Initial Observations of Combination Barbiturate Coma and Decompressive Craniectomy for the Management of Severe Pediatric Traumatic Brain Injury

Abstract

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.

Pathophysiology and Treatment of Severe Traumatic Brain Injuries in Children

“…Barbiturates decrease ICP by suppressing metabolism and altering vascular tone (Kochanek et al, 2012). Pentobarbital or thiopental are administered as the medications of choice (Glick, Ksendzovsky, Greesh, & Raksin, 2011; Marshall et al, 2010; Mellion et al, 2013). Nurses generally monitor patients with TBI who receive barbiturates for medically-induced comas closely.…”

Pathophysiology and Treatment of Severe Traumatic Brain Injuries in Children

“…Barbiturates decrease ICP by suppressing metabolism and altering vascular tone (Kochanek et al, 2012). Pentobarbital or thiopental are administered as the medications of choice (Glick, Ksendzovsky, Greesh, & Raksin, 2011;Marshall et al, 2010;Mellion et al, 2013). Nurses generally monitor patients with TBI who receive barbiturates for medically-induced comas closely.…”

The Anesthesiologist’s Role in Treating Abusive Head Trauma

“…Inducing a barbiturate coma with or without decompressive craniectomy or cerebrospinal fluid drainage may be required to treat refractory intracranial hypertension. 44,45 Barbiturate comas have primarily been reported for accidental TBI and not specifically for AHT. In one retrospective study of severe pediatric TBI with refractory intracranial hypertension, 45 pentobarbital administered to achieve electrographic burst suppression decreased the ICP to less than 20 mmHg in some cases.…”