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Villarreal EG, Patel RD, Farias JS, Flores S, Loomba RS. Predicting inpatient mortality in pediatric traumatic brain injury: insights from a national database. Childs Nerv Syst 2023; 39:3521-3530. [PMID: 37266680 DOI: 10.1007/s00381-023-06010-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 05/24/2023] [Indexed: 06/03/2023]
Abstract
PURPOSE The purpose of this study was to determine factors significantly associated with mortality and length of stay (LOS) in admissions to the pediatric intensive care unit (PICU) for traumatic brain injury (TBI). METHODS A cross-sectional, retrospective cohort study that identified PICU admissions with TBI from forty-nine hospitals in the USA using the Pediatric Health Information System database from 2016 to 2021. Univariable analyses comparing those who did and did not experience mortality were performed. The following regression analyses were conducted: logistic regression with mortality as dependent variable; linear regression with LOS as the dependent variable; logistic regression with mortality as the dependent variable but only included patients with cerebral edema; and linear regression with LOS as the dependent variable but only included patients who survived. From the regression analysis for mortality in all TBI patients was utilized to develop a mortality risk score. RESULTS A total of 3041 admissions were included. Those with inpatient mortality (18.5%) tended to be significantly younger (54 vs. 92 months, p < 0.01), have < 9 pediatric Glasgow Coma Scale on admission (100% vs. 52.9%, p < 0.01) and more likely to experience acute renal, hepatic and respiratory failure, acidosis, central diabetes insipidus, hyperkalemia, and hypocalcemia. Regression analysis identified that pediatric Glasgow Coma Scale, alkalosis and cardiac arrest significantly increased risks of mortality. The TBI mortality risk score had an area under the curve of 0.89 to identify those with mortality; a score of 6 ≤ was associated with 88% mortality. CONCLUSION Patients admitted to the PICU with TBI have 18.5% risk of inpatient mortality with most occurring the first 48 h and these are characterized with greater multisystem organ dysfunction, received medical and mechanical support. TBI mortality risk score suggested is a practical tool to identify patients with an increase likelihood to die.
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Affiliation(s)
- Enrique G Villarreal
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo Leon, Mexico.
| | - Riddhi D Patel
- Division of Cardiology, Advocate Children's Hospital, Chicago, IL, USA
| | | | - Saul Flores
- Division of Critical Care, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Rohit S Loomba
- Division of Cardiology, Advocate Children's Hospital/Chicago Medical School, Chicago, IL, USA
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2
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Blackwell LS, Grell R. Pediatric Traumatic Brain Injury: Impact on the Developing Brain. Pediatr Neurol 2023; 148:215-222. [PMID: 37652817 DOI: 10.1016/j.pediatrneurol.2023.06.019] [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: 02/15/2023] [Revised: 05/16/2023] [Accepted: 06/23/2023] [Indexed: 09/02/2023]
Abstract
Traumatic brain injury (TBI) is a serious public health concern impacting millions of children and adolescents each year. Experiencing a brain injury during key critical periods of brain development can affect the normal formation of brain networks that are responsible for a range of complex neurocognitive outcomes. In addition, there are multiple pre- and postinjury factors that influence the trajectory of recovery and outcomes. In this review, we will focus on the current state of the literature within pediatric TBI; systematically review the available research on developmental aspects of TBI in children, focusing on the pathophysiology of the injury and its impact on the developing brain; and highlight knowledge gaps for further exploration.
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Affiliation(s)
| | - Robert Grell
- Department of Pediatrics, Emory University, Atlanta, Georgia
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3
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Kochanek PM, Adelson PD, Rosario BL, Hutchison J, Miller Ferguson N, Ferrazzano P, O’Brien N, Beca J, Sarnaik A, LaRovere K, Bennett TD, Deep A, Gupta D, Willyerd FA, Gao S, Wisniewski SR, Bell MJ. Comparison of Intracranial Pressure Measurements Before and After Hypertonic Saline or Mannitol Treatment in Children With Severe Traumatic Brain Injury. JAMA Netw Open 2022; 5:e220891. [PMID: 35267036 PMCID: PMC8914575 DOI: 10.1001/jamanetworkopen.2022.0891] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
IMPORTANCE Hyperosmolar agents are cornerstone therapies for pediatric severe traumatic brain injury. Guideline recommendations for 3% hypertonic saline (HTS) are based on limited numbers of patients, and no study to date has supported a recommendation for mannitol. OBJECTIVES To characterize current use of hyperosmolar agents in pediatric severe traumatic brain injury and assess whether HTS or mannitol is associated with greater decreases in intracranial pressure (ICP) and/or increases in cerebral perfusion pressure (CPP). DESIGN, SETTING, AND PARTICIPANTS In this comparative effectiveness research study, 1018 children were screened and 18 were excluded; 787 children received some form of hyperosmolar therapy during the ICP-directed phase of care, with 521 receiving a bolus. Three of these children were excluded because they had received only bolus administration of both HTS and mannitol in the same hour, leaving 518 children (at 44 clinical sites in 8 countries) for analysis. The study was conducted from February 1, 2014, to September 31, 2017, with follow-up for 1 week after injury. Final analysis was performed July 20, 2021. INTERVENTIONS Boluses of HTS and mannitol were administered. MAIN OUTCOMES AND MEASURES Data on ICP and CPP were collected before and after medication administration. Statistical methods included linear mixed models and corrections for potential confounding variables to compare the 2 treatments. RESULTS A total of 518 children (mean [SD] age, 7.6 [5.4] years; 336 [64.9%] male; 274 [52.9%] White) were included. Participants' mean (SD) Glasgow Coma Scale score was 5.2 (1.8). Bolus HTS was observed to decrease ICP and increase CPP (mean [SD] ICP, 1.03 [6.77] mm Hg; P < .001; mean [SD] CPP, 1.25 [12.47] mm Hg; P < .001), whereas mannitol was observed to increase CPP (mean [SD] CPP, 1.20 [11.43] mm Hg; P = .009). In the primary outcome, HTS was associated with a greater reduction in ICP compared with mannitol (unadjusted β, -0.85; 95% CI, -1.53 to -0.19), but no association was seen after adjustments (adjusted β, -0.53; 95% CI, -1.32 to 0.25; P = .18). No differences in CPP were observed. When ICP was greater than 20 mm Hg, greater than 25 mm Hg, or greater than 30 mm Hg, HTS outperformed mannitol for each threshold in observed ICP reduction (>20 mm Hg: unadjusted β, -2.51; 95% CI, -3.86 to -1.15, P < .001; >25 mm Hg: unadjusted β, -3.88; 95% CI, -5.69 to -2.06, P < .001; >30 mm Hg: unadjusted β, -4.07; 95% CI, -6.35 to -1.79, P < .001), with results remaining significant for ICP greater than 25 mm Hg in adjusted analysis. CONCLUSIONS AND RELEVANCE In this comparative effectiveness research study, bolus HTS was associated with lower ICP and higher CPP, whereas mannitol was associated only with higher CPP. After adjustment for confounders, both therapies showed no association with ICP and CPP. During ICP crises, HTS was associated with better performance than mannitol.
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Affiliation(s)
- Patrick M. Kochanek
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - P. David Adelson
- Barrow Neurological Institute at Phoenix Children’s Hospital, Phoenix, Arizona
| | - Bedda L. Rosario
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - James Hutchison
- Department of Critical Care Medicine, Toronto Sick Children’s Hospital, Toronto, Ontario, Canada
| | - Nikki Miller Ferguson
- Department of Pediatrics, Virginia Commonwealth University School of Medicine, Richmond
| | - Peter Ferrazzano
- Department of Pediatrics, University of Wisconsin School of Medicine, Madison
| | - Nicole O’Brien
- Department of Pediatrics, The Ohio State University School of Medicine, Columbus
| | - John Beca
- Department of Pediatrics, Starship Children’s Hospital, Auckland, New Zealand
| | - Ajit Sarnaik
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Kerri LaRovere
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
| | - Tellen D. Bennett
- Department of Pediatrics, University of Colorado School of Medicine, Aurora
| | - Akash Deep
- Department of Pediatrics, King’s College Hospital NHS Foundation Trust, London, UK
| | - Deepak Gupta
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi
| | - F. Anthony Willyerd
- Barrow Neurological Institute at Phoenix Children’s Hospital, Phoenix, Arizona
| | - Shiyao Gao
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Michael J. Bell
- Department of Pediatrics, Children’s National Hospital, Washington, DC
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4
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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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5
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Afroze F, Sarmin M, Kawser CA, Nuzhat S, Shahrin L, Saha H, Jahan Shaly N, Parvin I, Bint-E Sharif M, Mamun MA, Ahmed T, Chisti MJ. Effect of hypertonic saline in the management of elevated intracranial pressure in children with cerebral edema: A systematic review and meta-analysis. SAGE Open Med 2021; 9:20503121211004825. [PMID: 33854775 PMCID: PMC8010820 DOI: 10.1177/20503121211004825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/02/2021] [Indexed: 12/02/2022] Open
Abstract
Objective: To determine the hypertonic saline efficacy in children with cerebral edema and raised intracranial pressure. Method: Studies assessing the efficacy and safety of hypertonic saline in children with cerebral edema and elevated intracranial pressure were identified using Medline, Web of Science, Scopus, and Google Scholar databases. Two reviewers independently assessed papers for inclusion. The primary outcome was a reduction of elevated intracranial pressure by the administration of hypertonic saline. Results: We initially evaluated 1595 potentially relevant articles, and only 7 studies met the eligibility criteria for the final analysis. Out of the seven studies, three of them were randomized controlled trials. Three of the studies found that hypertonic saline significantly reduced elevated intracranial pressure compared to control. One study reported a resolution of the comatose state as a measure of reduced intracranial pressure. It also found a significantly higher resolution of coma in the hypertonic saline group rather than the control. Three studies reported that the reduction of intracranial pressure was comparable between the groups. The random-effects model using pooled estimates from four studies showed no difference in hypertonic saline and conventional therapy mortality outcomes. Hypertonic saline was administered as bolus-only therapy at a rate of 1–10 mL/kg/dose over 5 min to 2 h and or bolus followed by infusion therapy (0.5–2 mL/kg/h). One study reported a twofold faster resolution of high intracranial pressure following hypertonic saline administration compared to controls. The re-dosing schedule varied greatly in all included studies. However, three studies reported adverse events but not methodically, and there were no reports on neurological sequelae. Conclusion: Hypertonic saline appears to reduce intracranial pressure in children with cerebral edema. However, we cannot draw a firm conclusion regarding the safest dose regimens of hypertonic saline, including the safe and effective therapeutic hypernatremia threshold in the management of raised intracranial pressure with cerebral edema. Future clinical trials should focus on the appropriate concentration, dose, duration, mode of administration, and adverse effects of hypertonic saline to standardize the treatment.
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Affiliation(s)
- Farzana Afroze
- Intensive Care Unit, Nutrition & Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR, B), Dhaka, Bangladesh
| | - Monira Sarmin
- Intensive Care Unit, Nutrition & Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR, B), Dhaka, Bangladesh
| | - C A Kawser
- Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh
| | - Sharika Nuzhat
- Intensive Care Unit, Nutrition & Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR, B), Dhaka, Bangladesh
| | - Lubaba Shahrin
- Intensive Care Unit, Nutrition & Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR, B), Dhaka, Bangladesh
| | - Haimanti Saha
- Intensive Care Unit, Nutrition & Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR, B), Dhaka, Bangladesh
| | - Nusrat Jahan Shaly
- Intensive Care Unit, Nutrition & Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR, B), Dhaka, Bangladesh
| | - Irin Parvin
- Intensive Care Unit, Nutrition & Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR, B), Dhaka, Bangladesh
| | - Mohsena Bint-E Sharif
- Intensive Care Unit, Nutrition & Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR, B), Dhaka, Bangladesh
| | - M Al Mamun
- Library, International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR, B), Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Intensive Care Unit, Nutrition & Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR, B), Dhaka, Bangladesh
| | - Mohammod Jobayer Chisti
- Intensive Care Unit, Nutrition & Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR, B), Dhaka, Bangladesh
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Bussolin L, Falconi M, Leo MC, Parri N, DE Masi S, Rosati A, Cecchi C, Spacca B, Grandoni M, Bettiol A, Lucenteforte E, Lubrano R, Falsaperla R, Melosi F, Agostiniani R, Mangiantini F, Talamonti G, Calderini E, Mancino A, DE Luca M, Conti G, Petrini F. The management of pediatric severe traumatic brain injury: Italian Guidelines. Minerva Anestesiol 2021; 87:567-579. [PMID: 33432789 DOI: 10.23736/s0375-9393.20.14122-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The aim of the work was to update the "Guidelines for the Management of Severe Traumatic Brain Injury" published in 2012, to reflect the new available evidence, and develop the Italian national guideline for the management of severe pediatric head injuries to reduce variation in practice and ensure optimal care to patients. EVIDENCE ACQUISITION MEDLINE and EMBASE were searched from January 2009 to October 2017. Inclusion criteria were English language, pediatric populations (0-18 years) or mixed populations (pediatric/adult) with available age subgroup analyses. The guideline development process was started by the Promoting Group that composed a multidisciplinary panel of experts, with the representatives of the Scientific Societies, the independent expert specialists and a representative of the Patient Associations. The panel selected the clinical questions, discussed the evidence and formulated the text of the recommendations. The documentarists of the University of Florence oversaw the bibliographic research strategy. A group of literature reviewers evaluated the selected literature and compiled the table of evidence for each clinical question. EVIDENCE SYNTHESIS The search strategies identified 4254 articles. We selected 3227 abstract (first screening) and, finally included 67 articles (second screening) to update the guideline. This Italian update includes 25 evidence-based recommendations and 5 research recommendations. CONCLUSIONS In recent years, progress has been made on the understanding of severe pediatric brain injury, as well as on that concerning all major traumatic pathology. This has led to a progressive improvement in the clinical outcome, although the quantity and quality of evidence remains particularly low.
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Affiliation(s)
- Leonardo Bussolin
- Neuroanesthesiology, Intensive Care and Trauma Center, A. Meyer University Hospital, Florence, Italy
| | - Martina Falconi
- Techical-Scientific Secretary, Pediatric Regional and Ethical Committee, A. Meyer University Hospital, Florence, Italy
| | - Maria C Leo
- Techical-Scientific Secretary, Pediatric Regional and Ethical Committee, A. Meyer University Hospital, Florence, Italy
| | - Niccolò Parri
- Emergency Department and Trauma Center, A. Meyer University Hospital, Florence, Italy -
| | - Salvatore DE Masi
- Clinical Trial Office, A. Meyer University Hospital, Florence, Italy
| | - Anna Rosati
- Neurosciences Excellence Center, A. Meyer University Hospital, Florence, Italy
| | - Costanza Cecchi
- Anestesiology and Intensive Care Unit, A. Meyer University Hospital, Florence, Italy
| | - Barbara Spacca
- Unit of Neurosurgery, A. Meyer University Hospital, Florence, Italy
| | - Manuela Grandoni
- Unit of Neurosurgery, A. Meyer University Hospital, Florence, Italy
| | | | | | - Riccardo Lubrano
- Società Italiana di Medicina Emergenza Urgenza Pediatrica (SIMEUP), Milan, Italy.,Pediatrics Unit, Pediatric Emergency Department, Neonatology and Neonatal Intensive Care, "Rodolico-San Marco" University Hospital, Catania, Italy
| | - Raffaele Falsaperla
- Società Italiana di Medicina Emergenza Urgenza Pediatrica (SIMEUP), Milan, Italy.,Pediatrics and Neonatology Unit, Department of Maternal and Urological Sciences, Sapienza University, Latina, Rome, Italy
| | - Francesca Melosi
- Anestesiology and Intensive Care Unit, A. Meyer University Hospital, Florence, Italy.,Società Italiana di Neurosonologia ed Emodinamica Cerebrale (SINSEC), Bologna, Italy
| | | | | | | | - Edoardo Calderini
- Società Italiana di Anestesia Analgesia Rianimazione e Terapia Intensiva (SIAARTI), Rome, Italy
| | - Aldo Mancino
- Società di Anestesia e Rianimazione Neonatale e Pediatrica Italiana (S.A.R.N.eP.I), Rome, Italy
| | - Marco DE Luca
- Accademia Medica ed Infermieristica di Emergenza e Terapia Intensiva Pediatrica (AMIETIP), Bologna, Italy
| | - Giorgio Conti
- Accademia Medica ed Infermieristica di Emergenza e Terapia Intensiva Pediatrica (AMIETIP), Bologna, Italy.,IRCCS A. Gemelli, Catholic University, Rome, Italy
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7
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Schwimmbeck F, Voellger B, Chappell D, Eberhart L. Hypertonic Saline Versus Mannitol for Traumatic Brain Injury: A Systematic Review and Meta-analysis With Trial Sequential Analysis. J Neurosurg Anesthesiol 2021; 33:10-20. [PMID: 31567726 DOI: 10.1097/ana.0000000000000644] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mannitol and hypertonic saline are widely used to treat raised intracranial pressure (ICP) after traumatic brain injury (TBI), but the clinical superiority of one over the other has not been demonstrated. METHODS According to the PRISMA statement, this meta-analysis reports on randomized controlled trials investigating hypertonic saline compared with mannitol in the treatment of elevated ICP following TBI. The protocol for the literature searches (Medline, Embase, Central databases), quality assessment, endpoints (mortality, favorable outcome, brain perfusion parameters), and statistical analysis plan (including a trial sequential analysis) were prospectively specified and registered on the PROSPERO database (CRD42017057112). RESULTS A total of 12 randomized controlled trials with 464 patients were eligible for inclusion in this analysis. Although there was a nonsignificant trend in favor of hypertonic saline, there were no significant differences in mortality between the 2 treatments (relative risk [RR]: 0.69, 95% confidence interval [CI]: 0.45, 1.04; P=0.08). There were also no significant differences in favorable neurological outcome between hypertonic saline (HS) and mannitol (RR: 1.28, 95% CI: 0.86, 1.90; P=0.23). There was no difference in ICP at 30 to 60 minutes after treatment (mean difference [MD]: -0.19 mm Hg, 95% CI: -0.54, 0.17; P=0.30), whereas ICP was significantly lower after HS compared with mannitol at 90 to 120 minutes (MD: -2.33 mm Hg, 95% CI: -3.17, -1.50; P<0.00001). Cerebral perfusion pressure was higher between 30 to 60 and 90 to 120 minutes after treatment with HS compared with after treatment with mannitol (MD: 5.48 mm Hg, 95% CI: 4.84, 6.12; P<0.00001 and 9.08 mm Hg, 95% CI: 7.54, 10.62; P<0.00001, respectively). Trial sequential analysis showed that the number of cases was insufficient to produce reliable statements on long-term outcomes. CONCLUSION There are indications that HS might be superior to mannitol in the treatment of TBI-related raised ICP. However, there are insufficient data to reach a definitive conclusion, and further studies are warranted.
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Affiliation(s)
- Franz Schwimmbeck
- Department of Anaesthesiology, University Hospital of Munich (LMU), Marchioninistr, Munich
| | | | - Daniel Chappell
- Department of Anaesthesiology, University Hospital of Munich (LMU), Marchioninistr, Munich
| | - Leopold Eberhart
- Anesthesiology and Intensive Care Therapy, Philipps University Marburg, Baldingerstr, Marburg, Germany
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8
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Hyperosmolar Therapy in Pediatric Severe Traumatic Brain Injury-A Systematic Review. Crit Care Med 2020; 47:e1022-e1031. [PMID: 31567404 DOI: 10.1097/ccm.0000000000004003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Traumatic brain injury is a leading cause of hospital visits for children. Hyperosmolar therapy is often used to treat severe traumatic brain injury. Hypertonic saline is used predominantly, yet there remains disagreement about whether hypertonic saline or mannitol is more effective. DATA SOURCES Literature search was conducted using Pubmed, Cochrane, and Embase. Systematic review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. STUDY SELECTION Retrospective and prospective studies assessing use of hyperosmolar therapy in pediatric patients with severe traumatic brain injury were included. DATA EXTRACTION Two independent authors performed article review. Two-thousand two-hundred thirty unique articles were initially evaluated, 11 were included in the final analysis, with a total of 358 patients. Study quality was assessed using Modified Newcastle-Ottawa Scale and Jadad score. DATA SYNTHESIS Of the 11 studies, all evaluated hypertonic saline and four evaluated both hypertonic saline and mannitol. Nine reported that hypertonic saline lowered intracranial pressure and two reported that mannitol lowered intracranial pressure. The studies varied significantly in dose, concentration, and administrations schedule for both hypertonic saline and mannitol. Five studies were prospective, but only one directly compared mannitol to hypertonic saline. The prospective comparison study found no difference in physiologic outcomes. Clinical outcomes were reported using different measures across studies. For hypertonic saline-treated patients, mechanical ventilation was required for 6.9-9 days, decompressive craniectomy was required for 6.25-29.3% of patients, ICU length of stay was 8.0-10.6 days, in-hospital mortality was 10-48%, and 6-month mortality was 7-17%. In mannitol-treated patients, ICU length of stay was 9.5 days, in-hospital mortality was 56%, and 6-month mortality was 19%. CONCLUSIONS Both hypertonic saline and mannitol appear to lower intracranial pressure and improve clinical outcomes in pediatric severe traumatic brain injury, but the evidence is extremely fractured both in the method of treatment and in the evaluation of outcomes. Given the paucity of high-quality data, it is difficult to definitively conclude which agent is better or what treatment protocol to follow.
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9
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Derakhshanfar H, Pourbakhtyaran E, Rahimi S, Sayyah S, Soltantooyeh Z, Karbasian F. Clinical guidelines for traumatic brain injuries in children and boys. Eur J Transl Myol 2020; 30:8613. [PMID: 32499878 PMCID: PMC7254418 DOI: 10.4081/ejtm.2019.8613] [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] [Received: 10/08/2019] [Accepted: 10/30/2019] [Indexed: 11/26/2022] Open
Abstract
The main aim of management of pediatric traumatic brain injury (TBI) is to hold normal ranges for optimizing the most proper outcomes. However, to provide physiologic requirements to an injured brain it is very important to enhance the quality of recovery and minimize secondary injuries. The aim of study is to identify proper guidelines to manage pediatric TBI. A comprehensive research was conducted on biomedical and pharmacologic bibliographic databases of life sciences, i.e., PubMed, EMBASE, MEDLINE, LILACS database, global independent network of Cochrane, Science Direct and global health library of Global Index Medicus (GIM) from 2000 to 2019. Main objective of this study was to provide a comprehensive review of available clinical practice guidelines for TBI. These guidelines can be administered to a pediatric population to improve the quality of clinical practice for TBI. These guidelines could be applied worldwide, despite different traditional demographic and geographic boundaries, which could affect pediatric populations in various ranges of ages. Accordingly, advances in civil foundations and reforms of health policies may decrease pediatric TBI socioeconomic burdens.
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Affiliation(s)
- Hojjat Derakhshanfar
- Department of Pediatric Emergency Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Elham Pourbakhtyaran
- Department of Pediatric Emergency Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Samane Rahimi
- Department of Pediatric Emergency Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Samira Sayyah
- Department of Pediatric Emergency Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Fereshteh Karbasian
- Department of Pediatric Emergency Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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10
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Kochanek PM, Tasker RC, Carney N, Totten AM, Adelson PD, Selden NR, Davis-O'Reilly C, Hart EL, Bell MJ, Bratton SL, Grant GA, Kissoon N, Reuter-Rice KE, Vavilala MS, Wainwright MS. Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines, Executive Summary. Neurosurgery 2020; 84:1169-1178. [PMID: 30822776 DOI: 10.1093/neuros/nyz051] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 02/05/2019] [Indexed: 12/28/2022] Open
Abstract
The purpose of this work is to identify and synthesize research produced since the second edition of these Guidelines was published and incorporate new results into revised evidence-based recommendations for the treatment of severe traumatic brain injury in pediatric patients. This document provides an overview of our process, lists the new research added, and includes the revised recommendations. Recommendations are only provided when there is supporting evidence. This update includes 22 recommendations, 9 are new or revised from previous editions. New recommendations on neuroimaging, hyperosmolar therapy, analgesics and sedatives, seizure prophylaxis, temperature control/hypothermia, and nutrition are provided. None are level I, 3 are level II, and 19 are level III. The Clinical Investigators responsible for these Guidelines also created a companion algorithm that supplements the recommendations with expert consensus where evidence is not available and organizes possible interventions into first and second tier utilization. The complete guideline document and supplemental appendices are available electronically (https://doi.org/10.1097/PCC.0000000000001735). The online documents contain summaries and evaluations of all the studies considered, including those from prior editions, and more detailed information on our methodology. New level II and level III evidence-based recommendations and an algorithm provide additional guidance for the development of local protocols to treat pediatric patients with severe traumatic brain injury. Our intention is to identify and institute a sustainable process to update these Guidelines as new evidence becomes available.
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Affiliation(s)
- Patrick M Kochanek
- Department of Critical Care Medicine, Department of Anesthesiology, Pe-diatrics, Bioengineering, and Clinical and Translational Science, Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert C Tasker
- Department of Neurology, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital; Harvard Medical School, Boston, Massachusetts
| | - Nancy Carney
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Annette M Totten
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - P David Adelson
- Deptartment of Pediatric Neurosurgery, BARROW Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Nathan R Selden
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Cynthia Davis-O'Reilly
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Erica L Hart
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Michael J Bell
- Department Critical Care Medicine, Children's National Medical Center, Washington, District of Columbia
| | - Susan L Bratton
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Gerald A Grant
- Department of Neurosurgery, Stanford University, Stanford, California
| | - Niranjan Kissoon
- Department of Pediatrics, British Columbia's Children's Hospital, Child and Family Research Institute, University of British Columbia, Vancouver, Canada
| | - Karin E Reuter-Rice
- School of Nursing/School of Medicine, Department of Pediatrics, Division of Pediatric Critical Care Medicine, Duke University, Durham, North Carolina
| | - Monica S Vavilala
- Department of Anesthesiology & Pain Medicine, Department of Pediatrics, Harborview Injury Prevention and Research Center (HIPRC), University of Washington, Seattle, Washington
| | - Mark S Wainwright
- Division of Pediatric Neurology, University of Washington, Seattle Children's Hospital, Seattle, Washington
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11
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Cully M. Spontaneous brain arteriovenous malformation rupture with atrioventricular block in a pediatric patient. Am J Emerg Med 2019; 38:409.e1-409.e3. [PMID: 31785977 DOI: 10.1016/j.ajem.2019.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 10/01/2019] [Accepted: 10/07/2019] [Indexed: 11/17/2022] Open
Abstract
This case reports 9 year-old-female with atrioventricular block and seizure. Careful evaluation, including electrocardiogram (ECG) and computerized tomography (CT) revealed a high-grade atrioventricular block and spontaneous brain arteriovenous malformation (AVM) rupture. The patient had complete resolution of her bradycardia and AV block following atropine. This case is to our knowledge the first description of a pediatric spontaneous brain AVM rupture presenting with high degree AV block responsive to intravenous atropine.
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Affiliation(s)
- Matthew Cully
- Division of Emergency Medicine, Department of Pediatrics, Nemours Alfred I. duPont Hospital for Children. Wilmington, DE, USA.
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12
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Fenn NE, Sierra CM. Hyperosmolar Therapy for Severe Traumatic Brain Injury in Pediatrics: A Review of the Literature. J Pediatr Pharmacol Ther 2019; 24:465-472. [PMID: 31719807 PMCID: PMC6836706 DOI: 10.5863/1551-6776-24.6.465] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2019] [Indexed: 11/11/2022]
Abstract
Traumatic brain injury remains a leading cause of morbidity and mortality in children. The use of hyperosmolar therapy to offset increased intracranial pressure (ICP) is described in pediatric guidelines, yet some controversy remains regarding which option to select. A search was conducted using the PubMed, MEDLINE, Cumulative Index of Nursing and Allied Health, Academic Search Premier, PsycInfo, and Cochrane Library databases. Studies were included if they described the hyperosmolar therapy use, involved severe traumatic brain injury (TBI), and patient age was 0 to 18 years. A total of 331 studies published between 1987 and 2017 were retrieved; of these, 9 met the inclusion criteria. Included studies were evaluated for the type and concentration of hyperosmolar therapy, associated mortality outcomes, ICP and coronary perfusion pressure (CPP) measurements, concurrent medications, and reported serum sodium and serum osmolarity or osmolality values. Hypertonic saline was the most commonly reported hyperosmolar therapy. Mannitol was less studied, but collectively demonstrated a higher incidence of mortality than hypertonic saline. There were several studies that did not report monitoring outcomes associated with serum sodium and/or serum osmolarity, despite the use of hyperosmolar therapies. Inconsistencies were noted between the studies in the overall study design as well as reported monitoring parameters and length of stay. Hypertonic saline appears to be safe and efficacious at several concentrations for treatment of increased ICP associated with severe TBI in pediatric patients. The limited available data regarding the use of mannitol do not allow a strong conclusion to be made regarding its use.
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Comparison of equiosmolar dose of hyperosmolar agents in reducing intracranial pressure-a randomized control study in pediatric traumatic brain injury. Childs Nerv Syst 2019; 35:999-1005. [PMID: 30879126 DOI: 10.1007/s00381-019-04121-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 03/08/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION There are no comparative studies available for hyperosmolar therapy in children. The present study is a prospective open label randomized control trial to compare the effect of equiosmolar doses of mannitol and hypertonic saline in reducing intracranial pressure in children who sustained severe traumatic brain injury. METHODS This is a prospective open-label randomized controlled trial. Thirty children aged less than or equal to 16 years with severe traumatic brain injury and raised intracranial pressure as measured by ventricular catheter insertion were enrolled. Sixteen children received 20% mannitol, and 14 children received 3% saline as 2.5 ml/kg bolus for episodes of intracranial pressure above cutoff value for age. The mean reduction in intracranial pressure and Glasgow outcome scale at 6 months after injury was measured. RESULTS The mean reduction in intracranial pressure in mannitol group was 7.13 mmHg and in hypertonic saline group was 5.67 mmHg, and the difference was not statistically significant, p = 0.33. The incidence of death or survival in vegetative state was 23.07% in mannitol group and 16.66% in hypertonic saline group, and the difference was not statistically significant, p = 0.69. CONCLUSION Both mannitol and hypertonic saline were equally effective for treatment of raised intracranial pressure in children with severe traumatic brain injury.
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14
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Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines, Executive Summary. Pediatr Crit Care Med 2019; 20:280-289. [PMID: 30830016 DOI: 10.1097/pcc.0000000000001736] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The purpose of this work is to identify and synthesize research produced since the second edition of these Guidelines was published and incorporate new results into revised evidence-based recommendations for the treatment of severe traumatic brain injury in pediatric patients. METHODS AND MAIN RESULTS This document provides an overview of our process, lists the new research added, and includes the revised recommendations. Recommendations are only provided when there is supporting evidence. This update includes 22 recommendations, nine are new or revised from previous editions. New recommendations on neuroimaging, hyperosmolar therapy, analgesics and sedatives, seizure prophylaxis, temperature control/hypothermia, and nutrition are provided. None are level I, three are level II, and 19 are level III. The Clinical Investigators responsible for these Guidelines also created a companion algorithm that supplements the recommendations with expert consensus where evidence is not available and organizes possible interventions into first and second tier utilization. The purpose of publishing the algorithm as a separate document is to provide guidance for clinicians while maintaining a clear distinction between what is evidence based and what is consensus based. This approach allows, and is intended to encourage, continued creativity in treatment and research where evidence is lacking. Additionally, it allows for the use of the evidence-based recommendations as the foundation for other pathways, protocols, or algorithms specific to different organizations or environments. The complete guideline document and supplemental appendices are available electronically from this journal. These documents contain summaries and evaluations of all the studies considered, including those from prior editions, and more detailed information on our methodology. CONCLUSIONS New level II and level III evidence-based recommendations and an algorithm provide additional guidance for the development of local protocols to treat pediatric patients with severe traumatic brain injury. Our intention is to identify and institute a sustainable process to update these Guidelines as new evidence becomes available.
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Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines. Pediatr Crit Care Med 2019; 20:S1-S82. [PMID: 30829890 DOI: 10.1097/pcc.0000000000001735] [Citation(s) in RCA: 164] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Ichkova A, Rodriguez-Grande B, Bar C, Villega F, Konsman JP, Badaut J. Vascular impairment as a pathological mechanism underlying long-lasting cognitive dysfunction after pediatric traumatic brain injury. Neurochem Int 2017; 111:93-102. [PMID: 28377126 DOI: 10.1016/j.neuint.2017.03.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 03/29/2017] [Accepted: 03/31/2017] [Indexed: 12/11/2022]
Abstract
Traumatic brain injury (TBI) is the leading cause of death and disability in children. Indeed, the acute mechanical injury often evolves to a chronic brain disorder with long-term cognitive, emotional and social dysfunction even in the case of mild TBI. Contrary to the commonly held idea that children show better recovery from injuries than adults, pediatric TBI patients actually have worse outcome than adults for the same injury severity. Acute trauma to the young brain likely interferes with the fine-tuned developmental processes and may give rise to long-lasting consequences on brain's function. This review will focus on cerebrovascular dysfunction as an important early event that may lead to long-term phenotypic changes in the brain after pediatric TBI. These, in turn may be associated with accelerated brain aging and cognitive dysfunction. Finally, since no effective treatments are currently available, understanding the unique pathophysiological mechanisms of pediatric TBI is crucial for the development of new therapeutic options.
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Affiliation(s)
| | | | - Claire Bar
- CNRS UMR 5287, INCIA, University of Bordeaux, France; Department of Pediatric Neurology, University Children's Hospital of Bordeaux, France
| | - Frederic Villega
- Department of Pediatric Neurology, University Children's Hospital of Bordeaux, France
| | | | - Jerome Badaut
- CNRS UMR 5287, INCIA, University of Bordeaux, France; Department of Basic Sciences, Loma Linda University School of Medicine, Loma Linda, CA, USA.
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Nagumo MM, Teixeira MJ, Paiva WS. Pediatric traumatic brain injury: discussion about hyperosmolar therapy. Childs Nerv Syst 2017; 33:9-10. [PMID: 27889819 DOI: 10.1007/s00381-016-3298-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 11/11/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Marcia Mitie Nagumo
- Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil
| | - Manoel Jacobsen Teixeira
- Division of Neurosurgery at University of São Paulo Medical School, 255 Eneas Aguiar, São Paulo, 05403-000, Brazil
| | - Wellingson Silva Paiva
- Division of Neurosurgery at University of São Paulo Medical School, 255 Eneas Aguiar, São Paulo, 05403-000, Brazil.
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Pediatric traumatic brain injury: discussion about hyperosmolar therapy. Childs Nerv Syst 2017; 33:11-12. [PMID: 27942924 DOI: 10.1007/s00381-016-3308-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 11/29/2016] [Indexed: 10/20/2022]
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