High-dose barbiturate control of elevated intracranial pressure in patients with severe head injury

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✓ In a five-center study, 73 patients with severe head injury and elevated intracranial pressure (ICP) were randomly assigned to receive either a regimen that included high-dose pentobarbital or one that was otherwise similar but did not include pentobarbital. The results indicated a 2:1 benefit for those treated with the drug with regard to ICP control. When patients were stratified by prerandomization cardiac complications, the advantage increased to 4:1. A multiple logistic model considering treatment and selected baseline variables indicated a significant positive treatment effect of barbiturates, a significant effect of time from injury to randomization, and an interaction of treatment with cardiovascular complications. However, of 925 patients potentially eligible for randomization, only 12% met ICP randomization criteria. The results support the hypothesis that high-dose pentobarbital is an effective adjunctive therapy, but that it is indicated in only a small subset of patients with severe head injury.

Article Information

Address reprint requests to: Howard M. Eisenberg, M.D., Division of Neurosurgery, E-17, The University of Texas Medical Branch, Galveston, Texas 77550.

© AANS, except where prohibited by US copyright law.

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    Schema of study design with details of “conventional therapy” and “barbiturate therapy.” ICP = intracranial pressure; CT = computerized tomography; n = number of cases.

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    Criteria for intracranial pressure (ICP) randomization and treatment failure. Eight patients were in the opened skull subgroup. “Opened skull” indicates craniectomy > 25 sq cm with the dura left open. A patient could not be considered a barbiturate treatment failure unless the full loading dose had been given or unless, in the event of cardiovascular compromise, as high a dose as could be tolerated had been administered.

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