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Effect of intravenous midazolam on icp during endotracheal suctioning in severe head injured patients


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Effect of intravenous midazolam on icp during endotracheal suctioning in severe head injured patients

  1. 1. EFFECT OF INTRAVENOUS MIDAZOLAM ON ICP DURING ENDOTRACHEAL SUCTIONING IN SEVERE HEAD INJURED PATIENTS<br />Anjusha T ,Deepak Agrawal<br />Department of Neurosurgery<br />JPN Apex Trauma Centre, AIIMS, New Delhi<br />
  2. 2. BACKGROUND OF THE STUDY<br />Presence of intracranial hypertension after traumatic brain injury (TBI) affects patient’s outcome<br />Patients with head injury require elective ventilation and sedation to decrease ICP and any increase in ICP (even for brief period) may be detrimental<br />
  3. 3. PILOT STUDY<br />As a precursor to the present study a pilot study was done to assess changes in ICP following response checking & endotracheal suctioning<br />Pertinent data of the pilot study is presented as background to our present study<br />
  4. 4. PROCEDURE (PILOT STUDY)<br /><ul><li>At first the baseline ICP was recorded.
  5. 5. It was followed by response checking using supra orbital pain stimuli & peak ICP as well as time to return to the baseline was noted.
  6. 6. In the same way the ICP was assessed while doing oro-tracheal suctioning.
  7. 7. The variation in ICP in both cases as well as the duration of change was noted</li></li></ul><li>OBSERVATIONS (PILOT STUDY) <br />The total no. of patients taken - 12<br />The total no. of readings – 54<br />Mean GCS – 6.87<br />
  8. 8. Mean variation in ICP during response checking–6.19mmHg<br />(67% increase from baseline)<br />Mean variation in ICP during suctioning-19.61mmHg<br />(168% increase from baseline)<br />Mean duration of raised ICP with response checking<br />9.76 seconds<br />Mean duration of raised ICP with suctioning<br />26.56 seconds<br />OBSERVATIONS (PILOT STUDY)<br />
  9. 9. Patient 1<br />Graph showing change in ICP with time during response checking<br />
  10. 10. Patient 1<br />Graph showing change in ICP with time during suctioning<br />
  11. 11. STATISTICAL ANALYSIS<br />A paired T test was done<br />Change in ICP during response checking was highly significant [p<0.001]<br />Change in ICP during suctioning was also very highly significant [p<0.001]<br />
  12. 12. RESULTS (PILOT STUDY)<br />This rise in ICP and time to return to baseline are significantly higher during suctioning compared to response checking.<br />This pilot study suggested that extra-sedation may be warranted prior to suctioning to prevent the rise in ICP.<br />
  14. 14. AIMS & OBJECTIVES<br />To assess the variation in ICP during ET suctioning.<br />To assess the variation in ICP after administering bolus dose of Inj. Midazolam.<br />To compare the variation in ICP in both cases.<br />
  15. 15. METHODOLOGY<br />A prospective study was done in the NS ICU for the last one month in all ventilated severe head injury patients with ICP monitoring.<br />In the control group ICP was monitored before, during & after ET suctioning and readings were noted.<br />In the interventional group 2mg Inj. Midazolam was given just before doing ET suction & the readings were similarly noted.<br />
  16. 16. ICP MONITORINGMETHODS<br />There are mainly three ways for measuring ICP<br /><ul><li>By using intraventricular catheter
  17. 17. Subarachnoid screw or bolt
  18. 18. Epidural sensor
  19. 19. CODMAN Parenchymal Monitoring system (Electronic)</li></li></ul><li>ICP MONITORING DEVICES<br />Codman monitor<br />
  20. 20. OBSERVATIONS<br />Total no. of patients -8<br />Total no. of readings-36<br />Mean GCS -6.8<br />
  21. 21. Patient 1<br /><ul><li>Graph showing change in ICP with time during ET suctioning</li></ul>10 20 30 40 50<br />0 5 10 15 20 25 30 35 40 45<br />Time in (Seconds)<br />
  22. 22. Patient 1<br /><ul><li>Graph showing change in ICP with time after giving IV midaz</li></ul>10 20 30 40 50<br />0 5 10 15 20 25 30 35 40 45<br />Time in (Seconds)<br />
  23. 23. STATISTICALANALYSIS<br />A paired T test was done.<br />Mean rise of ICP in control group- 24.1mm Hg(SD-11.1)<br />Mean rise of ICP in interventional group-18.25mmHg(SD-9.29), P=0.017<br />
  24. 24. CONCLUSIONS<br />Our study suggest that additional bolus of Inj Midazolam prior to suctioning may significantly reduce the rise in ICP & should be practiced by ICU nurses.<br />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.<br />