THE USE OF INDOMETHACIN TO TREAT ACUTE RISES OF INTRACRANIAL-PRESSUREAND IMPROVE GLOBAL CEREBRAL PERFUSION IN A CHILD WITH HEAD TRAUMA

Background: The use of vasoconstrictors (e.g. dihydroergotamine, indom ethacin) for the treatment of increased intracranial pressure (ICP) se condary to brain trauma is controversial. In particular, it has been s uggested that vasoconstrictors be employed only for intracranial hyper tension secondary to hyperemia, when venous jugular bulb saturation (S jO(2)) is >75%. Method: We administered indomethacin as a bolus i.v. ( 5-10 mg) on 18 occasions to a multiple-injured 3-year-old child with a cute rises of ICP secondary to severe brain trauma (GCS score 7) deter mining a large hypodensity area in and swelling of the right hemispher e. Results: Before indomethacin administration the average of mean ICP was 68.1+/-10.8 (SD) mm Hg (range 47-84) and the cerebral perfusion p ressure (CCP) was 38.4+/-10.4 mm Hg (range 30-65). In response to indo methacin, ICP dropped in a few seconds to 22.7+/-5.6 and CCP increased to 82.4+/-6.1 mm Hg (P<0.001), while the mean arterial pressure remai ned unchanged. On 6 occasions SjO(2) was also evaluated immediately be fore and 5 and 10 min after indomethacin administration. Before indome thacin administration, SjO(2) values were within the normal range on 2 occasions and abnormally low on four. SjO(2) increased from the mean value of 45.6+/-15.7 to 59.8+/-8.9 (after 5 min) and 60.6+/-12.4% (aft er 10 min) (P<0.01 versus pre-indomethacin). At the same time the cere bral venous pH increased from 7.43+/-0.01 to 7.45+/-0.01 (P=0.01). The se findinge suggest that the global cerebral perfusion was improved. E ighteen days after injury the child was awake and was discharged from the ICU. Conclusion: To our knowledge, increase of SjO(2) in response to indomethacin has not been previously reported. Although great cauti on is necessary in the use of indomethacin for the treatment of ICP, t hese findings suggest that indomethacin can be useful for the treatmen t of acute rises of ICP compromising severely the CCP, even if SjO(2) is normal or abnormally low. Under these circumstances, indomethacin c an improve the global cerebral perfusion. (C) Acta Anaesthesiologica S candinavica 41 (1997).