Safety of Extended Sedation with Sevoflurane in Patients with Severe Traumatic Brain Injury

Abstract

   RELEVANCE. In conditions of increased sensitivity of damaged brain tissue to disruption of homeostasis, it is important to achieve stabilization of the vital functions of the body as soon as possible. Given the excess afferent impulse, adequate sedation and analgesia are an integral component of intensive care for patients with traumatic brain injury. The use of halogenated anesthetics is associated with a lower risk of complications associated with long-term sedation with intravenous drugs. In the example of two patients with severe traumatic brain injury, the effectiveness and safety of sevoflurane for prolonged inhalation sedation was noted. This study was approved at a meeting of the Local Ethics Committee of the Federal Scientific and Clinical Center for Resuscitation and Rehabilitation, an extract from protocol No. 5/21/1 dated December 23, 2021, as well as at a meeting of the LEC of the N. V. Sklifosovsky Research Institute for Emergency Medicine of the Moscow Health Department, meeting No. 1-2022 dated January 11, 2022.   AIM OF STUDY. To demonstrate the safety of inhalation sedation in patients with traumatic brain injury using clinical observations as an example.   MATERIAL AND METHODS. An analysis of two clinical observations of patients with severe traumatic brain injury was carried out. The effectiveness and safety of prolonged inhalation sedation was assessed by indicators: intracranial pressure, dynamics of mean arterial pressure and blood saturation in the jugular vein bulb, as well as the total duration of artificial ventilation and stay in the intensive care unit. Clinical observation No. 1. Patient B., 41 years old, was admitted with cerebral insufficiency (GCS 8) with damage to the soft tissues of the head. As a result of the examination, the patient wasdiagnosed with “Closed craniocerebral injury.” Fracture of the bones of the vault and base of the skull. Severe brain contusion. Traumatic subarachnoid hemorrhage, acute subdural hematoma in the left frontotemporal region 3 cm3”. Considering the size of the trauma (65 cm3) and the life-threatening dislocation syndrome, the patient underwent surgical intervention: “Decompressive craniotomy, removal of contusion areas. Installation of a ventricular intracranial pressure sensor.” The early course of the postoperative period was complicated by the development of infectious complications, which led to the need for prolonged sedation in the intensive care unit. On the 3rd day, a lower tracheostomy was performed. The total time of sedation was 3 days, and the duration of artificial ventilation was 10 days. On the 21st day, the patient was decannulated and transferred to a specialized department. Clinical observation No. 2. Patient K, 42 years old, was admitted to the hospital with a depressed level of consciousness (GCS 6). Based on the results of the examination, a diagnosis was made: “Penetrating traumatic brain injury with severe brain contusion, a focus of crush contusion in the right temporal lobe, acute subdural hematoma of the right frontal-temporo-parietal region 100 cm3 and a fracture of the bones of the vault and base of the skull, facial skeleton, micropneumocephaly”. Considering the size and location of the hematoma, the patient underwent surgery including decompressive craniotomy, removal of an acute subdural hematoma, and a Spiegelberg intracranial pressure sensor was installed. In the early postoperative period, severe hemodynamic instability associated with vascular insufficiency of central origin was noted. The use of inhalational sedation sevoflurane did not lead to the development of intracranial hypertension and escalation of vasopressor therapy. The total time of use of sevoflurane was 36 hours. Spontaneous breathing was restored by the 18th day. The patient’s stay in the ICU was 31 bed days.   CONCLUSION. Based on the data obtained, we may conclude that the use of inhalation sedation in this category of patients is safe, as well as the absence of a significant effect of sevoflurane on the level of intracranial pressure and central hemodynamic parameters. However, secondary complications that developed in patients do not allow us to draw an unambiguous conclusion about the effect of this method of sedation on the duration of artificial ventilation and stay in the intensive care unit. Only the accumulation of a sufficient volume of clinical material will reveal all the advantages and disadvantages of this method.