This study examines the effects of intravenous midazolam on intracranial pressure (ICP) during endotracheal suctioning in patients with severe head injuries. A previous pilot study found that ICP rose more during suctioning than response checking, suggesting extra sedation may help. The current study divided patients into a control group that underwent suctioning without medication and an intervention group that received 2mg of midazolam before suctioning. It found that midazolam reduced the average ICP rise during suctioning from 24.1mm Hg to 18.25mm Hg. However, a significant ICP rise from baseline still occurred with suctioning even with midazolam. The study concludes that

1. EFFECT OF INTRAVENOUS MIDAZOLAM ON ICP DURING ENDOTRACHEAL SUCTIONING IN SEVERE HEAD INJURED PATIENTS Anjusha T ,Deepak Agrawal Department of Neurosurgery JPN Apex Trauma Centre, AIIMS, New Delhi

2. 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

3. PILOT STUDY As 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

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

8. 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)

9. Patient 1 Graph showing change in ICP with time during response checking

10. Patient 1 Graph showing change in ICP with time during suctioning

11. 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]

12. 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.

13. RATIONALE FOR STUDY BASED ON THESE OBSERVATIONS WE DESIGNED THE CURRENT STUDY

14. 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.

15. METHODOLOGY A 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.

17. Subarachnoid screw or bolt

18. Epidural sensor

20. OBSERVATIONS Total no. of patients -8 Total no. of readings-36 Mean GCS -6.8

23. STATISTICALANALYSIS 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

24. CONCLUSIONS 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. 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.