Complications associated with barbiturate therapy

Anti‐inflammatory and immune‐mediated therapy for a case of febrile infection‐related epilepsy syndrome with rapid recurrence

Febrile infection‐related epilepsy syndrome (FIRES) is a disease of unknown etiology, characterized by refractory frequent focal seizures, which require prolonged intensive care. We successfully treated a boy with FIRES with anti‐inflammatory and immunosuppressive therapy. This case suggests that an autoimmune mechanism may play a role in the development of FIRES.

Immune suppression was effective in a patient with short‐term relapse, suggesting the probability of an immune‐mediated mechanism for Febrile infection‐related epilepsy syndrome.

Intracranial pressure-based barbiturate coma treatment in children with refractory intracranial hypertension due to traumatic brain injury

OBJECTIVE

Refractory intracranial pressure (ICP) hypertension following traumatic brain injury (TBI) is a severe condition that requires potentially harmful treatment strategies such as barbiturate coma. However, the use of barbiturates may be restricted due to concerns about inducing multiorgan system complications related to the therapy. The purpose of this study was to evaluate the outcome and occurrence of treatment-related complications to barbiturate coma treatment in children with refractory intracranial hypertension (RICH) due to TBI in a modern multimodality neurointensive care unit (NICU).

METHODS

The authors conducted a retrospective cohort study of 21 children ≤ 16 years old who were treated in their NICU between 2005 and 2015 with barbiturate coma for RICH following TBI. Demographic and clinical data were acquired from patient records and physiological data from digital monitoring system files.

RESULTS

The median age of these 21 children was 14 years (range 2-16 years) and at admission the median Glasgow Coma Scale score was 7 (range 4-8). Barbiturate coma treatment was added due to RICH at a median of 46 hours from trauma and had a median duration of 107 hours. The onset of barbiturate coma resulted in lower ICP values, lower pulse amplitudes on the ICP curve, and decreased amount of A-waves. No major disturbances in blood gases, liver and kidney function, or secondary insults were observed during this period. Outcome 1 year later revealed a median Glasgow Outcome Scale score of 5 (good recovery), however on the King's Outcome Scale for Childhood Head Injury, the median was 4a (moderate disability).

CONCLUSIONS

The results of this study indicate that barbiturate coma, when used in a modern NICU, is an effective means of lowering ICP without causing concomitant severe side effects in children with RICH and was compatible with good long-term outcome.

High-dose phenobarbital with intermittent short-acting barbiturates for acute encephalitis with refractory, repetitive partial seizures

Acute encephalitis with refractory, repetitive partial seizures (AERRPS) is characterized by repetitive seizures during the acute and chronic phases and has a poor neurological outcome. Burst-suppression coma via continuous i.v. infusion of a short-acting barbiturate is used to terminate refractory seizures, but the severe side-effects of short-acting barbiturates are problematic. We report on a 9-year-old boy with AERRPS who was effectively treated with very-high-dose phenobarbital (VHDPB) combined with intermittent short-acting barbiturates. VHDPB side-effects were mild, especially compared with those associated with continuous i.v. infusion of short-acting barbiturates (dosage, 40-75 mg/kg/day; maximum blood level, 290 μg/mL). Using VHDPB as the main treatment, short-acting barbiturates were used intermittently and in small amounts. This is the first report to show that VHDPB, combined with intermittent short-acting barbiturates, can effectively treat AERRPS. After treatment, convulsions were suppressed and daily life continued, but intellectual impairment and high-level dysfunction remained.

Ventilator-Associated Pneumonia in Pediatric Traumatic Brain Injury

Ventilator-associated pneumonia (VAP) is a common occurrence among intubated pediatric traumatic brain injury (TBI) patients. However, little is known about the epidemiology, risk factors, and microbiology of VAP in pediatric TBI. We reviewed a cohort of 119 pediatric moderate-to-severe TBI patients and identified 42 with VAP by positive protected bronchial brush specimens. Location of intubation, severity of injury, and antibiotic administration within 2 days after injury were not associated with VAP. Most treatments for elevated intracranial pressure were associated with increased risk of VAP; however, in a multi-variable analysis barbiturate coma (hazard ratio [HR], 3.2; 95% confidence interval [CI] 1.4-7.3), neuromuscular blockade (NMBA; HR, 3.4; 95% CI 1.6-7.3), and use of a cooling blanket for euthermia (HR 2.4; 95% CI 1.1-5.5) remained independently associated with VAP. Most VAP (55%) occurred prior to hospital Day 4 and only 7% developed VAP after Day 7. Methicillin-sensitive Staphylococcus aureus (34%), Haemophilus influenzae (22%), and Streptococcus pneumoniae (15%) were the most common organisms, comprising 71% of isolated pathogens (36% of infections were polymicrobial). Patients with VAP had significantly longer intensive care unit and hospital stays, as well as increased risk of chronic care needs after discharge, but not mortality. VAP is a common occurrence in pediatric TBI patients, and early empiric therapy for patients requiring barbiturate infusion, NMBA, or use of a cooling blanket could mitigate morbidity.

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

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.

Non-neurologic organ dysfunction in acute brain injury

Patients with acute brain injury are a distinct group within the ICU who may develop non-neurologic organ dysfunction in the absence of systemic injury or infection. This dysfunction may arise directly as a result of the brain injury or indirectly with complications of brain-specific therapies. This article reviews the current literature with respect to the incidence of organ dysfunction or failure and its association with outcome in patients with acute brain injury. Organ system-specific etiologic considerations and management are discussed.

Issues of pharmacology in pediatric cardiac extracorporeal membrane oxygenation with special reference to analgesia and sedation

Sufficient analgesia, sedation, and paralysis, if necessary, are cornerstones of extracorporeal membrane oxygenation (ECMO) treatment protocols. However, increased distribution volumes, drug absorption by circuit materials, and impaired drug elimination, as well as alternations of cerebral perfusion and blood brain barrier function, result in the markedly altered pharmacodynamics of applied drugs. Today, narcotics combined with benzodiazepines, sometimes enforced by barbiturates, are commonly used in clinical practice. Paralysis is usually achieved by pancuronium or vecuronium. Although these drugs are used widely, actual efficacy remains uncertain because of the lack of reliable tools to measure pain relief and degree of sedation during ECMO, especially during paralysis. Taking into account the detrimental effects of insufficient pain relief and inadequate sedation in such unstable patients as children during pediatric cardiac ECMO, further studies on this topic seem urgently necessary.

Experimental study on the indications for barbiturate therapy. Change in haemodynamics and the influence of dopamine

The effect of barbiturates on the cerebral haemodynamics and the influence of dopamine on barbiturates were investigated using 20 cats, and clinical indication of barbiturate therapy is discussed. Cerebral blood flow, oxygen extraction fraction, and cerebro-vascular resistance as well as physiological variables were evaluated at various concentrations of barbiturates in the blood. Thiamylal caused simultaneous reduction of mean arterial blood pressure and cerebral blood flow. As the disruption of autoregulation proceeded, cerebro-vascular resistance and oxygen extraction fraction increased till the barbiturate-induced coma stage. Furthermore, cerebro-vascular resistance increased much more markedly by the combined use of dopamine. Clinically, our results indicate barbiturates would increase cerebral circulatory disturbances caused by vasospasm following subarachnoid haemorrhage because barbiturates further increase cerebro-vascular resistance. Then again, the combined use of dopamine is not preferable because of deterioration in vasospasm.

Complications and side effects during thiopentone therapy in patients with severe head injuries

This study reports all complications and side effects occurring in 38 patients with severe traumatic brain lesions treated with barbiturate coma because of a dangerous increase in intracranial pressure. The treatment was induced by intravenous infusion of thiopentone (5-11 mg.kg-1) followed by a continuous infusion of 4-8 mg.kg-1.h-1. The subsequent rate of thiopentone infusion was governed by the level of the intracranial pressure with the intention of keeping ICP below 20 mmHg (2.7 kPa). The duration of treatment was 1-15 days. Arterial hypotension occurred in 58%, hypokalemia in 82%, respiratory complications in 76%, infections in 55%, hepatic dysfunction in 87% and renal dysfunction in 47% of the patients. Twenty patients survived. Mortality in 17 patients was caused by an untreatable increase in intracranial pressure. In one patient complications due to barbiturate treatment may have contributed to the fatal outcome. In none of the other cases were the noted complications and side effects associated with any permanent symptoms or dysfunctions.

Critical care in uraemic children

The special problems posed by renal disease have to be considered when a uraemic child requires intensive care. This report gives an overview on the problems of dialysis treatment, circulatory support, infectious complications, coagulation disorders and increased intracranial pressure.

Influence of dopamine on cerebral blood flow, and metabolism for oxygen and glucose under barbiturate administration in cats

The effect of dopamine during barbiturate therapy was investigated in 29 cats including 5 sham-operated cats. According to Kiersey's classification of electro-encephalographic patterns, physiological variables, cerebral metabolic rates for oxygen and glucose, cerebral blood flow (CBF), and intracranial pressure (ICP), etc. were evaluated in each electro-encephalographic pattern. Oxygen-glucose index was calculated and used as an indicator for aerobic or anaerobic metabolism of glucose. Group 1 (12 cats), to which only thiamylal was administered, maintained aerobic glycolysis due to a parallel reduction of cerebral metabolic rates for oxygen and glucose (about half of the initial value at Kiersey's fifth pattern) in spite of reduction of CBF and mean arterial blood pressure (MABP). Group 2 (12 cats), to which dopamine was administered in addition to thiamylal due to a reduction of MABP, showed anaerobic glycolysis though MABP and CBF were maintained. These findings are ascribed to an increase of cerebral metabolic rate for glucose up to 130% of the initial value though cerebral metabolic rate for oxygen decreased down to half of the initial value: The beneficial effect of barbiturate on cerebral metabolism was reduced by use of dopamine. ICP was reduced in both groups. Our result indicates that administration of extracellular fluid may be preferable for treatment of hypotension during barbiturate therapy than dopamine medication.