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Published on: March 26, 2019
Initial observations of combination barbiturate coma and decompressive craniectomy for the management of severe
Roberta P Glick1, Alexander Ksendzovsky, John Greesh
1Department of Neurosurgery, Mount Sinai Hospital, Rush Medical College, University of Illinois College of Medicine, Chicago, IL 60608, USA. rpglick@hotmail.com
Insights
Aggressive treatment combining barbiturate coma with decompressive craniectomy and external ventricular drainage shows promise for severe pediatric traumatic brain injury (TBI). This approach led to favorable outcomes in a small group of critically injured children.
Area of Science:
- Pediatric neurosurgery
- Traumatic Brain Injury (TBI) management
- Critical care neurology
Background:
- Treatment for pediatric severe traumatic brain injury (TBI) with low Glasgow Coma Score (GCS) and fixed, dilated pupils remains controversial.
- Aggressive management strategies like barbiturate coma and decompressive craniectomy are infrequently studied in this population.
Observation:
- Six pediatric patients (<18 years) with severe TBI, GCS <5, fixed/dilated pupils, and CT-evident lesions/edema were treated.
- Despite standard interventions, intracranial pressure remained elevated, necessitating decompressive craniectomy, external ventricular drainage, and barbiturate coma for 72 hours.
Findings:
- Four out of six pediatric patients with severe TBI achieved good to excellent outcomes (GOS 4-5).
- One patient expired, and one remained in a vegetative state.
Implications:
- Combination therapy of barbiturate coma, decompressive craniectomy, and external ventricular drainage can yield positive results in select pediatric TBI cases.
- Further research is warranted to explore this aggressive management approach for severe pediatric TBI.
Objective:
In the pediatric population, treatment of severely injured children presenting with low Glasgow Coma Score (GCS) and fixed and dilated pupils is controversial. The combination of barbiturate coma and decompressive craniectomy as an aggressive means of controlling intracranial pressure is limited to few studies. In the present series, we report our experience with aggressive combination therapy resulting in good outcomes in pediatric patients with severe traumatic brain injury (TBI).
Patients And Methods:
Six TBI patients, aged <18 years, either presented with or deteriorated to a GCS <5 with fixed and dilated pupils and CT evidence of surgical lesions with brain edema. Despite hyperventilation, anesthesia, and mannitol, intracranial pressures remained elevated and all patients underwent decompressive craniectomy and external ventricular drainage and were subsequently placed into barbiturate coma for 72 h.
Results:
One patient died and 1 patient remained vegetative. Two patients had excellent recoveries (GOS 5/Rankin 1 or 0, no cognitive deficits) and 2 patients had good recoveries (GOS 4/Rankin 1, mild cognitive deficits).
Conclusions:
Combination of barbiturate coma with decompressive craniectomy and external ventricular drainage led to good outcomes in a small group of pediatric patients with severe TBI. Based on this series we recommend further investigation into aggressive combination management.
