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Evidence summaries

Barbiturates for Acute Traumatic Brain Injury

Barbiturate therapy in acute severe head injury appears not to improve outcome. Barbiturate therapy appears to result in a fall in blood pressure in one in four patients. This hypotensive effect may offset any ICP lowering effect on cerebral perfusion pressure. Level of evidence: "B"

A Cochrane review [Abstract] 1 included 7 studies with a total of 341 participants. For barbiturates versus no barbiturate, the pooled RR of death from 3 trials (n=208) was 1.09 (95% CI 0.81 to 1.47). Death or disability, measured using the Glasgow Outcome Scale was assessed in two trials (n=135), the RR with barbiturates was 1.15 (95% CI 0.81 to 1.64). Two trials examined the effect of barbiturate therapy on intracranial pressure (ICP). In one (n=73), a smaller proportion of patients in the barbiturate group had uncontrolled ICP (68% vs. 83%); the RR for uncontrolled ICP was 0.81 (95% CI 0.62 to 1.06). In the other, mean ICP was also lower in the barbiturate group. Barbiturate therapy results in an increased occurrence of hypotension (RR 1.80; 95% CI 1.19 to 2.70; 2 trials, n=126). For every 4 patients treated, one developed clinically significant hypotension. Mean body temperature was significantly lower in the barbiturate group.In one study of pentobarbital vs. mannitol there was no difference in death between the two study groups (RR 1.21; 95% CI 0.75 to 1.94; n=59). Pentobarbital was less effective than mannitol for control of raised ICP (RR 1.75; 95% CI 1.05 to 2.92; one study, n=59).In one study (n=42) the RR of death with pentobarbital vs. thiopental was 1.78 (95% CI 1.03 to 3.08) in favour of thiopental. Fewer people had uncontrollable ICP with thiopental (RR 1.64; 95% CI 1.03 to 2.60; one study, n=44). There was no significant difference in the effects of pentobarbital vs. thiopental for death or disability, measured using the Glasgow Outcome Scale (RR 1.31; 95% CI 0.88 to 1.94; one study, n=42), or hypotension (RR 0.95; 95% CI 0.81 to 1.12; one study, n=44).

Comment: The quality of evidence is downgraded by imprecise results (few trials in each comparison).

    References

    • Roberts I, Sydenham E. Barbiturates for acute traumatic brain injury. Cochrane Database Syst Rev 2012;12():CD000033. [PubMed]

Primary/Secondary Keywords