taken - 12

The total no. of readings – 54

Mean GCS – 6.87

Mean variation in ICP during response checking–6.19mmHg

(67% increase from baseline)

Mean variation in ICP during suctioning-19.61mmHg

(168% increase from baseline)

Mean duration of raised ICP with response checking

9.76 seconds

Mean duration of raised ICP with suctioning

26.56 seconds

OBSERVATIONS (PILOT STUDY)

Patient 1Graph showing change in ICP with time during

response checking

0 4 8 140

5

10

15

20

25

Response checking

Patient 1Graph showing change in ICP with time during

suctioning

0 4 8 380

5

10

15

20

25

30

35

40

45

Suctioning

STATISTICAL ANALYSIS

A paired T test was done

Change in ICP during response checking was highly significant [p<0.001]

Change in ICP during suctioning was also very highly significant [p<0.001]

RESULTS (PILOT STUDY)This rise in ICP and time to return to baseline are significantly

higher during suctioning compared to response checking.

This pilot study suggested that extra-sedation may be

warranted prior to suctioning to prevent the rise in ICP.

BASED ON THESE OBSERVATIONS WE DESIGNED THE CURRENT STUDY

RATIONALE FOR STUDY

AIMS & OBJECTIVES

To assess the variation in ICP during ET suctioning.

To assess the variation in ICP after administering

bolus dose of Inj. Midazolam.

To compare the variation in ICP in both cases.

METHODOLOGYA prospective study was done in the NS ICU for the

last one month in all ventilated severe head injury patients with ICP monitoring.

In the control group ICP was monitored before, during & after ET suctioning and readings were noted.

In the interventional group 2mg Inj. Midazolam was given just before doing ET suction & the readings were similarly noted.

ICP MONITORING METHODS

There are mainly three ways for measuring ICP

By using intraventricular catheter

Subarachnoid screw or bolt

Epidural sensor

CODMAN Parenchymal Monitoring system (Electronic)

ICP MONITORING DEVICES

Codman monitor

OBSERVATIONSTotal no. of patients -8

Total no. of readings-36

Mean GCS -6.8

Patient 1Graph showing change in ICP with time during ET

suctioning

0 5 10 15 20 25 30 35 40 45Time in (Seconds)

10

20

30

40

50

Patient 1Graph showing change in ICP with time after giving IV

midaz

0 5 10 15 20 25 30 35 40 45Time in (Seconds)

10

20

30

40

50

STATISTICAL ANALYSIS A paired T test was done.

Mean rise of ICP in control group- 24.1mm Hg(SD-

11.1)

Mean rise of ICP in interventional group-

18.25mmHg(SD-9.29), P=0.017

CONCLUSIONSOur study suggest that additional bolus of Inj

Midazolam prior to suctioning may significantly reduce the rise in ICP & should be practiced by ICU nurses.

However, significant rise in ICP from baseline still occurs so additional interventions will need to be defined to further decrease in ICP during suctiong in severe head injury patients.