Role of barbiturate coma in the management of focally induced, severe cerebral edema in children

Report of 3 cases

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Barbiturates are widely used in the management of high intracranial pressure (ICP) caused by diffuse brain swelling. The cardiovascular, renal, and immunological side effects of these drugs limit them to last-line therapy. There are few published data regarding the role of barbiturates in focal brain lesions causing refractory elevated ICP and intraoperative brain swelling in the pediatric population. The authors here present 3 cases of nontraumatic, focally induced, refractory intracranial hypertension due to 2 tumors and 1 arteriovenous malformation, in which barbiturate therapy was used successfully to control elevated ICP. They focus on cardiovascular, renal, and immune function during the course of pentobarbital therapy. They also discuss the role of pentobarbital-induced hypothermia. From this short case series, they demonstrate that barbiturates in conjunction with standard medical therapy can be used to safely reduce postoperative refractory intracranial hypertension and intraoperative brain swelling in children with focal brain lesions.

Abbreviations used in this paper:AVM = arteriovenous malformation; CPP = cerebral perfusion pressure; EEG = electroencephalography; EVD = external ventricular drain; ICP = intracranial pressure; PICU = pediatric intensive care unit; SVR = systemic vascular resistance.

Article Information

Address correspondence to: Nassir Mansour, M.D., Section of Neurosurgery, University of Chicago, MC 3026, Chicago, Illinois 60637. email: nmonim@surgery.bsd.uchicago.edu.

Please include this information when citing this paper: published online May 3, 2013; DOI: 10.3171/2013.3.PEDS12196.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 1. Intracranial pressure tracings obtained after the patient's first craniotomy. Pentobarbital boluses were initiated at postoperative Hour 2 and were continued on an as-needed basis until postoperative Hour 24, when they were transitioned to scheduled doses. h = hour.

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    Case 2. Postoperative axial nonenhanced head CT depicting residual tumor and significant postoperative swelling causing midline shift and displacement of the bone flap.

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    Case 3. Postoperative axial nonenhanced head CT revealing hematoma evacuation and significant brain edema with herniation of the anterior frontal lobes beyond the confines of the craniotomy flap.

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    Case 3. Graph showing the ICP tracings in a patient treated with an initial pentobarbital bolus followed by an infusion titrated for ICP control.

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