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

Report of 3 cases

Restricted access

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:

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.



  • View in gallery

    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.

  • View in gallery

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

  • View in gallery

    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.

  • View in gallery

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


  • 1

    Adelson PDRagheb JKanev PBrockmeyer DBeers SRBrown SD: Phase II clinical trial of moderate hypothermia after severe traumatic brain injury in children. Neurosurgery 56:7407542005

  • 2

    Aoki NMizutani H: Arteriovenous malformation in the territory of the occluded middle cerebral artery with massive intraoperative brain swelling: case report. Neurosurgery 16:6606621985

  • 3

    Chen HIMalhotra NROddo MHeuer GGLevine JMLe-Roux PD: Barbiturate infusion for intractable intracranial hypertension and its effect on brain oxygenation. Neurosurgery 63:8808872008

  • 4

    Cormio MGopinath SPValadka ARobertson CS: Cerebral hemodynamic effects of pentobarbital coma in head-injured patients. J Neurotrauma 16:9279361999

  • 5

    Demopoulos HBFlamm ESPietronigro DDSeligman ML: The free radical pathology and the microcirculation in the major central nervous system disorders. Acta Physiol Scand Suppl 492:911191980

  • 6

    Eberhardt KEThimm BMSpring AMaskos WR: Dose-dependent rate of nosocomial pulmonary infection in mechanically ventilated patients with brain oedema receiving barbiturates: a prospective case study. Infection 20:12181992

  • 7

    Frewen TCSwedlow DBWatcha MRaphaely RCGodinez RIHeiser MS: Outcome in severe Reye syndrome with early pentobarbital coma and hypothermia. J Pediatr 100:6636651982

  • 8

    Kageyama GPark KCYoshimine YYokota J: Extensive subdural empyema treated with drainage and barbiturate therapy under intracranial pressure monitoring: case report. Neurol Res 22:6016042000

  • 9

    Kaieda RTodd MMWeeks JBWarner DS: A comparison of the effects of halothane, isoflurane, and pentobarbital anesthesia on intracranial pressure and cerebral edema formation following brain injury in rabbits. Anesthesiology 71:5715791989

  • 10

    Kasoff SSLansen TAHolder DFilippo JS: Aggressive physiologic monitoring of pediatric head trauma patients with elevated intracranial pressure. Pediatr Neurosci 14:2412491988

  • 11

    Koch JDKernie SG: Protecting the future: neuroprotective strategies in the pediatric intensive care unit. Curr Opin Pediatr 23:2752802011

  • 12

    Marion DWPenrod LEKelsey SFObrist WDKochanek PMPalmer AM: Treatment of traumatic brain injury with moderate hypothermia. N Engl J Med 336:5405461997

  • 13

    Marshall LFHoi SU: Treatment of massive intraoperative brain swelling. Neurosurgery 13:4124141983

  • 14

    Marshall LFShapiro HMRauscher AKaufman NM: Pentobarbital therapy for intracranial hypertension in metabolic coma. Reye's syndrome. Crit Care Med 6:151978

  • 15

    Nussbaum EMaggi JC: Pentobarbital therapy does not improve neurologic outcome in nearly drowned, flaccid-comatose children. Pediatrics 81:6306341988

  • 16

    Oda SShimoda MYamada SSato OTsugane R: [Problems in general management during barbiturate therapy.]. No Shinkei Geka 20:124112461992. (Jpn)

  • 17

    Piatt JH JrSchiff SJ: High dose barbiturate therapy in neurosurgery and intensive care. Neurosurgery 15:4274441984

  • 18

    Pittman TBucholz RWilliams D: Efficacy of barbiturates in the treatment of resistant intracranial hypertension in severely head-injured children. Pediatr Neurosci 15:13171989

  • 19

    Roberts I: Barbiturates for acute traumatic brain injury. Cochrane Database Syst Rev 2CD0000332000

  • 20

    Sato MTanaka SSuzuki KKohama AFujii C: Complications associated with barbiturate therapy. Resuscitation 17:2332411989

  • 21

    Schaible DHCupit GCSwedlow DBRocci ML Jr: Highdose pentobarbital pharmacokinetics in hypothermic brain-injured children. J Pediatr 100:6556601982

  • 22

    Stover JFStocker R: Barbiturate coma may promote reversible bone marrow suppression in patients with severe isolated traumatic brain injury. Eur J Clin Pharmacol 54:5295341998

  • 23

    Swedlow DRaphaely RKettrick RGodinez RHeiser MBruce D: Cardiovascular performance with hypothermia and deep pentobarbital coma in children. Crit Care Med 8:2361980. (Abstract)

  • 24

    Traeger SMHenning RJDobkin WGiannotta SWeil MHWeiss M: Hemodynamic effects of pentobarbital therapy for intracranial hypertension. Crit Care Med 11:6977011983

  • 25

    Woodcock JRopper AHKennedy SK: High dose barbiturates in non-traumatic brain swelling: ICP reduction and effect on outcome. Stroke 13:7857871982




All Time Past Year Past 30 Days
Abstract Views 278 278 33
Full Text Views 128 128 1
PDF Downloads 375 375 9
EPUB Downloads 0 0 0


Google Scholar