Article Text

  1. S. A. Falkos,
  2. A. M. Chung
  1. University of South Alabama, Children's and Women's Hospital, Mobile, AL


Introduction Severe increased intracranial pressure (ICP) requires multiple medications to balance ICP control with support of cerebral perfusion. Current therapies frequently decrease systemic blood pressure (SBP), resulting in decreased cerebral perfusion pressure (CPP). Etomidate is a sedative-hypnotic agent with minimal cardiovascular effects that is known to decrease cerebral edema.

Case We present a previously healthy, 30 kg, 9-year-old female who suffered a brain injury in a motor vehicle accident resulting in severe cerebral edema. ICP was measured by an Integra Neurosciences Camino (Plainsboro, NJ). Therapy included head positioning, mechanical ventilation with mild hyperventilation (average arterial pCO2 = 30 mm Hg), and midazolam, fentanyl or morphine, and vecuronium continuous infusions. Hypertonic (3%) saline boluses and subsequent infusion at 20 cc/hr were administered within the first 24 hours. She had frequent increases in ICP > 20 cm H2O (spikes). Spikes were effectively treated with mannitol 12.5 g and boluses of 3% saline. However, midazolam (0.1 mg/kg) and fentanyl boluses (1 μg/kg) were minimally effective and produced decreases in SBP with each dose. On hospital day 3, she required a minimal dose dopamine drip to support SBP. She continued to have frequent spikes, but bolus therapy with 3% saline, midazolam, fentanyl, morphine, and doses of mannitol was no longer effective. Her SBP was negatively affected by propofol and thiopental. In an effort to treat ICP and preserve SBP (and CPP), intermittent etomidate therapy was initiated at 0.07-0.1 mg/kg IV as needed for ICP spikes. Etomidate was immediately effective, reducing ICP and preserving SBP. She received 37 doses of etomidate over 48 hours. Dopamine was discontinued in less than 24 hours of initiation of etomidate. Etomidate can induce adrenal suppression. A cortisol level (μg/dL) prior to etomidate therapy was 21.5. Forty-eight hours later, the cortisol level dropped to 3.3, and hydrocortisone therapy was initiated. Her cortisol level improved in 24 hours to 8. Six months after the accident, this child is cognitively normal and walking with assistance.

Conclusion Therapy for patients with severe increased ICP typically involves pressor therapy to maintain CPP while treating cerebral edema with sedative and sedative-like medications. Intermittent etomidate was a very effective treatment of severe increased ICP and had positive effects on systemic blood pressure, allowing pressor therapy to be discontinued. Cortisol levels must be monitored and empiric hydrocortisone therapy considered until more information is known about etomidate and pediatric adrenal suppression in critically ill children.

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