Effects of Fiberoptic Bronchoscopy on Intracranial Pressure in Patients with Brain Injury: A Prospective Clinical Study
BACKGROUNDFiberoptic bronchoscopy (FB) plays an important role in making the diagnosis of nosocomial pneumonia and resolving lobar atelectasis in critically injured trauma patients. It has been shown to be a safe procedure with only occasional complications. However, in patients with head injuries,...
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| description | BACKGROUNDFiberoptic bronchoscopy (FB) plays an important role in making the diagnosis of nosocomial pneumonia and resolving lobar atelectasis in critically injured trauma patients. It has been shown to be a safe procedure with only occasional complications. However, in patients with head injuries, FB can lead to intracranial hypertension. Sustained increases in intracranial pressure (ICP) leads to poor outcome in these patients. Because of this, a prospective study was done not only to assess the effect of FB on ICP and cerebral perfusion pressure (CPP) in patients with brain injuries, but also to identify a regimen of sedation and anesthesia that could prevent significant increases in ICP during FB.
METHODSTwenty-six FB were performed in 23 patients with ICP monitors or ICP monitors and ventriculostomy drains in place for Glasgow Coma Scale score < 8 or management of postcraniotomy trauma. FB was performed to aid in the diagnosis of nosocomial pneumonia or to aid in resolving lobar atelectasis. Before FB, all patients received a standard anesthetic regimen consisting of vecuronium (10 mg), morphine sulfate (4 mg), and midazolam (2.5 mg). Patients with diminished cranial compliance, defined as ICP > 10 mm Hg, also received a nebulizer treatment of 3 mL of 4% lidocaine before FB. All patients were preoxygenated with Fio2 = 1.0 for 10 minutes. Intracranial pressure, mean arterial pressure, and CPP were monitored continuously throughout the procedure. These same variables were also recorded at baseline and at 2-minute intervals during the procedure. The time to return to baseline ICP was also recorded.
RESULTSThe mean ICP at baseline (immediately before FB) was 12.6 mm Hg. After introduction of the bronchoscope, the ICP rapidly increased in 21 procedures (81%) and the mean highest ICP was 38.0 mm Hg. There was also a concomitant increase in mean arterial pressure such that there was no substantial change in CPP. The mean lowest CPP was 73.1 mm Hg. The average time for return of ICP to baseline was 13.9 minutes. In the subgroup of patients with ICP > 10, attempting to blunt the tracheal stimulation by anesthetizing the trachea with 4% nebulized lidocaine did not seem to be successful. The mean highest ICP in this subgroup was 41.8 mm Hg. The CPP changed in a similar manner, as the mean lowest CPP was 74.0 mm Hg. The mean time to return to baseline was 12.5 minutes. No patient had acute neurologic deterioration secondary to FB.
CONCLUSIONSAlthough FB is an imp |
| doi_str_mv | 10.1097/00005373-200005000-00011 |
| format | Article |
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METHODSTwenty-six FB were performed in 23 patients with ICP monitors or ICP monitors and ventriculostomy drains in place for Glasgow Coma Scale score < 8 or management of postcraniotomy trauma. FB was performed to aid in the diagnosis of nosocomial pneumonia or to aid in resolving lobar atelectasis. Before FB, all patients received a standard anesthetic regimen consisting of vecuronium (10 mg), morphine sulfate (4 mg), and midazolam (2.5 mg). Patients with diminished cranial compliance, defined as ICP > 10 mm Hg, also received a nebulizer treatment of 3 mL of 4% lidocaine before FB. All patients were preoxygenated with Fio2 = 1.0 for 10 minutes. Intracranial pressure, mean arterial pressure, and CPP were monitored continuously throughout the procedure. These same variables were also recorded at baseline and at 2-minute intervals during the procedure. The time to return to baseline ICP was also recorded.
RESULTSThe mean ICP at baseline (immediately before FB) was 12.6 mm Hg. After introduction of the bronchoscope, the ICP rapidly increased in 21 procedures (81%) and the mean highest ICP was 38.0 mm Hg. There was also a concomitant increase in mean arterial pressure such that there was no substantial change in CPP. The mean lowest CPP was 73.1 mm Hg. The average time for return of ICP to baseline was 13.9 minutes. In the subgroup of patients with ICP > 10, attempting to blunt the tracheal stimulation by anesthetizing the trachea with 4% nebulized lidocaine did not seem to be successful. The mean highest ICP in this subgroup was 41.8 mm Hg. The CPP changed in a similar manner, as the mean lowest CPP was 74.0 mm Hg. The mean time to return to baseline was 12.5 minutes. No patient had acute neurologic deterioration secondary to FB.
CONCLUSIONSAlthough FB is an important procedure in the pulmonary care of head injured patients, it produces substantial, but transient, increases in ICP and should be used with caution in patients with diminished cranial compliance. Sedation, analgesia, paralysis, and topical tracheal anesthesia did not completely prevent the rise in ICP. Although no acute deterioration in condition occurred, secondary brain injury caused by localized cerebral ischemia is certainly possible. Because of the substantial increases in ICP, herniation may be precipitated in an occasional patient. Further study is needed to identify a regimen that will confer protection.</description><identifier>ISSN: 0022-5282</identifier><identifier>EISSN: 1529-8809</identifier><identifier>DOI: 10.1097/00005373-200005000-00011</identifier><identifier>PMID: 10823531</identifier><language>eng</language><publisher>United States: Lippincott Williams & Wilkins, Inc</publisher><subject>Adolescent ; Adult ; Anesthesia - methods ; Blood Pressure ; Brain Injuries - complications ; Brain Injuries - physiopathology ; Bronchoscopy - adverse effects ; Cerebrovascular Circulation ; Conscious Sedation - methods ; Cross Infection - complications ; Cross Infection - diagnosis ; Female ; Glasgow Coma Scale ; Humans ; Injury Severity Score ; Intracranial Hypertension - etiology ; Intracranial Hypertension - physiopathology ; Intracranial Hypertension - prevention & control ; Intracranial Pressure ; Male ; Middle Aged ; Monitoring, Physiologic ; Pneumonia - complications ; Pneumonia - diagnosis ; Positive-Pressure Respiration ; Prospective Studies ; Pulmonary Atelectasis - complications ; Pulmonary Atelectasis - diagnosis ; Time Factors ; Ventriculostomy</subject><ispartof>The journal of trauma, 2000-05, Vol.48 (5), p.878-883</ispartof><rights>2000 Lippincott Williams & Wilkins, Inc.</rights><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c3171-7ef68899a1ee982865175106f0ac7b5d21b17abfaf33ada6eae32f9021e3c38e3</citedby><cites>FETCH-LOGICAL-c3171-7ef68899a1ee982865175106f0ac7b5d21b17abfaf33ada6eae32f9021e3c38e3</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><link.rule.ids>314,776,780,27903,27904</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/10823531$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Kerwin, Andrew J.</creatorcontrib><creatorcontrib>Croce, Martin A.</creatorcontrib><creatorcontrib>Timmons, Shelley D.</creatorcontrib><creatorcontrib>Maxwell, Robert A.</creatorcontrib><creatorcontrib>Malhotra, Ajai K.</creatorcontrib><creatorcontrib>Fabian, Timothy C.</creatorcontrib><title>Effects of Fiberoptic Bronchoscopy on Intracranial Pressure in Patients with Brain Injury: A Prospective Clinical Study</title><title>The journal of trauma</title><addtitle>J Trauma</addtitle><description>BACKGROUNDFiberoptic bronchoscopy (FB) plays an important role in making the diagnosis of nosocomial pneumonia and resolving lobar atelectasis in critically injured trauma patients. It has been shown to be a safe procedure with only occasional complications. However, in patients with head injuries, FB can lead to intracranial hypertension. Sustained increases in intracranial pressure (ICP) leads to poor outcome in these patients. Because of this, a prospective study was done not only to assess the effect of FB on ICP and cerebral perfusion pressure (CPP) in patients with brain injuries, but also to identify a regimen of sedation and anesthesia that could prevent significant increases in ICP during FB.
METHODSTwenty-six FB were performed in 23 patients with ICP monitors or ICP monitors and ventriculostomy drains in place for Glasgow Coma Scale score < 8 or management of postcraniotomy trauma. FB was performed to aid in the diagnosis of nosocomial pneumonia or to aid in resolving lobar atelectasis. Before FB, all patients received a standard anesthetic regimen consisting of vecuronium (10 mg), morphine sulfate (4 mg), and midazolam (2.5 mg). Patients with diminished cranial compliance, defined as ICP > 10 mm Hg, also received a nebulizer treatment of 3 mL of 4% lidocaine before FB. All patients were preoxygenated with Fio2 = 1.0 for 10 minutes. Intracranial pressure, mean arterial pressure, and CPP were monitored continuously throughout the procedure. These same variables were also recorded at baseline and at 2-minute intervals during the procedure. The time to return to baseline ICP was also recorded.
RESULTSThe mean ICP at baseline (immediately before FB) was 12.6 mm Hg. After introduction of the bronchoscope, the ICP rapidly increased in 21 procedures (81%) and the mean highest ICP was 38.0 mm Hg. There was also a concomitant increase in mean arterial pressure such that there was no substantial change in CPP. The mean lowest CPP was 73.1 mm Hg. The average time for return of ICP to baseline was 13.9 minutes. In the subgroup of patients with ICP > 10, attempting to blunt the tracheal stimulation by anesthetizing the trachea with 4% nebulized lidocaine did not seem to be successful. The mean highest ICP in this subgroup was 41.8 mm Hg. The CPP changed in a similar manner, as the mean lowest CPP was 74.0 mm Hg. The mean time to return to baseline was 12.5 minutes. No patient had acute neurologic deterioration secondary to FB.
CONCLUSIONSAlthough FB is an important procedure in the pulmonary care of head injured patients, it produces substantial, but transient, increases in ICP and should be used with caution in patients with diminished cranial compliance. Sedation, analgesia, paralysis, and topical tracheal anesthesia did not completely prevent the rise in ICP. Although no acute deterioration in condition occurred, secondary brain injury caused by localized cerebral ischemia is certainly possible. Because of the substantial increases in ICP, herniation may be precipitated in an occasional patient. Further study is needed to identify a regimen that will confer protection.</description><subject>Adolescent</subject><subject>Adult</subject><subject>Anesthesia - methods</subject><subject>Blood Pressure</subject><subject>Brain Injuries - complications</subject><subject>Brain Injuries - physiopathology</subject><subject>Bronchoscopy - adverse effects</subject><subject>Cerebrovascular Circulation</subject><subject>Conscious Sedation - methods</subject><subject>Cross Infection - complications</subject><subject>Cross Infection - diagnosis</subject><subject>Female</subject><subject>Glasgow Coma Scale</subject><subject>Humans</subject><subject>Injury Severity Score</subject><subject>Intracranial Hypertension - etiology</subject><subject>Intracranial Hypertension - physiopathology</subject><subject>Intracranial Hypertension - prevention & control</subject><subject>Intracranial Pressure</subject><subject>Male</subject><subject>Middle Aged</subject><subject>Monitoring, Physiologic</subject><subject>Pneumonia - complications</subject><subject>Pneumonia - diagnosis</subject><subject>Positive-Pressure Respiration</subject><subject>Prospective Studies</subject><subject>Pulmonary Atelectasis - complications</subject><subject>Pulmonary Atelectasis - diagnosis</subject><subject>Time Factors</subject><subject>Ventriculostomy</subject><issn>0022-5282</issn><issn>1529-8809</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2000</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNp1kU1PAyEQhonRaP34C4aTt1UGul3Wmzb1IzHRRD0Tlg4pul1WYG3670WrxoskE-bwvAN5hhAK7BRYXZ2xfEpRiYJ_dbmKXABbZAQlrwspWb1NRoxxXpRc8j2yH-NLRsZjIXfJHjDJRSlgRFYza9GkSL2lV67B4PvkDL0MvjMLH43v19R39LZLQZugO6db-hAwxiEgdR190Mlhl_MrlxY5pt0n_DKE9Tm9yKSPfR7v3pFOW9c5k-OPaZivD8mO1W3Eo-_7gDxfzZ6mN8Xd_fXt9OKuMAIqKCq0EynrWgNiLbmclFCVwCaWaVM15ZxDA5VurLZC6LmeoEbBbc04oDBCojggJ5u5ffBvA8akli4abFvdoR-iqgB4CWOWQbkBTf5zDGhVH9xSh7UCpj6lqx_p6le6-pKeo8ffbwzNEud_ghvLGRhvgJVvE4b42g4rDGqBuk0L9d8yxQfZ_o1r</recordid><startdate>200005</startdate><enddate>200005</enddate><creator>Kerwin, Andrew J.</creator><creator>Croce, Martin A.</creator><creator>Timmons, Shelley D.</creator><creator>Maxwell, Robert A.</creator><creator>Malhotra, Ajai K.</creator><creator>Fabian, Timothy C.</creator><general>Lippincott Williams & Wilkins, Inc</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope></search><sort><creationdate>200005</creationdate><title>Effects of Fiberoptic Bronchoscopy on Intracranial Pressure in Patients with Brain Injury: A Prospective Clinical Study</title><author>Kerwin, Andrew J. ; Croce, Martin A. ; Timmons, Shelley D. ; Maxwell, Robert A. ; Malhotra, Ajai K. ; Fabian, Timothy C.</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c3171-7ef68899a1ee982865175106f0ac7b5d21b17abfaf33ada6eae32f9021e3c38e3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2000</creationdate><topic>Adolescent</topic><topic>Adult</topic><topic>Anesthesia - methods</topic><topic>Blood Pressure</topic><topic>Brain Injuries - complications</topic><topic>Brain Injuries - physiopathology</topic><topic>Bronchoscopy - adverse effects</topic><topic>Cerebrovascular Circulation</topic><topic>Conscious Sedation - methods</topic><topic>Cross Infection - complications</topic><topic>Cross Infection - diagnosis</topic><topic>Female</topic><topic>Glasgow Coma Scale</topic><topic>Humans</topic><topic>Injury Severity Score</topic><topic>Intracranial Hypertension - etiology</topic><topic>Intracranial Hypertension - physiopathology</topic><topic>Intracranial Hypertension - prevention & control</topic><topic>Intracranial Pressure</topic><topic>Male</topic><topic>Middle Aged</topic><topic>Monitoring, Physiologic</topic><topic>Pneumonia - complications</topic><topic>Pneumonia - diagnosis</topic><topic>Positive-Pressure Respiration</topic><topic>Prospective Studies</topic><topic>Pulmonary Atelectasis - complications</topic><topic>Pulmonary Atelectasis - diagnosis</topic><topic>Time Factors</topic><topic>Ventriculostomy</topic><toplevel>online_resources</toplevel><creatorcontrib>Kerwin, Andrew J.</creatorcontrib><creatorcontrib>Croce, Martin A.</creatorcontrib><creatorcontrib>Timmons, Shelley D.</creatorcontrib><creatorcontrib>Maxwell, Robert A.</creatorcontrib><creatorcontrib>Malhotra, Ajai K.</creatorcontrib><creatorcontrib>Fabian, Timothy C.</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>MEDLINE - Academic</collection><jtitle>The journal of trauma</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Kerwin, Andrew J.</au><au>Croce, Martin A.</au><au>Timmons, Shelley D.</au><au>Maxwell, Robert A.</au><au>Malhotra, Ajai K.</au><au>Fabian, Timothy C.</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Effects of Fiberoptic Bronchoscopy on Intracranial Pressure in Patients with Brain Injury: A Prospective Clinical Study</atitle><jtitle>The journal of trauma</jtitle><addtitle>J Trauma</addtitle><date>2000-05</date><risdate>2000</risdate><volume>48</volume><issue>5</issue><spage>878</spage><epage>883</epage><pages>878-883</pages><issn>0022-5282</issn><eissn>1529-8809</eissn><abstract>BACKGROUNDFiberoptic bronchoscopy (FB) plays an important role in making the diagnosis of nosocomial pneumonia and resolving lobar atelectasis in critically injured trauma patients. It has been shown to be a safe procedure with only occasional complications. However, in patients with head injuries, FB can lead to intracranial hypertension. Sustained increases in intracranial pressure (ICP) leads to poor outcome in these patients. Because of this, a prospective study was done not only to assess the effect of FB on ICP and cerebral perfusion pressure (CPP) in patients with brain injuries, but also to identify a regimen of sedation and anesthesia that could prevent significant increases in ICP during FB.
METHODSTwenty-six FB were performed in 23 patients with ICP monitors or ICP monitors and ventriculostomy drains in place for Glasgow Coma Scale score < 8 or management of postcraniotomy trauma. FB was performed to aid in the diagnosis of nosocomial pneumonia or to aid in resolving lobar atelectasis. Before FB, all patients received a standard anesthetic regimen consisting of vecuronium (10 mg), morphine sulfate (4 mg), and midazolam (2.5 mg). Patients with diminished cranial compliance, defined as ICP > 10 mm Hg, also received a nebulizer treatment of 3 mL of 4% lidocaine before FB. All patients were preoxygenated with Fio2 = 1.0 for 10 minutes. Intracranial pressure, mean arterial pressure, and CPP were monitored continuously throughout the procedure. These same variables were also recorded at baseline and at 2-minute intervals during the procedure. The time to return to baseline ICP was also recorded.
RESULTSThe mean ICP at baseline (immediately before FB) was 12.6 mm Hg. After introduction of the bronchoscope, the ICP rapidly increased in 21 procedures (81%) and the mean highest ICP was 38.0 mm Hg. There was also a concomitant increase in mean arterial pressure such that there was no substantial change in CPP. The mean lowest CPP was 73.1 mm Hg. The average time for return of ICP to baseline was 13.9 minutes. In the subgroup of patients with ICP > 10, attempting to blunt the tracheal stimulation by anesthetizing the trachea with 4% nebulized lidocaine did not seem to be successful. The mean highest ICP in this subgroup was 41.8 mm Hg. The CPP changed in a similar manner, as the mean lowest CPP was 74.0 mm Hg. The mean time to return to baseline was 12.5 minutes. No patient had acute neurologic deterioration secondary to FB.
CONCLUSIONSAlthough FB is an important procedure in the pulmonary care of head injured patients, it produces substantial, but transient, increases in ICP and should be used with caution in patients with diminished cranial compliance. Sedation, analgesia, paralysis, and topical tracheal anesthesia did not completely prevent the rise in ICP. Although no acute deterioration in condition occurred, secondary brain injury caused by localized cerebral ischemia is certainly possible. Because of the substantial increases in ICP, herniation may be precipitated in an occasional patient. Further study is needed to identify a regimen that will confer protection.</abstract><cop>United States</cop><pub>Lippincott Williams & Wilkins, Inc</pub><pmid>10823531</pmid><doi>10.1097/00005373-200005000-00011</doi><tpages>6</tpages></addata></record> |
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| subjects | Adolescent Adult Anesthesia - methods Blood Pressure Brain Injuries - complications Brain Injuries - physiopathology Bronchoscopy - adverse effects Cerebrovascular Circulation Conscious Sedation - methods Cross Infection - complications Cross Infection - diagnosis Female Glasgow Coma Scale Humans Injury Severity Score Intracranial Hypertension - etiology Intracranial Hypertension - physiopathology Intracranial Hypertension - prevention & control Intracranial Pressure Male Middle Aged Monitoring, Physiologic Pneumonia - complications Pneumonia - diagnosis Positive-Pressure Respiration Prospective Studies Pulmonary Atelectasis - complications Pulmonary Atelectasis - diagnosis Time Factors Ventriculostomy |
| title | Effects of Fiberoptic Bronchoscopy on Intracranial Pressure in Patients with Brain Injury: A Prospective Clinical Study |
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