Intracranial pressure–based barbiturate coma treatment in children with refractory intracranial hypertension due to traumatic brain injury

Restricted access

OBJECTIVE

Refractory intracranial pressure (ICP) hypertension following traumatic brain injury (TBI) is a severe condition that requires potentially harmful treatment strategies such as barbiturate coma. However, the use of barbiturates may be restricted due to concerns about inducing multiorgan system complications related to the therapy. The purpose of this study was to evaluate the outcome and occurrence of treatment-related complications to barbiturate coma treatment in children with refractory intracranial hypertension (RICH) due to TBI in a modern multimodality neurointensive care unit (NICU).

METHODS

The authors conducted a retrospective cohort study of 21 children ≤ 16 years old who were treated in their NICU between 2005 and 2015 with barbiturate coma for RICH following TBI. Demographic and clinical data were acquired from patient records and physiological data from digital monitoring system files.

RESULTS

The median age of these 21 children was 14 years (range 2–16 years) and at admission the median Glasgow Coma Scale score was 7 (range 4–8). Barbiturate coma treatment was added due to RICH at a median of 46 hours from trauma and had a median duration of 107 hours. The onset of barbiturate coma resulted in lower ICP values, lower pulse amplitudes on the ICP curve, and decreased amount of A-waves. No major disturbances in blood gases, liver and kidney function, or secondary insults were observed during this period. Outcome 1 year later revealed a median Glasgow Outcome Scale score of 5 (good recovery), however on the King’s Outcome Scale for Childhood Head Injury, the median was 4a (moderate disability).

CONCLUSIONS

The results of this study indicate that barbiturate coma, when used in a modern NICU, is an effective means of lowering ICP without causing concomitant severe side effects in children with RICH and was compatible with good long-term outcome.

ABBREVIATIONS CPP = cerebral perfusion pressure; CVP = central venous pressure; EVD = external ventricular drain; GCS = Glasgow Coma Scale; GMT = good monitoring time; GOS = Glasgow Outcome Scale; ICP = intracranial pressure; KOSCHI = King’s Outcome Scale for Childhood Head Injury; MAP = mean arterial pressure; MVO = motor vehicle occupant; NICU = neurointensive care unit; pCO2 = partial pressure of carbon dioxide; RICH = refractory intracranial hypertension; TBI = traumatic brain injury.
Article Information

Contributor Notes

Correspondence Fartein Velle: Uppsala University Hospital, Uppsala, Sweden. fartein.velle@neuro.uu.se; fartein.velle@akademiska.se.INCLUDE WHEN CITING Published online December 27, 2019; DOI: 10.3171/2019.10.PEDS19268.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
Headings
References
  • 1

    Adelson PDSrinivas RChang YBell MKochanek PM: Cerebrovascular response in children following severe traumatic brain injury. Childs Nerv Syst 27:146514762011

    • Search Google Scholar
    • Export Citation
  • 2

    Almaas RSaugstad ODPleasure DRootwelt T: Effect of barbiturates on hydroxyl radicals, lipid peroxidation, and hypoxic cell death in human NT2-N neurons. Anesthesiology 92:7647742000

    • Search Google Scholar
    • Export Citation
  • 3

    Calvert SMiller HECurran AHameed BMcCarter REdwards RJ: The King’s Outcome Scale for Childhood Head Injury and injury severity and outcome measures in children with traumatic brain injury. Dev Med Child Neurol 50:4264312008

    • Search Google Scholar
    • Export Citation
  • 4

    Cole DJCross LMDrummond JCPatel PMJacobsen WK: Thiopentone and methohexital, but not pentobarbitone, reduce early focal cerebral ischemic injury in rats. Can J Anaesth 48:8078142001

    • Search Google Scholar
    • Export Citation
  • 5

    Contant CFValadka ABGopinath SPHannay HJRobertson CS: Adult respiratory distress syndrome: a complication of induced hypertension after severe head injury. J Neurosurg 95:5605682001

    • Search Google Scholar
    • Export Citation
  • 6

    Crouchman MRossiter LColaco TForsyth R: A practical outcome scale for paediatric head injury. Arch Dis Child 84:1201242001

  • 7

    Czosnyka MSmielewski PPiechnik SSteiner LAPickard JD: Cerebral autoregulation following head injury. J Neurosurg 95:7567632001

    • Search Google Scholar
    • Export Citation
  • 8

    Drummond JCPatel PMCole DJ: Cerebral protection: are all barbiturates created equal? Anesthesiology 85:150415051996

  • 9

    Eisenberg HMFrankowski RFContant CFMarshall LFWalker MD: High-dose barbiturate control of elevated intracranial pressure in patients with severe head injury. J Neurosurg 69:15231988

    • Search Google Scholar
    • Export Citation
  • 10

    Elf KNilsson PEnblad P: Outcome after traumatic brain injury improved by an organized secondary insult program and standardized neurointensive care. Crit Care Med 30:212921342002

    • Search Google Scholar
    • Export Citation
  • 11

    Elf KNilsson PRonne-Engström EHowells TEnblad P: Cerebral perfusion pressure between 50 and 60 mm Hg may be beneficial in head-injured patients: a computerized secondary insult monitoring study. Neurosurgery 56:9629712005

    • Search Google Scholar
    • Export Citation
  • 12

    Howells TElf KJones PARonne-Engström EPiper INilsson P: Pressure reactivity as a guide in the treatment of cerebral perfusion pressure in patients with brain trauma. J Neurosurg 102:3113172005

    • Search Google Scholar
    • Export Citation
  • 13

    Howells TPPiper IRSouter MJSouter MJMiller JD: Design of a research database for the study of secondary insults following head injury. J Neurotrauma 12:4714721995 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 14

    Jennett BBond M: Assessment of outcome after severe brain damage. Lancet 1:4804841975

  • 15

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

    • Search Google Scholar
    • Export Citation
  • 16

    Kochanek PMTasker RCCarney NTotten AMDavid APSelden NR: Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines. Pediatr Crit Care Med 20 (1 Suppl):S1S822019

    • Search Google Scholar
    • Export Citation
  • 17

    Lee MWDeppe SASipperly MEBarrette RRThompson DR: The efficacy of barbiturate coma in the management of uncontrolled intracranial hypertension following neurosurgical trauma. J Neurotrauma 11:3253311994

    • Search Google Scholar
    • Export Citation
  • 18

    Liesemer KRiva-Cambrin JBennett KSBratton SLTran HMetzger RR: Use of Rotterdam CT scores for mortality risk stratification in children with traumatic brain injury. Pediatr Crit Care Med 15:5545622014

    • Search Google Scholar
    • Export Citation
  • 19

    Maas AIHukkelhoven CWMarshall LFSteyerberg EW: Prediction of outcome in traumatic brain injury with computed tomographic characteristics: a comparison between the computed tomographic classification and combinations of computed tomographic predictors. Neurosurgery 57:117311822005

    • Search Google Scholar
    • Export Citation
  • 20

    Marshall GTJames RFLandman MPO’Neill PJCotton BAHansen EN: Pentobarbital coma for refractory intra-cranial hypertension after severe traumatic brain injury: mortality predictions and one-year outcomes in 55 patients. J Trauma 69:2752832010

    • Search Google Scholar
    • Export Citation
  • 21

    Marshall LFSmith RWShapiro HM: The outcome with aggressive treatment in severe head injuries. Part II: acute and chronic barbiturate administration in the management of head injury. J Neurosurg 50:26301979

    • Search Google Scholar
    • Export Citation
  • 22

    Mellion SABennett KSEllsworth GLMoore KRiva-Cambrin JMetzger RR: High-dose barbiturates for refractory intracranial hypertension in children with severe traumatic brain injury. Pediatr Crit Care Med 14:2392472013

    • Search Google Scholar
    • Export Citation
  • 23

    Nyholm LLewén AFröjd CHowells TNilsson PEnblad P: The use of nurse checklists in a bedside computer-based information system to focus on avoiding secondary insults in neurointensive care. ISRN Neurol 2012:9039542012

    • Search Google Scholar
    • Export Citation
  • 24

    Orliaguet GAMeyer PGBaugnon T: Management of critically ill children with traumatic brain injury. Paediatr Anaesth 18:4554612008

    • Search Google Scholar
    • Export Citation
  • 25

    Paget SPBeath AWBarnes EHWaugh MC: Use of the King’s Outcome Scale for Childhood Head Injury in the evaluation of outcome in childhood traumatic brain injury. Dev Neurorehabil 15:1711772012

    • Search Google Scholar
    • Export Citation
  • 26

    Pérez-Bárcena JLlompart-Pou JAHomar JAbadal JMRaurich JMFrontera G: Pentobarbital versus thiopental in the treatment of refractory intracranial hypertension in patients with traumatic brain injury: a randomized controlled trial. Crit Care 12:R1122008

    • Search Google Scholar
    • Export Citation
  • 27

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

    • Search Google Scholar
    • Export Citation
  • 28

    Rea GLRockswold GL: Barbiturate therapy in uncontrolled intracranial hypertension. Neurosurgery 12:4014041983

  • 29

    Roberts ISydenham E: Barbiturates for acute traumatic brain injury. Cochrane Database Syst Rev 12:CD0000332012

  • 30

    Rosner MJRosner SDJohnson AH: Cerebral perfusion pressure: management protocol and clinical results. J Neurosurg 83:9499621995

  • 31

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

  • 32

    Schalén WMesseter KNordström CH: Complications and side effects during thiopentone therapy in patients with severe head injuries. Acta Anaesthesiol Scand 36:3693771992

    • Search Google Scholar
    • Export Citation
  • 33

    Shibuta SKosaka JMashimo TFukuda YYoshiya I: Nitric oxide-induced cytotoxicity attenuation by thiopentone sodium but not pentobarbitone sodium in primary brain cultures. Br J Pharmacol 124:8048101998

    • Search Google Scholar
    • Export Citation
  • 34

    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

    • Search Google Scholar
    • Export Citation
  • 35

    Sundstrøm TSollid SWentzel-Larsen TWester K: Head injury mortality in the Nordic countries. J Neurotrauma 24:1471532007

  • 36

    Swedish National Board of Health and Welfare: [Causes of Death 2014.] Stockholm: Official Statistics of Sweden 2015 (Swedish) (https://www.socialstyrelsen.se/globalassets/sharepoint-dokument/artikelkatalog/statistik/2015-8-1.pdf) [Accessed October 25 2019]

  • 37

    Thomale UWGraetz DVajkoczy PSarrafzadeh AS: Severe traumatic brain injury in children—a single center experience regarding therapy and long-term outcome. Childs Nerv Syst 26:156315732010

    • Search Google Scholar
    • Export Citation
  • 38

    Thurman DJ: The epidemiology of traumatic brain injury in children and youths: a review of research since 1990. J Child Neurol 31:20272016

    • Search Google Scholar
    • Export Citation
TrendMD
Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 260 260 181
Full Text Views 37 37 13
PDF Downloads 35 35 14
EPUB Downloads 0 0 0
PubMed
Google Scholar