Intravenous paracetamol for fever control in acute brain-injured patients: cerebral and hemodynamic effects

Abstract

Introduction Fever is a dangerous secondary insult for the injured brain [1]. We investigated the cerebral and hemodynamic effects of intravenous (i.v.) paracetamol administration for the control of fever in neurointensive care unit (NICU) patients. Methods The i.v. paracetamol (1 g in 15 minutes) was administered to NICU patients with a body temperature (Temp.) >37.5degreeC. Its effects on mean arterial pressure (MAP), heart rate (HR), intracranial pressure (ICP), cerebral perfusion pressure (CPP), jugular venous oxygen saturation (SjVO 2) and Temp. were recorded at the start of paracetamol infusion (T0) and after 30 (T30), 60 (T60) and 120 (T120) minutes. Interventions for the maintenance of CPP >60 mmHg or ICP <20 mmHg were recorded. (TABLE PRESENTED) (GRAPH PRESENTED) Results Fifteen NICU patients (nine subarachnoid hemorrhage, f ve traumatic brain injury, mean age 54.9 +/- 16.8, seven (50%) males, median GCS 7) were prospectively studied. We analyzed the administration of one dose of paracetamol for each patient (total 14 cases). After infusion of paracetamol we found a decrease of Temp. (from 37.8 +/- 0.3 to 37.4 +/- 0.4degreeC, P <0.001), MAP (from 94.7 +/- 9.9 to 86.1 +/- 6.7 mmHg, P = 0.008), CPP (from 79.6 +/- 13.1 to 70.8 +/- 7.6 mmHg, P = 0.011) and HR (from 71.5 +/- 14.9 to 63.8 +/- 16.3 bpm, P <0.001) with respect to the starting value (ANOVA for repeated measures), whereas ICP and SjVO 2 remained unchanged (Figure 1). In f ve cases norepinephrine infusion was started for CPP <60 mmHg. In another two cases, for the same reason, the norepinephrine dosage was augmented. The proportion of patients who had infusion of norepinephrine increased from 42.8% at T0 to 78.6% at T120 (P = 0.02, chi-square for trends). Conclusion Use of i.v. paracetamol is effective in the maintenance of normothermia in acute brain-injured patients. However, adverse hemodynamic effects, which could represent a secondary insult for the injured brain, must be rapidly recognized and treated.