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High-dose barbiturates for refractory intracranial hypertension in children with severe traumatic brain injury
Sarah A Mellion1, Kimberly Statler Bennett, German L Ellsworth
1Department of Pediatrics, University of Utah, Salt Lake City, UT, USA.
Insights
High-dose barbiturates controlled refractory intracranial hypertension in 28% of pediatric severe traumatic brain injury patients. Achieving this control improved long-term outcomes, highlighting its potential as a second-tier therapy.
Area of Science:
- Pediatric critical care medicine
- Neurotrauma research
- Pharmacological interventions
Background:
- Refractory intracranial hypertension is a life-threatening complication of severe traumatic brain injury (TBI) in children.
- Standard management protocols may not effectively reduce elevated intracranial pressure (ICP) in all pediatric TBI cases.
- Exploring second-tier therapies is crucial for improving outcomes in pediatric TBI.
Purpose of the Study:
- To evaluate the efficacy of high-dose barbiturates as a second-tier therapy for pediatric refractory intracranial hypertension.
- To assess the impact of barbiturate therapy on ICP control and neurological outcomes in children with severe TBI.
- To identify factors associated with treatment response and long-term outcomes.
Main Methods:
- Retrospective cohort study of 36 children with severe TBI and refractory intracranial hypertension (ICP > 20 mm Hg) at a single Level I pediatric trauma center.
- High-dose barbiturates administered for a minimum of 6 hours, with continuous electroencephalography (EEG) monitoring.
- Primary outcomes included ICP control within 6 hours and Pediatric Cerebral Performance Category (PCP) scores at discharge and follow-up.
Main Results:
- Twenty-eight percent (10 of 36) of patients achieved control of refractory intracranial hypertension.
- Patients who responded to barbiturates received treatment significantly later after injury (76 vs. 29 median hours).
- Among survivors, barbiturate control of ICP was associated with significantly better PCP scores and a twofold likelihood of acceptable long-term outcomes.
Conclusions:
- High-dose barbiturates can achieve refractory intracranial hypertension control in approximately 30% of pediatric severe TBI patients.
- Control of intracranial hypertension with barbiturates is linked to a higher probability of acceptable long-term neurological outcomes.
- Further research may optimize the timing and patient selection for barbiturate therapy in pediatric refractory intracranial hypertension.
Objectives:
To evaluate high-dose barbiturates as a second-tier therapy for pediatric refractory intracranial hypertension complicating severe traumatic brain injury.
Design:
This is a retrospective cohort study of children with refractory intracranial hypertension treated with high-dose barbiturates.
Setting:
A single center level I pediatric trauma from 2001 to 2010.
Patients:
Thirty-six children with refractory intracranial hypertension defined as intracranial pressure greater than 20 mm Hg despite standard management treated with high-dose barbiturates after severe traumatic brain injury.
Interventions:
High-dose barbiturates were administered for refractory intracranial hypertension for a minimum duration of 6 hours and monitored by continuous electroencephalography.
Measurements And Main Results:
Exposure was control of refractory intracranial hypertension defined as > 20 mm Hg within 6 hours after starting barbiturates. Pediatric cerebral performance category scores at hospital discharge and at 3 months (or longer) follow-up were the primary outcomes. Ten of 36 patients (28%) had control of refractory intracranial hypertension. Neither demographic nor injury characteristics were associated with refractory intracranial hypertension control. Children who responded received barbiturates significantly later after injury (76 vs. 29 median hours). Overall, 14 children died, 13 without control of intracranial pressure. Survival was more common in those who responded compared with those who did not respond to high-dose barbiturates, although this did not reach statistical significance (relative risk of death 0.2; 95% confidence interval; [0.03-1.3]). Of the 22 survivors, 19 had an acceptable survival (pediatric cerebral performance category less than 3) at 3 months or longer after injury; however, only three returned to normal function. Among survivors, control of refractory intracranial hypertension was associated with significantly better pediatric cerebral performance category scores and over two-fold likelihood of acceptable long-term outcome (relative risk 2.3; 95% confidence interval [1.4-4.0]) compared with uncontrolled refractory intracranial hypertension despite high-dose barbiturates.
Conclusions:
Addition of high-dose barbiturates achieved control of refractory intracranial hypertension in almost 30% of treated children. Control of refractory intracranial hypertension was associated with increased likelihood of an acceptable long-term outcome.
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