Efficacy of barbiturates in the treatment of resistant intracranial hypertension in severely head-injured children

Cerebral perfusion pressures (CPP) of less than 50 torr are associated with marginal cerebral blood flow and poor outcome. We report our experience with a group of 7 children who survived long periods with CPP of less than 50 torr during treatment with pentobarbital. The study group was identified through a retrospective review of all head-injured patients admitted to Cardinal Glennon Memorial Hospital for Children between 1984 and 1986. All of the patients presented had sustained intracranial pressure of greater than 20 torr which was resistant to conventional therapy. All patients received pentobarbital for at least 24 h and all had documented CPP of less than 50 torr for more than 30 min during that time. Of these 7 children: 3 made good recoveries; 2 are moderately disabled, and 2 are vegetative. Neither the CPP nor the length of pentobarbital coma was an accurate predictor of outcome. It seems likely that these children are a subset of those previously defined as having resistant intracranial hypertension and that, as a group, they may have benefited from pentobarbital administration. It is also apparent that, in this group, low CPP was not indicative of irreversible brain damage or brain death.