Early, routine paralysis for intracranial pressure control in severe head injury: is it necessary?

OBJECTIVE: To investigate the efficacy of early, routine use of neuromuscular blocking agents for intracranial pressure management in patients with severe head injury. DESIGN: Retrospective review of data from the Traumatic Coma Data Bank. The Traumatic Coma Data Bank was a collaborative project of the National Institute of Neurological Disorders and Stroke that involved four Level I trauma centers. The Traumatic Coma Data Bank prospectively collected data on 1,030 severe head-injured patients (Glasgow Coma Score of < or = 8) between 1984 and 1987. SETTING: Four Level I trauma centers coordinated by the National Institute of Neurological Disorders and Stroke. PATIENTS: A total of 514 Traumatic Coma Data Bank patients who met study inclusion criteria were divided into two groups: group 1 consisted of 239 patients who were pharmacologically paralyzed starting within the first intensive care unit (ICU) shift or < or = 6 hrs into the second shift and lasting for at least 12 hrs. Group 2 contained the remaining 275 patients who did not fulfill these criteria. MEASUREMENTS AND MAIN RESULTS: We analyzed the acute care course of these patients from the time of injury through admission, resuscitation, and ICU stay, as well as their rehabilitation follow-up results for < or = 1 yr. These two groups did not differ significantly regarding admission intracranial computed tomography diagnosis, admission Glasgow motor score, percentage of monitored time that intracranial pressure was > or = 20 mm Hg, or frequency of initial intracranial pressure > or = 20 mm Hg. In group 2, more patients were aged > 40 yrs (24% vs. 15% in group 1) or had admission hypotension (33% in group 2 vs. 25% in group 1). Multivariate regression analysis showed that ICU stay was significantly longer in group 1 (mean 7.76 days) than group 2 (mean 4.84 days; p < .001). The occurrence of pneumonia was significantly higher in group 1 (29% vs. 15%, p < .001). There was a tendency toward a higher occurrence of sepsis in group 1, but this difference did not reach statistical significance (11% vs. 7%, p = .08). The final Glasgow Outcome Scale scores for the two groups were not significantly different in those survivors with good and moderate outcomes. Although there were more deaths in group 2 (39% vs. 24%, p < .001), there were more vegetative or severely disabled survivors in group 1 (8% vs. 4% and 21% vs. 13%, respectively). CONCLUSIONS: Our findings suggest that early, routine, long-term use of neuromuscular blocking agents in patients with severe head injuries to manage intracranial pressure does not improve overall outcome and may actually be detrimental because of the prolongation of their ICU stay and the increased frequency of extracranial complications associated with pharmacologic paralysis. We suggest that routine early management of the head-injured patient in the ICU should be accomplished using sedation alone and that neuromuscular blockade should be generally reserved for patients with intracranial hypertension who require escalation of treatment intensity.

Pharmacoeconomic issues of sedation, analgesia, and neuromuscular blockade in critical care.

Neuromuscular blocking agents (NMBAs) are commonly prescribed as adjunct therapy for many critically ill patients. Controversy exists regarding the appropriate long-term use of these agents, particularly since there are severe potential clinical consequences. The expanded use of NMBAs has had a significant effect on the cost of ICU care. One should determine whether or not NMBAs are being used as adjunct therapy, or as a replacement for optimal sedation and/or analgesia. This article reviews some of the indicative economic issues surrounding the use of sedatives, analgesics, and NMBAs in the critical care arena. Understanding the pharmacokinetic and pharmacodynamic differences of these agents can aid in drug selection and route of administration. Appropriate drug selection can influence the pharmacoeconomics of these agents in the ICU.

Analysis of workload and staffing requirements for a critical-care satellite pharmacy.

A study to determine the workload and the staffing requirements of a proposed critical-care satellite pharmacy is reported. Data for all patients admitted to the adult surgical intensive-care units (SICUs) of an acute-care teaching hospital were recorded for 30 days. Both clinical and distributive data were collected, such as the number and times of patient admissions to the SICUs, the times medication orders were written and their nature, the number and types of drugs administered per patient per day, the number of medication profile reviews per day, and the number and types of interventions. Productivity standards were determined for specific clinical and distributive tasks and used to project the staffing requirements of the new satellite pharmacy. It was determined that proposed changes in distributive services, including expansion of the i.v. admixture program and implementation of a syringe-pump infusion system, would increase the pharmacist and technician staffing requirements by 1.91 and 6.77 hours per day, respectively. Expansion of clinical services, such as pharmacokinetic monitoring, would increase the pharmacist staffing requirements by 8.68 hours per day. It was estimated that the SICU satellite pharmacy could save the hospital more than $200,000 per year. Hospital administration approved a request to increase staffing by 3 full-time-equivalent (FTE) pharmacists and 1.6 FTE technicians. Workload analyses and projections of staffing requirements must incorporate measurements for clinical as well as distributive services.

Audit of serum drug concentration analysis for patients in the surgical intensive care unit.

Serum drug concentration measurements can help the practitioner attain maximal therapeutic efficacy and minimal undesirable effects of certain medications. It is necessary, however, to obtain serum samples appropriately to assure that the result will provide useful information. In preparation for expansion of clinical pharmacy services to the surgical ICU, a study was performed to a) identify the drugs for which serum samples were requested and b) assess whether the results of the serum samples were being used appropriately to adjust doses. Currently, the pharmacy pharmacokinetics service routinely analyzes serum concentrations for antimicrobial agents, theophylline, and other drugs as requested. By the end of this year, we expect further expansion to include phenytoin, pentobarbital, phenobarbital, procainamide/NAPA, lidocaine, and digoxin.

Drug utilization review: dipyridamole plus aspirin antiplatelet therapy.

To assess whether dipyridamole was being used appropriately in providing antiplatelet therapy at the San Diego VAMC, a drug utilization review was conducted. Concomitant aspirin therapy was required for dipyridamole to be considered effective in the disease states reviewed. Seventy-three patients on antiplatelet therapy were evaluated, using dosing criteria established through a literature review. Our data indicated tht based on the criteria, only 11% of patients received dipyridamole in appropriate doses; it was underdosed in 89% of patients, and in 19% of patients, it was used when not indicated. In addition, 19% of patients did not receive concomitant aspirin therapy. Results suggest hat dipyridamole is not used optimally in providing antiplatelet therapy to patients in this institution.