Refractory Intracranial Hypertension Due to Fentanyl Administration Following Closed Head Injury

Abstract

Background: Although the effects of opioids on intracranial pressure (ICP) have long been a subject of controversy, they are frequently administered to patients with severe head trauma. We present a patient with an uncommon paradoxical response to opioids.Case Report: A patient with refractory intracranial hypertension after closed head injury was managed with standard medical therapy with only transient decreases in the ICP. Only after discontinuation of opiates did the ICP become manageable without metabolic suppression and rescue osmotic therapy, implicating opiates as the etiology of refractory intracranial hypertension in this patient.Conclusion: Clinicians should consider opioids as a contributing factor in malignant intracranial hypertension when findings on neuroimaging do not explain persistent and refractory intracranial hypertension.

Differential effects of early postinjury treatment with neuroprotective drugs in a mouse model using diffuse reflectance spectroscopy

“…Once injected, morphine enters the blood stream, which carries it to the brain and other parts of the body where it acts primarily as an agonist of the μ opioid receptors in the central nervous system and in peripheral tissue. [58][59][60] Recently, Holbrook et al demonstrated that the administration of morphine for optimal control of pain and anxiety after injury may reduce the risk of post-traumatic stress disorder. 61 …”

Sedation practices in the Neurocritical Care Unit

“…However, a longer elimination half-life (2-4 h) and longer context-sensitive half-life (200 min for 6 h infusion and 300 min for 12 h infusion) [19] may be a major shortcoming in long-term sedation as it does not favour rapid NWTs. Fentanyl used as bolus or infusion have again been associated with increased ICP, [42][43][44] and thus it is recommended to be used in patients with stable haemodynamic profile and as stable infusions without significant changes in dosing. [45] Suggested fentanyl doses in patients with traumatic brain injury are 2 mcg/kg test dose followed by 2-5 mcg/kg/h continuous infusion.…”

Sudden unexpected nocturnal death in Chiari type 1 malformation and potential role of opioid analgesics

“…[ 4 5 ] Hydrocephalus, chronic opioid use, and bolus dosing of opioid analgesics are also risk factors for disordered breathing during sleep. [ 2 4 5 ] Bolus opiate dosing and sleep apnea associated hypercapnia are known to contribute to intracranial hypertension. [ 2 5 ] Therefore in a patient with clinical evidence of high ICP and chronic opioid use, bolus administrations of opioid analgesics can further increase the ICP.…”

“…[ 2 4 5 ] Bolus opiate dosing and sleep apnea associated hypercapnia are known to contribute to intracranial hypertension. [ 2 5 ] Therefore in a patient with clinical evidence of high ICP and chronic opioid use, bolus administrations of opioid analgesics can further increase the ICP. [ 2 5 ] Increased ICP can give rise to further downward displacement of the brain into the spinal canal and additional compression of vital brain structures.…”

“…[ 2 5 ] Therefore in a patient with clinical evidence of high ICP and chronic opioid use, bolus administrations of opioid analgesics can further increase the ICP. [ 2 5 ] Increased ICP can give rise to further downward displacement of the brain into the spinal canal and additional compression of vital brain structures. These effects can cause more instability of the cardiopulmonary control centers in the brain stem, resulting in cardiorespiratory arrest with possible sudden “neurogenic” cardiorespiratory death.…”