[Vance]

I understand that barbiturates are neuroprotective in CNS/brain injury. Why don't I see their use, particularly when sedation is warranted? Instead, it's seems propofol and/or a benzodiazapine are used, without further consideration. Have barbiturates been retired from use in critical care? Thank you for your reply.

[suzanne4]

Barbituate comas are still used all of the time. Remember that they are not used for their sedative properties, but to decrease any type of brain evoked potential. Propofol is wonderful for sedation in the Neuro ICU as you can turn it off, and then almost immediately do a neuro check and then turn it back up.

Hope that this helps........................

[gwenith]

At one time we were commonly inducing head injuries into a "barbituate coma" as part of "neuro protection" however we discovered that the darn stuff took forever to wear off again making neuro assessment impossible. But as Susanne says - it is still used especially for intractable status epilepticus.

hope this helps..........

[Elenaster]

In my experience, barbituate comas are still used, but only as a last ditch effort for cerebral hypertension (not hydrocephalus) refractory to other treatments, such as mannitol in addition to what Gwenith stated.

Barbituate comas have some very negative side effects, such as pneumonia, paralytic ileus and severe skin breakdown Additionally its use delays brain death testing, as the drug must be out of the system entirely before testing can be initiated. Pentobarb is fat soluable and takes days to clear.

I have seen patients come out of barbituate comas and survive, but their quality of life is questionable (trached, pegged, in a nursing home). The majority of patients I've seen have died, either from complications or the progression of brain death.

[gwenith]

Thanks Elanaster - I have not seen it except for a VERY intractable status epilepticus patient who was post surgery - we have used it occasionally for a very short term but nothing like we originally tried. Rotten stuff took two - three weeks to wear off - in the meantime you had a completely paralysed patient with all the negative outcomes that causes.

[suzanne4]

It is still used in Pediatric ICUs, especially after severe traumatic brain injuries, when necessary.

[mwbeah]

Propofol is the hypnotic

agent of choice in patients with an acute neurologic

insult, as it is easily titratable and rapidly reversible

once discontinued. These properties permit predictable

sedation yet allow for periodic neurologic evaluation

of the patient.116,117 Propofol has additional

properties that may be beneficial in the head-injured

patient, including a decrease in cerebral metabolic

rate, potentiation of Gamma-aminobuturate A (GABAergic)

inhibition, and inhibition of methyl-D-aspartate

glutamate receptors and voltage-dependent calcium

channels.118 Propofol is also a potent antioxidant and

inhibitor of lipid peroxidation.119

Link: http://www.chestjournal.org/cgi/reprint/122/2/699

[Elenaster]

I agree that propofol is a far superior drug for providing sedation in ICU patients under most circumstances, however it should be noted that some patients experience a sustained drop in blood pressure that limits its use, particularly if they have increased ICP.

For those who are unfamiliar, it is exceedingly important to maintain cerebral perfusion pressure, usually greater than 60-70 mmHg, in a patient with high ICP. The formula is:

(MAP) - (ICP) = CPP

[mwbeah]

Originally Posted by Elenaster

I agree that propofol is a far superior drug for providing sedation in ICU patients under most circumstances, however it should be noted that some patients experience a sustained drop in blood pressure that limits its use, particularly if they have increased ICP.

For those who are unfamiliar, it is exceedingly important to maintain cerebral perfusion pressure, usually greater than 60-70 mmHg, in a patient with high ICP. The formula is:

(MAP) - (ICP) = CPP

Are you implying...........?

Lets see, I work with propofol daily. When the BP drops, I believe that you turn the infusion down.....correct me if I am wrong..........

I am a Doctoral Neuroscience student.........I should know the formula..... (JK)

(One question, how can Right atrial pressure affect ICP?)

The CPP number which has been evidenced based is 70mmHg or above with injury:

Chan K H, Miller J D, Dearden N M, Andrews P J D & Midgley S. "The effects of changes in cerebral perfusion pressure upon middle cerebral artery blood flow velocity and jugular bulb venous oxygen saturation after severe brain trauma." J.Neurosurgery 1992; 77: 55- 61.

[hrtprncss]

HI quick question, I know that sedation then let's say norcuron then barb coma, with concommitant use of mannitol and other things are being implemented. I just want to know how many people still use hyperventilation as a technique to decrease ICP, i know it's been basically supposedly phased out...But is anyone still hyperventilating a patient, post 24 hours, to well i don't mean to control ICP but used as a short term adjunct to temporary decrease it in emergent situations...Curious to know...hrtprncss