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

Abstract

Background: Contemporary intracranial hypertension guidelines, including SIBICC (2019) and the 2024 ACS Best Practices, list neuromuscular blockade as a Tier Two, short-duration option for refractory ICP elevation. Despite its physiologic rationale, the real-world effect of initiating continuous paralysis on ICP has not been quantified using large-scale intra-patient physiologic data. Methods: We performed a retrospective intra-patient before–after study at a Level 1 trauma and neurocritical care center (2016-2021). Among 9373 ICU admissions, 106 patients receiving a Rocuronium infusion with continuous invasive ICP monitoring met inclusion criteria. ICP values were compared using symmetric pre/post windows (−165-0 min; +15-180 min). A generalized additive model (GAM) evaluated time-dependent ICP changes adjusting for sedatives and hypertonic saline. Results: Median ICP decreased from 20.7 to 18.6 mm Hg (within-patient Δ −0.9 mm Hg; P = .017). Cerebral perfusion pressure increased from 71.1 ± 10.5 to 75.2 ± 12.5 mm Hg (P < .001). In patients with pre-treatment ICP > 20 mm Hg, median ΔICP was −2.0 mm Hg (P < .001). Adjusted GAM modeling demonstrated reductions of −1.66 mm Hg at 3 h and −2.23 mm Hg at 6 h. Conclusions: Continuous Rocuronium infusion was associated with modest (approximately 1-2 mm Hg) reductions in ICP and improved CPP. Although these physiologic changes are small and may have limited clinical significance, this study provides the largest real-world evaluation and quantification of the effect of continuous neuromuscular blockade on ICP control and directly informs a major evidence gap highlighted in contemporary guidelines.