Effect of sedative agent selection on morbidity, mortality and length of stay in patients with increase in intracranial pressure

doi:10.5847/wjem.j.1920-8642.2018.04.003

Abstract

Abstract:

BACKGROUND: To identify the effects of sedative agent selection on morbidity, mortality, and length of stay in patients with suspected increase in intracranial pressure. Recent trends and developments have resulted in changes to medications that were previously utilized as pharmacological adjuncts in the sedation and intubation of patients with suspected increases in intracranial pressure. Medications that were previously considered contraindicated are now being used with increasing regularity without demonstrated safety and effectiveness. The primary objective of this study is to evaluate and compare the use of Ketamine as an induction agent for patients with increased intracranial pressure. The secondary objective was to evaluate and compare the use of Etomidate, Midazolam, and Ketamine in patients with increased intracranial pressure.
METHODS: We conducted a retrospective chart review of patients transported to our facility with evidence of intracranial hypertension that were intubated before trauma center arrival. Patients were identified during a 22-month period from January 2014 to October 2015. Goals were to evaluate the impact of sedative agent selection on morbidity, mortality, and length of stay.
RESULTS: During the review 148 patients were identified as meeting inclusion criteria, 52 were excluded due to incomplete data. Of those the patients primarily received; Etomidate, Ketamine, and Midazolam. Patients in the Ketamine group were found to have a lower mortality rate after injury stratification.
CONCLUSION: Patients with intracranial hypertension should not be excluded from receiving Ketamine during intubation out of concern for worsening outcomes.

Key words: Ketamine, Intracranial hypertension, Craniocerebral trauma, Head injury, Intubation

Brian G. Cornelius, Elizabeth Webb, Angela Cornelius, Kenneth W.G. Smith, Srdan Ristic, Jay Jain, Urska Cvek, Marjan Trutschl. Effect of sedative agent selection on morbidity, mortality and length of stay in patients with increase in intracranial pressure[J]. World Journal of Emergency Medicine, 2018, 9(4): 256-261.

Figures/Tables 3

Table 1

Table 2

Table 3

Comparative P-values with 95% CI

Characteristics	Etomidate vs. Ketamine				Versed vs. Ketamine
Characteristics	Etomidate (n=47)	Ketamine (n=15)	P-value	95% CI	Versed (n=27)	Ketamine (n=15)	P-value	95% CI
Age, mean (SD)	46 (18.2)	45.7 (19.3)	0.9687	-11.49032 11.93855	49.1 (18.6)	45.7 (19.3)	0.5827	-9.167172 15.996801
Type of injury, n(%)
Blunt (0)	41 ( 87.2)	14 (93.3)	0.4673	-0.1080769 0.2300627	24 (88.9)	14 (93.3)	0.6276	-0.1399556 0.2288445
Penetrating (1)	6 (12.8)	1 (6.7)	0.4673	-0.1080769 0.2300627	3 (11.1)	1 (6.7)	0.6276	-0.1399556 0.2288445
Physiological, n(%)
Glasgow Coma Scale
≤3	11 (23.4)	2 (13.3)	0.4449	-3.324433 1.508830	12 (44.4)	2 (13.3)	0.01708	-5.4116685 -0.5883315
4-8	21 (44.7)	9 (60)			13 (48.1)	9 (60)
9-15	15 (31.9)	4 (26.7)			2 (7.4)	4 (26.7)
Revised Trauma Score
0-2.9	3 (6.4)	0 (0)	0.2594	-0.3511343 1.2493754	0 (0)	0 (0)	0.02659	0.115652 1.725237
3.0-5.9	32 (68.1)	11 (73.3)			25 (92.6)	11 (73.3)
6.0-7.8	10 (21.3)	4 (26.7)			2 (7.4)	4 (26.7)
Injury Severity Score
1-29	35 (74.1)	10 (66.7)	0.9291	-8.735452 8.012048	19 (70.4)	10 (66.7)	0.8361	-9.664398 7.886620
30-59	12 (25.5)	5 (33.3)			8 (29.6)	5 (33.3)
60-75	0 (0)	0 (0)			0 (0)	0 (0)
Length of stay
<7	21 (44.7)	2 (13.3)	0.07181	-1.348035 28.840234	12 (44.4)	2 (13.3)	0.04712	0.2176381 30.6268064
7-9	2 (4.3)	1 (6.7)			3 (11.1)	1 (6.7)
>9	24 (51.1)	12 (80)			12 (44.4)	12 (80)
Trauma Injury Severity Score
8-100	20 (42.6)	11 (73.3)	0.3061	-27.503740 9.028846	11 (40.7)	11 (73.3)	0.1443	-33.029921 5.106958
21-80	21 (44.7)	2 (13.3)			15 (55.6)	2 (13.3)
0-20	5 (10.6)	2 (13.3)			1 (3.7)	2 (13.3)
Initial SBP, mean (SD)	125.7 (45.3)	118.6 (27.4)	0.47	-12.50310 26.62224	142.7 (36)	118.6 (27.4)	0.01992	4.038233 44.169174
ED.SBP, mean (SD)	114.3 (45.2)	117.6 (25.6)	0.7111	-21.40795 14.71859	122.1 (35.3)	117.6 (25.6)	0.6238	-13.95205 22.97427
ED.GCS, mean (SD)	3.5 (1.3)	3.5 (2.1)	0.9686	-1.217183 1.171793	3.4 (1.1)	3.5 (2.1)	0.8291	-1.331139 1.079287
Time of mortality
Number of patients, n (%)	18 (38.3)	2 (13.3)	-	-87.79211 100.90322	11 (40.7 %)	2 (13.3 %)	-	-70.24677 75.97404
Time of mortality, mean (SD)	1.9 (1.6)	8.5 (10.6)	0.5425	-87.79211 100.90322	5.6 (6.7)	8.5 (10.6)	0.7687	-70.24677 75.97404
Release type, n
Long-term acute care (1)	17	9	0.2066	-0.6741488 0.1521630	9	9	0.2256	-0.7447146 0.1817516
Expired/death (2)	18	2			11	2
Home (0)	12	4			7	4

Table 3

References 24

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Mean values	Etomidate	Ketamine	Midazolam	Overall
Initial GCS^a	7.4	8.3	5.3	7.0
Initial SBP^b	125.6	118.6	142.7	130.9
Age	45.9	45.7	49.1	46.0
ED GCS^a	3.5	3.5	3.4	3.5
ED RTS^c	5.5	6.0	5.1	5.5
ED ISS^d	26.6	27.0	26.1	26.7
ED SBP^b	114.3	117.6	122.1	118.1
LOS^e	15.8	29.5	14.1	17.0
TRISS^f	67.9	77.2	63.2	68.5

Mean values	Etomidate	Ketamine	Midazolam	Overall
Length of stay (days)	15.8	29.5	14.1	17.0
Long-term acute care (%)	36.2	60.0	33.3	37.5
Home (%)	25.5	26.7	25.9	26.0
Expired (%)	38.3	13.3	40.7	36.5
Penetrating (%)	87.2	93.3	88.9	88.5
Blunt (%)	12.8	6.7	11.1	11.5
Time of mortality (days)	1.9	8.5	5.6	5.4