Abstract
Purpose: To describe a traumatic brain injury patient who experienced profound dyskalemia upon the initiation and cessation of a pentobarbital infusion and propose management options for future patients receiving this intervention. Methods: Case report. Results: Case report. Conclusions: Dyskalemia has become an anticipated side effect of high dose barbiturate infusions in the setting of elevated intracranial pressure. Hypokalemia during the administration of a barbiturate infusion has been identified within this patient population and was an expected adverse event during this intervention. However, in this case we observed a significant and complicated refractory hyperkalemia upon cessation of the barbiturate infusion which required aggressive management. An objective causality assessment suggests that this adverse event was possibly related to pentobarbital. What this case documents that other cases have not is that upon re-introduction of the pentobarbital infusion, serum potassium levels did not normalize. This questions whether severe rebound hyperkalemia is a pharmacodynamic or infusion-related reaction. More data is needed to identify the mechanism of this adverse event and recommend an appropriate treatment approach.
Highlights
Barbiturates have been used for more than 70 years, generally at low doses for their anesthetic and anti-seizure properties
We report the case of a traumatic brain injury patient with refractory, elevated ICP who was initiated on a pentobarbital infusion
Fluctuations in serum potassium concentrations have been directly associated with barbiturates, there are few published case reports describing life-threatening, rebound hyperkalemia upon the reduction or cessation of the infusion [2] [3] [5] [6]
Summary
Barbiturates have been used for more than 70 years, generally at low doses for their anesthetic and anti-seizure properties. Higher doses of barbiturates have been shown to be effective in reducing refractory elevated intracra-. The higher doses required to lower ICP typically result in a comatose state and increase the risk for adverse events such as: arterial hypotension, infection, immunosuppression, respiratory complications, hepatic dysfunction, renal dysfunction and suppressed cortical activity [2] [3]. Barbiturate-induced hypokalemia, initially observed in laboratory animals, was documented in humans almost 10 years later [4]. We report the case of a traumatic brain injury patient with refractory, elevated ICP who was initiated on a pentobarbital infusion. Almost immediately after discontinuation of the pentobarbital infusion, the patient experienced hyperkalemia. In addition to worsened ICP control, resistance of hyperkalemia to standard therapeutic interventions directed the team to re-start the pentobarbital infusion. Re-initiation of the infusion was found to have no impact on serum potassium levels
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