Pentobarbital coma for management of intracranial hypertension following traumatic brain injury: Lack of early response to treatment portends poor outcomes

Introduction: Traumatic brain injury (TBI) results in the death of over 50,000 and the permanent disability of 80,000 individuals annually in the United States. Much of the permanent disability is the result of secondary brain injury from intracranial hypertension (ICH). Pentobarbital coma is often instituted following the failure of osmotic interventions and sedation to control intracranial pressure (ICP). The goal of this study was to evaluate the efficacy of pentobarbital coma with respect to ICP management and long-term functional outcome. Methods: Traumatic brain injury patients who underwent pentobarbital coma at a level 1 trauma center between 2014 and 2021 were identified. Patient demographics, injury characteristics, Glasgow Coma Scale (GCS) scores, intracranial pressures (ICPs), and outcomes were obtained from the trauma registry as well as inpatient and outpatient medical records. The proportion of ICPs below 20 for each hospitalized patient-day was calculated. The primary outcome measured was GCS score at the last follow-up visit. Results: 25 patients were identified, and the majority were male (n = 23, 92%) with an average age of 30.0 years +/- 12.9 and median injury severity score of 30 (21.5-33.5). ICPs were monitored for all patients with a median of 464 (326-1034) measurements. The average hospital stay was 16.9 days +/- 11.5 and intensive care stay was 16.9 +/- 10.8 days. 9 (36.0%) patients survived to hospital discharge. Mean follow-up time in months was 36.9 +/- 28.0 (min-max 3-80). 7 of the 9 surviving patients presented as GCS 15 on follow-up and the remaining were both GCS 9. Patients presenting at last follow-up with GCS 15 had a significantly higher proportion of controlled ICPs throughout their hospitalization compared to patients who expired or with follow-up GCS <15 (GCS 15: 88% +/- 10% vs. GCS <15 or dead: 68% +/- 22%, P = 0.006). A comparison of the daily proportion of controlled ICPs by group revealed negligible differences prior to pentobarbital initiation. Groups diverged nearly immediately upon pentobarbital coma initiation with a higher proportion of controlled ICPs for patients with follow-up GCS of 15. Conclusion: Patients that do not have an immediate response to pentobarbital coma therapy for ICH universally had poor outcomes. Alternative therapy or earlier palliation should be considered for such patients. In contrast, patients whose ICPs responded quickly to pentobarbital had excellent long-term outcomes.

Automated summary

Traumatic brain injury (TBI) often leads to death or permanent disability, mainly due to secondary brain injury from intracranial hypertension (ICH). This study evaluated the efficacy of pentobarbital coma therapy in managing ICH and long-term functional outcomes. The results indicated that patients who did not respond immediately to pentobarbital coma therapy had poor outcomes, suggesting the need for alternative treatments or early intervention. In contrast, patients who responded quickly to pentobarbital coma therapy had excellent long-term outcomes.