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

Report of 3 cases

Nassir Mansour M.D., M.R.C.S.1, Ruth-Mary deSouza M.D., M.R.C.S.2, Christian Sikorski M.D.3, Madelyn Kahana M.D.4, and David Frim M.D., Ph.D.1
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  • 1 Section of Neurosurgery, University of Chicago, Illinois;
  • | 2 King's College Hospital, London, United Kingdom;
  • | 3 Lake Michigan Neurological Surgery, Saint Joseph, Michigan; and
  • | 4 Pediatrics Department, Stanford University, Palo Alto, California
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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.

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