Susan Hamblin, BCPS, PharmD, BCCCP
Assistant Professor
Lipscomb University College of Pharmacy
Nashville, Tennessee
Disclosure information not submitted.
Candice Smith, BSN, RN, CCRN
Research Nurse III
Vanderbilt University Medical Center, Tennessee, United States
Disclosure information not submitted.
Jennifer Beavers, PharmD, BCPS
Clinical Pharmacist
Vanderbilt University Medical Center, Tennessee, United States
Disclosure information not submitted.
Melissa Smith, MSN, RN
Trauma Program Manager
Vanderbilt University Medical Center, Tennessee, United States
Disclosure information not submitted.
Bradley Dennis, MD, FACS
Associate Professor of Surgery
Vanderbilt University Medical Center, United States
Disclosure information not submitted.
Oscar Guillamondegui, MD, MPH
Chief, Division of Trauma and Surgical Critical Care
Vanderbilt University Medical Center Dept of Surgery, Division of Trauma, United States
Disclosure information not submitted.
Title: Characteristics of Non-Survivors Following Pentobarbital for Severe Traumatic Brain Injury
Introduction: Pentobarbital (PB) continues to be a last-line pharmacologic treatment option in refractory intracranial hypertension (RICH) following traumatic brain injury (TBI). Failure of therapy is common, frequently leading to withdrawal of care or brain death. We aim to describe this process. We hypothesize that most patients with RICH undergoing PB coma will not survive.
Methods: An IRB-approved retrospective analysis was conducted at a level 1 trauma center. Patients 16 years and older admitted to the trauma service from September 2015 to June 2021 receiving a PB infusion for RICH were included. All patients received weight-based PB loading doses followed by titration to burst suppression and concomitant narcotic analgesia. Appropriate demographic and trauma registry data was collected. The primary outcome was PB non-survivors who transitioned to comfort measures or confirmed brain death. Secondary outcomes included time to PB use, length of time on PB, time to withdrawal, failure to control ICPs, frequency of palliative care team consults, and organ donation disposition. Appropriate statistics were performed using SPSS.
Results: Thirty-five patients received PB for RICH. Twenty-one patients (60%) were non-survivors. In the non-survivors, the median Injury Severity Score was 30 (IQR 26-38) and the max Abbreviated Injury Scale Head was 5 (IQR 4-5). The median time from admission to PB was 77 hours (IQR 44-119), and time on PB was 15 hours (IQR 7-23). PB failed to control ICP in 91% of the non-survivors. Seven patients (33.3%) had confirmed brain death via imaging. Fifteen patients (71%) transitioned to organ donation, while 6 (29%) transitioned to comfort measures. Median time to initiate PB was 101 hours (IQR 68-131) in patients who transitioned to comfort measures and 72 hours (IQR 42-104) in organ donors (p=NS). A palliative care consult was obtained in 18 patients (86%). Withdrawal of care or brain death occurred a median of 45 hours (IQR 27-85) following PB discontinuation.
Conclusion: PB coma is often a terminal treatment for severe intracranial hypertension with a mortality of approximately 60% and greater than 70% of non-survivors transitioning to organ donation. This process was often mediated with a palliative care support team.