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Title: The Impact of Sedative Choice on Intracranial and Systemic Physiology in Moderate to Severe Traumatic Brain Injury: A Scoping Review.
Austin Authors: Jeffcote, Toby;Weir, Timothy;Anstey, James;Mcnamara, Robert;Bellomo, Rinaldo ;Udy, Andrew
Affiliation: Intensive Care..
Department of Intensive Care, Royal Perth Hospital, Perth, WA, Australia..
Department of Critical Care, University of Melbourne, Parkville Australia..
Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, Vic. Australia..
Department of Intensive Care Medicine, The Alfred Hospital, Melbourne, Australia..
Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia..
Issue Date: 1-Jul-2023
Date: 2022
Publication information: Journal of Neurosurgical Anesthesiology 2023; 35(3)
Abstract: Although sedative use is near-ubiquitous in the acute management of moderate to severe traumatic brain injury (m-sTBI), the evidence base for these agents is undefined. This review summarizes the evidence for analgosedative agent use in the intensive care unit management of m-sTBI. Clinical studies of sedative and analgosedative agents currently utilized in adult m-sTBI management (propofol, ketamine, benzodiazepines, opioids, and alpha-2 agonists) were identified and assessed for relevance and methodological quality. The primary outcome was the effect of the analgosedative agent on intracranial pressure (ICP). Secondary outcomes included intracranial hemodynamic and metabolic parameters, systemic hemodynamic parameters, measures of therapeutic intensity, and clinical outcomes. Of 594 articles identified, 61 met methodological review criteria, and 40 were included in the qualitative summary; of these, 33 were prospective studies, 18 were randomized controlled trials, and 8 were blinded. There was consistent evidence for the efficacy of sedative agents in the management of m-sTBI and raised ICP, but the overall quality of the evidence was poor, consisting of small studies (median sample size, 23.5) of variable methodological quality. Propofol and midazolam achieve the goals of sedation without notable differences in efficacy or safety, although high-dose propofol may disrupt cerebral autoregulation. Dexmedetomidine and propofol/ dexmedetomidine combination may cause clinically significant hypotension. Dexmedetomidine was effective to achieve a target sedation score. De novo opioid boluses were associated with increased ICP and reduced cerebral perfusion pressure. Ketamine bolus and infusions were not associated with increased ICP and may reduce the incidence of cortical spreading depolarization events. In conclusion, there is a paucity of high-quality evidence to inform the optimal use of analgosedative agents in the management of m-sTBI, inferring significant scope for further research.
DOI: 10.1097/ANA.0000000000000836
ORCID: 0000-0002-1650-8939
Journal: Journal of neurosurgical anesthesiology
PubMed URL: 35142704
PubMed URL:
Type: Journal Article
Appears in Collections:Journal articles

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