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

A Secondary Analysis From a Randomized, Controlled Trial of Therapeutic Hypothermia

Chin, Katherine H., BS1,2; Bell, Michael J., MD1,2,3; Wisniewski, Stephen R., PhD4; Balasubramani, Goundappa K., PhD4; Kochanek, Patrick M., MD1,2; Beers, Sue R., PhD5; Brown, S. Danielle, MS6; Adelson, P. David, MD6 for the Pediatric Traumatic Brain Injury Consortium: Hypothermia Investigators

Pediatric Critical Care Medicine: May 2015 - Volume 16 - Issue 4 - p 352–358
doi: 10.1097/PCC.0000000000000344
Neurocritical Care
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Objective: To evaluate the association between neuromuscular blocking agents and outcome, intracranial pressure, and medical complications in children with severe traumatic brain injury.

Design: A secondary analysis of a randomized, controlled trial of therapeutic hypothermia.

Setting: Seventeen hospitals in the United States, Australia, and New Zealand.

Patients: Children (< 18 yr) with severe traumatic brain injury.

Interventions: None for this secondary analysis.

Measurements and Main Results: Children received neuromuscular blocking agent on the majority of days of the study (69.6%), and the modified Pediatric Intensity Level of Therapy scores (modified by removing neuromuscular blocking agent administration from the score) were increased on days when neuromuscular blocking agents were used (9.67 ± 0.21 vs 5.48 ± 0.26; p < 0.001). Children were stratified into groups based on exposure to neuromuscular blocking agents (group 1 received neuromuscular blocking agents each study day; group 2 did not). Group 1 had increased number of daily intracranial pressure readings more than 20 mm Hg (4.4 ± 1.1 vs 2.4 ± 0.5;p = 0.015) and longer ICU and hospital length of stay (p = 0.003 and 0.07, respectively, Kaplan-Meier). The Glasgow Outcome Score-Extended for Pediatrics at hospital discharge and 3, 6, and 12 months after traumatic brain injury and medical complications observed during the acute hospitalization were similar between groups.

Conclusions: Administration of neuromuscular blocking agents was ubiquitous and daily administration of neuromuscular blocking agents was associated with intracranial hypertension but not outcomes—likely indicating that increased injury severity prompted their use. Despite this, neuromuscular blocking agent 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 neuromuscular blocking agent use is helpful after severe traumatic brain injury in children.

1Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA.

2Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA.

3Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA

4Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA.

5Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA.

6Barrow Neurological Institute of Phoenix Children’s Hospital, Phoenix, AZ.

Supported, in part, by the Office of the Dean of the University of Pittsburgh School of Medicine. Pediatric Traumatic Brain Injury Consortium: Hypothermia was funded by the National Institute of Neurological Disorders and Stroke (NINDS) (NS052478).

Dr. Bell was supported by federal grants from the NINDS (HD0499893, HD08003, NS072308, and NS081041). Dr. Wisniewski was supported by federal grants from the NINDS (NS069247 and NS081041). Dr. Kochanek was supported by federal grants from the NINDS (NS070324 and NS081041). Dr. Beers was supported by federal grants from the NINDS (MH56612, MH085722, and NS081041). Dr. Adelson was supported by federal grants from the NINDS (NS081041).

Dr. Bell received support for article research from the National Institutes of Health (NIH). His institution received grant support from the NINDS. Dr. Chin received grant support from the NIH. Her institution received grant support from the NIMH and NIDDK and is employed by the University of Pittsburgh School of Medicine. Dr. Wisniewski received support for article research from the NIH. His institution received grant support from the NIH. Dr. Goundappa is employed by the University of Pittsburgh. His institution received grant support from the NIMH and NIDDK. Dr. Kochanek is a co-provisional patent holder on 3 patents, received royalties (Textbook of Critical Care Medicine and Pediatric Critical Care Medicine journal editor), and received support for article research from the NIH. His institution received grant support from the NIH (NIH NS070324 and NS081041), the U.S. Army, and the Laerdal Foundation (Dr. Kochanek has numerous grants under consideration from these entities, including grants for trainee). Dr. Beers received royalties, consulted for GlaxoSmithKline, is employed by the University of Pittsburgh School of Medicine, and received support for article research from the NIH. Her institution received grant support from the NINDS and the NIH and provided expert testimony for various law firms (paid to University of Pittsburgh Physicians, Inc). Dr. Brown received support for article research from the NIH. Her institution received grant support, support for travel, and support for participation in review activities from the NINDS. Dr. Adelson consulted for Tramatec, is employed by Phoenix Children's Hospital, provided expert testimony for various medical legal cases, and received royalties from Thieme Publishing. His institution received grant support from the NIH, Codman, and Baxter.

For information regarding this article, E-mail: bellmj4@upmc.edu

©2015The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies