The effects of post-intubation hypertension in severe traumatic brain injury

Introduction. The effect of post-intubation hypertension in severe traumatic brain injury (TBI) patients remains uncertain. We aimed to determine the relationship between post-intubation hypertension (mean arterial pressure (MAP) > 110mmHg) and outcomes in severe TBI. 

Methods. In this retrospective cohort study, adults who presented with isolated TBI and a MAP 􀀁 70mmHg were assessed. Data were retrieved from our institutional trauma registry and the admission list of our neurosurgical intensive care unit (ICU). Results. We enrolled 126 patients, 81 of whom had a MAP 􀀂 110 mmHg after intubation and were assigned to group 1; 45 patients who had a MAP > 110 mmHg were assigned to group 2. Only age (P = 0.008), heart rate (HR; P = 0.036), and MAP before intubation (P < 0.001) were significantly different between groups. We found no significant intergroup differences in mortality (35.8 vs. 35.6%, P = 1.000) or in the motor function of survivors at discharge (P = 0.333). The length of ventilator-dependent (median: 2.0 vs. 5.0 days; P = 0.003) and ICU stays (median: 4.5 vs. 10.0 days; P = 0.005) were significantly longer in group 2. Post-intubation hypertension remained significantly associated with longer ICU stay (􀀁 7 days) and poor neurologic outcome (motor < 4 at discharge) after adjusting for other variables (post-intubation MAP >110 mmHg, P < 0.034, OR 3.119, 95% CI 1.087–8.953). 

Conclusion. Post-intubation hypertension was associated with longer ventilator-dependent and ICU stays in patients with severe TBI. 

endotracheal intubati-on, hemodynamics, blood pressure, mean arterial pressure, intracranial hemorrhage

1. Kuzak N, Harrison DW, Zed PJ. Use of lidocaine and fentanyl premedication for neuroprotective rapid sequence intubation in the emergency department. CJEM 2006;8:80-4.

2. Brenner M, Stein DM, Hu PF, Aarabi B, Sheth K, Scalea TM. Traditional systolic blood pressure targets underestimate hypotension-induced secondary brain injury. J Trauma Acute Care Surg 2012;72(5):1135-9.

3. Shutter LA, Narayan RK. Blood pressure management in traumatic brain injury. Ann Emerg Med 2008;51(3 Suppl):S37-8.

4. Stein DM, Hu PF, Brenner M, Sheth KN, Liu KH, Xiong W, et al. Brief episodes of intracranial hypertension and cerebral hypoperfusion are associated with poor functional outcome after severe traumatic brain injury. J Trauma 2011;71(2):364-73.

5. Asfar SN, Abdulla WY. The effect of various administration routes of lidocaine on hemodynamics and ECG rhythm during endotracheal intubation. Acta Anaesthesiol Belg 1990;41:17-24.

6. Czosnyka M, Smielewski P, Kirkpatrick P, Piechnik S, Laing R, Pickard JD. Continuous monitoring of cerebrovascular pressure-reactivity in head injury. Acta Neurochir Suppl 1998;71:74 –7.

7. Howells T, Elf K, Jones PA, Ronne-Englstrom E, Piper I, Nilsson P, et al. Pressure reactivity as a guide in the treatment of cerebral perfusion pressure in patients with brain trauma. J Neurosurg 2005;102:311–7.

8. Steiner LA, Czosnyka M, Piechnik SK, Smielewski P, Chatfield D, Menon DK, et al. Continuous monitoring of cerebrovascular pressure reac-tivity allows determination of optimal cerebral perfusion pressure in patients with traumatic brain injury. Crit Care Med 2002;30:733– 8.

9. Walia S, Sutcliffe AJ. The relationship between blood glucose, mean arterial pressure and outcome after severe head injury: an observational study. Injury 2002;33(4):339-44.

10. Zafar SN, Millham FH, Chang Y, Fikry K, Alam HB, King DR, et a. Presenting blood pressure in traumatic brain injury: a bimodal distribution of death. J Trauma 2011;71(5):1179-84.

11. Forbes AM, Dally FG. Acute hypertension during induction of anaesthesia and endotracheal intubation in normotensive man. Br J Anaesth 1970;42:618-24.

12. Kayhan Z, Aldemir D, Mutlu H, O􀀃ü􀀄 E. Which is responsible for the haemodynamic response due to laryngoscopy and endotracheal intubation? Catecholamines, vasopressin or angiotensin? Eur J Anaesthesiol 2005;22(10):780-5.

13. Bullock RM, Chesnut R, Clifton GL, Ghajar J, Marion DW, Narayan RK, et al. Management and prognosis of severe traumatic brain injury, part 1: Guidelines for the management of severe traumatic brain injury. J Neurotrauma 2000;17:451-553.

14. Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, et al. American Heart Association/American Stroke Association Stroke Council: American Heart Association/American Stroke Association High Blood Pressure Research Council: Quality of Care and Outcomes in Research Interdisciplinary Working Group: Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Circulation 2007;116:e391–413.

15. Steiner T, Kaste M, Forsting M, Mendelow D, Kwiecinski H, Szikora I, et al. Recommendations for the management of intracranial haemor-rhage - part I: Spontaneous intracerebral haemorrhage. The European Stroke Initiative Writing Committee and the Writing Committee for the EUSI Executive Committee. Cerebrovasc Dis 2006;22:294–316.

16. Blackman JA, Patrick PD, Buck ML, Rust RS Jr. Paroxysmal autonomic instability with dystonia after brain injury. Arch Neurol 2004;61:321–8.

17. Steiner LA, Andrews PJ. Monitoring the injured brain: ICP and CBF. British J Anaesth 2006;97(1):26–38.

18. Robertson CS, Valadka AB, Hannay HJ, Contant CF, Gopinath SP, Cormio M, et al. Prevention of secondary ischemic insults after severe head injury. Crit Care Med 1999;27:2086-95.

19. Contant CF, Valadka AB, Gopinath SP, Hannay HJ, Robertson CS. Adult respiratory distress syndrome: a complication of induced hyper-tension after severe head injury. J Neurosurg 2001;95:560-8.

20. Ley EJ, Singer MB, Clond MA, Gangi A, Mirocha J, Bukur M, et al. Elevated admission systolic blood pressure after blunt trauma predicts delayed pneumonia and mortality. J Trauma 2011;71(6):1689-93.

21. Steyerberg EW, Mushkudiani N, Perel P, Butcher I, Lu J, McHugh GS, et al. Predicting outcome after traumatic brain injury: Development and international validation of prognostic scores based on admission characteristics. PLoS Med 2008;5:e165.

22. Utomo WK, Gabbe BJ, Simpson PM, Cameron PA. Predictors of in-hospital mortality and 6-month functional outcomes in older adults after moderate to severe traumatic brain injury. Injury 2009;40(9):973-7.

23. Franschman G, Peerdeman SM, Andriessen TM, Greuters S, Toor AE, Vos PE, et al. Effect of secondary prehospital risk factors on outcome in severe traumatic brain injury in the context of fast access to trauma care. J Trauma 2011;71(4):826-32.

24. Klemenc-Ketis Z, Bacovnik-Jansa U, Ogorevc M, Kersnik J. Outcome predictors of Glasgow Outcome Scale score in patients with severe traumatic brain injury. Ulus Travma Acil Cerrahi Derg 2011;17(6):509-15.

25. Kiboi JG, Kitunguu PK, Angwenyi P, Mbuthia F, Sagina LS. Predictors of functional recovery in African patients with traumatic intracranial hematomas. World Neurosurg 2011;75(5-6):586-91.