Hemodynamic Effects of Fentanyl During Endotracheal Intubation in Moderate to Severe Traumatic Brain Injury

Patients with moderate to severe traumatic brain injury (TBI) are at high risk of secondary brain injury, particularly from peri-intubation hypotension. Fentanyl is commonly administered during intubation to attenuate the sympathetic response to laryngoscopy but may adversely affect blood pressure. This study aimed to assess the association between peri-intubation fentanyl administration and systolic blood pressure (SBP) changes in patients with moderate to severe TBI undergoing endotracheal intubation in the ED.

We conducted a retrospective cohort study at the ED of the Hôpital du Sacré-Cœur de Montréal, Canada. Patients aged ≥16 years with moderate to severe blunt TBI (Glasgow Coma Scale ≤12) who required endotracheal intubation between June 2018 and December 2023 were included. Patients with penetrating trauma or cardiac were excluded. Patients were categorized based on peri-intubation fentanyl administration. The primary outcome was the change in SBP (mmHg) from pre-intubation to the maximum and minimum SBP recorded within the immediate post-intubation period (20 minutes). Groups were compared using ANOVA and multivariable ANCOVA adjusting for pertinent covariables. Anticipating a moderate effect size (F = 0.30), a sample size of 120 patients would provide more than 90% power at an alpha level of 0.05, allowing adjustment for up to five covariates.

Among 707 screened patients, 123 met inclusion criteria (fentanyl: n=66; no fentanyl: n=57). Baseline characteristics were similar between groups, including age (54 vs 55 years), sex (70% vs 64% male), initial GCS score (7 vs 7), and co-administered sedative use (etomidate 91% vs 83%). Compared with no fentanyl, fentanyl administration was associated with larger peri-intubation SBP decreases from pre- to maximal post-intubation SBP (fentanyl: -16 mmHg [95%CI -36 to 4]; no fentanyl: 0mmHg [95%CI -19 to 19]; adjusted mean difference: 16 mmHg (95%CI 4-29; p=0.013) and to minimum post-intubation SBP (fentanyl: -20 mmHg [95%CI -40 to -1]; no fentanyl: -4mmHg [95%CI -22 to 15]; adjusted mean difference: 16 mmHg [95%CI 5–29]; p=0.008).

Peri-intubation fentanyl administration in patients with moderate to severe TBI is associated with a decrease in SBP. Future studies should explore dose-response relationships, sedative choice, and vasopressor use to better inform peri-intubation analgesia strategies.