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.

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Contributor Notes

Address reprint requests to: Howard M. Eisenberg, M.D., Division of Neurosurgery, E-17, The University of Texas Medical Branch, Galveston, Texas 77550.
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References
  • 1.

    Bowers SAMarshall LF: Outcome in 200 consecutive cases of severe head injury treated in San Diego County: a prospective analysis. Neurosurgery 6:2372421980Bowers SA Marshall LF: Outcome in 200 consecutive cases of severe head injury treated in San Diego County: a prospective analysis. Neurosurgery 6:237–242 1980

    • Search Google Scholar
    • Export Citation
  • 2.

    Bricolo APGlick RP: Barbiturate effects on acute experimental intracranial hypertension. J Neurosurg 55:3974061981Bricolo AP Glick RP: Barbiturate effects on acute experimental intracranial hypertension. J Neurosurg 55:397–406 1981

    • Search Google Scholar
    • Export Citation
  • 3.

    Clasen RAPandolfi SCasey D Jr: Furosemide and pentobarbital in cryogenic cerebral injury and edema. Neurology 24:6426481974Clasen RA Pandolfi S Casey D Jr: Furosemide and pentobarbital in cryogenic cerebral injury and edema. Neurology 24:642–648 1974

    • Search Google Scholar
    • Export Citation
  • 4.

    Eisenberg HMCayard CPapanicolaou Aet al: The effects of three potentially preventable complications on outcome after severe closed head injury in Ishii SNagai HBrock M (eds): Intracranial Pressure V. Berlin: Springer-Verlag1983 pp 549553Eisenberg HM Cayard C Papanicolaou A et al: The effects of three potentially preventable complications on outcome after severe closed head injury in Ishii S Nagai H Brock M (eds): Intracranial Pressure V. Berlin: Springer-Verlag 1983 pp 549–553

    • Search Google Scholar
    • Export Citation
  • 5.

    Gennarelli TASpielman GMLangfitt TWet al: Influence of the type of intracranial lesion on outcome from severe head injury. A multicenter study using a new classification system. J Neurosurg 56:26321982Gennarelli TA Spielman GM Langfitt TW et al: Influence of the type of intracranial lesion on outcome from severe head injury. A multicenter study using a new classification system. J Neurosurg 56:26–32 1982

    • Search Google Scholar
    • Export Citation
  • 6.

    Harrell FE Jr: The LOGIST procedure in SAS Institute Supplemental Library User's Guide Version 5. Cary, NC: SAS Institute1986 pp 269292Harrell FE Jr: The LOGIST procedure in SAS Institute Supplemental Library User's Guide Version 5. Cary NC: SAS Institute 1986 pp 269–292

    • Search Google Scholar
    • Export Citation
  • 7.

    Ishii S: Brain-swelling. Studies of structural, physiologic and biochemical alterations in Caveness WFWalker AE (eds): Head Injury. Conference Proceedings. Philadelphia: JB Lippincott1966 pp 276299Ishii S: Brain-swelling. Studies of structural physiologic and biochemical alterations in Caveness WF Walker AE (eds): Head Injury. Conference Proceedings. Philadelphia: JB Lippincott 1966 pp 276–299

    • Search Google Scholar
    • Export Citation
  • 8.

    Jennett BBond M: Assessment of outcome after severe brain damage. A practical scale. Lancet 1:4804841975Jennett B Bond M: Assessment of outcome after severe brain damage. A practical scale. Lancet 1:480–484 1975

    • Search Google Scholar
    • Export Citation
  • 9.

    Levati AFarina MLVecchi Get al: Prognosis of severe head injuries. J Neurosurg 57:7797831982Levati A Farina ML Vecchi G et al: Prognosis of severe head injuries. J Neurosurg 57:779–783 1982

    • Search Google Scholar
    • Export Citation
  • 10.

    Marshall LFBarba DToole BMet al: The oval pupil: clinical significance and relationship to intracranial hypertension. J Neurosurg 58:5665681983Marshall LF Barba D Toole BM et al: The oval pupil: clinical significance and relationship to intracranial hypertension. J Neurosurg 58:566–568 1983

    • Search Google Scholar
    • Export Citation
  • 11.

    Marshall LFBecker DPBowers SAet al: The National Traumatic Coma Data Bank. Part 1: Design, purpose, goals, and results. J Neurosurg 59:2762841983Marshall LF Becker DP Bowers SA et al: The National Traumatic Coma Data Bank. Part 1: Design purpose goals and results. J Neurosurg 59:276–284 1983

    • Search Google Scholar
    • Export Citation
  • 12.

    Marshall LFSmith RWShapiro HM: The outcome with aggressive treatment in severe head injuries. Part 2: Acute and chronic barbiturate administration in the management of head injury. J Neurosurg 50:26301979Marshall LF Smith RW Shapiro HM: The outcome with aggressive treatment in severe head injuries. Part 2: Acute and chronic barbiturate administration in the management of head injury. J Neurosurg 50:26–30 1979

    • Search Google Scholar
    • Export Citation
  • 13.

    Miller JD: Barbiturates and raised intracranial pressure. Ann Neurol 6:1891931979Miller JD: Barbiturates and raised intracranial pressure. Ann Neurol 6:189–193 1979

    • Search Google Scholar
    • Export Citation
  • 14.

    Miller JDBecker DPWard JDet al: Significance of intracranial hypertension in severe head injury. J Neurosurg 47:5035161977Miller JD Becker DP Ward JD et al: Significance of intracranial hypertension in severe head injury. J Neurosurg 47:503–516 1977

    • Search Google Scholar
    • Export Citation
  • 15.

    Miller JDSweet RCNarayan Ret al: Early insults to the injured brain. JAMA 240:4394421978Miller JD Sweet RC Narayan R et al: Early insults to the injured brain. JAMA 240:439–442 1978

    • Search Google Scholar
    • Export Citation
  • 16.

    Narayan RKKishore PRSBecker DPet al: Intracranial pressure: to monitor or not to monitor? J Neurosurg 56:6506591982Narayan RK Kishore PRS Becker DP et al: Intracranial pressure: to monitor or not to monitor? J Neurosurg 56:650–659 1982

    • Search Google Scholar
    • Export Citation
  • 17.

    Pazzaglia PFrank GFrank Fet al: Clinical course and prognosis of acute post-traumatic coma. J Neurol Neurosurg Psychiatry 38:1491541975Pazzaglia P Frank G Frank F et al: Clinical course and prognosis of acute post-traumatic coma. J Neurol Neurosurg Psychiatry 38:149–154 1975

    • Search Google Scholar
    • Export Citation
  • 18.

    Rea GLRockswold GL: Barbiturate therapy in uncontrolled intracranial hypertension. Neurosurgery 12:4014041983Rea GL Rockswold GL: Barbiturate therapy in uncontrolled intracranial hypertension. Neurosurgery 12:401–404 1983

    • Search Google Scholar
    • Export Citation
  • 19.

    Rockoff MAMarshall LFShapiro M: High-dose barbiturate therapy in humans: a clinical review of 60 patients. Ann Neurol 6:1941991979Rockoff MA Marshall LF Shapiro M: High-dose barbiturate therapy in humans: a clinical review of 60 patients. Ann Neurol 6:194–199 1979

    • Search Google Scholar
    • Export Citation
  • 20.

    Saul TGDucker TB: Effect of intracranial pressure monitoring and aggressive treatment on mortality in severe head injury. J Neurosurg 56:4985031982Saul TG Ducker TB: Effect of intracranial pressure monitoring and aggressive treatment on mortality in severe head injury. J Neurosurg 56:498–503 1982

    • Search Google Scholar
    • Export Citation
  • 21.

    Schwartz MLTator CHRowed DWet al: The University of Toronto Head Injury Treatment Study: a prospective, randomized comparison of pentobarbital and mannitol. Can J Neurol Sci 11:4344401984Schwartz ML Tator CH Rowed DW et al: The University of Toronto Head Injury Treatment Study: a prospective randomized comparison of pentobarbital and mannitol. Can J Neurol Sci 11:434–440 1984

    • Search Google Scholar
    • Export Citation
  • 22.

    Seelig JMMarshall LFToutant SMet al: Traumatic acute epidural hematoma: unrecognized high lethality in comatose patients. Neurosurgery 15:6176201984Seelig JM Marshall LF Toutant SM et al: Traumatic acute epidural hematoma: unrecognized high lethality in comatose patients. Neurosurgery 15:617–620 1984

    • Search Google Scholar
    • Export Citation
  • 23.

    Teasdale GJennett B: Assessment of coma and impaired consciousness. A practical scale. Lancet 2:81841974Teasdale G Jennett B: Assessment of coma and impaired consciousness. A practical scale. Lancet 2:81–84 1974

    • Search Google Scholar
    • Export Citation
  • 24.

    Tsiatis AA: A note on a goodness-of-fit test for the logistic regression model. Biometrika 67:2502511980Tsiatis AA: A note on a goodness-of-fit test for the logistic regression model. Biometrika 67:250–251 1980

    • Search Google Scholar
    • Export Citation
  • 25.

    Walker SHDuncan DB: Estimation of the probability of an event as a function of several independent variables. Biometrika 54:1671791967Walker SH Duncan DB: Estimation of the probability of an event as a function of several independent variables. Biometrika 54:167–179 1967

    • Search Google Scholar
    • Export Citation
  • 26.

    Ward JDBecker DPMiller JDet al: Failure of prophylactic barbiturate coma in the treatment of severe head injury. J Neurosurg 62:3833881985Ward JD Becker DP Miller JD et al: Failure of prophylactic barbiturate coma in the treatment of severe head injury. J Neurosurg 62:383–388 1985

    • Search Google Scholar
    • Export Citation
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