Raised intracranial pressure (ICP): management in emergency department

Changes in optic nerve sheath diameter and its correlation with degree of consciousness, pupil diameter, and light reflex in children with central nervous system infection after osmotherapy

Background

High intracranial pressure (ICP) is one of the most common complications of central nervous system (CNS) infection. Failure to control high intracranial pressure results in brain herniation and death. One of the treatments for high ICP involves the administration of osmotherapy in the form of 3% NaCl or 20% mannitol with observation during administration. Observation of ICP during administration of osmotherapy is possible through measurement of optic nerve sheath diameter (ONSD), which could be correlated with degree of consciousness, pupil diameter, and light reflex. Previous studies have not correlated ONSD with degree of consciousness, pupil diameter, and light reflex during the administration of osmotherapy.

Purpose

To provide insights of incorporating ONSD measurement as a form of non-invasive bedside method for ICP monitoring by correlating it with degree of consciousness, pupil diameter, and light reflex at several time points.

Methods

This study is a prospective cohort study, performed at Dr. Hasan Sadikin General Central Hospital Bandung, Cibabat General Regional Hospital, and General Regional Hospital Bandung Kiwari on children aged 2-18 years with decreased consciousness and CNS infection, from June 2023. Inter-rater reliability was performed with a correlation coefficient of 0.90. Measurement of ONSD, degree of consciousness, pupil diameter, and light reflex simultaneously up to 48 h after initiation of osmotherapy to 30 patients. Correlational analyses were performed using Spearman's rank.

Results

Observation for 48 h after administration of osmotherapy showed changes in ONSD. A significant positive correlation was found between ONSD and degree of consciousness (r = 0.621 for the right eye and r = 0.602 for the left eye, p < 0.001). A significant positive correlation was found between ONSD and light reflex (r = 0.801 for the right eye and r = 0.812 for the left eye, p < 0.001). No significant correlation was found with changes of pupil diameter (r = -0.136 for the right eye and r = -0.141 for the left eye, p > 0.05).

Conclusion

A significant correlation was found between ONSD and degree of consciousness and light reflex in children aged 2-18 years with CNS infection during administration of osmotherapy.

A Prospective Cohort Study on Serum Sodium and Clinical Outcome in Pediatric Nontraumatic Coma

OBJECTIVE

To study the serum sodium level and clinical outcome in pediatric nontraumatic coma.

METHODS

A prospective cohort study was conducted in a tertiary care pediatric intensive care unit (PICU) from September 2015 to June 2016. Children aged < 13 y with nontraumatic coma [modified-Glasgow Coma Scale (m-GCS) score ≤ 8 or fall of ≥ 3 from baseline within 24 h of admission] were included. Children who received intravenous fluids for > 24 h, those with developmental delay, or died within 24 h of admission were excluded. The serum sodium profile (mEq/L) in the first 72 h and clinical outcome [mortality, length of stay in mechanical ventilation, PICU, and hospital] were studied.

RESULTS

Eighty patients [Died n = 26 and Survived n = 54] were enrolled. Median [interquartile range (IQR)] age and m-GCS were 21 (4-78) mo and 9 (7-11), respectively. The mean [standard deviation (SD)] Pediatric Risk of Mortality-III (PRISM-III) was 17.7 (4). The most common etiology was acute central nervous system (CNS) infections (30%, n = 24) followed by an intracranial bleed (11.3%, n = 9). Mean (Standard error, SE) sodium levels and fluctuation of serum sodium from baseline up to 72 h were similar between nonsurvivors and survivors [140.8 (1.3) vs. 139.6 (0.8), p = 0.421] and [1.2 (0.3) vs. 0.8 (0.2), p = 0.307], respectively. On multivariate analysis, the need for vasoactive therapy was an independent predictor of mortality [adjusted odds ratio = 20.78, 95% CI 4.24-101.85, p = < 0.001, R² = 0.62].

CONCLUSION

Mean serum sodium within normal range and fluctuation of serum sodium of 0.8 to 1.2 mEq/L over 72 h was not associated with poor outcomes in pediatric nontraumatic coma. Vasoactive therapy was an independent predictor of mortality.

Decompressive craniectomy in pediatric non-traumatic intracranial hypertension: a single center experience

Purpose: To study the clinical profile and predictors of outcome in children undergoing decompressive craniectomy (DC) for non-traumatic intracranial hypertension (ICH).Materials and methods: Mixed observational study of children, aged 1 month-12 years, who underwent DC for non-traumatic ICH in a tertiary care pediatric intensive care unit from 2012 to 2017. Data on clinical profile and outcome were retrieved retrospectively and survivors were assessed prospectively. The primary outcome was neurological outcome using Glasgow Outcome Scale-Extended (GOS-E) at minimum 6 months' post-discharge. GOS-E of 1-4 were classified as a poor and 5-8 as a good outcome.Results: Thirty children, median (IQR) age of 6.5 (2, 50) months, underwent DC; of which 26 (86.7%) were boys. Altered sensorium (n = 26, 86.7%), seizures (n = 25, 83.3%), pallor (n = 19, 63.3%) and anisocoria (n = 14, 46.7%) were common signs and symptoms. Median (IQR) Glasgow Coma Scale at admission was 9 (6,11). Commonest etiology was intracranial bleed (n = 24; 80%). Median (IQR) time to DC was 24 (24,72) h. Eight (26.7%) children died; 2 during PICU stay and 6 during follow-up. Neurological sequelae at discharge (n = 28) were seizures (n = 25; 89.2%) and hemiparesis (n = 16; 57.1%). Twenty-one children were followed-up at median (IQR) duration of 12 (6,54) months. Good neurological outcome was seen in 14/29 (48.2%) and hemiparesis in 10/21 (47.6%) patients. On regression analysis, anisocoria at admission was an independent predictor of poor outcome [OR 7.33; 95%CI: 1.38-38.87; p = 0.019].Conclusions: DC is beneficial in children with non-traumatic ICH due to a focal pathology and midline shift. Evidence on indications and timing of DC in NTC is still evolving.

Spontaneous intracranial haemorrhage in children-intensive care needs and predictors of in-hospital mortality: a 10-year single-centre experience

PURPOSE

Spontaneous intracranial haemorrhage (SICH) in children, although uncommon, is associated with significant mortality and morbidity. Paediatric data is however limited.

MATERIAL AND METHODS

Case records of 105 children with SICH, > 1 month to 12 years, admitted to a tertiary level PICU of a teaching and referral hospital between January 2009 and May 2018 were analysed retrospectively. In-hospital mortality was the primary outcome. Variables between survivors and non-survivors were compared to  determine predictors of mortality.

RESULTS

The median (IQR) age of subjects was 6 (2.25, 70) months. Common clinical features were altered sensorium (n = 87, 82.9%), seizures (n = 73, 69.5%), pallor (n = 66, 62.9%) and bulging anterior fontanelle (n = 52, 49.5%). Median (IQR) Glasgow Coma Scale (GCS) at admission was 10 (6, 13) with herniation noted in 27 (25.7%) children. Vitamin K deficiency bleeding (VKDB) and arteriovenous malformation (AVM) were the most common etiology for bleeding among infants and older children respectively. The most common site of bleeding was intracerebral (n = 47, 44.8%) followed by subdural (n = 26; 24.8%). Sixteen (15.2%) children died during hospital stay. On univariate analysis, GCS < 8, Pediatric Risk of Mortality score (PRISM III) > 20, need for intubation, thiopentone coma for refractory intracranial pressure (ICP) and progression to shock and acute kidney injury (AKI) predicted mortality. Seizures were favourably associated with survival. Age, site of bleeding, etiology or type of management for raised ICP (conservative versus decompressive craniectomy) did not affect the outcome. On multivariable analysis, progression to AKI (OR 5.86; 95% CI, 1.53-22.4; p 0.01) predicted poor outcome. Seizures, however, were associated with better odds for survival (OR 0.12; 95% CI, 0.03-0.47; p 0.002).

CONCLUSIONS

VKDB and AVM were the common etiologies among infants and older children respectively. Age, site, etiology of bleeding and type of management did not affect outcome. Severe decompensation at presentation, thiopentone for refractory ICP and progression to multiorgan dysfunction determined mortality.

Principles of Management of Central Nervous System Infections

CNS infections in children are medical emergency and are associated with high mortality and morbidity. For diagnosis, a high index of suspicion is required. Clinical assessment should be supplemented by laboratory investigations including CSF Gram stain and cultures, blood culture, PCR on CSF, serological tests, and imaging. Commonly associated life threatening complications include coma, seizure, raised intracranial pressure (ICP), focal deficits, shock, respiratory failure, and fluid and electrolyte abnormalities. Immediate management should first address control of airway, breathing and circulation; protocolized management of raised ICP and status epilepticus; maintaining adequate intravascular volume; and close monitoring for early detection of complications. Appropriate antimicrobial agents should be administered promptly according to the suspected pathogen. Clinical evaluation, laboratory workup, specific antimicrobial therapy, supportive treatment, and management of associated complications should go hand in hand in a protocolized way for better outcome.

The clinical presentation of acute bacterial meningitis varies with age, sex and duration of illness

AIM

This Swedish study reviewed differences in clinical presentation and laboratory findings of acute bacterial meningitis in children aged one month to 17 years in Västerbotten County, Sweden.

METHODS

A register-based study was performed for the period 1986 to 2013 using the Västerbotten County Council's patient registration and laboratory records at the Department of Laboratory Medicine at Umeå University Hospital. The medical records were reviewed to extract data and confirm the diagnosis.

RESULTS

We found 103 cases of acute bacterial meningitis, and Haemophilus influenzae was the most common pathogen, causing 40.8% of all cases, followed by Streptococcus pneumoniae at 30.1% and Neisseria meningitidis at 9.7%. Significant differences in clinical presentation and laboratory findings were found. Younger children were more unwell than older ones and had more diffuse symptoms on admission. In addition, important sex-related differences were found that might explain the higher case fatality rates for boys than girls. For example, boys tended to have a higher disturbance in the blood-brain barrier, which is known to be a negative prognostic factor.

CONCLUSION

This study showed that clinical presentation for acute bacterial meningitis varied with age and sex and, to a lesser extent, on the duration of the illness.

Bedside burr hole for intracranial pressure monitoring performed by pediatric intensivists in children with CNS infections in a resource-limited setting: 10-year experience at a single center

OBJECTIVE

Intracranial pressure monitoring can help in early identification of raised intracranial pressure and in setting more informed goals for treatment. We describe our 10-year experience of bedside burr holes performed by pediatric intensivists to establish intracranial pressure monitoring in children with CNS infections in a resource-limited setting and the technical difficulties and complications encountered.

DESIGN

Descriptive study of prospectively recorded data.

SETTING

PICU of a tertiary care academic institute.

PATIENTS

Consecutive comatose patients with raised intracranial pressure who underwent intracranial pressure monitoring from 2004 to 2013.

INTERVENTION

An intraparenchymal (1.2 mm) or an intraventricular transducer (3.4 mm) (Codman) was placed by a pediatric intensivist through a micro burr hole using a standard protocol. Technical difficulties during the procedure and complications were recorded.

MEASUREMENTS AND MAIN RESULTS

Over 10 years, 265 intracranial pressure catheters were placed in 259 patients, mainly for acute CNS infections (n = 242, 93.4%). Median age of patients was 4.8 years, youngest being 6 weeks; 21 patients (8.1%) were younger than 1 year. Intraparenchymal transducer was used in 252 patients (97.3%). Median (interquartile range) duration of intracranial pressure monitoring was 96 hours (72-144 hr). Complications were seen in 3.5% of patients (n = 9/259); the incidence was 0.28 per 1,000 hours of intracranial pressure monitoring. Procedure-related ventriculitis occurred in three of seven patients (42.8%) with intraventricular catheter, in contrast to none in patients with intraparenchymal transducer. Overall mortality was 32.8% (n = 85). On Cox-regression analysis, "blood component therapy" was an independent predictor of poor outcome defined as death or severe neurodisability (adjusted hazard ratio, 1.58; 95% CI, 1.16-2.16; p = 0.004).

CONCLUSIONS

In a resource-limited setting, pediatric intensivists can safely and successfully perform burr holes at bedside for establishing intraparenchymal intracranial pressure monitoring in children with acute CNS infections. However, our data do not support placement of ventriculostomy catheters by pediatric intensivists in similar settings.

Newly diagnosed immune thrombocytopenia: update on diagnosis and management

Immune thrombocytopenia (ITP) continues to intrigue pediatricians and hematologists alike. Patients can have a dramatic presentation with wide-spread bleeds over a few days. There is an aura and fear of intra-cranial hemorrhage that drives the physician to recommend and the patient's family to accept drug treatment. Difference of opinion among physicians in the recommendations for treatment is not uncommon, even though recent evidence-based guidelines recommend a conservative, observation-based approach for the majority of patients with newly diagnosed childhood ITP. It is important to note that a specific 'platelet cut-off count', is no longer suggested as an indication by itself to recommend drug therapy. The manuscript is an update on newly diagnosed ITP in children. Recent changes in definitions and recommendations for treatment are highlighted. Pros and cons of 1st line drugs, including corticosteroids, intravenous immunoglobulin and anti-D are listed. Adjunctive therapies for the management of epistaxis and menorrhagia are described. Role of splenic artery embolization and emergency splenectomy in the backdrop of severe thrombocytopenia is discussed. Realistic case scenarios, common errors and frequently asked questions are included for a practical and easy reading.