569 - Impact of Pentobarbital on Nutritional Delivery in Pediatric Severe Traumatic Brain Injury: A Retrospective Cohort Study

Publication Number: 1546.569

Sonal Mahindroo, George Washington University School of Medicine and Health Sciences, Morganville, NJ, United States; Dana Harrar, Children’s National Hospital, Washington, DC, United States; Elizabeth Elliott, Children's National Health System, Washington, DC, United States

Background: In critically ill pediatric patients that have suffered a severe traumatic brain injury (sTBI), nutritional support is critical to meet metabolic demand, maintain lean body mass, and support rehabilitation and recovery. Guidelines recommend initiation of enteral nutrition within 48 hours of admission and delivery of two-thirds of the calorie and protein goal by 7 days. However, prescription of nutrition therapy for pediatric patients after sTBI is complex because of injury- and treatment-related physiologic derangements. Pentobarbital, a medication that treats refractory intracranial hypertension, alters cellular metabolism and slows intestinal motility. Our study aims to assess the impact of exposure to pentobarbital on nutrition delivery during the acute period after sTBI.

Objective: To assess the impact of pentobarbital exposure on the timing, method, and adequacy of enteral nutrition delivery during the first 7 days post-sTBI in pediatric patients.

Design/Methods: A retrospective cohort study (2010-2022) was conducted at a level 1 pediatric trauma center. Children with sTBI ( < 18y; GCS ≤ 8 or ICP monitor placement) with ICU stay >7d were included. Caloric goal was assigned by a dietician and the cumulative amount of calories and protein administered over the first 7 days post injury were recorded. The manner, timing, and adequacy of feeding was compared for patients who did vs. did not receive pentobarbital.

Results: A total of 93 patients were analyzed (4.4y; 58% male; GCS 5); 24 (26%) received pentobarbital. A summary of clinical variables is available in Table 1. Compared with patients who did not receive pentobarbital, exposure to pentobarbital was associated with significant differences in time to initiation of enteral nutrition (p=0.0003), manner of feeding (p < 0.0001), and the proportion of calories (p=0.01) and protein (p=0.002) delivered enterally (Table 2). The adequacy of calorie and protein support between groups did not differ based on exposure to pentobarbital.

Conclusion(s): In this single-center retrospective study, pentobarbital exposure was associated with delayed enteral nutrition initiation, greater TPN use, and lower enteral calorie and protein delivery in pediatric sTBI patients, though overall nutritional adequacy was similar. Most patients did not meet guideline targets, underscoring pentobarbital's impact on nutrition therapy and the need for further outcome-focused research.

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Table 2: Comparison of Timing, Manner, and Adequacy of Feeding by Exposure to Pentobarbital
^a adequacy of calorie/protein support is defined as the proportion of prescribed calories/protein delivered to a patient over the first 7 days of PICU admission
^b n = 20 because 4 patients received no enteral feeds
^c n = 67 because 2 patients received no enteral feeds

Data are presented as median (Q1-Q3) for continuous variables, count (%) for categorical variables p values were calculated using Wilcoxon rank-sum test or Pearson's chi-square test as appropriate; p < 0.05 considered significant