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

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.