(669) Use of Analgesia, Sedation, and Neuromuscular Blockade in Pediatric Severe Traumatic Brain Injury

Introduction: Severe traumatic brain injury (sTBI) management necessitates analgesic, sedative, and neuromuscular blocking (A/S/NMB) medications for pain management, tolerance of mechanical ventilation, and to manage intracranial hypertension. Limited evidence is available to guide their use, and practice patterns have not been widely reported in children. This study aims to describe A/S/NMB medication use in children following sTBI.

Methods: This is a secondary analysis of the publicly available Approaches and Decisions for Acute Pediatric TBI (ADAPT) database which included patients < 18 years, Glasgow Coma Scale ≤ 8 with intracranial pressure monitoring. Daily records of continuous A/S/NMB infusions including individual medications and their respective classes (e.g. opioid, benzodiazepine) were analyzed for the first 7 days of intensive care unit (ICU) admission. Mortality was compared between patients based on medication administration. Categorical data is presented as frequency (%) and statistical analyses were performed using a chi-squared test. Mann-Whitney U test was used when data did not follow a normal distribution. Statistical significance was assessed using a p-value < 0.05.

Results: Data were analyzed from 929 patients, with 9192 total infusion-days of A/S/NMB medications. Most patients (866, 93%) received an opioid (primarily fentanyl, 659/866, 76%) and 679 (73%) received a benzodiazepine infusion (primarily midazolam, 671/679, 99%), while 362 (39%) received NMB (primarily vecuronium, 141/362, 39%). Propofol was administered to 264 (28%), alpha-2 agonist to 263 (28%) , and ketamine to 4 (0.43%) patients. Median number of infusions per patient was 2 [1 – 2] and temporal usage was highest on ICU day 2. Morphine and dexmedetomidine infusions were used more often in survivors than non-survivors (33% vs. 16%, and 30% vs. 9%, respectively, p < 0.001).

Conclusions: Opioids and benzodiazepines, predominately fentanyl and midazolam, are administered to a majority of children with sTBI. While less frequent, propofol and alpha-2 agonist use is common. Differences in continuous infusions between survivors and non-survivors may reflect physiologic indicators of disease severity influencing medication selection. Further studies are warranted to inform optimal A/S/NMB strategies following pediatric sTBI.