A Prospective Randomised, Double-blinded Study on the Cerebral Haemodynamic Effects of Ketamine Versus Propofol Sedation in Patients with Severe Traumatic Brain Injury Admitted in Trauma Intensive Care

INTRODUCTION: Although pediatric studies have shown promising results with the use of ketamine for sedoanalgesia in traumatic brain injury, studies in the adult population are lacking. We conceptualized the present study to compare the effects of continuous ketamine versus propofol sedation on cerebral hemodynamics in adult trauma patients admitted to intensive care with severe brain injury. OBJECTIVES: Our primary objective was to observe the effect of continuous infusion of either sedative on maintenance of cerebral perfusion pressure higher than 60 mm Hg. Main secondary objectives included excursions in intracranial pressures above normal, mean arterial blood pressure, vasopressor use as rescue therapy, ventilator free days, ventilator associated adverse events, GCS at discharge and GOS-E at 3 month follow up. MATERIALS AND METHODS: 40 patients of severe traumatic brain injury requiring intubation and mechanical ventilation were enrolled into the study and 20 each were allocated to both groups. Intraparenchymal ICP catheter was placed and data such as mean arterial pressure, cerebral perfusion pressure, intracranial pressure were made note of. RESULTS: Both the groups had comparable demographics. We report maintenance of cerebral perfusion pressures > 60 mm Hg in both groups (p 0.422), however significantly higher percentage of patients (80%) in the propofol group required rescue vasopressor therapy to keep CPP in targeted range (p 0.03). On further analysis, we compared CPP values from baseline to various time points in both intragroup using mixed ANOVA. On intragroup comparison, statistically significant higher CPP values were noted from baseline to specified time points in ketamine group (p <0.05). Critical neuroworsening was seen only in the propofol group (n=3/20), whereas ketamine group had no in hospital neuroworsening. Bradycardia and ventilator associated adverse events were higher in the propofol group (p<0.05). GOS-E at 3 months and GCS by discharge was comparable in both groups. DISCUSSION: The results of our study showed that adult trauma patients admitted in intensive care following severe traumatic head injuries and receiving ketamine sedation had higher cerebral perfusion pressures at various study time points when compared with propofol sedation. The intracranial pressures were maintained within normal range in both the groups but mean arterial pressures were higher in ketamine group. To keep cerebral perfusion pressure and mean arterial pressure in target range, the use of rescue vasopressor therapy was noted in only propofol group (p 0.002). The episodes of ICP excursions were noted in propofol group only. Mortality by discharge from intensive care was seen in three patients from propofol group only whereas neurosurgical intervention and GOS-E at 90 days was comparable between the groups. CONCLUSION: Ketamine sedation in acute traumatic brain injury maintained cerebral perfusion pressure and mean arterial pressure while reducing intracranial pressures, without the need for rescue vasopressor therapy, when compared to propofol. Ketamine was also associated with lesser bradycardia, in hospital neuroworsening, and ventilator associated adverse events. Although pediatric studies in traumatic brain injury already strongly advocate the use of ketamine sedation, there is much evidence to consider the role of ketamine in adult traumatic brain injury due to its favorable hemodynamic profile and neuroprotective ability.