The Role of Neuromuscular Blockade in Patients with Traumatic Brain Injury: A Systematic Review

Management of Traumatic Brain Injury (TBI)focuses on controlling intracranial pressure (ICP), whileother treatments, such as the use of neuromuscular blockingagents (NMBAs), need scientific evidence. Weconducted a systematic review to investigate the usefulnessof NMBAs in the context of TBI and/or increased ICP. Wesearched MEDLINE and EMBASE databases up to January31st 2014, including both clinical and experimentalfindings. We found a total of 34 articles, of which 22 wereprospective clinical trials. No systematic review/metaanalyseswere found. Seven studies evaluated NMBAboluses in preventing stimulation-related ICP surges:paralysis was effective during tracheal suctioning andphysiotherapy but not during bronchoscopy. Fourteensmall studies (8 to 25 patients) assessed the effect ofNMBA boluses on ICP. Two studies showed an ICPincrease by succinylcholine and one found a decrease inICP after atracurium. No ICP changes were observed in theother studies. One prospective study confirmed that discontinuingparalysis increases energy expenditure. Tworetrospective studies investigated mortality/morbidity: onefound that early paralysis (continued for >12 h) was notbeneficial and potentially associated with extra-cranialcomplications, while the second demonstrated a correlationbetween continuous infusion of NMBA and time spent withICP > 20 mmHg. Eight animal studies were alsoretrieved. In most studies, NMBA bolus was beneficial incontrolling ICP, especially when performing stimulatingprocedures. However, retrospective evidence found