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.