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Optic Nerve Sheath Diameter Ultrasound: A Non-Invasive Approach to Evaluate Increased Intracranial Pressure in Critically Ill Pediatric Patients. Diagnostics (Basel) 2022; 12:diagnostics12030767. [PMID: 35328319 PMCID: PMC8946972 DOI: 10.3390/diagnostics12030767] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/15/2022] [Accepted: 03/15/2022] [Indexed: 01/16/2023] Open
Abstract
Early diagnosis of increased intracranial pressure (ICP) is crucial for prompt diagnosis and treatment of intracranial hypertension in critically ill pediatric patients, preventing secondary brain damage and mortality. Although the placement of an external ventricular drain coupled to an external fluid-filled transducer remains the gold standard for continuous ICP monitoring, other non-invasive approaches are constantly being improved and can provide reliable estimates. The use of point-of-care ultrasound (POCUS) for the assessment of ICP has recently become widespread in pediatric emergency and critical care settings, representing a valuable extension of the physical examination. The aim of this manuscript is to review and discuss the basic principles of ultra-sound measurement of the optic nerve sheath diameter (ONSD) and summarize current evidence on its diagnostic value in pediatric patients with ICP. There is increasing evidence that POCUS measurement of the ONSD correlates with ICP, thus appearing as a useful extension of the physical examination in pediatrics, especially in emergency medicine and critical care settings for the initial non-invasive assessment of patients with suspected raised ICP. Its role could be of value even to assess the response to therapy and in the follow-up of patients with diagnosed intracranial hypertension if invasive ICP monitoring is not available. Further studies on more homogeneous and extensive study populations should be performed to establish ONSD reference ranges in the different pediatric ages and to define cut-off values in predicting elevated ICP compared to invasive ICP measurement.
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52
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Effects of a reduction of the number of electrodes in the EEG montage on the number of identified seizure patterns. Sci Rep 2022; 12:4621. [PMID: 35301386 PMCID: PMC8930978 DOI: 10.1038/s41598-022-08628-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 03/04/2022] [Indexed: 12/02/2022] Open
Abstract
Continuous EEG monitoring (cEEG) is frequently used in neurocritical care. The detection of seizures is one of the main objectives. The placement of the EEG electrodes is time consuming, therefore a reduced montage might lead to an increased availability in the ICU setting. It is unknown whether such a reduction of electrodes reduces the number of seizure patterns that are detected. A total of 95 seizure and 95 control EEG sequences from a pediatric epilepsy monitoring unit (EMU) were anonymized and reduced to an eight-lead montage. Two experts evaluated the recordings and the seizure detection rates using the reduced and the full montage were compared. Sensitivity and specificity for the seizure detection were calculated using the original EMU findings as gold standard. The sensitivity to detect seizures was 0.65 for the reduced montage compared to 0.76 for the full montage (p = 0.031). The specificities (0.97 and 0.96) were comparable (p = 1). A total of 4/9 (44%) of the generalized, 12/44 (27%) of the frontal, 6/14 (43%) of the central, 0/1 (0%) of the occipital, 6/20 (30%) of the temporal, and 5/7 (71%) of the parietal seizure patterns were not detected using the reduced montage. The median time difference between the onset of the seizure pattern in the full and reduced montage was 0.026s (IQR 5.651s). In this study the reduction of the EEG montage from 21 to eight electrodes reduced the sensitivity to detect seizure patterns from 0.76 to 0.65. The specificity remained virtually unchanged.
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53
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Lengel D, Romm ZL, Bostwick AL, Huh JW, Snyder NW, Smith G, Raghupathi R. Glucocorticoid Receptor Overexpression in the Dorsal Hippocampus Attenuates Spatial Learning and Synaptic Plasticity Deficits Following Pediatric Traumatic Brain Injury. J Neurotrauma 2022; 39:979-998. [PMID: 35293260 DOI: 10.1089/neu.2022.0012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Traumatic brain injury (TBI) in children younger than 4 years old leads to long-term deficits in cognitive and learning abilities that can persist or even worsen as children age into adolescence. In this study, the role of glucocorticoid receptor (GR) function in the dorsal hippocampus (DH) in hippocampal-dependent cognitive function and synaptic plasticity were assessed following injury to the 11-day-old rat. Brain injury produced significant impairments in spatial learning and memory in the Morris water maze in male and female rats at 1-month post-injury (adolescence) which was accompanied by impairments in induction and maintenance of long-term potentiation (LTP) in the CA1 region of the DH. Brain injury resulted in a significant decrease in the expression of the glucocorticoid-inducible gene, serum- and glucocorticoid-kinase 1 (sgk1), suggestive of an impairment in GR transcriptional activity within the hippocampus. Lentiviral transfection of the human GR (hGR) in the DH improved spatial learning and memory in the Morris water maze and attenuated LTP deficits following TBI. GR overexpression in the DH was also associated with a significant increase in the mRNA expression levels of sgk1, and the glutamate receptor subunits GluA1 and GluA2 within the hippocampus. Overall, these findings support an important role of dorsal hippocampal GR function in learning and memory deficits following pediatric TBI and suggest that these effects may be related to the regulation of glutamate receptor subunit expression in the DH.
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Affiliation(s)
- Dana Lengel
- Drexel University College of Medicine, 12312, Philadelphia, Pennsylvania, United States.,Mount Sinai School of Medicine, 5925, Neuroscience, New York, New York, United States;
| | - Zoe L Romm
- Drexel University College of Medicine, 12312, Neurobiology and Anatomy, Philadelphia, Pennsylvania, United States;
| | - Anna L Bostwick
- Temple University, 6558, Microbiology and Immunology, Philadelphia, Pennsylvania, United States;
| | - Jimmy W Huh
- Childrens Hospital of Philadelphia, Anesthesiology and Critical Care, Critical Care Office-7C26, 34th Street & Civic Center Blvd., Philadelphia, Pennsylvania, United States, 19104;
| | - Nathaniel W Snyder
- Temple University, 6558, Microbiology and Immunology, Philadelphia, Pennsylvania, United States;
| | - George Smith
- Temple University, 6558, Pediatric Research Center, Philadelphia, Pennsylvania, United States;
| | - Ramesh Raghupathi
- Drexel University, 6527, Neurobiology and Anatomy, 2900 Queen Lane, Philadelphia, Philadelphia, Pennsylvania, United States, 19104-2816;
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54
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Sporns PB, Fullerton HJ, Lee S, Kim H, Lo WD, Mackay MT, Wildgruber M. Childhood stroke. Nat Rev Dis Primers 2022; 8:12. [PMID: 35210461 DOI: 10.1038/s41572-022-00337-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/07/2022] [Indexed: 01/09/2023]
Abstract
Stroke is an important cause of neurological morbidity in children; most survivors have permanent neurological deficits that affect the remainder of their life. Stroke in childhood, the focus of this Primer, is distinguished from perinatal stroke, defined as stroke before 29 days of age, because of its unique pathogenesis reflecting the maternal-fetal unit. Although approximately 15% of strokes in adults are haemorrhagic, half of incident strokes in children are haemorrhagic and half are ischaemic. The causes of childhood stroke are distinct from those in adults. Urgent brain imaging is essential to confirm the stroke diagnosis and guide decisions about hyperacute therapies. Secondary stroke prevention strongly depends on the underlying aetiology. While the past decade has seen substantial advances in paediatric stroke research, the quality of evidence for interventions, such as the rapid reperfusion therapies that have revolutionized arterial ischaemic stroke care in adults, remains low. Substantial time delays in diagnosis and treatment continue to challenge best possible care. Effective primary stroke prevention strategies in children with sickle cell disease represent a major success, yet barriers to implementation persist. The multidisciplinary members of the International Pediatric Stroke Organization are coordinating global efforts to tackle these challenges and improve the outcomes in children with cerebrovascular disease.
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Affiliation(s)
- Peter B Sporns
- Department of Neuroradiology, Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland.,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Heather J Fullerton
- Departments of Neurology and Pediatrics, Benioff Children's Hospital, University of California at San Francisco, San Francisco, CA, USA
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Helen Kim
- Departments of Anesthesia and Perioperative Care, and Epidemiology and Biostatistics, Center for Cerebrovascular Research, University of California at San Francisco, San Francisco, CA, USA
| | - Warren D Lo
- Departments of Pediatrics and Neurology, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
| | - Mark T Mackay
- Department of Neurology, Royal Children's Hospital, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Moritz Wildgruber
- Department of Radiology, University Hospital Munich, LMU Munich, Munich, Germany.
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55
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Qiu W, Chen M, Wang X, Qiu W, Chen M, Wang X. Pre-hospital mild therapeutic hypothermia for patients with severe traumatic brain injury. Brain Inj 2022; 36:72-76. [PMID: 35143363 DOI: 10.1080/02699052.2022.2034946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND We aimed to assess the effects of pre-hospital mild therapeutic hypothermia (MTH) on patients with severe traumatic brain injury (sTBI). METHODS Eighty-six patients with sTBI were prospectively enrolled into the pre-hospital MTH group and the late MTH group (initiated in hospital). Patients in the pre-hospital MTH group were maintained at a tympanic temperature of 33°C-35°C before admission and continued to be treated with a therapeutic hypothermia device for 4 days. Patients in the late MTH group were treated with the same MTH parameters. Intracranial pressure (ICP), complications and Glasgow Outcome Scale (GOS) scores were monitored. RESULTS ICP was significantly lower for patients in the pre-hospital MTH group 24, 48, and 72 h after treatment (17.38 ± 4.88 mmHg, 18.40 ± 4.50 mmHg, and 16.40 ± 4.13 mmHg, respectively) than that in the late MTH group (20.63 ± 3.00 mmHg, 21.80 ± 6.00 mmHg, and 18.81 ± 4.50 mmHg) (P < .05). The favorable prognosis (GOS scores 4-5) rate in the pre-hospital MTH group was higher tha n the late MTH group (65.1% vs. 37.2%, respectively; P < .05) without complications . CONCLUSION Pre-hospital MTH for patients with STBI can reduce ICP and improve neurological outcomes.
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Affiliation(s)
- Wusi Qiu
- Department of Neurosurgery, Affiliated Hospital of Hangzhou Normal University, Zhejiang, People's Republic of China
| | - Mingmin Chen
- Department of Neurosurgery, Affiliated Hospital of Hangzhou Normal University, Zhejiang, People's Republic of China
| | - Xu Wang
- Department of Neurosurgery, Affiliated Hospital of Hangzhou Normal University, Zhejiang, People's Republic of China
| | - Ws Qiu
- Department of Neurosurgery, Affiliated Hospital of Hangzhou Normal University, Zhejiang, People's Republic of China.,Department of Emergency, Affiliated Hospital of Hangzhou Normal University, Zhejiang, People's Republic of China
| | - Mm Chen
- Department of Neurosurgery, Affiliated Hospital of Hangzhou Normal University, Zhejiang, People's Republic of China.,Department of Emergency, Affiliated Hospital of Hangzhou Normal University, Zhejiang, People's Republic of China
| | - X Wang
- Department of Neurosurgery, Affiliated Hospital of Hangzhou Normal University, Zhejiang, People's Republic of China.,Department of Emergency, Affiliated Hospital of Hangzhou Normal University, Zhejiang, People's Republic of China
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56
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Read C, Wignell A, Stewart C, Davies P. Clinical effects of hypertonic saline boluses in children with severe traumatic brain injury. J Paediatr Child Health 2022; 58:256-260. [PMID: 34427010 DOI: 10.1111/jpc.15695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 07/28/2021] [Indexed: 11/28/2022]
Abstract
AIM To quantify the effects of 3% hypertonic saline (HTS) boluses on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in children. METHODS A retrospective study of patients admitted to a regional neurosurgical children's intensive care unit. RESULTS A total of 156 HTS boluses were given to children with traumatic brain injury. ICP decreased 6 mmHg (P < 0.01) and CPP increased 4 mmHg (P = 0.003) 1-h post-bolus. Effects persisted for 3 h post-dose ICP was 5 mmHg lower) and 4 h post-bolus CPP was 3 mmHg higher. ICP change was not associated with pre-bolus serum sodium concentration. CONCLUSIONS Hypertonic saline 3% at 5 mL/kg is an effective osmolar therapy for reducing ICP and increasing CPP in children for up to 3 h. '53-53' is a suitable guide - 5 mL/kg of 3% HTS will on average decrease ICP by at least 5 mmHg for 3 h. Pre-bolus serum sodium concentration is not correlated with effect size.
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Affiliation(s)
- Claire Read
- Paediatric Critical Care Unit, Nottingham Children's Hospital, Nottingham, United Kingdom.,School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Andrew Wignell
- Paediatric Critical Care Unit, Nottingham Children's Hospital, Nottingham, United Kingdom.,Pharmacy Department, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Craig Stewart
- Paediatric Critical Care Unit, Nottingham Children's Hospital, Nottingham, United Kingdom
| | - Patrick Davies
- Paediatric Critical Care Unit, Nottingham Children's Hospital, Nottingham, United Kingdom.,School of Medicine, University of Nottingham, Nottingham, United Kingdom
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57
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Burton L, Bhargava V, Kong M. Point-of-Care Ultrasound in the Pediatric Intensive Care Unit. Front Pediatr 2022; 9:830160. [PMID: 35178366 PMCID: PMC8845897 DOI: 10.3389/fped.2021.830160] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 12/29/2021] [Indexed: 12/30/2022] Open
Abstract
Ultrasonography has been widely used in medicine for decades but often by specific users such as cardiologists, obstetricians, and radiologists. In the last several years, the use of this imaging modality has moved to the bedside, with clinicians performing and interpreting focused point of care ultrasonography to aid in immediate assessment and management of their patients. The growth of point of care ultrasonography has been facilitated by advancement in ultrasound-related technology and emerging studies and protocols demonstrating its utility in clinical practice. However, considerable challenges remain before this modality can be adopted across the spectrum of disciplines, primarily as it relates to training, competency, and standardization of usage. This review outlines the history, current state, challenges and the future direction of point of care ultrasonography specifically in the field of pediatric critical care medicine.
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58
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Shao XL, Wang YZ, Chen XH, Ding WJ. Impact of failure mode and effects analysis-based emergency management on the effectiveness of craniocerebral injury treatment. World J Clin Cases 2022; 10:554-562. [PMID: 35097081 PMCID: PMC8771373 DOI: 10.12998/wjcc.v10.i2.554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/14/2021] [Accepted: 11/28/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Craniocerebral injuries encompass brain injuries, skull fractures, cranial soft tissue injuries, and similar injuries. Recently, the incidence of craniocerebral injuries has increased dramatically due to the increased numbers of traffic accidents and aerial work injuries, threatening the physical and mental health of patients.
AIM To investigate the impact of failure modes and effects analysis (FMEA)-based emergency management on craniocerebral injury treatment effectiveness.
METHODS Eighty-four patients with craniocerebral injuries, treated at our hospital from November 2019 to March 2021, were selected and assigned, using the random number table method, to study (n = 42) and control (n = 42) groups. Patients in the control group received conventional management while those in the study group received FMEA theory-based emergency management, based on the control group. Pre- and post-interventions, details regarding the emergency situation; levels of inflammatory stress indicators [Interleukin-6 (IL-6), C-reactive protein (CRP), and procalcitonin (PCT)]; incidence of complications; prognoses; and satisfaction regarding patient care were evaluated for both groups.
RESULTS For the study group, the assessed parameters [pre-hospital emergency response time (9.13 ± 2.37 min), time to receive a consultation (2.39 ± 0.44 min), time needed to report imaging findings (1.15 ± 4.44 min), and test reporting time (32.19 ± 6.23 min)] were shorter than those for the control group (12.78 ± 4.06 min, 3.58 ± 0.71 min, 33.49 ± 5.51 min, 50.41 ± 11.45 min, respectively; P < 0.05). Pre-intervention serum levels of IL-6 (78.71 ± 27.59 pg/mL), CRP (19.80 ± 6.77 mg/L), and PCT (3.66 ± 1.82 ng/mL) in the study group patients were not significantly different from those in the control group patients (81.31 ± 32.11 pg/mL, 21.29 ± 8.02 mg/L, and 3.95 ± 2.11 ng/mL respectively; P > 0.05); post-intervention serum indicator levels were lower in both groups than pre-intervention levels. Further, serum levels of IL-6 (17.35 ± 5.33 pg/mL), CRP (2.27 ± 0.56 mg/L), and PCT (0.22 ± 0.07 ng/mL) were lower in the study group than in the control group (30.15 ± 12.38 pg/mL, 3.13 ± 0.77 mg/L, 0.38 ± 0.12 ng/mL, respectively; P < 0.05). The complication rate observed in the study group (9.52%) was lower than that in the control group (26.19%, P < 0.05). The prognoses for the study group patients were better than those for the control patients (P < 0.05). Patient care satisfaction was higher in the study group (95.24%) than in the control group (78.57%, P < 0.05).
CONCLUSION FMEA-based craniocerebral injury management effectively shortens the time spent on emergency care, reduces inflammatory stress and complication risk levels, and helps improve patient prognoses, while achieving high patient care satisfaction levels.
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Affiliation(s)
- Xiao-Lan Shao
- Department of Emergency Surgery Ward 48, First Affiliated Hospital of Soochow University, Suzhou 215000, Jiangsu Province, China
| | - Ya-Zhou Wang
- Department of Emergency Surgery Ward 48, First Affiliated Hospital of Soochow University, Suzhou 215000, Jiangsu Province, China
| | - Xiong-Hui Chen
- Department of Emergency Surgery Ward 48, First Affiliated Hospital of Soochow University, Suzhou 215000, Jiangsu Province, China
| | - Wen-Juan Ding
- Department of Emergency Surgery Ward 48, First Affiliated Hospital of Soochow University, Suzhou 215000, Jiangsu Province, China
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59
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Surtees TL, Kumar I, Garton HJL, Rivas-Rodriguez F, Parmar H, McCaffery H, Riebe-Rodgers J, Shellhaas RA. Levetiracetam Prophylaxis for Children Admitted With Traumatic Brain Injury. Pediatr Neurol 2022; 126:114-119. [PMID: 34839268 DOI: 10.1016/j.pediatrneurol.2021.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 10/02/2021] [Accepted: 10/11/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Prophylactic antiseizure medications (ASMs) for pediatric traumatic brain injury (TBI) are understudied. We evaluated clinical and radiographic features that inform prescription of ASMs for pediatric TBI. We hypothesized that despite a lack of evidence, levetiracetam is the preferred prophylactic ASM but that prophylaxis is inconsistently prescribed. METHODS This retrospective study assessed children admitted with TBI from January 1, 2017, to December 31, 2019. TBI severity was defined using Glasgow Coma Scale (GCS) scores. Two independent neuroradiologists reviewed initial head computed tomography and brain magnetic resonance imaging. Fisher exact tests and descriptive and regression analyses were conducted. RESULTS Among 167 children with TBI, 44 (26%) received ASM prophylaxis. All 44 (100%) received levetiracetam. Prophylaxis was more commonly prescribed for younger children, those with neurosurgical intervention, and abnormal neuroimaging (particularly intraparenchymal hematoma) (odds ratio = 10.3, confidence interval 1.8 to 58.9), or GCS ≤12. Six children (13.6%), all on ASM, developed early posttraumatic seizures (EPTSs). Of children with GCS ≤12, four of 17 (23.5%) on levetiracetam prophylaxis developed EPTSs, higher than the reported rate for phenytoin. CONCLUSIONS Although some studies suggest it may be inferior to phenytoin, levetiracetam was exclusively used for EPTS prophylaxis. Intraparenchymal hematoma >1 cm was the single neuroimaging feature associated with ASM prophylaxis regardless of the GCS score. Yet these trends are not equivalent to optimal evidence-based management. We still observed important variability in neuroimaging characteristics and TBI severity for children on prophylaxis. Thus, further study of ASM prophylaxis and prevention of pediatric EPTSs is warranted.
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Affiliation(s)
- Taryn-Leigh Surtees
- Department of Neurology, Washington University in St. Louis School of Medicine, St. Louis, Missouri.
| | - Ishani Kumar
- Departments of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | | | | | - Hemant Parmar
- Radiology, University of Michigan, Ann Arbor, Michigan
| | - Harlan McCaffery
- Departments of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | | | - Renée A Shellhaas
- Departments of Pediatrics, University of Michigan, Ann Arbor, Michigan
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60
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Mangham WM, Gordon WE, Einhaus SL. Intracranial gunshot wounds in utero: case report and review. Childs Nerv Syst 2021; 37:3973-3976. [PMID: 33760968 DOI: 10.1007/s00381-021-05124-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 03/11/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND IMPORTANCE We present a rare case of an in utero intracranial gunshot wound with survival of the baby and neurosurgical intervention in the first 6 h of life. CLINICAL PRESENTATION A pregnant 19-year old sustained multiple gunshot wounds and underwent an emergency cesarean section. At the time of delivery, there was a penetrating wound noted to the uterus and to the left side of the baby's head. The baby was taken urgently for craniotomy. Thorough washout was performed, and a pericranial graft was harvested from the frontal vertex to assist in dural closure. The largest displaced bone fragment was soaked in betadine and sutured back into place. The baby was observed for several days and then discharged home with normal neurological examination. CONCLUSION There are scattered reports of in utero intracranial gunshot wounds in the literature dating back to the nineteenth century; however, our case appears to be the first reported that involved urgent surgical intervention.
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Affiliation(s)
- William M Mangham
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - William E Gordon
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Stephanie L Einhaus
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA.,Semmes-Murphey Clinic, Memphis, TN, USA.,Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, TN, USA.,Neurosurgery, Regional One Health, Memphis, TN, USA
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61
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Busch R, Cady RG. Discharge nurse intervention on a pediatric rehabilitation unit: Retrospective chart review to evaluate the Does it impact on number of unmet needs during the transition home following neurological injury. Dev Neurorehabil 2021; 24:561-568. [PMID: 33896361 DOI: 10.1080/17518423.2021.1915403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE The purpose of this study is to describe the post-discharge needs of children and adolescents when transitioning home after an inpatient comprehensive rehabilitation stay following an acute neurological injury and to evaluate if trends in those needs changed with implementation of a discharge nurse intervention. DESIGN Retrospective medical record review was conducted 1-year prior (T1) and 1-year after (T2) a discharge nurse intervention. METHODS Medical charts of 80 pediatric patients with acute neurological injury (T1 = 39; T2 = 41) were reviewed. Post-discharge communication from the 8-week post-discharge period was reviewed to identify and categorize care coordination needs, using 18 pre-defined care coordination categories. T1 and T2 findings were compared using two sample proportion z-test. FINDINGS Patients discharged following inpatient rehabilitation for acute neurological injury have unmet care coordination needs. The proportion of unmet needs decreased significantly for 10/18 care coordination categories after implementation of the discharge nurse intervention. CONCLUSIONS Data from this study support proactive care coordination by inpatient rehabilitation nurses to reduce unmet post-discharge care coordination needs and provides preliminary evidence that the role of a discharge nurse may have a positive impact on the transition from inpatient rehabilitation to home.
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Affiliation(s)
- Rebecca Busch
- Gillette Children's Specialty Healthcare, St. Paul, MN, USA
| | - Rhonda G Cady
- Gillette Children's Specialty Healthcare, St. Paul, MN, USA
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62
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Ganeshalingham A, Beca J. Serum biomarkers in severe paediatric traumatic brain injury-a narrative review. Transl Pediatr 2021; 10:2720-2737. [PMID: 34765496 PMCID: PMC8578762 DOI: 10.21037/tp-20-386] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 05/14/2021] [Indexed: 11/22/2022] Open
Abstract
Severe traumatic brain injury continues to present complex management and prediction challenges for the clinician. While there is some evidence that better systems of care can improve outcome, multiple multi-centre randomised controlled trials of specific therapies have consistently failed to show benefit. In addition, clinicians are challenged in attempting to accurately predict which children will recover well and which children will have severe and persisting neurocognitive deficits. Traumatic brain injury is vastly heterogeneous and so it is not surprising that one therapy or approach, when applied to a mixed cohort of children in a clinical trial setting, has yielded disappointing results. Children with severe traumatic brain injury have vastly different brain injury pathologies of widely varying severity, in any number of anatomical locations at what may be disparate stages of brain development. This heterogeneity may also explain why clinicians are unable to accurately predict outcome. Biomarkers are objective molecular signatures of injury that are released following traumatic brain injury and may represent a way of unifying the heterogeneity of traumatic brain injury into a single biosignature. Biomarkers hold promise to diagnose brain injury severity, guide intervention selection for clinical trials, or provide vital prognostic information so that early intervention and rehabilitation can be planned much earlier in the course of a child's recovery. Serum S100B and serum NSE levels show promise as a diagnostic tool with biomarker levels significantly higher in children with severe TBI including children with inflicted and non-inflicted head injury. Serum S100B and serum NSE also show promise as a predictor of neurodevelopmental outcome. The role of biomarkers in traumatic brain injury is an evolving field with the potential for clinical application within the next few years.
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Affiliation(s)
| | - John Beca
- Paediatric Intensive Care Unit, Starship Children's Hospital, Auckland, New Zealand
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63
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Binder H, Majdan M, Leitgeb J, Payr S, Breuer R, Hajdu S, Tiefenboeck TM. Management and Outcome of Traumatic Intracerebral Hemorrhage in 79 Infants and Children from a Single Level 1 Trauma Center. CHILDREN (BASEL, SWITZERLAND) 2021; 8:854. [PMID: 34682119 PMCID: PMC8534601 DOI: 10.3390/children8100854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 09/20/2021] [Accepted: 09/21/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Traumatic brain injury is a leading form of pediatric trauma and a frequent cause of mortality and acquired neurological impairment in children. The aim of this study was to present the severity and outcomes of traumatic intracerebral bleeding in children and adolescence. METHODS Seventy-nine infants and children with intracerebral bleedings were treated between 1992 and 2020 at a single level 1 trauma center. Data regarding accident, treatment and outcomes were collected retrospectively. The Glasgow Outcome Scale was used to classify the outcome at hospital discharge and at follow-up visits. CT scans of the brain were classified according to the Rotterdam score. RESULTS In total, 41 (52%) patients with intracerebral bleedings were treated surgically, and 38 (48%) patients were treated conservatively; in 15% of the included patients, delayed surgery was necessary. Patients presenting multiple trauma (p < 0.04), higher ISS (p < 0.01), poor initial neurological status (p < 0.001) and a higher Rotterdamscore (p = 0.038) were significantly more often treated surgically. Eighty-three percent of patients were able to leave the hospital, and out of these patients, about 60% showed good recovery at the latest follow-up visit. Overall, 11 patients (14%) died. CONCLUSION The findings in this study verified intracerebral bleeding as a rare but serious condition. Patients presenting with multiple traumas, higher initial ISS, poor initial neurological status and a higher Rotterdamscore were more likely treated by surgery. TRIAL REGISTRATION (researchregistry 2686).
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Affiliation(s)
- Harald Binder
- Department of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.B.); (J.L.); (S.P.); (R.B.); (S.H.)
| | - Marek Majdan
- Institute for Global Health and Epidemiology, Department of Public Health, Trnava University, 91701 Trnava, Slovakia;
| | - Johannes Leitgeb
- Department of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.B.); (J.L.); (S.P.); (R.B.); (S.H.)
- Institute for Global Health and Epidemiology, Department of Public Health, Trnava University, 91701 Trnava, Slovakia;
| | - Stephan Payr
- Department of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.B.); (J.L.); (S.P.); (R.B.); (S.H.)
| | - Robert Breuer
- Department of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.B.); (J.L.); (S.P.); (R.B.); (S.H.)
| | - Stefan Hajdu
- Department of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.B.); (J.L.); (S.P.); (R.B.); (S.H.)
| | - Thomas M. Tiefenboeck
- Department of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.B.); (J.L.); (S.P.); (R.B.); (S.H.)
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Non-traumatic pediatric intracranial hypertension: key points for different etiologies, diagnosis, and treatment. Acta Neurol Belg 2021; 121:823-836. [PMID: 33829371 DOI: 10.1007/s13760-021-01626-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 02/02/2021] [Indexed: 12/30/2022]
Abstract
Intracranial hypertension can be an acute life-threatening event or slowly deteriorating condition, leading to a gradual loss of neurological function. The diagnosis should be taken in a timely fashioned process, which mandates expedite measures to save brain function and sometimes life. An optimal management strategy is selected according to the causative etiology with a core treatment paradigm that can be utilized in various etiologies. Distinct etiologies are intracranial bleeds caused by traumatic brain injury, spontaneous intracranial hemorrhage (e.g., neonatal intraventricular hemorrhage), or the rare pediatric hemorrhagic stroke. The other primary pediatric etiologies for elevated intracranial pressure are intracranial mass (e.g., brain tumor) and hydrocephalus related. Other unique etiologies in the pediatric population are related to congenital diseases, infectious diseases, metabolic or endocrine crisis, and idiopathic intracranial pressure. One of the main goals of treatment is to alleviate the growing pressure and prevent the secondary injury to brain parenchyma due to inadequate blood perfusion and eventually inadequate parenchymal oxygenation and metabolic state. Previous literature discussed essential characteristics of the treatment paradigm derived mainly from pediatric brain traumatic injuries' treatment methodology. Yet, many of these etiologies are not related to trauma; thus, the general treatment methodology must be tailored carefully for each patient. This review focuses on the different possible non-traumatic etiologies that can lead to intracranial hypertension with the relevant modification of each etiology's treatment paradigm based on the current literature.
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Traumatic Brain Injury-Related Pediatric Mortality and Morbidity in Low- and Middle-Income Countries: A Systematic Review. World Neurosurg 2021; 153:109-130.e23. [PMID: 34166832 DOI: 10.1016/j.wneu.2021.06.077] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/12/2021] [Accepted: 06/14/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND The burden of pediatric traumatic brain injury (pTBI) in low- and middle-income countries (LMICs) is unknown. To fill this gap, we conducted a review that aimed to characterize the causes of pTBI in LMICs, and their reported associated mortality and morbidity. METHODS A systematic review was conducted. MEDLINE, Embase, Global Health, and Global Index Medicus were searched from January 2000 to May 2020. Observational or experimental studies on pTBI of individuals aged between 0 and 16 years in LMICs were included. The causes of pTBI and morbidity data were descriptively analyzed, and case fatality rates were calculated. PROSPERO ID CRD42020171276. RESULTS A total of 136 studies were included. Fifty-seven studies were at high risk of bias. Of the remaining studies, 170,224 cases of pTBI were reported in 32 LMICs. The odds of having a pTBI were 1.8 times higher (95% confidence interval, 1.6-2.0) in males. The odds of a pTBI being mild were 4.4 times higher (95% confidence interval, 1.9-6.8) than a pTBI being moderate or severe. Road traffic accidents were the most common cause (n = 16,275/41,979; 39%) of pTBIs. On discharge, 24% of patients (n = 4385/17,930) had a reduction in their normal mental or physical function. The median case fatality rate was 7.3 (interquartile range, 2.1-7.7). CONCLUSIONS Less than a quarter (n = 32) of all LMICs have published high-quality data on the volume and burden of pTBI. From the limited data available, young male children are at a high risk of pTBIs in LMICs, particularly after road traffic accidents.
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Bailey ZS, Leung LY, Yang X, Cardiff K, Gilsdorf J, Shear D, Kochanek PM. Prehospital Whole Blood Resuscitation Reduces Fluid Requirement While Maintaining Critical Physiology in a Model of Penetrating Traumatic Brain Injury and Hemorrhage: Implications on Resource-Limited Combat Casualty Care. Shock 2021; 55:545-553. [PMID: 32925600 DOI: 10.1097/shk.0000000000001662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
ABSTRACT Prehospital resuscitation using whole blood (WB) is the standard of care for hemorrhagic shock (HS) but there is no consensus recommendation for resuscitation in the presence of traumatic brain injury (TBI) due to a lack of sufficient evidence. In order to evaluate the optimal resuscitation strategies for TBI+HS, Sprague-Dawley rats were randomized into four groups based on resuscitation fluid and prehospital mean arterial pressure (MAP) threshold (n = 9-10/group): Lactated Ringer's (LR)-60 mm Hg (LR60), LR-70 mm Hg (LR70), WB-60 mm Hg (WB60), WB-70 mm Hg (WB70). All groups received a frontal penetrating ballistic-like brain injury followed by a 35-min period of HS. During the prehospital phase, rats received an initial bolus of resuscitation fluid (WB or LR) followed by LR as needed to maintain MAP above the designated threshold for 90 min. During the in-hospital phase, rats received definitive resuscitation with shed WB. Physiological parameters were recorded continuously and cerebral edema was measured at 3 and 24 h postinjury. The WB60 group demonstrated a significantly lower prehospital fluid requirement compared WB70, LR60, and LR70 (P < 0.05). Compared to the respective LR groups, both the WB60 and WB70 groups also demonstrated improved MAP, cerebral perfusion pressure, brain tissue oxygen tension, and cerebral edema. The edema benefits were observed at 3 h, but not 24 h postinjury, and were localized to the injury site. Together, these results provide evidence that prehospital WB resuscitation and lower MAP resuscitation thresholds can reduce the prehospital fluid requirement while still maintaining critical cerebral physiology in a model of HS and concomitant TBI.
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Affiliation(s)
- Zachary S Bailey
- Brain Trauma Neuroprotection Branch, Center for Military Psychiatry and Neuroscience, Walter Army Institute of Research, Silver Spring, Maryland
| | - Lai Yee Leung
- Brain Trauma Neuroprotection Branch, Center for Military Psychiatry and Neuroscience, Walter Army Institute of Research, Silver Spring, Maryland
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Xiaofang Yang
- Brain Trauma Neuroprotection Branch, Center for Military Psychiatry and Neuroscience, Walter Army Institute of Research, Silver Spring, Maryland
| | - Katherine Cardiff
- Brain Trauma Neuroprotection Branch, Center for Military Psychiatry and Neuroscience, Walter Army Institute of Research, Silver Spring, Maryland
| | - Janice Gilsdorf
- Brain Trauma Neuroprotection Branch, Center for Military Psychiatry and Neuroscience, Walter Army Institute of Research, Silver Spring, Maryland
| | - Deborah Shear
- Brain Trauma Neuroprotection Branch, Center for Military Psychiatry and Neuroscience, Walter Army Institute of Research, Silver Spring, Maryland
| | - Patrick M Kochanek
- Safar Center for Resuscitation Research, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Chong SL, Dang H, Ming M, Mahmood M, Zheng CQS, Gan CS, Lee OPE, Ji J, Chan LCN, Ong JSM, Kurosawa H, Lee JH. Traumatic Brain Injury Outcomes in 10 Asian Pediatric ICUs: A Pediatric Acute and Critical Care Medicine Asian Network Retrospective Study. Pediatr Crit Care Med 2021; 22:401-411. [PMID: 33027240 DOI: 10.1097/pcc.0000000000002575] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Traumatic brain injury remains an important cause of death and disability. We aim to report the epidemiology and management of moderate to severe traumatic brain injury in Asian PICUs and identify risk factors for mortality and poor functional outcomes. DESIGN A retrospective study of the Pediatric Acute and Critical Care Medicine Asian Network moderate to severe traumatic brain injury dataset collected between 2014 and 2017. SETTING Patients were from the participating PICUs of Pediatric Acute and Critical Care Medicine Asian Network. PATIENTS We included children less than 16 years old with a Glasgow Coma Scale less than or equal to 13. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We obtained data on patient demographics, injury circumstances, and PICU management. We performed a multivariate logistic regression predicting for mortality and poor functional outcomes. We analyzed 380 children with moderate to severe traumatic brain injury. Most injuries were a result of road traffic injuries (174 [45.8%]) and falls (160 [42.1%]). There were important differences in temperature control, use of antiepileptic drugs, and hyperosmolar agents between the sites. Fifty-six children died (14.7%), and 104 of 324 survivors (32.1%) had poor functional outcomes. Poor functional outcomes were associated with non-high-income sites (adjusted odds ratio, 1.90; 95% CI, 1.11-3.29), Glasgow Coma Scale less than 8 (adjusted odds ratio, 4.24; 95% CI, 2.44-7.63), involvement in a road traffic collision (adjusted odds ratio, 1.83; 95% CI, 1.04-3.26), and presence of child abuse (adjusted odds ratio, 2.75; 95% CI, 1.01-7.46). CONCLUSIONS Poor functional outcomes are prevalent after pediatric traumatic brain injury in Asia. There is an urgent need for further research in these high-risk groups.
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Affiliation(s)
- Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Hongxing Dang
- Department of Pediatric Intensive Care Unit, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Meixiu Ming
- Department of Pediatric Intensive Care Unit, Children's Hospital of Fudan University, Shanghai, China
| | - Maznisah Mahmood
- Department of Paediatrics, Institute of Paediatric, Kuala Lumpur, Malaysia
| | - Charles Q S Zheng
- Department of Epidemiology, Singapore Clinical Research Institute, Singapore
| | - Chin Seng Gan
- Department of Paediatrics, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Olive P E Lee
- Department of Paediatrics, Sarawak General Hospital, Sarawak, Malaysia
| | - Jian Ji
- Department of Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Lawrence C N Chan
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Jacqueline S M Ong
- Khoo Teck Puat National University Children's Medical Institute, National University Hospital, Singapore
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Hiroshi Kurosawa
- Department of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Jan Hau Lee
- Duke-NUS Medical School, Singapore
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
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Yin X, Wu J, Zhou L, Ni C, Xiao M, Meng X, Zhu X, Cao Q, Li H. The pattern of hospital-community-home (HCH) nursing in tracheostomy patients with severe traumatic brain injury: Is it feasible? Int J Clin Pract 2021; 75:e13881. [PMID: 33283421 DOI: 10.1111/ijcp.13881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/01/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Tracheostomy is very common in patients with severe traumatic brain injury (TBI), long-term nursing care are needed for those patients. We aimed to evaluate the effects of hospital-community-home (HCH) nursing in those patients. METHODS This study was a before-after study design. Patients were divided into control groups (traditional nursing care) and HCH group(HCH nursing care). Tracheostomy patients with severe TBI needing long-term care were included. All patients underwent a two-month long follow-up. Glasgow coma score (GCS), Karnofsky, Self-Anxiety Scale (SAS) from caregiver and Barthel assessment at the discharge and two months after discharge were evaluated. The tracheostomy-related complications were recorded and compared. RESULTS A total of 60 patients were included. There were no significant differences between the two groups in the GCS, Karnofsky, SAS from caregiver and Barthel index at discharge((all P > .05); the GCS, Karnofsky and Barthel index were all significantly increased after two-month follow-up for the two groups (all P < .05), and the GCS, Karnofsky and Barthel index at two-month follow-up in HCH group were significantly higher than that of the control group(all P < .05), but the SAS from caregiver at two-month follow-up in HCH group was significantly less than that of the control group(P = .009). The incidence of block of artificial tracheal cannula and readmission in HCH group were significant less than that of control group (all P < .05). CONCLUSION HCH nursing care is feasible in tracheostomy patients with severe TBI, future studies are needed to further evaluate the role of HCH nursing care.
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Affiliation(s)
- Xiangyi Yin
- Department of Neurosurgery, The Affiliated Suzhou Science & Technology Town Hospital of Nanjing Medical University, Suzhou City, China
| | - Jie Wu
- Department of Neurosurgery, The Affiliated Suzhou Science & Technology Town Hospital of Nanjing Medical University, Suzhou City, China
| | - Lihui Zhou
- Department of General Surgery, The Affiliated Suzhou Science & Technology Town Hospital of Nanjing Medical University, Suzhou City, China
| | - Chunyan Ni
- Department of Nursing, The Affiliated Suzhou Science & Technology Town Hospital of Nanjing Medical University, Suzhou City, China
| | - Minyan Xiao
- Department of Neurosurgery, The Affiliated Suzhou Science & Technology Town Hospital of Nanjing Medical University, Suzhou City, China
| | - Xianlan Meng
- Department of Neurosurgery, The Affiliated Suzhou Science & Technology Town Hospital of Nanjing Medical University, Suzhou City, China
| | - Xiaowen Zhu
- Department of Neurosurgery, The Affiliated Suzhou Science & Technology Town Hospital of Nanjing Medical University, Suzhou City, China
| | - Qing Cao
- Department of Neurosurgery, The Affiliated Suzhou Science & Technology Town Hospital of Nanjing Medical University, Suzhou City, China
| | - Huifen Li
- Department of Nursing, The Affiliated Suzhou Science & Technology Town Hospital of Nanjing Medical University, Suzhou City, China
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Lugo GJ, Beletanga M, Goldstein L, Rana M, Jonas R, Torres AR. Assessment and Treatment of Concussion in the Pediatric Population. Semin Neurol 2021; 41:132-146. [PMID: 33657625 DOI: 10.1055/s-0041-1725135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Traumatic brain injury (TBI) is common in children. The evaluation and management of children with TBI is based on the research performed in adults. There is a relative paucity of research in the literature involving children and many of the practice recommendations for this age are based on expert opinion in the absence of good research studies in both sports and non-sports-related injuries. The pediatric population is heterogeneous and the approach might be specific for infants, preschoolers, school age children, and adolescents. Children may also suffer from neurodevelopmental disabilities, making their evaluation even more challenging. Adult neurologists are often asked to see children due to increasing demands. This review will focus on specific issues related to TBI in children that might be useful to adult neurologists. Science, however, is evolving rapidly and physicians should make sure to remain up to date to offer evidence-based services to their patients.
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Affiliation(s)
- Giancarlo J Lugo
- Division of Pediatric Neurology, Department of Pediatrics, Boston Medical Center, Boston, Massachusetts
| | - Maria Beletanga
- Division of Pediatric Neurology, Department of Pediatrics, Boston Medical Center, Boston, Massachusetts
| | - Laura Goldstein
- Division of Child Psychiatry, Department of Psychiatry, Boston Medical Center, Boston, Massachusetts
| | - Mandeep Rana
- Division of Pediatric Neurology, Department of Pediatrics, Boston Medical Center, Boston, Massachusetts
| | - Rinat Jonas
- Division of Pediatric Neurology, Department of Pediatrics, Boston Medical Center, Boston, Massachusetts
| | - Alcy R Torres
- Division of Pediatric Neurology, Department of Pediatrics, Boston Medical Center, Boston, Massachusetts.,Pediatric Brain Injury Program, Boston University School of Medicine, Boston, Massachusetts
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Polytraumaversorgung im Kindesalter – praktische und pragmatische Zusammenfassung der neuen Leitlinie. Notf Rett Med 2021. [DOI: 10.1007/s10049-020-00830-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Lengel D, Sevilla C, Romm ZL, Huh JW, Raghupathi R. Stem Cell Therapy for Pediatric Traumatic Brain Injury. Front Neurol 2020; 11:601286. [PMID: 33343501 PMCID: PMC7738475 DOI: 10.3389/fneur.2020.601286] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 11/10/2020] [Indexed: 12/11/2022] Open
Abstract
There has been a growing interest in the potential of stem cell transplantation as therapy for pediatric brain injuries. Studies in pre-clinical models of pediatric brain injury such as Traumatic Brain Injury (TBI) and neonatal hypoxia-ischemia (HI) have contributed to our understanding of the roles of endogenous stem cells in repair processes and functional recovery following brain injury, and the effects of exogenous stem cell transplantation on recovery from brain injury. Although only a handful of studies have evaluated these effects in models of pediatric TBI, many studies have evaluated stem cell transplantation therapy in models of neonatal HI which has a considerable overlap of injury pathology with pediatric TBI. In this review, we have summarized data on the effects of stem cell treatments on histopathological and functional outcomes in models of pediatric brain injury. Importantly, we have outlined evidence supporting the potential for stem cell transplantation to mitigate pathology of pediatric TBI including neuroinflammation and white matter injury, and challenges that will need to be addressed to incorporate these therapies to improve functional outcomes following pediatric TBI.
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Affiliation(s)
- Dana Lengel
- Graduate Program in Neuroscience, Drexel University College of Medicine, Philadelphia, PA, United States
| | - Cruz Sevilla
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA, United States
| | - Zoe L Romm
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA, United States
| | - Jimmy W Huh
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Ramesh Raghupathi
- Graduate Program in Neuroscience, Drexel University College of Medicine, Philadelphia, PA, United States.,Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA, United States
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The role of ICP monitoring in paediatric IIH. Childs Nerv Syst 2020; 36:3027-3033. [PMID: 32322974 DOI: 10.1007/s00381-020-04618-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 04/08/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Diagnosis of idiopathic intracranial hypertension (IIH) in children is an extrapolation of the guidelines suggested for adult population. Lumbar puncture (LP) plays a crucial role in the diagnosis. The diagnosis of IIH at times is solely dependent on the interpretation of the opening pressure (OP). Unfortunately, LP-OP can vary due circumstantial parameters and therefore may be an unreliable form of intracranial pressure (ICP) measurement. Confirming the diagnosis based (as suggested by guidelines) on LP-OP in a doubtful clinical situation would be inappropriate. The aim of our study was to analyse the reliability of LP-OP and importance of ICP monitoring in situations where diagnosis of IIH was questionable. METHODS Retrospective review of all children with diagnosis of IIH over a 10-year period was conducted. Children who underwent ICP monitoring (ICPM) were selected. We considered 2 LP-OP values-last LP (lLP) and the mean LP (mLP) for analysis. ICPM and LP-OP were compared. Follow-up till last clinic visit was also considered for long-term outcome. RESULTS Eleven children (male 3; female 8) were included in the study. Mean delay between LP and ICPM was 112.8 days (17-257 days). There was lack of correlation between LP-OP and ICP in 9 children. ICP monitoring refuted the diagnosis of IIH in 80% of children and prevented exposure to unnecessary medical and surgical intervention. There was 1complication with ICPM. In 90% of children, there was no progression of symptoms following a decision based on ICP monitoring on long-term follow-up (mean, 36.5 months). CONCLUSION When the diagnosis of IIH is in doubt, LP may be unreliable and formal ICP monitoring is advised.
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Khan AH, Gai J, Faruque F, Bost JE, Patel AK, Pollack MM. Pediatric Mortality and Acute Kidney Injury Are Associated with Chloride Abnormalities in Intensive Care Units in the United States: A Multicenter Observational Study. J Pediatr Intensive Care 2020; 11:91-99. [DOI: 10.1055/s-0040-1719172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/28/2020] [Indexed: 01/19/2023] Open
Abstract
AbstractOur objective was to determine in children in the intensive care unit (ICU) the incidence of hyperchloremia (>110 mmol/L) and hypochloremia (<98 mmol/L), the association of diagnoses with chloride abnormalities, and the associations of mortality and acute kidney injury (AKI) with chloride abnormalities. We analyzed the initial, maximum, and minimum chloride measurements of 14,684 children in the ICU with ≥1 chloride measurement in the Health Facts database between 2009 and 2016. For hyperchloremia and hypochloremia compared with normochloremia, mortality rates increased three to fivefold and AKI rates increased 1.5 to threefold. The highest mortality rate (7.7%; n = 95/1,234) occurred with hyperchloremia in the minimum chloride measurement group and the highest AKI rate (7.7%; n = 72/930) occurred with hypochloremia in the initial chloride measurement group. The most common diagnostic categories associated with chloride abnormalities were injury and poisoning; respiratory; central nervous system; infectious and parasitic diseases; and endocrine, nutritional, metabolic, and immunity disorders. Controlled for race, gender, age, and diagnostic categories, mortality odds ratios, and AKI odds ratios were significantly higher for hyperchloremia and hypochloremia compared with normochloremia. In conclusion, hyperchloremia and hypochloremia are independently associated with mortality and AKI in children in the ICU.
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Affiliation(s)
- Aamer H. Khan
- Division of Critical Care Medicine, Children's National Hospital, Washington, District of Columbia, United States
| | - Jiaxing Gai
- Division of Critical Care Medicine, Children's National Hospital, Washington, District of Columbia, United States
| | - Farhana Faruque
- Division of Critical Care Medicine, Children's National Hospital, Washington, District of Columbia, United States
| | - James E. Bost
- Division of Biostatistics and Study Methodology, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, United States
| | - Anita K. Patel
- Division of Critical Care Medicine, Children's National Hospital, Washington, District of Columbia, United States
- Division of Biostatistics and Study Methodology, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, United States
| | - Murray M. Pollack
- Division of Critical Care Medicine, Children's National Hospital, Washington, District of Columbia, United States
- Division of Biostatistics and Study Methodology, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, United States
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Tucker EW, Marais S, Seddon JA, van Crevel R, Ganiem AR, Ruslami R, Zhang W, Sun F, Zhou X, Solomons RS, Cresswell FV, Wilmshurst J, Rohlwink U. International Survey Reveals Opportunities to Improve Tuberculous Meningitis Management and the Need for Standardized Guidelines. Open Forum Infect Dis 2020; 7:ofaa445. [PMID: 33209947 PMCID: PMC7652100 DOI: 10.1093/ofid/ofaa445] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 09/17/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Tuberculous meningitis (TBM) is a medical emergency, yet there are no standardized treatment guidelines for the medical or neurosurgical management of these patients and little data on neurocritical care. We conducted an international survey to understand current medical and neurosurgical TBM management and resource availability to provide baseline data needed for future multicenter trials addressing unanswered clinical research questions and the establishment of standardized guidelines. METHODS An online survey of 77 questions covering medical and neurosurgical TBM management aimed at clinicians/nurses treating TBM was distributed as an anonymous link through email invitation, international organizations' membership distribution, and direct links on organizational webpages or social media. The survey remained open for 5 months. Data were summarized with frequencies and percentages. RESULTS The survey had 222 responses from 43 countries representing 6 continents. Most respondents were from tertiary care facilities, with broad access to medical and neurosurgical resources. There was significant heterogeneity in general supportive care, and TBM-specific management demonstrated considerable divergence from current standard-of-care practices. The lack of standardized guidelines was identified as a major challenge in TBM management. General and neurocritical care were largely absent. Resources for bedside supportive care and noninvasive monitoring were broadly accessible. CONCLUSIONS These findings suggest that current TBM management could be improved by the establishment of internationally accepted treatment guidelines based on available evidence, and that numerous centers have resources available to participate in future multicenter trials, even for basic interventions, that may further improve patient outcomes globally.
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Affiliation(s)
- Elizabeth W Tucker
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Pediatric Critical Care, Johns Hopkins All Children’s Hospital, St. Petersburg, Florida, USA
| | - Suzaan Marais
- Division of Neurology, Department of Medicine and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - James A Seddon
- Department of Infectious Diseases, Imperial College London, London, United Kingdom
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Reinout van Crevel
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Ahmad Rizal Ganiem
- Department of Neurology, Hasan Sadikin Hospital, Faculty of Medicine Universitas Padjadjaran, Bandung, Indonesia
| | - Rovina Ruslami
- Department of Neurology, Hasan Sadikin Hospital, Faculty of Medicine Universitas Padjadjaran, Bandung, Indonesia
| | - Wenhong Zhang
- Departments of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Feng Sun
- Departments of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Xian Zhou
- Departments of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Regan S Solomons
- Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Fiona V Cresswell
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Infectious Disease Institute, Mulago College of Health Sciences, Kampala, Uganda
- MRC-UVRI LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Jo Wilmshurst
- Neuroscience Institute and Department of Paediatric Neurology, University of Cape Town, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
| | - Ursula Rohlwink
- Division of Neurosurgery, Department of Surgery and Neuroscience Institute, University of Cape Town, Faculty of Health Sciences, Cape Town, South Africa
- The Francis Crick Institute, London, United Kingdom
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Lan Z, Richard SA, Li Q, Wu C, Zhang Q, Chen R, Yang C. Outcomes of patients undergoing craniotomy and decompressive craniectomy for severe traumatic brain injury with brain herniation: A retrospective study. Medicine (Baltimore) 2020; 99:e22742. [PMID: 33120775 PMCID: PMC7581028 DOI: 10.1097/md.0000000000022742] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The treatment of severe traumatic brain injury (TBI) with brain herniation is challenging because outcomes are often associated with high mortality and morbidity. Our aim was to identity factors contributing to decompressive craniectomy (DC) and evaluate treatment outcomes in patients with severe TBI with brain herniation.In this retrospective study, we analyzed medical records of severe TBI with brain herniation from May 2009 to December 2013. We reviewed their demographic data, mechanism of injury, Glasgow Coma Scale (GCS) score, pupil status, computed tomography findings, surgical treatment methods, time interval between brain herniation and surgery, as well as outcomes. GCS and pupil status are clinical parameters for detecting increase intracranial pressure while brain parenchyma bulged above the inner plate of the skull during operation indicated brain swelling as well as increased intracranial pressure on which basis the decision to perform DC or craniotomy was determined intraoperatively.One hundred ninety-four patients were included in the study. We performed DC in 143 of the patients while 51 of them we performed craniotomy. There were no statistically significant differences in the age, gender, or injury mechanism between the 2 groups. GCS, pupillary dilation, midline shift, hematoma type and timing of surgery were associated with DC. Nevertheless, logistic regression analysis revealed that hematoma type and timing of surgery were significantly associated with favorable DC outcomes (P < .001 and P = .023). Subdural hematoma and timing of surgery >1 hour were both identified as risk factors for DC. Six months after TBI, 34.0% of patients exhibited favorable outcomes. Overall mortality rate was 30.4%. Age, GCS, pupil dilation, hematoma type, and timing of surgery were all associated with patient outcomes. Further logistic regression analysis revealed that, lower GCS, bilateral pupil dilation, timing of surgery >1 hour, and advanced age were independent risk factors for poor outcomes (P = .001, P = .037, P = .028, and P = .001, respectively).Our study revealed that, DC is not mandatory for all TBI patients with brain herniation. Nevertheless, DC decreases mortality rate in severe TBI patients with brain herniation. Subdural hematoma and timing of surgery >1 hour are key indicators for DC. Lower GCS, bilateral pupil dilation, delayed timing of surgery and advance age are indicators of poor outcomes.
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Affiliation(s)
- Zhigang Lan
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, PR China
| | - Seidu A. Richard
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, PR China
- Department of Medicine, Princefield University, Ghana West Africa
| | - Qiang Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, PR China
| | - Cong Wu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, PR China
| | - Qiao Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, PR China
| | - Ruiqi Chen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, PR China
| | - Chaohua Yang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, PR China
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Abdullah MI, Ahmad A, Syed Saadun Tarek Wafa SWW, Abdul Latif AZ, Mohd Yusoff NA, Jasmiad MK, Udin N, Abdul Karim K. Determination of calorie and protein intake among acute and sub-acute traumatic brain injury patients. Chin J Traumatol 2020; 23:290-294. [PMID: 32423779 PMCID: PMC7567897 DOI: 10.1016/j.cjtee.2020.04.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 05/09/2020] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Malnutrition is a common problem among hospitalized patients, especially among traumatic brain injury (TBI) patients. It is developed from hypermetabolism and the condition may worsen under the circumstance of underfeeding or incompatible dietary management. However, the data of nutrient intake especially calorie and protein among TBI patients were scarce. Hence, this study aimed to determine the calorie and protein intake among acute and sub-acute TBI patients receiving medical nutrition therapy in hospital Sultanah Nur Zahirah, Terengganu. METHODS This observational study involved 50 patients recruited from the neurosurgical ward. Method of 24 h dietary recall was utilized and combined with self-administered food diaries for 2-8 days. Food consumptions including calorie intake and protein intake were analyzed using Nutritionist PRO™ (Woodinville, USA) and manual calculation based on the Malaysian food composition database (2015). RESULTS Patients consisted of 56% males and 44% females with the median age of 28.0 (IQR = 22.8-36.5) years, of which 92% were diagnosed as mild TBI and the remaining (8%) as moderate TBI. The Glasgow coma scale (GCS) was adopted to classify TBI severity with the score 13-15 being mild and 9-12 being moderate. The median length of hospital stay was 2 (IQR = 2.0-3.3) days. Calorie and protein intake improved significantly from day 1 to discharge day. However, the intake during discharge day was still considered as suboptimal, i.e. 75% of calorie requirement, whilst the median protein intake was only 61.3% relative to protein requirement. Moreover, the average percentages of calorie and protein intakes throughout hospitalization were remarkably lower, i.e. 52.2% and 41.0%, respectively. CONCLUSION Although the calorie and protein intakes had increased from baseline, hospitalized TBI patients were still at a risk to develop malnutrition as the average intakes were considerably low as compared to their requirements. Optimum nutrient intakes especially calorie and protein are crucial to ensure optimum recovery process as well as to minimize risks of infection and complications.
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Affiliation(s)
- Mohd Ibrahim Abdullah
- Faculty of Health Science, Universiti Sultan Zainal Abidin, Gong Badak Campus, 21300 Kuala Terenganu, Terengganu, Malaysia
| | - Aryati Ahmad
- Faculty of Health Science, Universiti Sultan Zainal Abidin, Gong Badak Campus, 21300 Kuala Terenganu, Terengganu, Malaysia.
| | | | - Ahmad Zubaidi Abdul Latif
- Faculty of Medicine, Universiti Sultan Zainal Abidin, Gong Badak Campus, 21300 Kuala Terenganu, Terengganu, Malaysia
| | - Noor Aini Mohd Yusoff
- Faculty of Health Science, Universiti Sultan Zainal Abidin, Gong Badak Campus, 21300 Kuala Terenganu, Terengganu, Malaysia
| | - Muhammad Khalis Jasmiad
- Faculty of Health Science, Universiti Sultan Zainal Abidin, Gong Badak Campus, 21300 Kuala Terenganu, Terengganu, Malaysia
| | - Nujaimin Udin
- Neurosurgery Department, Hospital Sultanah Nur Zahirah, Ministry of Health Malaysia, Jalan Sultan Mahmud, 20400 Kuala Terengganu, Terengganu, Malaysia
| | - Kartini Abdul Karim
- Dietetic and Food Service Department, Hospital Sultanah Nur Zahirah, Ministry of Health Malaysia, Jalan Sultan Mahmud, 20400 Kuala Terengganu, Terengganu, Malaysia
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77
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Chevignard M, Câmara-Costa H, Dellatolas G. Pediatric traumatic brain injury and abusive head trauma. HANDBOOK OF CLINICAL NEUROLOGY 2020; 173:451-484. [PMID: 32958191 DOI: 10.1016/b978-0-444-64150-2.00032-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Childhood traumatic brain injury (TBI) commonly occurs during brain development and can have direct, immediately observable neurologic, cognitive, and behavioral consequences. However, it can also disrupt subsequent brain development, and long-term outcomes are a combination of preinjury development and abilities, consequences of brain injury, as well as delayed impaired development of skills that were immature at the time of injury. There is a growing number of studies on mild TBI/sport-related concussions, describing initial symptoms and their evolution over time and providing guidelines for effective management of symptoms and return to activity/school/sports. Mild TBI usually does not lead to long-term cognitive or academic consequences, despite reports of behavioral/psychologic issues postinjury. Regarding moderate to severe TBI, injury to the brain is more severe, with evidence of a number of detrimental consequences in various domains. Patients can display neurologic impairments (e.g., motor deficits, signs of cerebellar disorder, posttraumatic epilepsy), medical problems (e.g., endocrine pituitary deficits, sleep-wake abnormalities), or sensory deficits (e.g., visual, olfactory deficits). The most commonly reported deficits are in the cognitive-behavioral field, which tend to be significantly disabling in the long-term, impacting the development of autonomy, socialization and academic achievement, participation, quality of life, and later, independence and ability to enter the workforce (e.g., intellectual deficits, slow processing speed, attention, memory, executive functions deficits, impulsivity, intolerance to frustration). A number of factors influence outcomes following pediatric TBI, including preinjury stage of development and abilities, brain injury severity, age at injury (with younger age at injury most often associated with worse outcomes), and a number of family/environment factors (e.g., parental education and occupation, family functioning, parenting style, warmth and responsiveness, access to rehabilitation and care). Interventions should identify and target these specific factors, given their major role in postinjury outcomes. Abusive head trauma (AHT) occurs in very young children (most often <6 months) and is a form of severe TBI, usually associated with delay before appropriate care is sought. Outcomes are systematically worse following AHT than following accidental TBI, even when controlling for age at injury and injury severity. Children with moderate to severe TBI and AHT usually require specific, coordinated, multidisciplinary, and long-term rehabilitation interventions and school adaptations, until transition to adult services. Interventions should be patient- and family-centered, focusing on specific goals, comprising education about TBI, and promoting optimal parenting, communication, and collaborative problem-solving.
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Affiliation(s)
- Mathilde Chevignard
- Rehabilitation Department for Children with Acquired Neurological Injury and Outreach Team for Children and Adolescents with Acquired Brain Injury, Saint Maurice Hospitals, Saint Maurice, France; Laboratoire d'Imagerie Biomédicale, Sorbonne Université, Paris, France; GRC 24, Handicap Moteur et Cognitif et Réadaptation, Sorbonne Université, Paris, France.
| | - Hugo Câmara-Costa
- GRC 24, Handicap Moteur et Cognitif et Réadaptation, Sorbonne Université, Paris, France; Centre d'Etudes en Santé des Populations, INSERM U1018, Paris, France
| | - Georges Dellatolas
- GRC 24, Handicap Moteur et Cognitif et Réadaptation, Sorbonne Université, Paris, France
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78
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Even KM, Subramanian S, Berger RP, Kochanek PM, Zuccoli G, Gaines BA, Fink EL. The Presence of Anemia in Children with Abusive Head Trauma. J Pediatr 2020; 223:148-155.e2. [PMID: 32532650 DOI: 10.1016/j.jpeds.2020.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/03/2020] [Accepted: 04/02/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To evaluate the incidence of anemia in patients with abusive head trauma (AHT), noninflicted traumatic brain injury (TBI), and physical abuse without AHT and the effect of anemia on outcome. STUDY DESIGN In a retrospective, single-center cohort study, we included children under the age of 3 years diagnosed with either AHT (n = 75), noninflicted TBI (n = 77), or physical abuse without AHT (n = 60) between January 1, 2014, and December 31, 2016. Neuroimaging was prospectively analyzed by pediatric neuroradiologists. Primary outcome was anemia at hospital presentation. Secondary outcomes included unfavorable outcome at hospital discharge, defined as a Glasgow Outcome Scale between 1 and 3, and intracranial hemorrhage (ICH) volume. RESULTS Patients with AHT had a higher rate of anemia on presentation (47.3%) vs noninflicted TBI (15.6%) and physical abuse without AHT (10%) (P < .001). Patients with AHT had larger ICH volumes (33.3 mL [10.1-76.4 mL] vs 1.5 mL [0.6-5.2 mL] ; P < .001) and greater ICH/total brain volume percentages than patients with noninflicted TBI (4.6% [1.4-8.2 %] vs 0.2% [0.1-0.7%]; P < .001). Anemia was associated with AHT (OR, 4.7; 95% CI, 2.2-10.2) and larger ICH/total brain volume percentage (OR, 1.1; 95% CI, 1.1-1.2) in univariate analysis. Unfavorable outcome at hospital discharge was associated with anemia (OR, 4.4; 95% CI, 1.6-12.6) in univariate analysis, but not after controlling for covariates. CONCLUSIONS Patients with AHT were more likely to present to the hospital with anemia and increased traumatic ICH volume than patients with noninflicted TBI or physical abuse without AHT. Children with anemia and AHT may be at increased risk for an unfavorable outcome.
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Affiliation(s)
- Katelyn M Even
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA.
| | - Subramanian Subramanian
- Department of Radiology, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Rachel P Berger
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA; Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Patrick M Kochanek
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA; Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Giulio Zuccoli
- Department of Radiology, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Barbara A Gaines
- Department of Surgery, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA; Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA
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79
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Wolf MS, Rakkar J, Horvat CM, Simon DW, Kochanek PM, Clermont G, Clark RSB. Assessment of Dynamic Intracranial Compliance in Children with Severe Traumatic Brain Injury: Proof-of-Concept. Neurocrit Care 2020; 34:209-217. [PMID: 32556856 PMCID: PMC7299131 DOI: 10.1007/s12028-020-01004-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background and Aims Intracranial compliance refers to the relationship between a change in intracranial volume and the resultant change in intracranial pressure (ICP). Measurement of compliance is useful in managing cardiovascular and respiratory failure; however, there are no contemporary means to assess intracranial compliance. Knowledge of intracranial compliance could complement ICP and cerebral perfusion pressure (CPP) monitoring in patients with severe traumatic brain injury (TBI) and may enable a proactive approach to ICP management. In this proof-of-concept study, we aimed to capitalize on the physiologic principles of intracranial compliance and vascular reactivity to CO2, and standard-of-care neurocritical care monitoring, to develop a method to assess dynamic intracranial compliance. Methods Continuous ICP and end-tidal CO2 (ETCO2) data from children with severe TBI were collected after obtaining informed consent in this Institutional Review Board-approved study. An intracranial pressure-PCO2 Compliance Index (PCI) was derived by calculating the moment-to-moment correlation between change in ICP and change in ETCO2. As such, “good” compliance may be reflected by a lack of correlation between time-synched changes in ICP in response to changes in ETCO2, and “poor” compliance may be reflected by a positive correlation between changes in ICP in response to changes in ETCO2. Results A total of 978 h of ICP and ETCO2 data were collected and analyzed from eight patients with severe TBI. Demographic and clinical characteristics included patient age 7.1 ± 5.8 years (mean ± SD); 6/8 male; initial Glasgow Coma Scale score 3 [3–7] (median [IQR]); 6/8 had decompressive surgery; 7.1 ± 1.4 ICP monitor days; ICU length of stay (LOS) 16.1 ± 6.8 days; hospital LOS 25.9 ± 8.4 days; and survival 100%. The mean PCI for all patients throughout the monitoring period was 0.18 ± 0.04, where mean ICP was 13.7 ± 2.1 mmHg. In this cohort, PCI was observed to be consistently above 0.18 by 12 h after monitor placement. Percent time spent with PCI thresholds > 0.1, 0.2, and 0.3 were 62% [24], 38% [14], and 23% [15], respectively. The percentage of time spent with an ICP threshold > 20 mmHg was 5.1% [14.6]. Conclusions Indirect assessment of dynamic intracranial compliance in TBI patients using standard-of-care monitoring appears feasible and suggests a prolonged period of derangement out to 5 days post-injury. Further study is ongoing to determine if the PCI—a new physiologic index, complements utility of ICP and/or CPP in guiding management of patients with severe TBI. Electronic supplementary material The online version of this article (10.1007/s12028-020-01004-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michael S Wolf
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Pediatrics, Division of Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Jaskaran Rakkar
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Christopher M Horvat
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Faculty Pavilion, Suite 2000, Brain Care Institute, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Dennis W Simon
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Faculty Pavilion, Suite 2000, Brain Care Institute, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Patrick M Kochanek
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Faculty Pavilion, Suite 2000, Brain Care Institute, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Gilles Clermont
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
| | - Robert S B Clark
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. .,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. .,Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. .,Faculty Pavilion, Suite 2000, Brain Care Institute, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA.
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Emergency Department Implementation of the Brain Trauma Foundation's Pediatric Severe Brain Injury Guideline Recommendations. Pediatr Emerg Care 2020; 36:e239-e241. [PMID: 31804428 DOI: 10.1097/pec.0000000000001903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The "Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines" published in Pediatric Critical Care Medicine in 2019 provides new and updated recommendations applicable to the emergency department management of children with severe traumatic brain injury. Practice-changing takeaways include specific recommendations for administration of 3% hypertonic saline, administration of seizure prophylaxis, and avoiding hyperventilation.
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81
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Pilar MR, Proctor EK, Pineda JA. Development, implementation, and evaluation of a novel guideline engine for pediatric patients with severe traumatic brain injury: a study protocol. Implement Sci Commun 2020; 1:31. [PMID: 32885190 PMCID: PMC7427929 DOI: 10.1186/s43058-020-00012-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 01/13/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Severe traumatic brain injury (TBI) is a leading cause of death and disability for children. The Brain Trauma Foundation released evidence-based guidelines, a series of recommendations regarding care for pediatric patients with severe TBI. Clinical evidence suggests that adoption of guideline-based care improves outcomes in patients with severe TBI. However, guideline implementation has not been systematic or consistent in clinical practice. There is also a lack of information about implementation strategies that are effective given the nature of severe TBI care and the complex environment in the intensive care unit (ICU). Novel technology-based strategies may be uniquely suited to the fast-paced, transdisciplinary care delivered in the ICU, but such strategies must be carefully developed and evaluated to prevent unintended consequences within the system of care. This challenge presents a unique opportunity for intervention to more appropriately implement guideline-based care for pediatric patients with severe TBI. METHODS This mixed-method study will develop a novel technology-based bedside guideline engine (the implementation strategy) to facilitate uptake of evidence-based guidelines (the intervention) for management of severe TBI. Group model building and systems dynamics will inform the guideline engine design, and bedside functionality will be initially assessed through patient simulation. Using the Promoting Action on Research Implementation in Health Services (PARIHS) framework, we will determine the feasibility of incorporating the guideline engine in the ICU. Study participants will include pediatric patients with severe TBI and providers at three trauma centers. Quantitative data will include measures of guideline engine acceptance and organizational readiness for change. Qualitative data will include semi-structured interviews from clinicians. We will test the feasibility of incorporating the guideline engine in "real life practice" in preparation for a future clinical trial that will assess clinical and implementation outcomes, including feasibility, acceptability, and adoption of the guideline engine. DISCUSSION This study will lead to the development and feasibility testing of an adaptable strategy for implementing guideline-based care for severe TBI, a strategy that meets the needs of individual critical care environments and patients. A future study will test the adaptability and impact of the bedside guideline engine in a randomized clinical trial.
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Affiliation(s)
- Meagan R. Pilar
- Washington University in St. Louis, Brown School, One Brookings Drive, Campus Box 1196, St. Louis, MO 63130 USA
| | - Enola K. Proctor
- Washington University in St. Louis, Brown School, One Brookings Drive, Campus Box 1196, St. Louis, MO 63130 USA
| | - Jose A. Pineda
- Children’s Hospital Los Angeles/University of Southern California, Keck School of Medicine, 4650 Sunset Blvd, Los Angeles, CA 90027 USA
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Donovan J, Rohlwink UK, Tucker EW, Hiep NTT, Thwaites GE, Figaji AA. Checklists to guide the supportive and critical care of tuberculous meningitis. Wellcome Open Res 2020. [PMID: 31984242 DOI: 10.12688/wellcomeopenres.15512.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
The assessment and management of tuberculous meningitis (TBM) is often complex, yet no standardised approach exists, and evidence for the clinical care of patients, including those with critical illness, is limited. The roles of proformas and checklists are increasing in medicine; proformas provide a framework for a thorough approach to patient care, whereas checklists offer a priority-based approach that may be applied to deteriorating patients in time-critical situations. We aimed to develop a comprehensive assessment proforma and an accompanying 'priorities' checklist for patients with TBM, with the overriding goal being to improve patient outcomes. The proforma outlines what should be asked, checked, or tested at initial evaluation and daily inpatient review to assist supportive clinical care for patients, with an adapted list for patients in critical care. It is accompanied by a supporting document describing why these points are relevant to TBM. Our priorities checklist offers a useful and easy reminder of important issues to review during a time-critical period of acute patient deterioration. The benefit of these documents to patient outcomes would require investigation; however, we hope they will promote standardisation of patient assessment and care, particularly of critically unwell individuals, in whom morbidity and mortality remains unacceptably high.
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Affiliation(s)
- Joseph Donovan
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Ursula K Rohlwink
- Neuroscience Institute and Division of Neurosurgery, University of Cape Town, Cape Town, 7700, South Africa
| | - Elizabeth W Tucker
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA.,Division of Pediatric Critical Care, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.,Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Nguyen Thi Thu Hiep
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Anthony A Figaji
- Neuroscience Institute and Division of Neurosurgery, University of Cape Town, Cape Town, 7700, South Africa
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Chen H, Song Z, Dennis JA. Hypertonic saline versus other intracranial pressure-lowering agents for people with acute traumatic brain injury. Cochrane Database Syst Rev 2020; 1:CD010904. [PMID: 31978260 PMCID: PMC6984412 DOI: 10.1002/14651858.cd010904.pub3] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Increased intracranial pressure has been shown to be strongly associated with poor neurological outcomes and mortality for patients with acute traumatic brain injury. Currently, most efforts to treat these injuries focus on controlling the intracranial pressure. Hypertonic saline is a hyperosmolar therapy that is used in traumatic brain injury to reduce intracranial pressure. The effectiveness of hypertonic saline compared with other intracranial pressure-lowering agents in the management of acute traumatic brain injury is still debated, both in the short and the long term. OBJECTIVES To assess the comparative efficacy and safety of hypertonic saline versus other intracranial pressure-lowering agents in the management of acute traumatic brain injury. SEARCH METHODS We searched Cochrane Injuries' Specialised Register, CENTRAL, PubMed, Embase Classic+Embase, ISI Web of Science: Science Citation Index and Conference Proceedings Citation Index-Science, as well as trials registers, on 11 December 2019. We supplemented these searches with searches of four major Chinese databases on 19 September 2018. We also checked bibliographies, and contacted trial authors to identify additional trials. SELECTION CRITERIA We sought to identify all randomised controlled trials (RCTs) of hypertonic saline versus other intracranial pressure-lowering agents for people with acute traumatic brain injury of any severity. We excluded cross-over trials as incompatible with assessing long-term outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently screened search results to identify potentially eligible trials and extracted data using a standard data extraction form. Outcome measures included: mortality at end of follow-up (all-cause); death or disability (as measured by the Glasgow Outcome Scale (GOS)); uncontrolled intracranial pressure (defined as failure to decrease the intracranial pressure to target and/or requiring additional intervention); and adverse events e.g. rebound phenomena; pulmonary oedema; acute renal failure during treatment). MAIN RESULTS Six trials, involving data from 287 people, met the inclusion criteria. The majority of participants (91%) had a diagnosis of severe traumatic brain injury. We had concerns about particular domains of risk of bias in each trial, as physicians were not reliably blinded to allocation, two trials contained participants with conditions other than traumatic brain injury and in one trial, we had concerns about missing data for important outcomes. The original protocol was available for only one trial and other trials (where registered) were registered retrospectively. Meta-analysis for both the primary outcome (mortality at final follow-up) and for 'poor outcome' as per conventionally dichotomised GOS criteria, was only possible for two trials. Synthesis of long-term outcomes was inhibited by the fact that two trials ceased data collection within two hours of a single bolus dose of an intracranial pressure-lowering agent and one at discharge from the intensive care unit (ICU). Only three trials collected data after participants were released from hospital, one of which did not report mortality and reported a 'poor outcome' by GOS criteria in an unconventional way. Substantial missing data in a key trial meant that in meta-analysis we report 'best-case' and 'worst-case' estimates alongside available case analysis. In no scenario did we discern a clear difference between treatments for either mortality or poor neurological outcome. Due to variation in modes of drug administration (including whether it followed or did not follow cerebrospinal fluid (CSF) drainage, as well as different follow-up times and ways of reporting changes in intracranial pressure, as well as no uniform definition of 'uncontrolled intracranial pressure', we did not perform meta-analysis for this outcome and report results narratively, by individual trial. Trials tended to report both treatments to be effective in reducing elevated intracranial pressure but that hypertonic saline had increased benefits, usually adding that pretreatment factors need to be considered (e.g. serum sodium and both system and brain haemodynamics). No trial provided data for our other outcomes of interest. We consider evidence quality for all outcomes to be very low, as assessed by GRADE; we downgraded all conclusions due to imprecision (small sample size), indirectness (due to choice of measurement and/or selection of participants without traumatic brain injury), and in some cases, risk of bias and inconsistency. Only one of the included trials reported data on adverse effects; a rebound phenomenon, which was present only in the comparator group (mannitol). None of the trials reported data on pulmonary oedema or acute renal failure during treatment. On the whole, trial authors do not seem to have rigorously sought to collect data on adverse events. AUTHORS' CONCLUSIONS This review set out to find trials comparing hypertonic saline to a potential range of other intracranial pressure-lowering agents, but only identified trials comparing it with mannitol or mannitol in combination with glycerol. Based on limited data, there is weak evidence to suggest that hypertonic saline is no better than mannitol in efficacy and safety in the long-term management of acute traumatic brain injury. Future research should be comprised of large, multi-site trials, prospectively registered, reported in accordance with current best practice. Trials should investigate issues such as the type of traumatic brain injury suffered by participants and concentration of infusion and length of time over which the infusion is given.
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Affiliation(s)
- Han Chen
- Third Xiangya Hospital, Central South UniversityDepartment of Neurology138 Tongzipo Road, Yulu DistrictChang ShaChina410013
| | - Zhi Song
- Third Xiangya Hospital, Central South UniversityDepartment of Neurology138 Tongzipo Road, Yulu DistrictChang ShaChina410013
| | - Jane A Dennis
- University of BristolMusculoskeletal Research Unit, School of Clinical SciencesLearning and Research Building [Level 1]Southmead HospitalBristolUKBS10 5NB
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84
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Phenytoin intoxication associated with omeprazole administration in a child with defective CYP2C9. Eur J Clin Pharmacol 2020; 76:731-732. [PMID: 31938857 DOI: 10.1007/s00228-019-02821-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 12/22/2019] [Indexed: 10/25/2022]
Abstract
Adverse drug reactions occur at a high rate in hospitalized children, frequently due to antiepileptic drug administration. Phenytoin is a commonly used drug, and its metabolism is mediated by a specific cytochrome-P450 isoform, CYP2C9, which is encoded by a polymorphic gene. It is worth noting that very frequently administered drugs, such as proton pump inhibitors, compete with phenytoin for CYP2C19-mediated metabolism. Here we describe a case of phenytoin intoxication in a child with defective CYP2C9, after omeprazole administration.
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85
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Figaji A. Commentary: Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines, Executive Summary. Neurosurgery 2020; 85:E386-E387. [PMID: 31215623 DOI: 10.1093/neuros/nyz208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 03/08/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Anthony Figaji
- Department of Paediatric Neurosurgery, University of Cape Town, and Red Cross War Memorial Children's Hospital, Cape Town, South Africa
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86
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Reisner A, Ralston AK, Vats A, Sawvel MS, Blackwell LS. Commentary: Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines, Executive Summary. Neurosurgery 2020; 85:E384-E385. [PMID: 31173145 DOI: 10.1093/neuros/nyz192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 02/25/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Andrew Reisner
- Department of Neurosurgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia.,Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Ashley K Ralston
- Department of Neurosurgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia.,Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Atul Vats
- Department of Pediatric Critical Care, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Michael S Sawvel
- Department of Neurosurgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Laura S Blackwell
- Department of Neuropsychology, Children's Healthcare of Atlanta, Atlanta, Georgia
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87
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Chen H, Song Z, Dennis JA. Hypertonic saline versus other intracranial pressure-lowering agents for people with acute traumatic brain injury. Cochrane Database Syst Rev 2019; 12:CD010904. [PMID: 31886900 PMCID: PMC6953360 DOI: 10.1002/14651858.cd010904.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Increased intracranial pressure (ICP) has been shown to be strongly associated with poor neurological outcomes and mortality for patients with acute traumatic brain injury (TBI). Currently, most efforts to treat these injuries focus on controlling the ICP. Hypertonic saline (HTS) is a hyperosmolar therapy that is used in traumatic brain injury to reduce intracranial pressure. The effectiveness of HTS compared with other ICP-lowering agents in the management of acute TBI is still debated, both in the short and the long term. OBJECTIVES To assess the comparative efficacy and safety of hypertonic saline versus other ICP-lowering agents in the management of acute TBI. SEARCH METHODS We searched the Cochrane Injuries Group's Specialised Register, The Cochrane Library, PubMed, Embase Classic+Embase (OvidSP), ISI Web of Science: Science Citation Index and Conference Proceedings Citation Index-Science, as well as trials registers, on 11 December 2019. We supplemented these searches using four major Chinese databases on 19 September 2018. We also checked bibliographies, and contacted study authors to identify additional studies. SELECTION CRITERIA We sought to identify all randomised controlled trials (RCTs) of HTS versus other intracranial pressure-lowering agents for people with acute TBI of any severity. We excluded cross-over trials as incompatible with assessing long term outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently screened search results to identify potentially eligible trials and extracted data using a standard data extraction form. Outcome measures included: mortality at end of follow-up (all-cause); death or disability (as measured by the Glasgow Outcome Scale (GOS)); uncontrolled ICP (defined as failure to decrease the ICP to target and/or requiring additional intervention); and adverse events (AEs) (e.g. rebound phenomena; pulmonary oedema; acute renal failure during treatment). MAIN RESULTS Six trials, involving data from 295 people, met the inclusion criteria. The majority of participants (89%) had a diagnosis of severe TBI. We had concerns about particular domains of risk of bias in each trial, as physicians were not reliably blinded to allocation, two trials contained participants with conditions other than TBI and in one trial, there were concerns about missing data for important outcomes. The original protocol was available for only one study and other trials (where registered) were registered retrospectively. Meta-analysis for both the primary outcome (mortality at final follow up) and for 'poor outcome' as per conventionally dichotomised GOS criteria, was only possible for two studies. Synthesis of long-term outcomes was inhibited by the fact that two ceased data collection within two hours of a single bolus dose of an ICP-lowering agent and one at discharge from ICU. Only three studies collected data after release from hospital. Due to variation in modes of drug administration, follow-up times, and ways of reporting changes in ICP, as well as no uniform definition of 'uncontrolled ICP', we did not perform meta-analysis for this outcome and report results narratively, by individual trial. Trials tended to report both treatments to be effective in reducing elevated ICP but that HTS had increased benefits, usually adding that pretreatment factors need to be considered (e.g. serum sodium and both system and brain hemodynamics). No trial provided data for our other outcomes of interest. Evidence for all outcomes is considered very low, as assessed by GRADE. All conclusions were downgraded due to imprecision (small sample size), indirectness (due to choice of measurement and/or selection of patients without TBI), and in some cases, risk of bias and inconsistency. Only one of the included trials reported data on adverse effects (AEs) - a rebound phenomenon, which was present only in the comparator group (mannitol). No data were reported on pulmonary oedema or acute renal failure during treatment. On the whole, investigators do not seem to have rigorously sought to collect data on AEs. AUTHORS' CONCLUSIONS This review set out to find trials comparing HTS to a potential range of other ICP-lowering agents, but only identified trials comparing it with mannitol or mannitol in combination with glycerol. Based on limited data, there is weak evidence to suggest that HTS is no better than mannitol in efficacy and safety in the long-term management of acute TBI. Future research should be comprised of large, multi-site trials, prospectively registered, reported in accordance with current best practice. Issues such as the type of TBI suffered by participants and concentration of infusion and length of time over which the infusion is given should be investigated.
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Affiliation(s)
- Han Chen
- Third Xiangya Hospital, Central South UniversityDepartment of Neurology138 Tongzipo Road, Yulu DistrictChang ShaChina410013
| | - Zhi Song
- Third Xiangya Hospital, Central South UniversityDepartment of Neurology138 Tongzipo Road, Yulu DistrictChang ShaChina410013
| | - Jane A Dennis
- University of BristolMusculoskeletal Research Unit, School of Clinical SciencesLearning and Research Building [Level 1]Southmead HospitalBristolUKBS10 5NB
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88
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Duhaime AC, Christian CW. Abusive head trauma: evidence, obfuscation, and informed management. J Neurosurg Pediatr 2019; 24:481-488. [PMID: 31675688 DOI: 10.3171/2019.7.peds18394] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 07/29/2019] [Indexed: 11/06/2022]
Abstract
Abusive head trauma remains the major cause of serious head injury in infants and young children. A great deal of research has been undertaken to inform the recognition, evaluation, differential diagnosis, management, and legal interventions when children present with findings suggestive of inflicted injury. This paper reviews the evolution of current practices and controversies, both with respect to medical management and to etiological determination of the variable constellations of signs, symptoms, and radiological findings that characterize young injured children presenting for neurosurgical care.
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Affiliation(s)
- Ann-Christine Duhaime
- 1Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Cindy W Christian
- 2Department of Pediatrics, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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89
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Donovan J, Rohlwink UK, Tucker EW, Hiep NTT, Thwaites GE, Figaji AA. Checklists to guide the supportive and critical care of tuberculous meningitis. Wellcome Open Res 2019; 4:163. [PMID: 31984242 PMCID: PMC6964359 DOI: 10.12688/wellcomeopenres.15512.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2019] [Indexed: 12/21/2022] Open
Abstract
The assessment and management of tuberculous meningitis (TBM) is often complex, yet no standardised approach exists, and evidence for the clinical care of patients, including those with critical illness, is limited. The roles of proformas and checklists are increasing in medicine; proformas provide a framework for a thorough approach to patient care, whereas checklists offer a priority-based approach that may be applied to deteriorating patients in time-critical situations. We aimed to develop a comprehensive assessment proforma and an accompanying 'priorities' checklist for patients with TBM, with the overriding goal being to improve patient outcomes. The proforma outlines what should be asked, checked, or tested at initial evaluation and daily inpatient review to assist supportive clinical care for patients, with an adapted list for patients in critical care. It is accompanied by a supporting document describing why these points are relevant to TBM. Our priorities checklist offers a useful and easy reminder of important issues to review during a time-critical period of acute patient deterioration. The benefit of these documents to patient outcomes would require investigation; however, we hope they will promote standardisation of patient assessment and care, particularly of critically unwell individuals, in whom morbidity and mortality remains unacceptably high.
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Affiliation(s)
- Joseph Donovan
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Ursula K. Rohlwink
- Neuroscience Institute and Division of Neurosurgery, University of Cape Town, Cape Town, 7700, South Africa
| | - Elizabeth W. Tucker
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
- Division of Pediatric Critical Care, Johns Hopkins All Children’s Hospital, St. Petersburg, FL, USA
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Nguyen Thi Thu Hiep
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Guy E. Thwaites
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Anthony A. Figaji
- Neuroscience Institute and Division of Neurosurgery, University of Cape Town, Cape Town, 7700, South Africa
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90
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Lehner M, Deininger S, Wendling-Keim D. Management des Schädel-Hirn-Traumas im Kindesalter. Monatsschr Kinderheilkd 2019. [DOI: 10.1007/s00112-019-00770-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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91
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Duhaime AC. Commentary: Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines, Executive Summary. Neurosurgery 2019; 85:E388-E389. [DOI: 10.1093/neuros/nyz209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 03/08/2019] [Indexed: 11/13/2022] Open
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92
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Ketharanathan N, Rohlwink UK, Tibboel D, Figaji AA. Biomarkers for paediatric traumatic brain injury. THE LANCET CHILD & ADOLESCENT HEALTH 2019; 3:516-518. [PMID: 31231067 DOI: 10.1016/s2352-4642(19)30200-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 06/03/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Naomi Ketharanathan
- Intensive Care and Department of Pediatric Surgery, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam 3015CN, Netherlands.
| | - Ursula K Rohlwink
- Division of Neurosurgery and Neuroscience Institute, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam 3015CN, Netherlands
| | - Anthony A Figaji
- Division of Neurosurgery and Neuroscience Institute, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
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