Commentary 6.1.3.

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SEDATIVES FOR TREATMENT OF BRAIN INJURY IN THE ICU
by Tomas Beran

Elevations of ICP occuring during minor procedures, such as suction of the airways or further examinations of the patient, may be dangerous, not least in patients with an already increased ICP. Sufficient analgesia and sedation - combined with skeletal muscle paralysis, if needed - is therefore an important part of the management of severe head injuries (GCS 3-8) in the ICU .

Sedatives are also useful for patients with moderate head injuries (GCS 9-12). They calm agitated states, prevent uncontrolled movements and relieve pain. Relative disadvantage of analgesics, sedatives and skeletal muscle relaxants is that they hinder clinical neurological examination (see Commentary 3.5.1.).

From sedatives, midazolam, propofol, and chlorpromazin are preferred1-5.Morfin and fentanyl are the recommended analgesics4,6,7.

References:
1. Chiolero RL, de Tribolet N: Sedatives and antagonists in the management of severely head injured patients. Acta Neurochir (Wien) 1992;55:43-46.
2. Schulte am Esch J, Kochs E: Midazolam and flumazenil in neuroanesthesia. Acta Anaesthesiol Scand 1990;92(Suppl): 96-102.
3. Malacrida R, Fritz ME, Suter PM, Crevoisier C: Pharmacokinetics of midazolam administered by continuous intravenous infusion to intensive care patients. Crit Care Med 1992;20(8):1123-1126.
4. Duhaime AC: Conventional drug therapies for head injury. In Narayan RK, Wilberger JR, Povlishock JT (eds): Neurotrauma. New York: McGraw-Hill 1996:365-374.
5. Pinaud M, Lelausque JN, Chetanneau A, et al: Effects of propofol on cerebral hemodynamics and metabolism in patients with brain trauma. Anesthesiology 1990;73(3):404-409.
6. Sperry RJ, Bailey PL, Reichman MV et al: Fentanyl and sufentanil increase intracranial pressure in head trauma patients. Anesthesiology 1992;77(3):416-420.
7. Weinstabl C, Mayer N, Richling B, Czech T and Spiss CK: Effect of sufentanil on intracranial pressure in neurosurgical patients. Anaesthesia 1991;46(10):837-840.

Last updated: 1999-09-06