Effect of Administration of Neuromuscular Blocking Agents in Children With Severe Traumatic Brain Injury on Acute Complication Rates and Outcomes

Abstract

Objective To evaluate the association between neuromuscular blocking agents (NMBA) and outcome, intracranial pressure (ICP) and medical complications in children with severe TBI. Design A secondary analysis of a randomized, controlled trial of therapeutic hypothermia. Setting 17 hospitals in US, Australia, and New Zealand Patients Children (< 18 y) with severe TBI. Interventions None for this secondary analysis. Measurements and Main Results Children received NMBA on the majority of days of the study (69.6%) and the modified Pediatric Intensity Level of Therapy (mPILOT) scores (modified by removing NMBA administration from the score) were increased on days when NMBA were used (9.67 ± 0.21 vs. 5.48 ± 0.26, p < 0.001). Children were stratified into groups based on exposure to NMBA (Group 1 received NMBA each study day; Group 2 did not). Group 1 had increased number of daily ICP readings > 20 mmHg (4.4 ± 1.1 v. 2.4 ± 0.5, p = 0.015) and longer ICU length of stay (LOS) and hospital length of stay (p = 0.003 and 0.07, respectively, Kaplan-Meier). The Glasgow Outcome Score – Extended for Pediatrics at hospital discharge, 3 mo, 6 mo and 12 mo after TBI and medical complications observed during the acute hospitalization were similar between groups. Conclusions Administration of NMBA was ubiquitous and daily administration of NMBA was associated with intracranial hypertension but not outcomes – likely indicating that increased injury severity prompted their use. Despite this, NMBA use was not associated with complications. A different study design – perhaps using randomization or methodologies – of a larger cohort will be required to determine if NMBA use is helpful after severe TBI in children.

Recommendations for analgesia and sedation in critically ill children admitted to intensive care unit

“…A prospective study on children ventilated more than 24 h and treated with NMBA in continuous infusion reported a reduction of the thickness of diaphragmatic muscle, but the clinical impact of these data needs to be confirmed [62]. A secondary analysis of an RCT on therapeutic hypothermia showed the use of NMBA does not impact mortality and morbidity of critically ill children [63]. A recent case-control study reported an increase in the incidence of infections in patients with acute kidney insufficiency treated NMBA [64].…”

Approaches to neuroprotection in pediatric neurocritical care

“…Neuromuscular blockade has also been shown to decrease global oxygen consumption and energy expenditure in mechanically ventilated children. This is an important consideration in children who are shivering when undergoing targeted temperature management and is used extensively in patients with refractory elevations in ICP[ 56 , 57 ]. The use of barbiturate coma to treat acute, refractory intracranial hypertension for pediatric TBI has been shown to be effective in decreasing ICP and is included as a consideration for second-tier therapies in the most recent consensus-based Brain Trauma Foundation guidelines[ 15 , 16 , 58 ].…”

Neurologic Outcomes Following Care in the Pediatric Intensive Care Unit

“…In a study evaluating adherence to the 2003 Pediatric TBI guidelines in children with severe TBI who survived past 48 hours of admission, for every 1% increase in adherence there was a 1% decrease in the chance of a poor outcome at discharge (42). Multiple predictors of unfavorable neurologic outcome following pediatric TBI have been described, including elevated intracranial pressure and decreased cerebral perfusion pressures (37,42,101), low Glasgow Coma Scale (GCS) on admission (40,41,44,46), subarachnoid hemorrhage and abnormal basal cisterns (35,44), and cerebral edema (35,41,46) on neuroimaging. However, several randomized controlled trials in pediatric TBI investigating therapies such as hypothermia (102), decompressive craniectomy (103), or immune-enhancing diet (104), have failed to improve patient outcomes.…”