Neuromuscular Blockade for Intracranial Hypertension: Quantifying Real-World Effectiveness on Intracranial Pressure.

Area of Science:

• Neurocritical Care
• Intensive Care Medicine
• Pharmacology

Background:

• Contemporary guidelines recommend neuromuscular blockade for refractory intracranial hypertension (ICP).
• The real-world impact of continuous paralysis on ICP has not been extensively quantified.
• A significant evidence gap exists regarding the efficacy of neuromuscular blockade in ICP management.

Purpose of the Study:

• To quantify the effect of continuous rocuronium infusion on ICP and cerebral perfusion pressure (CPP) in critically ill patients.
• To evaluate the intra-patient changes in ICP before and after initiating neuromuscular blockade.
• To address an evidence gap highlighted in current intracranial hypertension guidelines.

Main Methods:

• Retrospective before-and-after study of 106 patients with continuous invasive ICP monitoring receiving rocuronium infusion.
• Comparison of ICP values using symmetric pre/post time windows (-165 to 0 min; +15 to 180 min).
• Generalized additive model (GAM) used to assess time-dependent ICP changes, adjusting for sedatives and hypertonic saline.

Main Results:

• Median ICP decreased from 20.7 to 18.6 mm Hg (Δ -0.9 mm Hg; P=.017).
• Cerebral perfusion pressure (CPP) increased from 71.1 to 75.2 mm Hg (P<.001).
• In patients with ICP > 20 mm Hg, median ICP reduction was -2.0 mm Hg (P<.001); adjusted GAM showed reductions of -1.66 mm Hg at 3h and -2.23 mm Hg at 6h.

Conclusions:

• Continuous rocuronium infusion is associated with modest reductions in ICP (approx. 1-2 mm Hg) and improved CPP.
• While the physiologic changes are small, this study provides the largest real-world evaluation of neuromuscular blockade's effect on ICP.
• Findings inform contemporary guidelines regarding the use of neuromuscular blockade for ICP control.