Effect of neuromuscular blockers and opiates on the cerebrovascular response to endotracheal suctioning in adults with severe head injuries.

BACKGROUND Intracranial hypertension occurs in response to routine procedures such as endotracheal suctioning in patients with severe head injuries. In some patients, the intracranial pressure does not immediately return to baseline levels. OBJECTIVES To examine the effect of drug administration on cerebrovascular response to endotracheal suctioning in adults with severe head injuries. METHODS Seventy-one subjects were divided into 3 groups: those who received no drugs, those treated with opiates only (morphine sulfate and fentanyl citrate), and those treated with a neuromuscular blocking agent (vecuronium bromide) plus opiates. A controlled protocol involving 2 sequences of endotracheal suctioning that included hyperoxygenation, hyperinflation, and suctioning was used for all subjects. Two-way repeated-measures analyses of variance were done with type of drug as the between-subject factor and phase of suctioning as the within-subject factor. Survival analysis was used to compare the return of intracranial pressure to baseline levels among the 3 groups. RESULTS Changes in intracranial pressure were significantly smaller in subjects who received a neuromuscular blocking agent plus opiates than in subjects who did not receive any drugs or received opiates only. The greatest increase in intracranial pressure from baseline was in the first and second phases of suctioning. The 3 groups showed no significant difference in the return of intracranial pressure to baseline level. CONCLUSIONS Neuromuscular blockers attenuate the increases in intracranial pressure that occur with endotracheal suctioning. It is not known whether control of procedurally induced elevations in intracranial pressure affects long-term outcomes in adults with severe head injuries.

背景 在重度颅脑损伤患者中，诸如气管内吸痰等常规操作可引发颅内高压。在一些患者中，颅内压不会立即恢复到基线水平。 目的 研究药物给药对重度颅脑损伤成人患者气管内吸痰时脑血管反应的影响。 方法 71名受试者被分为3组：未用药组、仅使用阿片类药物（硫酸吗啡和枸橼酸芬太尼）治疗组以及使用神经肌肉阻滞剂（维库溴铵）加阿片类药物治疗组。对所有受试者采用一种包含2次气管内吸痰序列的对照方案，包括高氧、过度充气和吸痰。以药物类型作为组间因素，吸痰阶段作为组内因素进行双向重复测量方差分析。采用生存分析比较3组之间颅内压恢复到基线水平的情况。 结果 使用神经肌肉阻滞剂加阿片类药物的受试者颅内压变化明显小于未用药或仅使用阿片类药物的受试者。从基线水平来看，颅内压最大增幅出现在吸痰的第一和第二阶段。3组在颅内压恢复到基线水平方面无显著差异。 结论 神经肌肉阻滞剂可减轻气管内吸痰时出现的颅内压升高。目前尚不清楚控制由操作引起的颅内压升高是否会影响重度颅脑损伤成人患者的长期预后。