Commentary 6.1.4.

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SKELETAL MUSCLE RELAXANTS FOR TREATMENT
OF BRAIN INJURY IN THE ICU
by Tomas Beran

Skeletal muscle relaxants are used in patients with severe traumatic brain injury to avoid excessive motor activity that increases ICP. Patients must have continuous ICP monitoring. The recommended relaxants are succinylcholine, atracurium, vecuronium and pancuronium1-4.

After 72 hrs, it is preferable to induce analgesia and sedation. If skeletal muscle paralysis is necessary, atracurium, vecuronium or pancuronium are recommended 5-7.

References:
1. Redan JA, Livingston DH, Tortella BJ, Rush BFJ: The value of intubating and paralyzing patients with suspected head injury in the emergency department. J Trauma 1991; 31(3):371-375.
2. Hsiang J, Chesnut RM, Crisp CB, et al: Early, routine paralysis for ICP control in severe head injury: Is it necessary? In Proceedings of the Second International Neurotrauma Symposium, Glasgow 1993. J Crit Care Med 1993; 22:471-476.
3. Duhaime AC: Conventional drug therapies for head injury. In Narayan RK, Wilberger JR, Povlishock JT (eds): Neurotrauma. New York: McGraw-Hill 1996: 365-374.
4. Stirt JA, Maggio W, Hawoth C, et al: Vecuronium: Effect  on intracranial pressure and hemodymanics in neurosurgical patients. Anesthesiology 1987;67(4):570-573.
5. Partridge BL, Abrams JH, Bazemore C, Rubin R: Prolonged neuromuscular blockade after long-term infusion of vecuronium bromide in the intensive care unit. Crit Care Med 1990;18:1177-1179.
6. Segredo V, Caldwell JE, Matthay MA, et al: Persistent paralysis in critically ill patients after long-term administration of vecuronium. N Engl J Med 1992; 327:524-528.
7. Werba A, Klezl M, Schramm W, et al: The level of neuromuscular block needed to suppress diaphragmatic movement during tracheal suction in patients with raised intracranial pressure: A study with vecuronium and atracurium. Anesthesia 1993; 48(4):301-303.

Last updated: 1999-09-06