Analgesia, Sedation, and Neuromuscular Blockade in Pediatric Severe Traumatic Brain Injury: Secondary Analysis of the "Approaches and Decisions in Acute Pediatric TBI Trial" (ADAPT).

Abstract

Background: Sedative, analgesia, and neuromuscular blocking (NMB) medications may be necessary in the acute management of pediatric severe traumatic brain injury (sTBI), yet limited data exist to guide their use. We aimed to describe the use of continuous infusions of these medications in children with sTBI, to determine temporal trends during the first week of management, and to evaluate associations with in-hospital mortality.

Methods: We conducted a secondary analysis of the Approaches and Decisions in Acute Pediatric Traumatic Brain Injury Trial (NCT04077411, 2014-2017), a prospective multicenter observational study of patients < 18 years old with sTBI (Glasgow Coma Scale ≤ 8) who underwent intracranial pressure monitoring. Continuous analgesic, sedative, and NMB medication infusions administered in the first 7 days after sTBI were analyzed.

Results: Data from 929 patients were analyzed with a median Glasgow Coma Scale of 6 (interquartile range 3-7), 14% hospital mortality. In the 7 days after intracranial pressure monitor placement, 866 (93%) patients received an opioid infusion, with 659 (71%) patients having received fentanyl. A total of 679 (73%) patients received benzodiazepine: 671 (72%) patients received midazolam. A total of 362 (39%) patients received NMB, with the most common being vecuronium, administered to 141 (15%) patients. Propofol was administered to 264 (28%) patients, alpha-2 agonist to 263 (28%) patients, and ketamine to 4 (0.43%) patients. The median number of infusions per patient was 2 (interquartile range 1-2), with the highest number on intensive care unit day 2. Morphine and dexmedetomidine infusions were used more often in survivors than nonsurvivors (33 vs. 16%, and 30 vs. 9%, respectively, p < 0.001).

Conclusions: Fentanyl and midazolam were the most common analgesic and sedative continuous infusions during acute pediatric sTBI management. Propofol and dexmedetomidine were used less frequently. Opioid (specifically morphine) and dexmedetomidine infusions were associated with survival. Larger studies are needed to determine the safest and most effective analgesia, sedation, and NMB medication strategy for children with sTBI.