thiopental and Brain-Edema

Topics: Animals; Barbiturates; Brain; Brain Edema; Brain Ischemia; Cerebrovascular Circulation; Dogs; Humans; Hypertension; Hypoxia, Brain; Intracranial Pressure; Ischemic Attack, Transient; Phenobarbital; Thiopental

Treatment resistant intracranial hypertension after severe head injury has a very high mortality with conventional therapy such as hyperventilation and mannitol infusions. In this report, we describe the use of large doses of thiopental as a means of treating such swelling. From a consecutive series of 107 severe head injuries with a Glasgow Coma Score (GCS) of 6 or below, we selected all patients below 40 years age with a progressive increase in intracranial pressure (ICP) to 40 mm Hg. The first 16 patients (mean age 20 years, mean GCS 4.3) were treated with deep barbiturate coma and hypothermia (32-35 degrees Celsius) until stable lowering of ICP was achieved. The next 15 patients received conventional intensive care and were in other respects very similar to the barbiturate group (mean age 26, mean GCS 5.2). After 9-12 months the outcome was classified according to the Glasgow Outcome Scale (GOS). Therapy with barbiturate coma resulted in 6 good/moderate outcomes, 3 severe and 7 dead/vegetative. Conventional treatment resulted in 2 good/moderate outcomes and 13 dead/vegetative. This is a highly significant difference and cannot easily be explained by more severe injuries or complications in the conventional group. Superior control of ICP was achieved by large doses of thiopental and the final outcome was better.

Topics: Adolescent; Adult; Brain Concussion; Brain Edema; Brain Injuries; Child; Child, Preschool; Clinical Trials as Topic; Dose-Response Relationship, Drug; Hematoma, Subdural; Humans; Intracranial Pressure; Prognosis; Pseudotumor Cerebri; Thiopental

To determine the occurrence rate of central diabetes insipidus in pediatric patients with severe traumatic brain injury and to describe the clinical, injury, biochemical, imaging, and intervention variables associated with mortality.. Retrospective chart and imaging review.. Children's Hospital, level 1 trauma center.. Severely injured (Injury Severity Score ≥ 12) pediatric trauma patients (>1 month and <18 yr) with severe traumatic brain injury (presedation Glasgow Coma Scale ≤ 8 and head Maximum Abbreviated Injury Scale ≥ 4) that developed acute central diabetes insipidus between January 2000 and December 2011.. Of 818 severely injured trauma patients, 180 had severe traumatic brain injury with an overall mortality rate of 27.2%. Thirty-two of the severe traumatic brain injury patients developed acute central diabetes insipidus that responded to desamino-8-D-arginine vasopressin and/or vasopressin infusion, providing an occurrence rate of 18%. At the time of central diabetes insipidus diagnosis, median urine output and serum sodium were 6.8 ml/kg/hr (interquartile range = 5-11) and 154 mmol/L (interquartile range = 149-159), respectively. The mortality rate of central diabetes insipidus patients was 87.5%, with 71.4% declared brain dead after central diabetes insipidus diagnosis. Early central diabetes insipidus onset, within the first 2 days of severe traumatic brain injury, was strongly associated with mortality (p < 0.001), as were a lower presedation Glasgow Coma Scale (p = 0.03), a lower motor Glasgow Coma Scale (p = 0.01), an occurrence of fixed pupils (p = 0.04), and a prolonged partial thromboplastin time (p = 0.04). Cerebral edema on the initial computed tomography, obtained in the first 24 hrs after injury, was the only imaging finding associated with death (p = 0.002). Survivors of central diabetes insipidus were more likely to have intracranial pressure monitoring (p = 0.03), have thiopental administered to induce coma (p = 0.04) and have received a decompressive craniectomy for elevated intracranial pressure (p = 0.04).. The incidence of central diabetes insipidus in pediatric patients with severe traumatic brain injury is 18%. Mortality was associated with early central diabetes insipidus onset and cerebral edema on head computed tomography. Central diabetes insipidus nonsurvivors were less likely to have received intracranial pressure monitoring, thiopental coma and decompressive craniectomy.

Topics: Adolescent; Antidiuretic Agents; Brain Edema; Brain Injuries; Child; Child, Preschool; Coma; Deamino Arginine Vasopressin; Decompressive Craniectomy; Diabetes Insipidus, Neurogenic; Female; Glasgow Coma Scale; Humans; Hypnotics and Sedatives; Incidence; Intracranial Hypertension; Intracranial Pressure; Male; Monitoring, Physiologic; Partial Thromboplastin Time; Pupil Disorders; Radiography; Retrospective Studies; Thiopental; Time Factors

To investigate the effects of propofol, midazolam and thiopental sodium on outcomes and amino acid accumulation in focal cerebral ischemia-reperfusion in rats.. Male Sprague Dawley (SD) rats were scheduled to undergo 3-hour middle cerebral artery occlusion by intraluminal suture and 24-hour reperfusion. Neurologic outcomes were scored on a 0-5 grading scale. Infarct volume was shown with triphenyltetrazolium chloride staining and measured by an image analysis system. Concentrations of various amino acids (aspartate, glutamate, glycine, taurine, and gama-aminobutyric acid) were measured after 3 hours of reperfusion using high performance liquid chromatography. Propofol, midazolam and thiopental sodium were given intraperitoneally at the beginning of reperfusion.. Both propofol and midazolam attenuated neurological deficits and reduced infarct and edema volumes. Propofol showed better neurological protection than midazolam while thiopental sodium did not exhibit any protective effect. Both propofol and midazolam decreased excitatory amino acids accumulation, while propofol increased gama-aminobutyric acid accumulation in ischemic areas in reperfusion.. Propofol and midazolam, but not thiopental sodium, may provide protective effects against reperfusion induced injury in rats subjected to focal cerebral ischemia. This neurological protection may be due to the acceleration of excitatory amino acids elimination in reperfusion.

Topics: Adenosine Triphosphate; Animals; Brain; Brain Edema; Brain Ischemia; Excitatory Amino Acids; Male; Midazolam; Myocardial Infarction; Neuroprotective Agents; Propofol; Rats; Rats, Sprague-Dawley; Reperfusion Injury; Thiopental

Topics: Acetaminophen; Adult; Analgesics, Non-Narcotic; Brain Death; Brain Edema; Female; Hepatic Encephalopathy; Humans; Hypnotics and Sedatives; Intracranial Pressure; Liver Transplantation; Propofol; Thiopental

Topics: Anesthetics, Inhalation; Anesthetics, Intravenous; Animals; Brain; Brain Edema; Chloralose; Fentanyl; Isoflurane; Rats; Research Design; Sample Size; Thiopental

The objective of this study was to analyze the effects of various anesthetics on the formation of brain edema resulting from a focal cryogenic lesion. Thirty rabbits (six per group) were anesthetized with isoflurane (1 minimum alveolar anesthetic concentration [MAC] 2.1 vol%), fentanyl (bolus 5 micrograms/kg; infusion rate 1.0-0.5 micrograms.kg-1.min-1), thiopental (32.5 mg.kg-1.h-1), or alpha-chloralose (50 mg/kg). Control animals (sham operation, no lesion) received alpha-chloralose (50 mg/kg). Regional cerebral blood flow (rCBF) in perifocal brain tissue was measured by H2-clearance. Animals anesthetized with isoflurane required support of arterial pressure by angiotensin II (0.15 micrograms.kg-1.min-1). Six hours after trauma the animals were killed. Formation of brain edema was studied by specific gravity of cortical gray matter, white matter, hippocampus, caudate nucleus, putamen, and thalamus. Brain tissue samples were collected at multiple sites close to and distant from the lesion. Mean arterial pressure, arterial PCO2 and PO2, hematocrit, body temperature, and blood glucose were not different between groups during the posttraumatic course (except for an increased arterial pressure with alpha-chloralose compared to thiopental 4-6 h after trauma). The specific gravity of cortical gray matter was significantly reduced up to a distance of 6 mm from the center of the lesion in animals anesthetized with isoflurane, thiopental, or alpha-chloralose and up to 9 mm in animals given fentanyl.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Anesthetics; Animals; Brain; Brain Edema; Brain Injuries; Cerebrovascular Circulation; Chloralose; Fentanyl; Intracranial Pressure; Isoflurane; Rabbits; Specific Gravity; Thiopental

The effect of an intravenous injection of thiopental on middle cerebral artery blood velocities was assessed by transcranial pulsed Doppler monitoring in 20 children: ten head-injured patients and ten control subjects. Thiopental induced a moderate but immediate decrease of middle cerebral artery blood velocities in both groups; this variation was significant (P < 0.01) and more prolonged in the head-injured than in control patients. Transcranial Doppler ultrasonography thus appears to be suitable for monitoring children in intensive care units and could help to avoid the use of thiopental in patients with low cerebral artery blood flow velocity.

Topics: Adolescent; Blood Flow Velocity; Brain; Brain Edema; Child; Child, Preschool; Female; Head Injuries, Closed; Humans; Injections, Intravenous; Male; Thiopental; Ultrasonography, Doppler, Transcranial

The effects of antihypertensive drugs, such as nifedipine, chlorpromazine, reserpine and thiopental on mean arterial blood pressure (ABP), mean intracranial pressure (ICP) and cerebral perfusion pressure (CPP) were studied in 43 patients with systemic hypertension and intracranial hypertension due to hemorrhagic cerebrovascular diseases and other causes. These drugs are commonly used in neurosurgical practice for the treatment of systemic hypertension. Nifedipine, chlorpromazine and reserpine reduced the mean ABP, raised the mean ICP and decreased the CPP. The effects of these drugs on mean ICP and CPP were more pronounced in patients with severely increased ICP (more than 40 mmHg) than in patients with moderately increased ICP (20-40 mmHg). Thiopental reduced both mean ABP and ICP, whereas the CPP was unchanged from the preadministration level. During thiopental administration, however, respiratory depression was observed, and hence, intubation and ventilation were required. We suggest that, in the treatment of systemic hypertension in patients with increased ICP, barbiturates are more desirable than agents with calcium channel or alpha-adrenergic blocking actions, despite the problem of respiratory control.

Topics: Adult; Aged; Antihypertensive Agents; Blood Pressure; Brain Edema; Cerebral Hemorrhage; Cerebrospinal Fluid Pressure; Chlorpromazine; Female; Humans; Hypertension; Intracranial Pressure; Male; Middle Aged; Nifedipine; Pseudotumor Cerebri; Reserpine; Thiopental

The clinical course and the intracranial pressure (ICP) changes in 66 severe head injury patients presenting bulk enlargement of one cerebral hemisphere within a few hours of trauma have been analyzed. These patients represent 11% of a series of 589 severe head injury cases studied with computerized tomography (CT). Cerebral hemisphere swelling, which was associated with an ipsilateral subdural haematoma of variable extent in 58 patients (88%), or a large epidural haematoma in 5 patients (7%), and occurred as an isolated lesion in 3 patients (4%), carried the highest incidence of uncontrollable intracranial hypertension, the highest mortality rate and the shortest survival period after trauma in the authors' severe head injury series. The high incidence of arterial hypotension and/or hypoxaemia at admission (48% of cases), and the severity of clinical presentation (82%) of patients scored 5 patients or less in the Glasgow Coma Scale, 77% had uni- or bilateral mydriasis and 82% initial ICP above normal limits) correlated with the very poor final outcome (85% mortality). Only one of the 12 patients with normal initial ICP continued to have low pressure throughout the course. High dose thiopental failed to control severe intracranial hypertension in 29 patients (44%) who had a fulminant, malignant course. A transient decrease in ICP elevation was achieved in 17 patients (26%) and a definitive control in 12 patients (18%), among them the 10 survivors in this series. In the authors experience once ICP is controlled, and unless haemodynamic instability compells action to the contrary, barbiturate should not be discontinued until a control CT scan shows complete disappearance of the mass effect.

Topics: Adolescent; Adult; Aged; Brain Edema; Brain Injuries; Child; Child, Preschool; Humans; Hypertension; Hypoxia; Infant; Intracranial Pressure; Male; Middle Aged; Thiopental; Tomography, X-Ray Computed

The effects and indications of barbiturate therapy for brain protection, and prevention and reduction of the intracranial hypertension were investigated using an ultrashort acting barbiturate, thiamylal, in sixteen cases with intracranial lesions. Final outcome of the treatment revealed 8 good recoveries which were actively administered thiamylal during operation or immediately after. On the other hand, four cases, whose intracranial pressures (ICPS) of over 40 mmHg could not be controlled suffered brain death. Barbiturate therapy was not effective for brain protection of primary damaged lesions. It is concluded that barbiturate therapy may provide a satisfactory reduction of the intracranial hypertension in cases during the early postoperative stage or of under 40 mmHg initial ICP.

Topics: Adolescent; Adult; Aged; Brain Edema; Brain Injuries; Brain Neoplasms; Cerebral Hemorrhage; Child, Preschool; Female; Humans; Intracranial Aneurysm; Intracranial Arteriovenous Malformations; Male; Middle Aged; Postoperative Complications; Pseudotumor Cerebri; Thiamylal; Thiopental

The kinetics of thiopentone when administered in high doses were investigated in two patients with elevated intracranial pressure and three patients with focal cerebral ischemia. Initial saturation of the tissues is best achieved by a series of infusions with decreasing infusion rate. Administration of a bolus followed by maintenance doses proved unsuitable. The course of concentration under maintenance dosage was extremely variable, mainly due to interindividual and intraindividual variations in clearance. The apparent distribution volumes in these patients (1.38-3.10 l/kg, mean 2.43 l/kg) corresponded to the volumes determined after bolus administration. The total body clearance was low (45.8-103.4 ml/min, mean 72.3 ml/min) and was the reason for long elimination half-times (15.6-25.0 h, mean 23.2 h). Four patients biotransformed thiopentone regardless of the concentration. In one female patient the biotransforming enzyme systems may have been saturated. While conversion of thiopentone to pentobarbitone is generally only of secondary importance, an unusually high plasma pentobarbitone concentration was observed in one patient, reaching 50% of the concentration of the original substance. On the average, thiopentone was 75-80% proteinbound. The binding rate changed considerably with time. It could not be shown that this was influenced by albumin concentration between 25 and 50 g/l. The thiopentone concentration in the ventricular fluid corresponded approximately to that in the plasma fluid. Owing to the variability of the total body clearance and plasma protein binding, and the possibility of changes in tolerance, thiopentone administration must be controlled individually according to the EEG and intracranial pressure. Monitoring of the drug concentration in plasma is recommended.

Topics: Adult; Blood-Brain Barrier; Brain Edema; Brain Ischemia; Dose-Response Relationship, Drug; Female; Humans; Intracranial Pressure; Kinetics; Male; Middle Aged; Pentobarbital; Protein Binding; Thiopental

In order to investigate the usefulness of atracurium for neurosurgical anesthesia, we studied its impact on intracranial pressure (subarachnoid bolt) mean arterial pressure (radial artery catheter) and cerebral perfusion pressure (mean arterial pressure-intracranial pressure) in 20 patients undergoing elective craniotomy for brain tumor excision. General anesthesia was induced with thiopental, 4 mg/kg intravenously, and maintained with 70 percent nitrous oxide in oxygen. Ventilation was controlled by face mask, with end-tidal CO2 held constant. Once intracranial pressure and mean arterial pressure had stabilized, the response to atracurium, 0.5 mg/kg intravenously, was continuously recorded for 5 min in 10 patients. An additional 10 patients received no atracurium and served as matched controls. Thiopental caused reductions in ICP in both groups of patients. Comparing the responses of the patients who received atracurium with those who did not, we found that atracurium had no significant effect on intracranial pressure, mean arterial pressure or cerebral perfusion pressure. Based on these data we conclude that atracurium appears to be preferable to the other available neuromuscular blocking agents that have been evaluated for neurosurgical anesthesia.

Topics: Adult; Aged; Anesthesia, General; Atracurium; Blood Pressure; Brain; Brain Edema; Brain Neoplasms; Humans; Intracranial Pressure; Isoquinolines; Middle Aged; Neuromuscular Nondepolarizing Agents; Thiopental

We present an extremely rare case of an arteriovenous malformation (AVM) in the territory of the middle cerebral artery, the main trunk of which was occluded asymptomatically. Immediately after an uneventful excision of the entire AVM, massive brain swelling occurred unexpectedly and was treated successfully with high dose barbiturate therapy associated with other standard measures of controlling increased intracranial pressure. The underlying pathophysiological mechanisms leading to the massive intraoperative brain swelling in this case are discussed.

Topics: Adult; Brain Edema; Cerebral Angiography; Cerebral Arterial Diseases; Cerebral Hemorrhage; Cerebral Infarction; Constriction, Pathologic; Humans; Intracranial Arteriovenous Malformations; Intracranial Pressure; Male; Microsurgery; Postoperative Complications; Thiopental

To assess the uses of high dose barbiturate therapy in neurosurgery and intensive care, the authors have undertaken a concise survey of relevant experimental investigations and a comprehensive review of published clinical experiences.

Topics: Barbiturates; Brain; Brain Diseases; Brain Edema; Brain Ischemia; Cerebrovascular Circulation; Critical Care; Dose-Response Relationship, Drug; Electroencephalography; Energy Metabolism; Humans; Intracranial Pressure; Lipid Peroxides; Oxygen Consumption; Pentobarbital; Phenobarbital; Thiopental

Massive intraoperative brain swelling is an infrequent but catastrophic occurrence. In this report, we describe the use of very large doses of thiopental as a means of treating such swelling. In our initial 11 cases (5 arteriovenous malformations, 4 hematomas, and 2 penetrating injuries), this approach produced the following outcomes: 6 patients made a good recovery, 2 are moderately disabled, 1 is severely disabled, and 2 are dead. These results indicate that this condition, which once was considered unmanageable, can indeed be managed and that treatment often results in an acceptable outcome. More recent experience in an additional 6 patients suggests that the use of planned deep thiopental anesthesia, with induced cerebral silence, during intracranial surgery may even prevent the occurrence of this phenomenon.

Topics: Brain Diseases; Brain Edema; Brain Injuries; Dose-Response Relationship, Drug; Hematoma, Epidural, Cranial; Hematoma, Subdural; Humans; Intracranial Arteriovenous Malformations; Intraoperative Complications; Prognosis; Thiopental

The pathophysiology of brain trauma regarding disturbances of energy and transmitter metabolism, development of intra- and extracellular cerebral oedema are briefly outlined. Possible mechanisms of action of barbiturates in amelioration of cerebral ischaemia, decrease of cerebral metabolism, preservation of membrane stability, reduction of cerebral oedema and intracranial pressure are reviewed. We report on 6 patients with severe brain trauma due to head injury whose intracranial pressure despite conventional treatment with hyperventilation, steroids and osmotic diuresis remained above 25 mm Hg. They were infused with thiopentone 6--12 mg/kg x h for 6 to 15 days, to reduce cerebral electrical activity to the point of "burst suppression" in the electroencephalogram. Three patients survived, two of them regaining their previous good health. The results in these patients are discussed as regards thiopentone dosage and severity of trauma. Marked cardiovascular instability in one case and cholostatic jaundice due to barbiturate administration in two cases were the most important side effects. Barbiturate infusion seems to be indicated in brain trauma with sustained elevation of intracranial pressure above 25 mm Hg despite vigorous conventional therapy. Monitoring most essential to this aggressive treatment scheme comprises measurement of intracranial pressure and continuous observation of the EEG.

Topics: Adult; Barbiturates; Blood Pressure; Brain Edema; Brain Injuries; Electroencephalography; Energy Metabolism; Humans; Infusions, Parenteral; Intracranial Pressure; Male; Thiopental

Topics: Adolescent; Adult; Alfaxalone Alfadolone Mixture; Anesthesia, General; Brain Edema; Craniocerebral Trauma; Humans; Hypoxia; Intracranial Pressure; Intubation, Intratracheal; Male; Oxygen; Positive-Pressure Respiration; Postoperative Care; Respiration, Artificial; Thiopental

Topics: Betamethasone; Brain Edema; Diazepam; Ergoloid Mesylates; Female; Furosemide; Humans; Mannitol; Papaverine; Phytotherapy; Plants, Medicinal; Pre-Eclampsia; Pregnancy; Rauwolfia; Thiopental