Subcutaneous diclofenac at low dose is very effective in treating fever with an accompanying reduction in intracerebral pressure in NICU patients

Although rigorous control of fever is the current standard of care for the brain-injured patient, patient management strategies currently available are often suboptimal and may be contraindicated.

Objectives

We investigated a subcutaneous very low dose of diclofenac sodium (DCF SC) to treat fever in the NICU.

Methods

DCF SC (0.17 mg/kg [≈ 1/6 fl]) was administered to febrile patients and its effect was recorded continuously for 6 hours on the temperature (T°), intracranial pressure (ICP), cerebral perfusion pressure (CPP), mean arterial pressure (MAP), heart rate (HR) and diuresis. Adverse effects of DCF (allergic, gastrointestinal and central nervous system bleeding) were monitored.

Results

Thirty-five NICU patients (age 48.9 ± 19.5 years, male 64%, median Glasgow Coma Scale motor 5) (traumatic brain injury 63%, aneurismal subarachnoid hemorrhage 20%, postoperative 17%) were studied. Infection was clinically suspected in all patients and in 54% of them its was confirmed by microbiological data. We analysed a total of 177 SC doses at a mean 185 ± 89 hours after ICU admission with a median of five administrations per patient. The mean dose was 13.7 ± 6 mg (0.17 ± 0.04 mg/kg). T° decreased significantly after DCF SC, from 38.4 ± 0.4 to 37.6 ± 0.5°C (P < 0.0001), as did the ICP, from 16 ± 8 to 12.8 ± 6 mmHg (P = 0.0002). PaCO₂ and SjvO₂ were not different pre and post DCF. The CPP was stable after DCF (pre, 71 ± 15 mmHg; post, 69 ± 15 mmHg [NS]). The HR significantly dropped (from 97 ± 21 to 89 ± 20 beats/min, P < 0.0001). Blood gas analysis, renal and hepatic parameters were not different after DCF SC. Diuresis was maintained and it did not decrease much (from 175 ± 97 to142 ± 102 ml/hour, P < 0.05). The effects of DCF on T° and ICP are shown in Fig. 1. The effects of DCF on MAP, CPP and hourly urine output are shown in Fig. 2.

Figure 1

Figure 2

Conclusions

We conclude that DCF SC at low dosage was advantageous and effective. It enabled good reductions in body T° with an associated reduction in the ICP. Side effects on CPP or MAP were minimal, and renal and hepatic functions were not affected.