Impact of thiopental use on cerebral perfusion pressure in severe brain trauma: an example of caregivers' adaptation

Introduction

Thiopental (TP) is used in severe brain trauma to control high intracranial pressure episodes. Deleterious side effects were described that questioned its ability to reach its objectives securely and efficiently. We analyzed the impact of TP use on cerebral hemodynamics and caregivers' behavior towards recommendations using a high-rate recording information system.

Methods

A set of 813 hours of data were recorded at a rate of 0.5 Hz. The study was observational. Deleterious episodes were detected using the Information System (IS) and validated by two experts. We detected low cerebral perfusion pressure (CPP), high intracranial (HICP) and/or low mean arterial pressure (lMAP) episodes. We used commonly admitted threshold for the ICP (20 mmHg) and the CPP (60 mmHg). Medical orders intended to reach the recommended objectives were analyzed.

Results

Forty-eight periods stratified according to TP dose were analyzed on 16 patients. Cumulative duration with TP was 20,520 minutes and 26,294 minutes without TP. The mean dose of TP administration was 250 ± 20 mg/hour (3.4 ± 1.4 mg/kg/hour). The HICP incidence was 85 ± 16 per 100 hours with TP vs 95 ± 29 without TP (NS). HICP duration was longer with TP (27 ± 2 vs 19 ± 2 minutes, P < 0.005). The lMAP incidence was the same with or without TP (56 ± 19 vs 34 + 8 per 100 hours of monitoring). Duration of lMAP episodes was the same with or without TP (22 ± 2 vs 20 ± 2 minutes, NS). The incidence of orders intended to restore cerebral hemodynamics was equivalent in both situations (TP vs no TP, 79 ± 24 vs 104 ± 29 per 100 hours, NS). One hundred and eighty-eight medical orders were analyzed. Use of catecholamine was more frequent with TP (57% (n = 44) vs 43% (n = 33), P = 0.034).

Conclusions

The use of TP complies with the recommendations (prolonged HICP). It did not result in a significant increase in cerebral hypoperfusion episodes. We showed evidence of adaptations to its use by physicians. The doses are lower than the doses prescribed earlier in the literature and the use of catecholamine is more frequent during TP infusion. This could result in a better control of deleterious side effects of TP and a better compliance with recommendations. Our IS was efficient in physicians' orders' analysis.