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CRITICAL CARE AND TRAUMA

The Effects of Remifentanil on Endotracheal Suctioning-Induced Increases in Intracranial Pressure in Head-Injured Patients

Marc Leone, MD^*, Jacques Albanèse, MD^*, Xavier Viviand, MD^*, Franck Garnier, MD^*, Aurelie Bourgoin, MD^*, Karine Barrau, MD, and Claude Martin, MD^*

*Intensive Care Unit and Department of Anesthesiology and the Department of Biostatistics and Epidemiology, Nord Hospital, Marseilles University Hospital System (AP-HM), Marseilles School of Medicine, Marseilles, France

Address correspondence to Marc Leone, MD, Department of Anesthesiology and Critical Care, Washington University School of Medicine, Box 8054, 660 S Euclid Ave, Saint Louis, MO 63110. Address email to leonem{at}msnotes.wustl.edu

In patients with severe traumatic brain injury, bronchotracheal toilet may be accompanied by deleterious variations in intracranial pressure (ICP). To avoid these effects, IV opioids have been proposed. Twenty mechanically-ventilated patients received 3 ascending IV doses of remifentanil: dose 1 (1 µg/kg bolus, 0.25 µg/kg/min infusion); dose 2 (2 µg/kg bolus, 0.5 µg/kg/min infusion); and dose 3: (4 µg/kg bolus, 1 µg/kg/min infusion). Endotracheal suction was performed 20 min after the beginning of infusion to assess coughing. Heart rate, ICP, mean arterial blood pressure (MAP), cerebral perfusion pressure (CPP), middle cerebral artery mean flow velocity (V_MCA), and bispectral index were monitored throughout the 30-min study period. Twelve, 15, and 19 patients receiving dose 1, 2, and 3, respectively, required vasopressors to maintain CPP >60 mm Hg. Suctioning resulted in coughing in 16, 15, and 5 patients receiving dose 1, 2, and 3, respectively. An increase in ICP, without change in V_MCA, corresponded to the reduction in MAP consistent with the preservation of autoregulation. Remifentanil used as a continuous infusion in head-injured patients is not an effective drug to block responses to suctioning.

IMPLICATIONS: Remifentanil bolus in severe head trauma patients in the intensive care unit induces an increase in intracranial pressure related to a decrease in mean arterial blood pressure, suggesting the preservation of autoregulation. Only large doses of this opioid requiring hemodynamic support can block coughing induced by an endotracheal suction.

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