The Effect of Etomidate on Intracranial Pressure and Systemic Blood Pressure in Pediatric Patients with Severe Traumatic Brain Injury

Bramwell, Kenny; Haizlip, Julie; Pribble, Chuck; VanDerHeyden, T Chad; Witte, Madolin K.

doi:10.1097/01.pec.0000199563.64264.3a

Cited by 59 publications

(17 citation statements)

References 23 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…The size of this cohort is similar to (or larger than) those of several therapeutic studies cited in the most recent expert guidelines(15, 19, 25-28). Collecting data near-continuously uniquely strengthened our study by increasing the volume and precision of our data while objectively determining unbiased periods of intracranial hypertension(10).…”

Section: Discussionsupporting

confidence: 67%

Effectiveness of Pharmacological Therapies for Intracranial Hypertension in Children With Severe Traumatic Brain Injury—Results From an Automated Data Collection System Time-Synched to Drug Administration

Shein

Ferguson

Kochanek

et al. 2016

Pediatric Critical Care Medicine

View full text Add to dashboard Cite

Objective To describe acute cerebral hemodynamic effects of medications commonly used to treat intracranial hypertension in children with traumatic brain injury (TBI). Currently, data supporting the efficacy of these medications are insufficient. Design In this prospective observational study, intracranial hypertension (intracranial pressure [ICP] ≥ 20 mm Hg for > 5 min) was treated by clinical protocol. Administration times of medications for intracranial hypertension (fentanyl, 3% sodium chloride [HTS], mannitol and pentobarbital) were prospectively recorded and synchronized with an automated database that collected ICP and cerebral perfusion pressure (CPP) every 5 seconds. ICP crises confounded by external stimulation or mechanical ventilator adjustments were excluded. Mean ICP and CPP from epochs following drug administration were compared to baseline values using Kruskal-Wallis ANOVA and Dunn's test. Frailty modeling was used to analyze the time to ICP crisis resolution. Mixed effect models compared ICP and CPP 5min after the medication vs. baseline, and rates of treatment failure. Setting A tertiary care children's hospital. Patients Children with severe TBI (Glasgow Coma Scale score ≤ 8). Interventions None. Measurements and Main Results We analyzed 196 doses of fentanyl, HTS, mannitol and pentobarbital administered to 16 children (median: 12 doses/patient). Overall, ICP significantly decreased following fentanyl, HTS and pentobarbital. After controlling for administration of multiple medications, ICP was decreased following HTS and pentobarbital administration; CPP was decreased following fentanyl and was increased following HTS. After adjusting for significant covariates (including age, GCS score and ICP), HTS was associated with a two-fold faster resolution of intracranial hypertension than either fentanyl or pentobarbital. Fentanyl was significantly associated with the most frequent treatment failure. Conclusions ICP decreased after multiple drugs, but HTS may warrant consideration as the first-line drug for treating intracranial hypertension, as it was associated with the most favorable cerebral hemodynamics and fastest resolution of intracranial hypertension.

show abstract

Section: Discussionsupporting

confidence: 67%

Effectiveness of Pharmacological Therapies for Intracranial Hypertension in Children With Severe Traumatic Brain Injury—Results From an Automated Data Collection System Time-Synched to Drug Administration

Shein

Ferguson

Kochanek

et al. 2016

Pediatric Critical Care Medicine

View full text Add to dashboard Cite

show abstract

“…Although some authors proposed to avoid using etomidate due to high risk adrenal insufficiency [60], a study, in pediatric patients with severe head injury, revealed that etomidate treatment reduced intracranial pressure [61]. STZ-induced oxidative stress model is used in this study in order to simulate oxidative stress situation in different neurological pathologies such as trauma or Control STZ STZ+Etomidate STZ+Vehicle Fig.…”

Section: Discussionmentioning

confidence: 99%

Neuroprotective Effect of Etomidate in the Central Nervous System of Streptozotocin-Induced Diabetic Rats

et al. 2006

View full text Add to dashboard Cite

It is well known that hyperglycaemia due to diabetes mellitus leads to oxidative stress in the central nervous system. Oxidative stress plays important role in the pathogenesis of neurodegenerative changes. In the present study we investigated the possible neuroprotective effect of etomidate against streptozotocin-induced (STZ-induced) hyperglycaemia in the rat brain and spinal cord. A total of 40 rats were used in this study. Rats were divided into four groups: sham-control, diabetic, diabetic-etomidate treated and vehicle for etomidate treatment group. Diabetes mellitus was induced by a single injection of streptozotocin (60 mg/kg body weight). Three days after streptozotocin injection, etomidate (2 mg/kg) was injected intraperitoneally for etomidate group and lipid emulsion (10%) for vehicle group was injected with corresponding amount intraperitoneally every day for 6 weeks. Six weeks after streptozotocin injection, seven rats from each group were killed and brain, brain stem and cervical spinal cord were removed. The hippocampus, cortex, cerebellum, brain stem and spinal cord were dissected for the biochemical analysis (the level of malondialdehyde [MDA], total nitrite, reduced glutathione [GSH], and xanthine oxidase [XO] activity). STZ-induced diabetes resulted in significantly elevation of MDA, XO and nitrite levels in the hippocampus, cortex, cerebellum, brain stem and spinal cord of the rats (P < 0.05) while etomidate treatment provided significantly lower values (P < 0.05). This study demonstrated that etomidate have neuroprotective effect on the neuronal tissue against the diabetic oxidative damage.

show abstract

“…In 1979, Moss and colleagues demonstrated the efficacy of etomidate in causing a significant ICP reduction with a minimal reduction in MAP and CPP [39]. Similarly, in pediatrics, Bramwell and colleagues demonstrated that a single dose of etomidate is effective at reducing ICP while maintaining MAP and CPP [40]. However, the use of etomidate is currently being reviewed in TBI patients because of its potent effects on the adrenal axis-leading to relative adrenal insufficiency in animals and in some clinical reports.…”

Section: Contraindications Hypersensitivitymentioning

confidence: 93%

Management of Pediatric Traumatic Brain Injury

Mtaweh

Bell

2015

Curr Treat Options Neurol

View full text Add to dashboard Cite

Pediatric severe traumatic brain injury continues to be a major cause of disability and death. Rapid initial airway and hemodynamic stabilization is critical, followed by the need for immediate recognition of intracranial pathology that requires neurosurgical intervention. Intracranial hypertension and cerebral hypoperfusion have been recognized as major insults after trauma and management should be directed at preventing both. Sedation with opioids, moderate hyperventilation to arterial carbon dioxide level of 35-40 mmHg, hyperosmolar therapy with 3 % saline or mannitol, normothermia, and cerebrospinal fluid drainage continue to be the cornerstones of initial management of intracranial hypertension (intracranial pressure >20 mmHg). Refractory intracranial hypertension is treated with high-dose barbiturate therapy to achieve medical burst suppression on electroencephalography and decompressive craniectomy. In addition, those children require antiepileptic medications for seizure prophylaxis, adequate nutritional management, and early physical therapy and rehabilitation referrals. Most of the evidence for care of children with brain injury comes from center-specific practice and experience rather than objective data. This lack of evidence provides the ground for ongoing research; nevertheless, outcomes after traumatic brain injury continue to show improvement.

show abstract

The Effect of Etomidate on Intracranial Pressure and Systemic Blood Pressure in Pediatric Patients with Severe Traumatic Brain Injury

Abstract: In pediatric patients with severe traumatic brain injury, single-dose etomidate administration resulted in statistically significant reductions in ICP and improvement in cerebral perfusion pressure without significantly altering MAP.

Cited by 59 publications

References 23 publications

Effectiveness of Pharmacological Therapies for Intracranial Hypertension in Children With Severe Traumatic Brain Injury—Results From an Automated Data Collection System Time-Synched to Drug Administration

Effectiveness of Pharmacological Therapies for Intracranial Hypertension in Children With Severe Traumatic Brain Injury—Results From an Automated Data Collection System Time-Synched to Drug Administration

Neuroprotective Effect of Etomidate in the Central Nervous System of Streptozotocin-Induced Diabetic Rats

Management of Pediatric Traumatic Brain Injury

Contact Info

Product

Resources

About