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Denis M, Lauzier B, Roumeliotis N, Orliaguet G, Emeriaud G, Javouhey E, Brossier D. Severe Traumatic Brain Injury in French-Speaking Pediatric Intensive Care Units: Study of Practices. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1744298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
AbstractBest strategies for managing severe pediatric traumatic brain injury (TBI) are not established, with wide variations among professional practices. The main objective of this study was to assess compliance with updated pediatric TBI management guidelines (2019). A survey was distributed among French-speaking pediatric intensive care physicians from April 1 to June 30, 2019. The survey was based on a clinical case with a total of 70 questions that cover the 15 items of the 2019 TBI guidelines. The questions evaluated the assessment and management of TBI during the acute and intensive care phases. Of 487 e-mails sent, 78 surveys were included. Guidelines were adhered to (> 60%) for 10 of 15 items in the guidelines. Strong adherence to recent guideline changes was achieved for seizure prophylaxis with levetiracetam (n = 21/33, 64%) and partial pressure of carbon dioxide threshold (n = 52, 67%). However, management of the sodium and glucose thresholds and the role of transcranial Doppler were not consistent with the guidelines. Assessment of brain tissue oxygenation (n = 12, 16%) and autoregulation (n = 35, 45%) was not a common practice. There was strong agreement among clinicians on the intracranial pressure (> 80%) and cerebral perfusion pressure (> 70%) thresholds used according to age. Overall, stated practices for the management of TBI appear to be relatively standardized among responders. Variations persist in areas with a lack of evidence and pediatric-specific recommendations.
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Affiliation(s)
- Manon Denis
- Pediatric Intensive Care Unit, CHU de Caen, Caen, France
- Pediatric Intensive Care Unit, CHU de Nantes, Nantes, France
- Institut du thorax, INSERM, CNRS, Nantes Université, CHU de Nantes, France
- Institut du thorax, INSERM, CNRS, Nantes Université, France
| | | | - Nadia Roumeliotis
- Pediatric Intensive Care Unit, CHU Sainte Justine, Montréal, Quebec, Canada
- Department of Pediatrics, Université de Montréal, Montréal, Quebec, Canada
| | - Gilles Orliaguet
- Surgical Pediatric Intensive Care Unit, Necker–Enfants Malades University Hospital, Paris, France
- Department of Pediatric and Obstetrical Anaesthesia and Intensive Care, Necker–Enfants Malades University Hospital, GHU AP-HP Centre - Université de Paris, Paris, France
- EA08 Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte, Université de Paris, Paris, France
| | - Guillaumes Emeriaud
- Pediatric Intensive Care Unit, CHU Sainte Justine, Montréal, Quebec, Canada
- Department of Pediatrics, Université de Montréal, Montréal, Quebec, Canada
| | - Etienne Javouhey
- Pediatric Intensive Care Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - David Brossier
- Pediatric Intensive Care Unit, CHU de Caen, Caen, France
- Department of Pediatrics, Université de Montréal, Montréal, Quebec, Canada
- School of Medicine, University Caen Normandie, Caen, F-14000, France
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Assamadi M, Benantar L, Ait El Qadi A, Abou El Hassan T, Aniba K. [Epidemiological aspects and prognostic factors of severe traumatic brain injuries]. Neurochirurgie 2021; 67:571-578. [PMID: 33901522 DOI: 10.1016/j.neuchi.2021.04.005] [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: 03/16/2018] [Revised: 08/20/2019] [Accepted: 04/11/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine the severity factors in severe traumatic brain injuries. METHODS A prospective descriptive study of severe head injuries admitted to the emergency department at Ibn Tofail Hospital at the University Hospital of Marrakech over a period of six months from May to October 2015. The following data was collected: circumstances, clinical, biology, radiology, treatment and evolution. RESULTS One hundred and nineteen patients with severe traumatic brain injury were collected (101 males, 84,9%). The mean age was 37,73±15,7 years. Road accidents were the most common cause representing 84%. The median Glasgow coma scale (GCS) was 7±3. We noted 36 cases (30,3%) of anisocoria, 32 cases (26,9%) of bilateral mydriasis and 72 cases (60,5%) of hypoxia. Cerebral contusions (66,1%) and meningeal hemorrhage (66,6%) were the most frequent lesions on CT. Forty-seven patients (42%) had stage VI Marshall lesions. Twenty-four patients (20.1%) required a neurosurgical intervention, 12 extradural hematoma evacuations and 10 craniocerebral wounds. Mortality was 64.7% (77 deaths), the main cause was neurological (64,9%). In the latter group, we observed more frequently an older age (P=0.00001), a management delay (P=0.011), a low initial GCS (P=0.000001), a bilateral nonreactive mydriasis (P=0.0001), a hypoxia (P=0.0002), a subarachnoid hemorrhage (P=0.008), a high Marshall score (P=0.017) and an anemia (P=0.046). CONCLUSION Head trauma is a public health problem. The victims are young, and the sequelae are frequently disabling. Several parameters are associated with a poorer prognosis including age, neurological state and the initial delay in management.
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Affiliation(s)
- M Assamadi
- Service de Neurochirurgie, hôpital Ibn Tofail, CHU Mohammed 6, Marrakech, faculté de médecine et de pharmacie de Marrakech, université Cadi Ayyad de Marrakech, Maroc.
| | - L Benantar
- Service de Neurochirurgie, hôpital Ibn Tofail, CHU Mohammed 6, Marrakech, faculté de médecine et de pharmacie de Marrakech, université Cadi Ayyad de Marrakech, Maroc.
| | - A Ait El Qadi
- Service de Neurochirurgie, hôpital Ibn Tofail, CHU Mohammed 6, Marrakech, faculté de médecine et de pharmacie de Marrakech, université Cadi Ayyad de Marrakech, Maroc.
| | - T Abou El Hassan
- Service d'accueil des urgences vitales, CHU Mohammed 6, Marrakech, faculté de médecine et de pharmacie de Marrakech, université Cadi Ayyad de Marrakech, Maroc.
| | - K Aniba
- Service de Neurochirurgie, hôpital Ibn Tofail, CHU Mohammed 6, Marrakech, faculté de médecine et de pharmacie de Marrakech, université Cadi Ayyad de Marrakech, Maroc.
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Carlson AP, Schermer CR, Lu SW. Retrospective evaluation of anemia and transfusion in traumatic brain injury. ACTA ACUST UNITED AC 2006; 61:567-71. [PMID: 16966988 DOI: 10.1097/01.ta.0000231768.44727.a2] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite clear evidence in critical care that blood transfusion has an adverse impact on outcome, neurosurgical textbooks still recommend transfusion of patients with traumatic brain injury (TBI) to a hematocrit (HCT) of 30%. There is little empirical evidence to support this practice. The current study addresses transfusion requirements in TBI in terms of neurologic outcome. METHODS Retrospective record review of patients with severe TBI. Outcome measures were Glasgow Coma Scale score (GCS), Glasgow Outcome Score (GOS), and Ranchos Los Amigos Score (RLA) at hospital discharge (D/C); and GOS and Functional Independence Measures at follow-up. Association of outcomes with the number of days the HCT <30% and lowest measured HCT were evaluated. RESULTS In all, 169 patients reviewed; 150 with D/C outcome data and 72 with long-term follow-up data. Univariate analysis showed that lowest measured HCT was associated with lower D/C GCS, D/C GOS, and RLA scores. Linear regression showed that more days with HCT <30% were associated with improved neurologic outcomes measured by GOS (R2 = 0.424, p < 0.001), GCS (R2 = 0.381, p < 0.001) and RLA (R2 = 0.392, p < 0.001) scores on D/C. Both transfusion and lowest measured HCT were significantly associated with all lower outcome scores on D/C. Additional factors with adverse impact on outcome were head Abbreviated Injury Score (AIS), Injury Severity Score, hyperglycemia, and hypotension. Long-term outcomes were only significantly associated with head AIS. CONCLUSIONS Patients with severe TBI should not have a different transfusion threshold than other critical care patients. Prospective studies are needed to evaluate the effects of anemia in TBI.
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Affiliation(s)
- Andrew P Carlson
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico 87131-0001, USA
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Chambers IR, Kirkham FJ. What is the optimal cerebral perfusion pressure in children suffering from traumatic coma? Neurosurg Focus 2003; 15:E3. [PMID: 15305839 DOI: 10.3171/foc.2003.15.6.3] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Head injury is a major cause of death and disability in children. Despite advances in resuscitation, emergency care, intensive care monitoring, and clinical practices, there are few data demonstrating the predictive value of certain physiological variables regarding outcome in this patient population. Mean arterial blood pressure (MABP), intracranial pressure (ICP), and cerebral perfusion pressure (CPP = MABP − ICP) are routinely monitored in patients in many neurological intensive care units throughout the world, but there is little evidence indicating that advances in care have been matched with corresponding improvements in outcome.
Nonetheless, there is evidence that hypotension immediately following head injury is predictive of early death, and many patients with these features die with clinical signs of brain herniation caused by intracranial hypertension. Furthermore, available data indicate that a minimal and a mean CPP measured during intensive care are good predictors of outcome in survivors, but a target threshold to improve outcome has yet to be defined.
Some medical management strategies can have detrimental effects, and there is now a good case for undertaking a controlled trial of immediate or delayed craniectomy. Independent outcome in children following severe head injury is associated with higher levels of CPP. The ability to tolerate different levels of CPP may be related to age, and therefore any such surgical trial would need a carefully defined protocol so that the potential benefit of such a treatment is maximized.
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Affiliation(s)
- Iain R Chambers
- Regional Medical Physics Department, Newcastle General Hospital, Newcastle Upon Tyne, United Kingdom.
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Bissonnette B, Vinchon M. [Traumatic head injury in children: physiopathology and clinical management]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2002; 21:133-40. [PMID: 11915472 DOI: 10.1016/s0750-7658(01)00515-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Traumatic brain injury (TBI) constitutes a major health and economic problem for developed countries, being one of the main causes of mortality and morbidity in children. In a busy traumatology center, a child will be admitted daily in the emergency department with head trauma injury. The anaesthesiologist must have a complete understanding of the pathophysiology and develop a practical knowledge of initial management of such patients. Traumatic brain injury may have intracranial and systemic effects that combine to give global cerebral ischaemia. Injury to the nervous system, irrespective of the primary injury, initiates a multitude of inflammatory cascades resulting in secondary brain injury. The consequence of these secondary brain injuries is most often as important, if not, more important than the primary injury. This period of brain inflammation can last up to three weeks and renders the brain more susceptible to the effects of systemic insults such as hypotension, hypoxia and or pyrexia. It has been shown in post-mortem examination of patients dying from severe traumatic brain injury that more than 91% had evidence of secondary ischaemic damage. These secondary injuries may be responsible for the clinical presentation of the "child who talk and die". The concept of "cerebral protection" has been extended to encompass the active treatment of secondary injury and the prevention of cerebral ischaemia. Initial care focuses on achieving oxygenation, airway control and treatment of arterial hypotension.
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Affiliation(s)
- B Bissonnette
- Divisions of Neurosurgical Anaesthesia and Cardiovascular Anaesthesia Research, Department of Anaesthesia, Hospital for Sick Children, Toronto, Ontario, Canada, M5G 1X8.
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Carpentier A, Riegel B, Poidevin P, Dhellemmes P, Krivosic-Horber R. [Follow-up study of head-injured children]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2002; 21:157-61. [PMID: 11915475 DOI: 10.1016/s0750-7658(01)00502-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The authors reviewed in a retrospective study 61 cases of severely head injury children who where admitted in the rehabilitation centre to evaluate the outcome 1 and 5 years after the brain injury. Neurologic and neuropsychologic status of children was assessed ad admission, 1 and 5 years later. Duration on intubation and age at time of head trauma were the worst functional prognosis.
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Affiliation(s)
- A Carpentier
- Centre de rééducation fonctionnelle, APF Marc Sautelet, 64, rue de la Liberté, 59650 Villeneuve-d'Asq, France.
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Abstract
Neuroemergencies are life-threatening situations in which, whatever the cause, common pathologic phenomena result in secondary brain lesions. The goal of critical care management is to stop these self-aggravating processes as soon as possible. Initial resuscitation is devoted to control of the airway and hemodynamic and hydroelectrolytic stabilization. With mass lesions, minimal computed tomographic exploration immediately precedes surgical decompression. Further critical care adapted to the child's needs requires multimodal monitoring. Normoventilation, deep sedation, osmotherapy with mannitol or hypertonic saline solutions, and optimization of mean arterial pressure are the basis of management. A purely pressure-driven approach aimed at controlling cerebral perfusion pressure could be potentially harmful, and associated measurement of blood flow velocity with transcranial Doppler and jugular bulb oxygen saturation monitoring allows an approach to cerebral blood flow and metabolism. Outcome can be improved in dangerous situations such as severe brain injuries, cerebral arteriovenous malformation rupture, status epilepticus, and acute hydrocephalus, provided that emergency management could be applied efficiently.
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Affiliation(s)
- P G Meyer
- Pediatric Neurointensive Care Unit, Department of Anesthesiology and Critical Care Medicine, Centre Hospitalier Universitaire Necker Enfants Malades et Université V, Paris, France.
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Tentillier E, Ammirati C. [Prehospital management of patients with severe head injuries]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2000; 19:275-81. [PMID: 10836114 DOI: 10.1016/s0750-7658(99)00147-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Advanced prehospital emergency medical care of patients with a severe head injury must essentially focus on the impact of secondary cerebral insults of systemic origin on the outcome. The first objective of prehospital care is to prevent hypoxaemia and hypercapnia. Therefore, all patients with a Glasgow Coma Scale score equal to or lower than 8 must be treated with endotracheal intubation and controlled ventilation under continuous monitoring of SpO2 and PETCO2. Treatment is similar in head-injured patients with significant deterioration of consciousness level, seizures, respiratory distress, or severe facial and thoracoabdominal injuries. The endotracheal tube is inserted by the orotracheal route under direct laryngoscopy, after a rapid induction sequence of anaesthesia and immobilization of the cervical spine in neutral position. For the induction of anaesthesia in these high-risk patients (full stomach, unknown medical history, deteriorated haemodynamic status), etomidate and suxamethonium are the preferred agents. Sedation is maintained with an hypnoticopioid association (fentanyl). Simultaneously, the main goal is the maintenance of an optimal cerebral perfusion pressure, as arterial hypotension severely worsens cerebral ischaemia. Volume loading is accomplished with 0.9% saline and hydroxyethyl starch.
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