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Chesnut R, Temkin N, Pridgeon J, Sulzbacher S, Lujan S, Videtta W, Moya-Barquín L, Chaddock K, Bonow R, Petroni G, Guadagnoli N, Hendrickson P, Ramírez Cortez G, Carreazo NY, Vargas Aymituma A, Anchante D, Caqui P, Ramírez A, Munaico Abanto M, Ortiz Chicchon M, Cenzano Ramos J, Mazate-Mazariegos A, Castro Darce MDC, Sierra Morales R, Brol Lopez P, Menendez W, Posadas Gutierrez S, Kevin V, Mazariegos A, de Leon E, Rodas Barrios RE, Rodríguez S, Flores S, Alvarado O, Guzman Flores LJ, Moisa Martinez M, Gonzalez P. Development of a Randomized Trial Comparing ICP-Monitor-Based Management of Severe Pediatric Traumatic Brain Injury to Management Based on Imaging and Clinical Examination Without ICP Monitoring-Study Protocol. Neurosurgery 2024; 94:65-71. [PMID: 37409817 DOI: 10.1227/neu.0000000000002582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 04/26/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Traumatic brain injury (TBI) is a major global public health problem. It is a leading cause of death and disability in children and adolescents worldwide. Although increased intracranial pressure (ICP) is common and associated with death and poor outcome after pediatric TBI, the efficacy of current ICP-based management remains controversial. We intend to provide Class I evidence testing the efficacy of a protocol based on current ICP monitor-based management vs care based on imaging and clinical examination without ICP monitoring in pediatric severe TBI. METHODS A phase III, multicenter, parallel-group, randomized superiority trial performed in intensive care units in Central and South America to determine the impact on 6-month outcome of children aged 1-12 years with severe TBI (age-appropriate Glasgow Coma Scale score ≤8) randomized to ICP-based or non-ICP-based management. EXPECTED OUTCOMES Primary outcome is 6-month Pediatric Quality of Life. Secondary outcomes are 3-month Pediatric Quality of Life, mortality, 3-month and 6-month Pediatric extended Glasgow Outcome Score, intensive care unit length of stay, and number of interventions focused on treating measured or suspected intracranial hypertension. DISCUSSION This is not a study of the value of knowing the ICP in sTBI. This research question is protocol-based. We are investigating the added value of protocolized ICP management to treatment based on imaging and clinical examination in the global population of severe pediatric TBI. Demonstrating efficacy should standardize ICP monitoring in severe pediatric TBI. Alternate results should prompt reassessment of how and in which patients ICP data should be applied in neurotrauma care.
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Affiliation(s)
- Randall Chesnut
- Department of Neurological Surgery, University of Washington, Seattle , Washington , USA
- Department of Orthopaedic Surgery, University of Washington, Seattle , Washington , USA
- School of Global Health, University of Washington, Seattle , Washington , USA
- Harborview Medical Center, University of Washington, Seattle , Washington , USA
| | - Nancy Temkin
- Department of Neurological Surgery, University of Washington, Seattle , Washington , USA
- Department of Biostatistics, University of Washington, Seattle , Washington , USA
| | - James Pridgeon
- Department of Neurological Surgery, University of Washington, Seattle , Washington , USA
| | - Stephen Sulzbacher
- Department of Psychiatry and Behavioral Medicine, University of Washington, Seattle , Washington , USA
| | - Silvia Lujan
- Hospital Emergencia, Dr. Clemente Alvarez, Rosario , Argentina
- Centro de Informatica e Investigacion Clinica, Rosario , Argentina
| | - Walter Videtta
- Medicina Intensiva, Hospital Nacional Professor Alejandro Posadas, Buenos Aires , Argentina
| | | | - Kelley Chaddock
- Department of Neurological Surgery, University of Washington, Seattle , Washington , USA
| | - Robert Bonow
- Department of Neurological Surgery, University of Washington, Seattle , Washington , USA
| | - Gustavo Petroni
- Hospital Emergencia, Dr. Clemente Alvarez, Rosario , Argentina
- Centro de Informatica e Investigacion Clinica, Rosario , Argentina
| | - Nahuel Guadagnoli
- Hospital Emergencia, Dr. Clemente Alvarez, Rosario , Argentina
- Centro de Informatica e Investigacion Clinica, Rosario , Argentina
| | - Peter Hendrickson
- Department of Neurological Surgery, University of Washington, Seattle , Washington , USA
| | | | - Nilton Yhuri Carreazo
- Hospital de Emergencias Pediátricas, Lima , Peru
- Escuela de Medicina, Universidad Peruana de Ciencias Aplicadas, Lima , Peru
| | | | - Daniel Anchante
- Instituto Nacional de Salud del Niño - San Borja, Lima , Peru
| | - Patrick Caqui
- Instituto Nacional de Salud del Niño - San Borja, Lima , Peru
| | - Alberto Ramírez
- Instituto Nacional de Salud del Niño - San Borja, Lima , Peru
| | | | | | | | | | | | | | | | | | | | - Vicente Kevin
- Hospital Regional de Esquintla, Esquintla , Guatemala
| | - Andrea Mazariegos
- Hospital Regional de Occidente San Juan de Dios, Quetzaltenango , Guatemala
| | - Elie de Leon
- Hospital Regional de Occidente San Juan de Dios, Quetzaltenango , Guatemala
| | | | | | - Sandra Flores
- Hospital Escuela Universitario, Tegucigalpa , Honduras
| | | | | | | | - Pablo Gonzalez
- Hospital de Niños Benjamín Bloom, San Salvador , El Salvador
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Gerlach R, Kluwe W. [Prehospital care of pediatric traumatic brain injury]. Med Klin Intensivmed Notfmed 2023; 118:626-637. [PMID: 37450022 DOI: 10.1007/s00063-023-01046-3] [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: 06/05/2023] [Accepted: 06/09/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) in children and adolescents is associated with significant morbidity and, in severe TBI, mortality. The aim of this article is to provide an overview of the spectrum of TBI, its pathophysiology, and current treatment recommendations for prehospital management of children and adolescents with TBI. MATERIALS AND METHODS The current literature was reviewed for studies on the management of TBI in children and adolescents. RESULTS In recent years, a large number of scientific studies have been published that have resulted in evidence-based guidelines for primary care of children with TBI. The primary aim is to minimize secondary brain damage following TBI, for which immediate assessment of the severity of TBI at the scene based on clinical findings and the accident mechanism and initiation of specific treatment measures to prevent hypoxia, hypotension, and hypothermia are critical. Not only prehospital management, but also the rapid transfer of children with severe TBI to centers with high neurosurgical, pediatric surgical, and pediatric intensive care expertise is of particular importance to improve survival and neurological outcome after severe TBI. CONCLUSION Structured prehospital management may help reduce secondary brain injury after TBI and lead to improved clinical outcomes.
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Affiliation(s)
- Rüdiger Gerlach
- Klinik für Neurochirurgie, Helios Klinikum Erfurt, Nordhäuser Str. 74, 99089, Erfurt, Deutschland.
| | - Wolfram Kluwe
- Klinik für Kinderchirurgie und Kinderurologie, Helios Klinikum Erfurt, Erfurt, Deutschland
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Lang SS, Rahman R, Kumar N, Tucker A, Flanders TM, Kirschen M, Huh JW. Invasive Neuromonitoring Modalities in the Pediatric Population. Neurocrit Care 2023; 38:470-485. [PMID: 36890340 DOI: 10.1007/s12028-023-01684-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 01/30/2023] [Indexed: 03/10/2023]
Abstract
Invasive neuromonitoring has become an important part of pediatric neurocritical care, as neuromonitoring devices provide objective data that can guide patient management in real time. New modalities continue to emerge, allowing clinicians to integrate data that reflect different aspects of cerebral function to optimize patient management. Currently, available common invasive neuromonitoring devices that have been studied in the pediatric population include the intracranial pressure monitor, brain tissue oxygenation monitor, jugular venous oximetry, cerebral microdialysis, and thermal diffusion flowmetry. In this review, we describe these neuromonitoring technologies, including their mechanisms of function, indications for use, advantages and disadvantages, and efficacy, in pediatric neurocritical care settings with respect to patient outcomes.
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Affiliation(s)
- Shih-Shan Lang
- Division of Neurosurgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA. .,Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Raphia Rahman
- Division of Neurosurgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA.,School of Osteopathic Medicine, Rowan University, Stratford, NJ, USA
| | - Nankee Kumar
- Division of Neurosurgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
| | - Alexander Tucker
- Division of Neurosurgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
| | - Tracy M Flanders
- Division of Neurosurgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
| | - Matthew Kirschen
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jimmy W Huh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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4
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Lang SS, Kumar NK, Zhao C, Zhang DY, Tucker AM, Storm PB, Heuer GG, Gajjar AA, Kim CT, Yuan I, Sotardi S, Kilbaugh TJ, Huh JW. Invasive brain tissue oxygen and intracranial pressure (ICP) monitoring versus ICP-only monitoring in pediatric severe traumatic brain injury. J Neurosurg Pediatr 2022; 30:239-249. [PMID: 35623367 DOI: 10.3171/2022.4.peds21568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 04/07/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Severe traumatic brain injury (TBI) is a leading cause of disability and death in the pediatric population. While intracranial pressure (ICP) monitoring is the gold standard in acute neurocritical care following pediatric severe TBI, brain tissue oxygen tension (PbtO2) monitoring may also help limit secondary brain injury and improve outcomes. The authors hypothesized that pediatric patients with severe TBI and ICP + PbtO2 monitoring and treatment would have better outcomes than those who underwent ICP-only monitoring and treatment. METHODS Patients ≤ 18 years of age with severe TBI who received ICP ± PbtO2 monitoring at a quaternary children's hospital between 1998 and 2021 were retrospectively reviewed. The relationships between conventional measurements of TBI were evaluated, i.e., ICP, cerebral perfusion pressure (CPP), and PbtO2. Differences were analyzed between patients with ICP + PbtO2 versus ICP-only monitoring on hospital and pediatric intensive care unit (PICU) length of stay (LOS), length of intubation, Pediatric Intensity Level of Therapy scale score, and functional outcome using the Glasgow Outcome Score-Extended (GOS-E) scale at 6 months postinjury. RESULTS Forty-nine patients, including 19 with ICP + PbtO2 and 30 with ICP only, were analyzed. There was a weak negative association between ICP and PbtO2 (β = -0.04). Conversely, there was a strong positive correlation between CPP ≥ 40 mm Hg and PbtO2 ≥ 15 and ≥ 20 mm Hg (β = 0.30 and β = 0.29, p < 0.001, respectively). An increased number of events of cerebral PbtO2 < 15 mm Hg or < 20 mm Hg were associated with longer hospital (p = 0.01 and p = 0.022, respectively) and PICU (p = 0.015 and p = 0.007, respectively) LOS, increased duration of mechanical ventilation (p = 0.015 when PbtO2 < 15 mm Hg), and an unfavorable 6-month GOS-E score (p = 0.045 and p = 0.022, respectively). An increased number of intracranial hypertension episodes (ICP ≥ 20 mm Hg) were associated with longer hospital (p = 0.007) and PICU (p < 0.001) LOS and longer duration of mechanical ventilation (p < 0.001). Lower minimum hourly and average daily ICP values predicted favorable GOS-E scores (p < 0.001 for both). Patients with ICP + PbtO2 monitoring experienced longer PICU LOS (p = 0.018) compared to patients with ICP-only monitoring, with no significant GOS-E score difference between groups (p = 0.733). CONCLUSIONS An increased number of cerebral hypoxic episodes and an increased number of intracranial hypertension episodes resulted in longer hospital LOS and longer duration of mechanical ventilator support. An increased number of cerebral hypoxic episodes also correlated with less favorable functional outcomes. In contrast, lower minimum hourly and average daily ICP values, but not the number of intracranial hypertension episodes, were associated with more favorable functional outcomes. There was a weak correlation between ICP and PbtO2, supporting the importance of multimodal invasive neuromonitoring in pediatric severe TBI.
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Affiliation(s)
- Shih-Shan Lang
- 1Division of Neurosurgery, Children's Hospital of Philadelphia, Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- 2Center for Data Driven Discovery in Biomedicine, Children's Hospital of Philadelphia, Pennsylvania
| | - Nankee K Kumar
- 1Division of Neurosurgery, Children's Hospital of Philadelphia, Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Chao Zhao
- 1Division of Neurosurgery, Children's Hospital of Philadelphia, Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- 2Center for Data Driven Discovery in Biomedicine, Children's Hospital of Philadelphia, Pennsylvania
| | - David Y Zhang
- 1Division of Neurosurgery, Children's Hospital of Philadelphia, Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Alexander M Tucker
- 1Division of Neurosurgery, Children's Hospital of Philadelphia, Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- 2Center for Data Driven Discovery in Biomedicine, Children's Hospital of Philadelphia, Pennsylvania
| | - Phillip B Storm
- 1Division of Neurosurgery, Children's Hospital of Philadelphia, Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- 2Center for Data Driven Discovery in Biomedicine, Children's Hospital of Philadelphia, Pennsylvania
| | - Gregory G Heuer
- 1Division of Neurosurgery, Children's Hospital of Philadelphia, Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- 2Center for Data Driven Discovery in Biomedicine, Children's Hospital of Philadelphia, Pennsylvania
| | - Avi A Gajjar
- 1Division of Neurosurgery, Children's Hospital of Philadelphia, Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- 3Department of Chemistry, Union College, Schenectady, New York
| | - Chong Tae Kim
- 4Department of Physical Medicine and Rehabilitation and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Ian Yuan
- 5Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; and
| | - Susan Sotardi
- 6Department of Radiology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Todd J Kilbaugh
- 5Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; and
| | - Jimmy W Huh
- 5Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; and
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Ha EJ. Pediatric Severe Traumatic Brain Injury : Updated Management. J Korean Neurosurg Soc 2022; 65:354-360. [PMID: 35468706 PMCID: PMC9082122 DOI: 10.3340/jkns.2021.0308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/28/2022] [Indexed: 12/03/2022] Open
Abstract
Traumatic brain injury (TBI) is the leading cause of death and disability in children. Survivors of severe TBI are more susceptible to functional deficits, resulting in disability, poor quality of life, cognitive decline, and mental health problems. Despite this, little is known about the pathophysiology of TBI in children and how to manage it most effectively. Internationally, efforts are being made to expand knowledge of pathophysiology and develop practical clinical treatment recommendations to improve outcomes. Here we discuss recently updated evidence and management of severe pediatric TBI.
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Affiliation(s)
- Eun Jin Ha
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
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6
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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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Mizuguchi M, Ichiyama T, Imataka G, Okumura A, Goto T, Sakuma H, Takanashi JI, Murayama K, Yamagata T, Yamanouchi H, Fukuda T, Maegaki Y. Guidelines for the diagnosis and treatment of acute encephalopathy in childhood. Brain Dev 2021; 43:2-31. [PMID: 32829972 DOI: 10.1016/j.braindev.2020.08.001] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/04/2020] [Accepted: 08/04/2020] [Indexed: 12/16/2022]
Abstract
The cardinal symptom of acute encephalopathy is impairment of consciousness of acute onset during the course of an infectious disease, with duration and severity meeting defined criteria. Acute encephalopathy consists of multiple syndromes such as acute necrotizing encephalopathy, acute encephalopathy with biphasic seizures and late reduced diffusion and clinically mild encephalitis/encephalopathy with reversible splenial lesion. Among these syndromes, there are both similarities and differences. In 2016, the Japanese Society of Child Neurology published 'Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood', which made recommendations and comments on the general aspects of acute encephalopathy in the first half, and on individual syndromes in the latter half. Since the guidelines were written in Japanese, this review article describes extracts from the recommendations and comments in English, in order to introduce the essence of the guidelines to international clinicians and researchers.
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Affiliation(s)
- Masashi Mizuguchi
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Department of Developmental Medical Sciences, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Takashi Ichiyama
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Division of Pediatrics, Tsudumigaura Medical Center for Children with Disabilities, Yamaguchi, Japan
| | - George Imataka
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Department of Pediatrics, Dokkyo Medical University, Tochigi, Japan
| | - Akihisa Okumura
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Department of Pediatrics, Aichi Medical University, Aichi, Japan
| | - Tomohide Goto
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Division of Neurology, Kanagawa Children's Medical Center, Kanagawa, Japan
| | - Hiroshi Sakuma
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Department of Brain and Neurosciences, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
| | - Jun-Ichi Takanashi
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Department of Pediatrics, Tokyo Women's Medical University Yachiyo Medical Center, Yachiyo, Japan
| | - Kei Murayama
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Department of Metabolism, Chiba Children's Hospital, Chiba, Japan
| | - Takanori Yamagata
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Department of Pediatrics, Jichi Medical University, Tochigi, Japan
| | - Hideo Yamanouchi
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Department of Pediatrics, Comprehensive Epilepsy Center, Saitama Medical University, Saitama, Japan
| | - Tokiko Fukuda
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu, Japan; Committee for the Integration of Guidelines, Japanese Society of Child Neurology, Tokyo, Japan
| | - Yoshihiro Maegaki
- Committee for the Integration of Guidelines, Japanese Society of Child Neurology, Tokyo, Japan; Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan
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VV RC, Bodapati CMP, Paradesi R. Role of Intraoperative ICP And CPP Measurement for Predicting Surgical Outcome in Severe Traumatic Brain Injury. INDIAN JOURNAL OF NEUROTRAUMA 2020. [DOI: 10.1055/s-0040-1713324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Abstract
Introduction Traumatic brain injury (TBI) is one of the leading causes of mortality and disability worldwide, and optimizing the management of these patients is a continuing challenge. Intraoperative intracranial pressure (ICP) and cerebral perfusion pressure (CPP) were evaluated for use as prognostic indicators after surgery for severe TBI. Although ICP and CPP monitoring is standard postsurgery treatment for TBI, very few studies have reported the use of ICP and CPP values monitored during surgery.
Objectives The objectives of this study were to evaluate the use of intraoperative ICP and CPP values as prognostic indicators and as subjective guidelines for managing severe TBI.
Materials and Methods All patients with severe TBI who underwent surgical decompression and ICP monitoring intraoperatively were included in our study from 2017 to 2018. We measured ICP and CPP values after creation of the first burr hole, after hematoma evacuation, and after wound closure.
Results From the analysis of receiver-operated characteristic (ROC) curves, we observed that ICP initial (cutoff > 28 mm Hg) and CPP initial (cutoff < 44.5 mm Hg) are the best predictors of unfavorable outcomes. Favorable outcome (Glasgow outcome scale [GOS] 4 and 5) and unfavorable outcome (GOS 1–3) after 6 months were achieved in 64.1 and 35.8% of patients, respectively. There was significant difference between the ICP and CPP values which are measured after the first burrhole, after hematoma evacuation, and after scalp closure in both favorable and unfavorable outcomes. The highest positive Pearson’s correlation coefficient is found between GOS and ICP and CPP after first burr hole.
Conclusion Monitoring ICP and CPP during surgery improves management in patients with severe TBI and provides an early prognostic indicator in such patients.
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Affiliation(s)
- Ramesh Chandra VV
- Department of Neurosurgery, Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati, Andhra Pradesh, India
| | | | - Rajesh Paradesi
- Department of Neurosurgery, Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati, Andhra Pradesh, India
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Pedersen SH, Lilja-Cyron A, Astrand R, Juhler M. Monitoring and Measurement of Intracranial Pressure in Pediatric Head Trauma. Front Neurol 2020; 10:1376. [PMID: 32010042 PMCID: PMC6973131 DOI: 10.3389/fneur.2019.01376] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 12/12/2019] [Indexed: 01/09/2023] Open
Abstract
Purpose of Review: Monitoring of intracranial pressure (ICP) is an important and integrated part of the treatment algorithm for children with severe traumatic brain injury (TBI). Guidelines often recommend ICP monitoring with a treatment threshold of 20 mmHg. This focused review discusses; (1) different ICP technologies and how ICP should be monitored in pediatric patients with severe TBI, (2) existing evidence behind guideline recommendations, and (3) how we could move forward to increase knowledge about normal ICP in children to support treatment decisions. Summary: Current reference values for normal ICP in adults lie between 7 and 15 mmHg. Recent studies conducted in “pseudonormal” adults, however, suggest a normal range below this level where ICP is highly dependent on body posture and decreases to negative values in sitting and standing position. Despite obvious physiological differences between children and adults, no age or body size related reference values exist for normal ICP in children. Recent guidelines for treatment of severe TBI in pediatric patients recommend ICP monitoring to guide treatment of intracranial hypertension. Decision on ICP monitoring modalities are based on local standards, the individual case, and the clinician's choice. The recommended treatment threshold is 20 mmHg for a duration of 5 min. Both prospective and retrospective observational studies applying different thresholds and treatment strategies for intracranial hypertension were included to support this recommendation. While some studies suggest improved outcome related to ICP monitoring (lower rate of mortality and severe disability), most studies identify high ICP as a marker of worse outcome. Only one study applied age-differentiated thresholds, but this study did not evaluate the effect of these different thresholds on outcome. The quality of evidence behind ICP monitoring and treatment thresholds in severe pediatric TBI is low and treatment can potentially be improved by knowledge about normal ICP from observational studies in healthy children and cohorts of pediatric “pseudonormal” patients expected to have normal ICP. Acceptable levels of ICP − and thus also treatment thresholds—probably vary with age, disease and whether the patient has intact cerebral autoregulation. Future treatment algorithms should reflect these differences and be more personalized and dynamic.
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Affiliation(s)
| | | | - Ramona Astrand
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
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10
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Appavu B, Burrows BT, Foldes S, Adelson PD. Approaches to Multimodality Monitoring in Pediatric Traumatic Brain Injury. Front Neurol 2019; 10:1261. [PMID: 32038449 PMCID: PMC6988791 DOI: 10.3389/fneur.2019.01261] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 11/13/2019] [Indexed: 02/04/2023] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children. Improved methods of monitoring real-time cerebral physiology are needed to better understand when secondary brain injury develops and what treatment strategies may alleviate or prevent such injury. In this review, we discuss emerging technologies that exist to better understand intracranial pressure (ICP), cerebral blood flow, metabolism, oxygenation and electrical activity. We also discuss approaches to integrating these data as part of a multimodality monitoring strategy to improve patient care.
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Affiliation(s)
- Brian Appavu
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States.,Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, United States
| | - Brian T Burrows
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Stephen Foldes
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States.,Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, United States
| | - P David Adelson
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States.,Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, United States
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11
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Long J, Lin H, Cao G, Wang MZ, Huang XJ, Xia J, Sun Z. Relationship between intracranial pressure and phase-contrast cine MRI-derived measures of cerebrospinal fluid parameters in communicating hydrocephalus. Quant Imaging Med Surg 2019; 9:1413-1420. [PMID: 31559170 DOI: 10.21037/qims.2019.08.04] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Background To explore the correlation between intracranial pressure (ICP) and cerebrospinal fluid (CSF) parameters assessed by phase-contrast cine MRI (PC-MRI). Methods Fifteen normal people and 80 subjects with communicating hydrocephalus who underwent PC-MRI examinations from a single center were included in this cross-sectional study. In addition to recording patient's age, heart rate, blood pressure and body mass index (BMI), ICP and CSF hemodynamic parameters, such as flow velocity and aqueduct diameter, were measured for correlation analysis. Results The mean ICP and CSF aqueduct diameter in hydrocephalus patients were 151.05 mmH2O and 2.877 mm, respectively, and the maximum (6.938 cm/s) and mean (0.845 cm/s) CSF flow velocities were significantly higher in these patients compared with the controls (P<0.05). After adjusting for age, heart rate, blood pressure, and BMI, there was no significant relationship between peak velocity and ICP (P>0.05). Furthermore, a nonlinear relationship was observed between the ICP and the average velocity of CSF, and the ICP and aqueduct diameter. The ICP increased with the average velocity above 1.628 cm/s (P≤0.01), and the aqueduct diameter increased more than 3.6 mm (P<0.001). Conclusions This study found significant correlations between ICP and average velocity and aqueduct diameter. These findings can be useful in assisting clinicians in predicting ICP more effectively, thus improving patient management.
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Affiliation(s)
- Jia Long
- Department of Radiology, The First Affiliated Hospital of Shenzhen University/Shenzhen Second People's Hospital, Shenzhen University Health Science Center, Shenzhen 518035, China
| | - Hai Lin
- Department of Neurosurgery, The First Affiliated Hospital of Shenzhen University/Shenzhen Second People's Hospital, Shenzhen University Health Science Center, Shenzhen 518035, China
| | - Gan Cao
- Department of Radiology, Shenzhen Second People's Hospital, Clinical Medicine College of Anhui Medical University, Shenzhen 518000, China
| | - Meng-Zhu Wang
- MR Scientific Marketing, Siemens Healthineers, Guangzhou 510145, China
| | - Xian-Jian Huang
- Department of Neurosurgery, The First Affiliated Hospital of Shenzhen University/Shenzhen Second People's Hospital, Shenzhen University Health Science Center, Shenzhen 518035, China
| | - Jun Xia
- Department of Radiology, The First Affiliated Hospital of Shenzhen University/Shenzhen Second People's Hospital, Shenzhen University Health Science Center, Shenzhen 518035, China
| | - Zhonghua Sun
- Discipline of Medical Radiation Sciences, School of Molecular and Life Sciences, Curtin University, Perth, WA, Australia
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12
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Management of Pediatric Severe Traumatic Brain Injury: 2019 Consensus and Guidelines-Based Algorithm for First and Second Tier Therapies. Pediatr Crit Care Med 2019; 20:269-279. [PMID: 30830015 DOI: 10.1097/pcc.0000000000001737] [Citation(s) in RCA: 117] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To produce a treatment algorithm for the ICU management of infants, children, and adolescents with severe traumatic brain injury. DATA SOURCES Studies included in the 2019 Guidelines for the Management of Pediatric Severe Traumatic Brain Injury (Glasgow Coma Scale score ≤ 8), consensus when evidence was insufficient to formulate a fully evidence-based approach, and selected protocols from included studies. DATA SYNTHESIS Baseline care germane to all pediatric patients with severe traumatic brain injury along with two tiers of therapy were formulated. An approach to emergent management of the crisis scenario of cerebral herniation was also included. The first tier of therapy focuses on three therapeutic targets, namely preventing and/or treating intracranial hypertension, optimizing cerebral perfusion pressure, and optimizing partial pressure of brain tissue oxygen (when monitored). The second tier of therapy focuses on decompressive craniectomy surgery, barbiturate infusion, late application of hypothermia, induced hyperventilation, and hyperosmolar therapies. CONCLUSIONS This article provides an algorithm of clinical practice for the bedside practitioner based on the available evidence, treatment protocols described in the articles included in the 2019 guidelines, and consensus that reflects a logical approach to mitigate intracranial hypertension, optimize cerebral perfusion, and improve outcomes in the setting of pediatric severe traumatic brain injury.
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13
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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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14
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Martin-Jiménez C, Gaitán-Vaca DM, Areiza N, Echeverria V, Ashraf GM, González J, Sahebkar A, Garcia-Segura LM, Barreto GE. Astrocytes Mediate Protective Actions of Estrogenic Compounds after Traumatic Brain Injury. Neuroendocrinology 2019; 108:142-160. [PMID: 30391959 DOI: 10.1159/000495078] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 11/02/2018] [Indexed: 11/19/2022]
Abstract
Traumatic brain injury (TBI) is a serious public health problem. It may result in severe neurological disabilities and in a variety of cellular metabolic alterations for which available therapeutic strategies are limited. In the last decade, the use of estrogenic compounds, which activate protective mechanisms in astrocytes, has been explored as a potential experimental therapeutic approach. Previous works have suggested estradiol (E2) as a neuroprotective hormone that acts in the brain by binding to estrogen receptors (ERs). Several steroidal and nonsteroidal estrogenic compounds can imitate the effects of estradiol on ERs. These include hormonal estrogens, phytoestrogens and synthetic estrogens, such as selective ER modulators or tibolone. Current evidence of the role of astrocytes in mediating protective actions of estrogenic compounds after TBI is reviewed in this paper. We conclude that the use of estrogenic compounds to modulate astrocytic properties is a promising therapeutic approach for the treatment of TBI.
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Affiliation(s)
- Cynthia Martin-Jiménez
- Departamento de Nutrición y Bioquímica, Facultad de Ciencias Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Diana Milena Gaitán-Vaca
- Departamento de Nutrición y Bioquímica, Facultad de Ciencias Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Natalia Areiza
- Departamento de Nutrición y Bioquímica, Facultad de Ciencias Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Valentina Echeverria
- Universidad San Sebastián, Fac. Cs de la Salud, Concepción, Chile
- Research and Development Service, Bay Pines VA Healthcare System, Bay Pines, Florida, USA
| | - Ghulam Md Ashraf
- King Fahd Medical Research Center, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Janneth González
- Departamento de Nutrición y Bioquímica, Facultad de Ciencias Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Pharmaceutical technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
- Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Luis Miguel Garcia-Segura
- Instituto Cajal, CSIC, Madrid, Spain
- Centro de Investigación Biomédica en Red Fragilidad y Envejecimiento Saludable (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
| | - George E Barreto
- Departamento de Nutrición y Bioquímica, Facultad de Ciencias Pontificia Universidad Javeriana, Bogotá, Colombia,
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15
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Niedzwecki CM, Rogers AT, Fallat ME. Using Rehabilitation along the Pediatric Trauma Continuum as a Strategy to Define Outcomes in Traumatic Brain Injury. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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16
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Abstract
Airway management and ventilation are central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Furthermore, intubation, ventilation, and sedative choices directly affect brain perfusion. Therefore, Airway, Ventilation, and Sedation was chosen as an Emergency Neurological Life Support protocol. Topics include airway management, when and how to intubate with special attention to hemodynamics and preservation of cerebral blood flow, mechanical ventilation settings and the use of sedative agents based on the patient's neurological status.
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17
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Amagasa S, Tsuji S, Matsui H, Uematsu S, Moriya T, Kinoshita K. Prognostic factors of acute neurological outcomes in infants with traumatic brain injury. Childs Nerv Syst 2018; 34:673-680. [PMID: 29249074 DOI: 10.1007/s00381-017-3695-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 12/10/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE The purpose of this study is to clarify risk factors for poor neurological outcomes and distinctive characteristics in infants with traumatic brain injury. METHODS The study retrospectively reviewed data of 166 infants with traumatic intracranial hemorrhage from three tertiary institutions in Japan between 2002 and 2013. Univariate and multivariate analyses were used to identify clinical symptoms, vital signs, physical findings, and computed tomography findings associated with poor neurological outcomes at discharge from the intensive care unit. RESULTS In univariate analysis, bradypnea, tachycardia, hypotension, dyscoria, retinal hemorrhage, subdural hematoma, cerebral edema, and a Glasgow Coma Scale (GCS) score of ≤ 12 were significantly associated with poor neurological outcomes (P < 0.05). In multivariate analysis, a GCS score of ≤ 12 (OR = 130.7; 95% CI, 7.3-2323.2; P < 0.001), cerebral edema (OR = 109.1; 95% CI, 7.2-1664.1; P < 0.001), retinal hemorrhage (OR = 7.2; 95% CI, 1.2-42.1; P = 0.027), and Pediatric Index of Mortality 2 score (OR = 1.6; 95% CI, 1.1-2.3; P = 0.018) were independently associated with poor neurological outcomes. Incidence of bradypnea in infants with a GCS score of ≤ 12 (25/42) was significantly higher than that in infants with GCS score of > 12 (27/90) (P = 0.001). CONCLUSIONS Infants with a GCS score of ≤ 12 are likely to have respiratory disorders associated with traumatic brain injury. Physiological disorders may easily lead to secondary brain injury, resulting in poor neurological outcomes. Secondary brain injury should be prevented through early interventions based on vital signs and the GCS score.
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Affiliation(s)
- Shunsuke Amagasa
- Department of Pediatric Intensive Care, Nagano Children's Hospital, 3100, Toyoshina, Azumino City, Nagano, 399-8288, Japan. .,Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama City, Saitama, 330-8503, Japan.
| | - Satoshi Tsuji
- Department of Emergency Medicine and Transport Service, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Hikoro Matsui
- Department of Pediatric Intensive Care, Nagano Children's Hospital, 3100, Toyoshina, Azumino City, Nagano, 399-8288, Japan
| | - Satoko Uematsu
- Department of Emergency Medicine and Transport Service, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Takashi Moriya
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
| | - Kosaku Kinoshita
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1, Oyaguchikamichou, Itabashi-ku, Tokyo, 173-8610, Japan
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18
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Yumoto T, Naito H, Yorifuji T, Maeyama H, Kosaki Y, Yamamoto H, Tsukahara K, Osako T, Nakao A. Cushing's sign and severe traumatic brain injury in children after blunt trauma: a nationwide retrospective cohort study in Japan. BMJ Open 2018; 8:e020781. [PMID: 29502094 PMCID: PMC5855168 DOI: 10.1136/bmjopen-2017-020781] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE We tested whether Cushing's sign could predict severe traumatic brain injury (TBI) requiring immediate neurosurgical intervention (BI-NSI) in children after blunt trauma. DESIGN Retrospective cohort study using Japan Trauma Data Bank. SETTING Emergency and critical care centres in secondary and tertiary hospitals in Japan. PARTICIPANTS Children between the ages of 2 and 15 years with Glasgow Coma Scale motor scores of 5 or less at presentation after blunt trauma from 2004 to 2015 were included. A total of 1480 paediatric patients were analysed. PRIMARY OUTCOME MEASURES Patients requiring neurosurgical intervention within 24 hours of hospital arrival and patients who died due to isolated severe TBI were defined as BI-NSI. The combination of systolic blood pressure (SBP) and heart rate (HR) on arrival, which were respectively divided into tertiles, and its correlation with BI-NSI were investigated using a multiple logistic regression model. RESULTS In the study cohort, 297 (20.1%) exhibited BI-NSI. After adjusting for sex, age category and with or without haemorrhage shock, groups with higher SBP and lower HR (SBP ≥135 mm Hg; HR ≤92 bpm) were significantly associated with BI-NSI (OR 2.84, 95% CI 1.68 to 4.80, P<0.001) compared with the patients with normal vital signs. In age-specific analysis, hypertension and bradycardia were significantly associated with BI-NSI in a group of 7-10 and 11-15 years of age; however, no significant association was observed in a group of 2-6 years of age. CONCLUSIONS Cushing's sign after blunt trauma was significantly associated with BI-NSI in school-age children and young adolescents.
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Affiliation(s)
- Tetsuya Yumoto
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, Okayama, Japan
- Department of Emergency and Critical Care Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiromichi Naito
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, Okayama, Japan
| | - Takashi Yorifuji
- Department of Human Ecology, Okayama University Graduate School of Environmental and Life Science, Okayama, Japan
| | - Hiroki Maeyama
- Department of Emergency and Critical Care Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshinori Kosaki
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, Okayama, Japan
| | - Hirotsugu Yamamoto
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, Okayama, Japan
| | - Kohei Tsukahara
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, Okayama, Japan
| | - Takaaki Osako
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, Okayama, Japan
| | - Atsunori Nakao
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, Okayama, Japan
- Department of Emergency and Critical Care Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Multimodality neuromonitoring in severe pediatric traumatic brain injury. Pediatr Res 2018; 83:41-49. [PMID: 29084196 DOI: 10.1038/pr.2017.215] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 08/31/2017] [Indexed: 12/18/2022]
Abstract
Each year, the annual hospitalization rates of traumatic brain injury (TBI) in children in the United States are 57.7 per 100K in the <5 years of age and 23.1 per 100K in the 5-14 years age group. Despite this, little is known about the pathophysiology of TBI in children and how to manage it most effectively. Historically, TBI management has been guided by clinical examination. This has been assisted progressively by clinical imaging, intracranial pressure (ICP) monitoring, and finally a software that can calculate optimal brain physiology. Multimodality monitoring affords clinicians an early indication of secondary insults to the recovering brain including raised ICP and decreased cerebral perfusion pressure. From variables such as ICP and arterial blood pressure, correlations can be drawn to determine parameters of cerebral autoregulation (pressure reactivity index) and "optimal cerebral perfusion pressure" at which the vasculature is most reactive. More recently, significant advances using both direct and near-infrared spectroscopy-derived brain oxygenation plus cerebral microdialysis to drive management have been described. Here in, we provide a perspective on the state-of-the-art techniques recently implemented in clinical practice for pediatric TBI.
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Abstract
Neurological injury is the primary lethal mechanism of injury in children, and the primary etiology of long-term disability after trauma. Laboratories and clinical/translational teams have sought to develop stem/progenitor cell therapies to improve recovery in a clinical setting in which there is no significant reparative option. While none of these treatments are currently standard therapeutics, phase IIb clinical trials are underway in both adults and children in severe traumatic brain injury (TBI) and phase I/IIa trials in spinal cord injury. This review will characterize the cell therapy strategies: cell replacement and tissue integration vs. immunomodulation/enhanced endogenous tissue repair. TBI is somewhat different from other central nervous system injuries (spinal cord injury and stroke), in that TBI is a diffuse injury, whereas spinal cord injury and stroke are anatomically discrete. Importantly, this drives cell therapy approaches, as TBI is less apt to be treatable with a local cell replacement intervention. More localized injuries may be more amenable to local approaches and cell replacement to bridge focal gaps. This review focuses on a few reports in the field that highlight areas of progress, but is not intended to be a comprehensive survey of the state of regenerative medicine for neurological injuries.
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21
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Geeraerts T, Velly L, Abdennour L, Asehnoune K, Audibert G, Bouzat P, Bruder N, Carrillon R, Cottenceau V, Cotton F, Courtil-Teyssedre S, Dahyot-Fizelier C, Dailler F, David JS, Engrand N, Fletcher D, Francony G, Gergelé L, Ichai C, Javouhey É, Leblanc PE, Lieutaud T, Meyer P, Mirek S, Orliaguet G, Proust F, Quintard H, Ract C, Srairi M, Tazarourte K, Vigué B, Payen JF. Management of severe traumatic brain injury (first 24hours). Anaesth Crit Care Pain Med 2017; 37:171-186. [PMID: 29288841 DOI: 10.1016/j.accpm.2017.12.001] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The latest French Guidelines for the management in the first 24hours of patients with severe traumatic brain injury (TBI) were published in 1998. Due to recent changes (intracerebral monitoring, cerebral perfusion pressure management, treatment of raised intracranial pressure), an update was required. Our objective has been to specify the significant developments since 1998. These guidelines were conducted by a group of experts for the French Society of Anesthesia and Intensive Care Medicine (Société francaise d'anesthésie et de réanimation [SFAR]) in partnership with the Association de neuro-anesthésie-réanimation de langue française (ANARLF), The French Society of Emergency Medicine (Société française de médecine d'urgence (SFMU), the Société française de neurochirurgie (SFN), the Groupe francophone de réanimation et d'urgences pédiatriques (GFRUP) and the Association des anesthésistes-réanimateurs pédiatriques d'expression française (ADARPEF). The method used to elaborate these guidelines was the Grade® method. After two Delphi rounds, 32 recommendations were formally developed by the experts focusing on the evaluation the initial severity of traumatic brain injury, the modalities of prehospital management, imaging strategies, indications for neurosurgical interventions, sedation and analgesia, indications and modalities of cerebral monitoring, medical management of raised intracranial pressure, management of multiple trauma with severe traumatic brain injury, detection and prevention of post-traumatic epilepsia, biological homeostasis (osmolarity, glycaemia, adrenal axis) and paediatric specificities.
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Affiliation(s)
- Thomas Geeraerts
- Pôle anesthésie-réanimation, Inserm, UMR 1214, Toulouse neuroimaging center, ToNIC, université Toulouse 3-Paul Sabatier, CHU de Toulouse, 31059 Toulouse, France.
| | - Lionel Velly
- Service d'anesthésie-réanimation, Aix-Marseille université, CHU Timone, Assistance publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Lamine Abdennour
- Département d'anesthésie-réanimation, groupe hospitalier Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Karim Asehnoune
- Service d'anesthésie et de réanimation chirurgicale, Hôtel-Dieu, CHU de Nantes, 44093 Nantes cedex 1, France
| | - Gérard Audibert
- Département d'anesthésie-réanimation, hôpital Central, CHU de Nancy, 54000 Nancy, France
| | - Pierre Bouzat
- Pôle anesthésie-réanimation, CHU Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - Nicolas Bruder
- Service d'anesthésie-réanimation, Aix-Marseille université, CHU Timone, Assistance publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Romain Carrillon
- Service d'anesthésie-réanimation, hôpital neurologique Pierre-Wertheimer, groupement hospitalier Est, hospices civils de Lyon, 69677 Bron, France
| | - Vincent Cottenceau
- Service de réanimation chirurgicale et traumatologique, SAR 1, hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | - François Cotton
- Service d'imagerie, centre hospitalier Lyon Sud, hospices civils de Lyon, 69495 Pierre-Bénite cedex, France
| | - Sonia Courtil-Teyssedre
- Service de réanimation pédiatrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, 69677 Bron, France
| | | | - Frédéric Dailler
- Service d'anesthésie-réanimation, hôpital neurologique Pierre-Wertheimer, groupement hospitalier Est, hospices civils de Lyon, 69677 Bron, France
| | - Jean-Stéphane David
- Service d'anesthésie réanimation, centre hospitalier Lyon Sud, hospices civils de Lyon, 69495 Pierre-Bénite, France
| | - Nicolas Engrand
- Service d'anesthésie-réanimation, Fondation ophtalmologique Adolphe de Rothschild, 75940 Paris cedex 19, France
| | - Dominique Fletcher
- Service d'anesthésie réanimation chirurgicale, hôpital Raymond-Poincaré, université de Versailles Saint-Quentin, AP-HP, Garches, France
| | - Gilles Francony
- Pôle anesthésie-réanimation, CHU Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - Laurent Gergelé
- Département d'anesthésie-réanimation, CHU de Saint-Étienne, 42055 Saint-Étienne, France
| | - Carole Ichai
- Service de réanimation médicochirurgicale, UMR 7275, CNRS, Sophia Antipolis, hôpital Pasteur, CHU de Nice, 06000 Nice, France
| | - Étienne Javouhey
- Service de réanimation pédiatrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, 69677 Bron, France
| | - Pierre-Etienne Leblanc
- Département d'anesthésie-réanimation, hôpital de Bicêtre, hôpitaux universitaires Paris-Sud, AP-HP, Le Kremlin-Bicêtre, France; Équipe TIGER, CNRS 1072-Inserm 5288, service d'anesthésie, centre hospitalier de Bourg en Bresse, centre de recherche en neurosciences, Lyon, France
| | - Thomas Lieutaud
- UMRESTTE, UMR-T9405, IFSTTAR, université Claude-Bernard de Lyon, Lyon, France; Service d'anesthésie-réanimation, hôpital universitaire Necker-Enfants-Malades, université Paris Descartes, AP-HP, Paris, France
| | - Philippe Meyer
- EA 08 Paris-Descartes, service de pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte, 75743 Paris cedex 15, France
| | - Sébastien Mirek
- Service d'anesthésie-réanimation, CHU de Dijon, Dijon, France
| | - Gilles Orliaguet
- EA 08 Paris-Descartes, service de pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte, 75743 Paris cedex 15, France
| | - François Proust
- Service de neurochirurgie, hôpital Hautepierre, CHU de Strasbourg, 67098 Strasbourg, France
| | - Hervé Quintard
- Service de réanimation médicochirurgicale, UMR 7275, CNRS, Sophia Antipolis, hôpital Pasteur, CHU de Nice, 06000 Nice, France
| | - Catherine Ract
- Département d'anesthésie-réanimation, hôpital de Bicêtre, hôpitaux universitaires Paris-Sud, AP-HP, Le Kremlin-Bicêtre, France; Équipe TIGER, CNRS 1072-Inserm 5288, service d'anesthésie, centre hospitalier de Bourg en Bresse, centre de recherche en neurosciences, Lyon, France
| | - Mohamed Srairi
- Pôle anesthésie-réanimation, Inserm, UMR 1214, Toulouse neuroimaging center, ToNIC, université Toulouse 3-Paul Sabatier, CHU de Toulouse, 31059 Toulouse, France
| | - Karim Tazarourte
- SAMU/SMUR, service des urgences, hospices civils de Lyon, hôpital Édouard-Herriot, 69437 Lyon cedex 03, France
| | - Bernard Vigué
- Département d'anesthésie-réanimation, hôpital de Bicêtre, hôpitaux universitaires Paris-Sud, AP-HP, Le Kremlin-Bicêtre, France; Équipe TIGER, CNRS 1072-Inserm 5288, service d'anesthésie, centre hospitalier de Bourg en Bresse, centre de recherche en neurosciences, Lyon, France
| | - Jean-François Payen
- Pôle anesthésie-réanimation, CHU Grenoble-Alpes, 38043 Grenoble cedex 9, France
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Abstract
Airway management and ventilation are central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Furthermore, intubation, ventilation, and sedative choices directly affect brain perfusion. Therefore, airway, ventilation, and sedation was chosen as an emergency neurological life support protocol. Topics include airway management, when and how to intubate with special attention to hemodynamics and preservation of cerebral blood flow, mechanical ventilation settings, and the use of sedative agents based on the patient's neurological status.
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Intracranial Hypertension and Cerebral Hypoperfusion in Children With Severe Traumatic Brain Injury: Thresholds and Burden in Accidental and Abusive Insults. Pediatr Crit Care Med 2016; 17:444-50. [PMID: 27028792 PMCID: PMC4856573 DOI: 10.1097/pcc.0000000000000709] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES The evidence to guide therapy in pediatric traumatic brain injury is lacking, including insight into the intracranial pressure/cerebral perfusion pressure thresholds in abusive head trauma. We examined intracranial pressure/cerebral perfusion pressure thresholds and indices of intracranial pressure and cerebral perfusion pressure burden in relationship with outcome in severe traumatic brain injury and in accidental and abusive head trauma cohorts. DESIGN A prospective observational study. SETTING PICU in a tertiary children's hospital. PATIENTS Children less than18 years old admitted to a PICU with severe traumatic brain injury and who had intracranial pressure monitoring. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A pediatric traumatic brain injury database was interrogated with 85 patients (18 abusive head trauma) enrolled. Hourly intracranial pressure and cerebral perfusion pressure (in mm Hg) were collated and compared with various thresholds. C-statistics for intracranial pressure and cerebral perfusion pressure data in the entire population were determined. Intracranial hypertension and cerebral hypoperfusion indices were formulated based on the number of hours with intracranial pressure more than 20 mm Hg and cerebral perfusion pressure less than 50 mm Hg, respectively. A secondary analysis was performed on accidental and abusive head trauma cohorts. All of these were compared with dichotomized 6-month Glasgow Outcome Scale scores. The models with the number of hours with intracranial pressure more than 20 mm Hg (C = 0.641; 95% CI, 0.523-0.762) and cerebral perfusion pressure less than 45 mm Hg (C = 0.702; 95% CI, 0.586-0.805) had the best fits to discriminate outcome. Two factors were independently associated with a poor outcome, the number of hours with intracranial pressure more than 20 mm Hg and abusive head trauma (odds ratio = 5.101; 95% CI, 1.571-16.563). As the number of hours with intracranial pressure more than 20 mm Hg increases by 1, the odds of a poor outcome increased by 4.6% (odds ratio = 1.046; 95% CI, 1.012-1.082). Thresholds did not differ between accidental versus abusive head trauma. The intracranial hypertension and cerebral hypoperfusion indices were both associated with outcomes. CONCLUSIONS The duration of hours of intracranial pressure more than 20 mm Hg and cerebral perfusion pressure less than 45 mm Hg best discriminated poor outcome. As the number of hours with intracranial pressure more than 20 mm Hg increases by 1, the odds of a poor outcome increased by 4.6%. Although abusive head trauma was strongly associated with unfavorable outcome, intracranial pressure/cerebral perfusion pressure thresholds did not differ between accidental and abusive head trauma.
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Effectiveness of Pharmacological Therapies for Intracranial Hypertension in Children With Severe Traumatic Brain Injury--Results From an Automated Data Collection System Time-Synched to Drug Administration. Pediatr Crit Care Med 2016; 17:236-45. [PMID: 26673840 PMCID: PMC4779724 DOI: 10.1097/pcc.0000000000000610] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe acute cerebral hemodynamic effects of medications commonly used to treat intracranial hypertension in children with traumatic brain injury. Currently, data supporting the efficacy of these medications are insufficient. DESIGN In this prospective observational study, intracranial hypertension (intracranial pressure ≥ 20 mm Hg for > 5 min) was treated by clinical protocol. Administration times of medications for intracranial hypertension (fentanyl, 3% hypertonic saline, mannitol, and pentobarbital) were prospectively recorded and synchronized with an automated database that collected intracranial pressure and cerebral perfusion pressure every 5 seconds. Intracranial pressure crises confounded by external stimulation or mechanical ventilator adjustments were excluded. Mean intracranial pressure and cerebral perfusion pressure from epochs following drug administration were compared with baseline values using Kruskal-Wallis analysis of variance and Dunn test. Frailty modeling was used to analyze the time to intracranial pressure crisis resolution. Mixed-effect models compared intracranial pressure and cerebral perfusion pressure 5 minutes after the medication versus baseline and rates of treatment failure. SETTING A tertiary care children's hospital. PATIENTS Children with severe traumatic brain injury (Glasgow Coma Scale score ≤ 8). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We analyzed 196 doses of fentanyl, hypertonic saline, mannitol, and pentobarbital administered to 16 children (median: 12 doses per patient). Overall, intracranial pressure significantly decreased following the administration of fentanyl, hypertonic saline, and pentobarbital. After controlling for administration of multiple medications, intracranial pressure was decreased following hypertonic saline and pentobarbital administration; cerebral perfusion pressure was decreased following fentanyl and was increased following hypertonic saline administration. After adjusting for significant covariates (including age, Glasgow Coma Scale score, and intracranial pressure), hypertonic saline was associated with a two-fold faster resolution of intracranial hypertension than either fentanyl or pentobarbital. Fentanyl was significantly associated with the most frequent treatment failure. CONCLUSIONS Intracranial pressure decreased after multiple drug administrations, but hypertonic saline may warrant consideration as the first-line drug for treating intracranial hypertension, as it was associated with the most favorable cerebral hemodynamics and fastest resolution of intracranial hypertension.
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Schrieff-Elson LE, Thomas KGF, Rohlwink UK, Figaji AA. Low brain oxygenation and differences in neuropsychological outcomes following severe pediatric TBI. Childs Nerv Syst 2015; 31:2257-68. [PMID: 26337700 DOI: 10.1007/s00381-015-2892-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 08/24/2015] [Indexed: 11/27/2022]
Abstract
PURPOSE Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children. Preventing secondary injury by controlling physiological parameters (e.g. intracranial pressure [ICP], cerebral perfusion pressure [CPP] and brain tissue oxygen [PbtO2]) has a potential to improve outcome. Low PbtO2 is independently associated with poor clinical outcomes in both adults and children. However, no studies have investigated associations between low PbtO2 and neuropsychological and behavioural outcomes following severe pediatric TBI (pTBI). METHODS We used a quasi-experimental case-control design to investigate these relationships. A sample of 11 TBI patients with a Glasgow Coma Scale score ≤8 who had PbtO2 and ICP monitoring at the Red Cross War Memorial Children's Hospital underwent neuropsychological evaluation ≥1 year post-injury. Their performance was compared to that of 11 demographically matched healthy controls. We then assigned each TBI participant into one of two subgroups, (1) children who had experienced at least one episode of PbtO2 ≤ 10 mmHg or (2) children for whom PbtO2 > 10 mmHg throughout the monitoring period, and compared their results on neuropsychological evaluation. RESULTS TBI participants performed significantly more poorly than controls in several cognitive domains (IQ, attention, visual memory, executive functions and expressive language) and behavioural (e.g. externalizing behaviour) domains. The PbtO2 ≤ 10 mmHg group performed significantly worse than the PbtO2 > 10 mmHg group in several cognitive domains (IQ, attention, verbal memory, executive functions and expressive language), but not on behavioural measures. CONCLUSION Results demonstrate that low PbtO2 may be prognostic of not only mortality but also neuropsychological outcomes.
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Affiliation(s)
- L E Schrieff-Elson
- ACSENT Laboratory, Department of Psychology, University of Cape Town, Cape Town, South Africa.
| | - K G F Thomas
- ACSENT Laboratory, Department of Psychology, University of Cape Town, Cape Town, South Africa
| | - U K Rohlwink
- Division of Neurosurgery, Department of Surgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - A A Figaji
- Division of Neurosurgery, Department of Surgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
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26
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Abstract
Traumatic brain injury (TBI) refers to a spectrum of brain injury that can result in significant morbidity and mortality in pediatric patients. Pediatric head trauma is distinct from adult TBI. The purpose of this review article is to discuss pediatric TBI and current treatment modalities available.
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Affiliation(s)
- Nicole Sharp
- Department of Surgery, Children's Mercy Hospital and Clinics, Kansas City, Missouri, United States
| | - Kelly Tieves
- Department of Pediatrics, Critical Care Medicine, Children's Mercy Hospital and Clinics, Kansas City, Missouri, United States
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Effect of administration of neuromuscular blocking agents in children with severe traumatic brain injury on acute complication rates and outcomes: a secondary analysis from a randomized, controlled trial of therapeutic hypothermia. Pediatr Crit Care Med 2015; 16:352-8. [PMID: 25599147 PMCID: PMC4424136 DOI: 10.1097/pcc.0000000000000344] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To evaluate the association between neuromuscular blocking agents and outcome, intracranial pressure, and medical complications in children with severe traumatic brain injury. DESIGN A secondary analysis of a randomized, controlled trial of therapeutic hypothermia. SETTING Seventeen hospitals in the United States, Australia, and New Zealand. PATIENTS Children (< 18 yr) with severe traumatic brain injury. INTERVENTIONS None for this secondary analysis. MEASUREMENTS AND MAIN RESULTS Children received neuromuscular blocking agent on the majority of days of the study (69.6%), and the modified Pediatric Intensity Level of Therapy scores (modified by removing neuromuscular blocking agent administration from the score) were increased on days when neuromuscular blocking agents were used (9.67 ± 0.21 vs 5.48 ± 0.26; p < 0.001). Children were stratified into groups based on exposure to neuromuscular blocking agents (group 1 received neuromuscular blocking agents each study day; group 2 did not). Group 1 had increased number of daily intracranial pressure readings more than 20 mm Hg (4.4 ± 1.1 vs 2.4 ± 0.5;p = 0.015) and longer ICU and hospital length of stay (p = 0.003 and 0.07, respectively, Kaplan-Meier). The Glasgow Outcome Score-Extended for Pediatrics at hospital discharge and 3, 6, and 12 months after traumatic brain injury and medical complications observed during the acute hospitalization were similar between groups. CONCLUSIONS Administration of neuromuscular blocking agents was ubiquitous and daily administration of neuromuscular blocking agents was associated with intracranial hypertension but not outcomes-likely indicating that increased injury severity prompted their use. Despite this, neuromuscular blocking agent use was not associated with complications. A different study design-perhaps using randomization or methodologies-of a larger cohort will be required to determine if neuromuscular blocking agent use is helpful after severe traumatic brain injury in children.
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28
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Friess SH, Lapidus JB, Brody DL. Decompressive craniectomy reduces white matter injury after controlled cortical impact in mice. J Neurotrauma 2015; 32:791-800. [PMID: 25557588 DOI: 10.1089/neu.2014.3564] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Reduction and avoidance of increases in intracranial pressure (ICP) after severe traumatic brain injury (TBI) continue to be the mainstays of treatment. Traumatic axonal injury is a major contributor to morbidity after TBI, but it remains unclear whether elevations in ICP influence axonal injury. Here we tested the hypothesis that reduction in elevations in ICP after experimental TBI would result in decreased axonal injury and white matter atrophy in mice. Six-week-old male mice (C57BL/6J) underwent either moderate controlled cortical impact (CCI) (n=48) or Sham surgery (Sham, n=12). Immediately after CCI, injured animals were randomized to a loose fitting plastic cap (Open) or replacement of the previously removed bone flap (Closed). Elevated ICP was observed in Closed animals compared with Open and Sham at 15 min (21.4±4.2 vs. 12.3±2.9 and 8.8±1.8 mm Hg, p<0.0001) and 1 day (17.8±3.7 vs. 10.6±2.0 and 8.9±1.9 mm Hg, p<0.0001) after injury. Beta amyloid precursor protein staining in the corpus callosum and ipsilateral external capsule revealed reduced axonal swellings and bulbs in Open compared with Closed animals (32% decrease, p<0.01 and 40% decrease, p<0.001 at 1 and 7 days post-injury, respectively). Open animals were also found to have decreased neurofilament-200 stained axonal swellings at 7 days post-injury compared with Open animals (32% decrease, p<0.001). At 4 weeks post-injury, Open animals had an 18% reduction in white matter volume compared with 34% in Closed animals (p<0.01). Thus, our results indicate that CCI with decompressive craniectomy was associated with reductions in ICP and reduced pericontusional axonal injury and white matter atrophy. If similar in humans, therapeutic interventions that ameliorate intracranial hypertension may positively influence white matter injury severity.
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Affiliation(s)
- Stuart H Friess
- 1Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Jodi B Lapidus
- 1Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - David L Brody
- 2Department of Neurology, Washington University in St. Louis School of Medicine, St. Louis, Missouri
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Kukreti V, Mohseni-Bod H, Drake J. Management of raised intracranial pressure in children with traumatic brain injury. J Pediatr Neurosci 2015; 9:207-15. [PMID: 25624921 PMCID: PMC4302538 DOI: 10.4103/1817-1745.147572] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Increased intracranial pressure (ICP) is associated with worse outcome after traumatic brain injury (TBI). The current guidelines and management strategies are aimed at maintaining adequate cerebral perfusion pressure and treating elevated ICP. Despite controversies, ICP monitoring is important particularly after severe TBI to guide treatment and in developed countries is accepted as a standard of care. We provide a narrative review of the recent evidence for the use of ICP monitoring and management of ICP in pediatric TBI.
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Affiliation(s)
- Vinay Kukreti
- Department of Neurocritical Care, Children's National Medical Center, Washington, D.C., USA
| | - Hadi Mohseni-Bod
- Department of Pediatric Critical Care, The Hospital for Sick Children, University of Toronto, Canada
| | - James Drake
- Department of Neurosurgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada
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30
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Clevenger AC, Kilbaugh T, Margulies SS. Carotid artery blood flow decreases after rapid head rotation in piglets. J Neurotrauma 2014; 32:120-6. [PMID: 25133889 DOI: 10.1089/neu.2014.3570] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Modification of cerebral perfusion pressure and cerebral blood flow (CBF) are crucial components of the therapies designed to reduce secondary damage after traumatic brain injury (TBI). Previously we documented a robust decrease in CBF after rapid sagittal head rotation in our well-validated animal model of diffuse TBI. Mechanisms responsible for this immediate (<10 min) and sustained (∼24 h) reduction in CBF have not been explored. Because the carotid arteries are a major source of CBF, we hypothesized that blood flow through the carotid arteries (Q) and vessel diameter (D) would decrease after rapid nonimpact head rotation without cervical spine injury. Four-week-old (toddler) female piglets underwent rapid (<20 msec) sagittal head rotation without impact, previously shown to produce diffuse TBI with reductions in CBF. Ultrasonographic images of the bilateral carotid arteries were recorded at baseline (pre-injury), as well as immediately after head rotation and 15, 30, 45, and 60 min after injury. Diameter (D) and waveform velocity (V) were used to calculate blood flow (Q) through the carotid arteries using the equation Q=(0.25)πD(2)V. D, V, and Q were normalized to the pre-injury baseline values to obtain a relative change after injury in right and left carotid arteries. Three-way analysis of variance and post-hoc Tukey-Kramer analyses were used to assess statistical significance of injury, time, and side. The relative change in carotid artery diameter and flow was significantly decreased in injured animals in comparison with uninjured sham controls (p<0.0001 and p=0.0093, respectively) and did not vary with side (p>0.39). The average carotid blood velocity did not differ between sham and injured animals (p=0.91). These data suggest that a reduction in global CBF after rapid sagittal head rotation may be partially mediated by a reduction in carotid artery flow, via vasoconstriction.
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Affiliation(s)
- Amy C Clevenger
- 1 Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
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31
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Prabhakar H, Sandhu K, Bhagat H, Durga P, Chawla R. Current concepts of optimal cerebral perfusion pressure in traumatic brain injury. J Anaesthesiol Clin Pharmacol 2014; 30:318-27. [PMID: 25190937 PMCID: PMC4152669 DOI: 10.4103/0970-9185.137260] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Traumatic brain injury (TBI) consists of varied pathophysiological consequences and alteration of intracranial dynamics, reduction of the cerebral blood flow and oxygenation. In the past decade more emphasis has been directed towards optimizing cerebral perfusion pressure (CPP) in patients who have suffered TBI. Injured brain may show signs of ischemia if CPP remains below 50 mmHg and raising the CPP above 60 mmHg may avoid cerebral oxygen desaturation. Though CPP above 70 mmHg is influential in achieving an improved patient outcome, maintenance of CPP higher than 70 mmHg was associated with greater risk of acute respiratory distress syndrome (ARDS). The target CPP has been laid within 50-70 mmHg. Cerebral blood flow and metabolism are heterogeneous after TBI and with regional temporal differences in the requirement for CPP. Brain monitoring techniques such as jugular venous oximetry, monitoring of brain tissue oxygen tension (PbrO2), and cerebral microdialysis provide complementary and specific information that permits the selection of the optimal CPP. This review highlights the rationale for use CPP directed therapies and neuromonitoring to identify optimal CPP of head injured patients. The article also reviews the evidence provided by various clinical trials regarding optimal CPP and their application in the management of head injured patients.
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Affiliation(s)
- Hemanshu Prabhakar
- Department of Neuroanaesthesiology, Neurosciences Centre, All India Institute of Medical Sciences, PGIMER, Chandigarh, India
| | - Kavita Sandhu
- Department of Neuroanaesthesiology and Critical Care, Max Superspeciality Hospital, PGIMER, Chandigarh, India
| | - Hemant Bhagat
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
| | - Padmaja Durga
- Department of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Rajiv Chawla
- Department of Anaesthesiology and Intensive Care, G B Pant Hospital, New Delhi, India
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32
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Chesnut RM. What is wrong with the tenets underpinning current management of severe traumatic brain injury? Ann N Y Acad Sci 2014; 1345:74-82. [PMID: 25048398 DOI: 10.1111/nyas.12482] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The results of a recent randomized controlled trial comparing intracranial pressure (ICP) monitor-based treatment of severe traumatic brain injury (sTBI) to management without ICP monitoring prompt this skeptical reconsideration of the scientific foundation underlying current sTBI management. Much of current practice arises from research performed under conditions that are no longer relevant today. The definition of an episode of intracranial hypertension is incomplete, and the application of a fixed, universal ICP treatment threshold is poorly founded. Although intracranial hypertension is a valid indicator of disease severity, it remains to be demonstrated that lowering ICP improves outcome. Furthermore, sTBI has not been categorized on the basis of underlying pathophysiology despite the current capability to do so. Similar concerns also apply to manipulation of cerebral perfusion with respect to maintaining universal thresholds for contrived variables rather than tailoring treatment to monitored processes. As such, there is a failure to either optimize management approaches or minimize associated treatment risks for individual sTBI patients. The clinical and research TBI communities need to reassess many of the sTBI management concepts that are currently considered well established.
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Affiliation(s)
- Randall M Chesnut
- Departments of Neurological Surgery and Orthopaedics and Sports Medicine, Harborview Medical Center, School of Medicine and School of Global Health, University of Washington, Seattle, Washington
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Hardcastle N, Benzon HA, Vavilala MS. Update on the 2012 guidelines for the management of pediatric traumatic brain injury - information for the anesthesiologist. Paediatr Anaesth 2014; 24:703-10. [PMID: 24815014 PMCID: PMC4146616 DOI: 10.1111/pan.12415] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/27/2014] [Indexed: 01/05/2023]
Abstract
Traumatic brain injury (TBI) is a significant contributor to death and disability in children. Considering the prevalence of pediatric TBI, it is important for the clinician to be aware of evidence-based recommendations for the care of these patients. The first edition of the Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents was published in 2003. The Guidelines were updated in 2012, with significant changes in the recommendations for hyperosmolar therapy, temperature control, hyperventilation, corticosteroids, glucose therapy, and seizure prophylaxis. Many of these interventions have implications in the perioperative period, and it is the responsibility of the anesthesiologist to be familiar with these guidelines.
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Affiliation(s)
- Nina Hardcastle
- Department of Pediatric Anesthesiology, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Hubert A. Benzon
- Department of Pediatric Anesthesiology, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Monica S. Vavilala
- Department of Pediatric Anesthesiology, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA, USA
- Department of Anesthesiology and Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle, WA, USA
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34
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Abstract
Stroke is a rare but increasingly recognized disorder in children. Current therapies for arterial ischemic stroke include thrombolytic, antithrombotic and antiplatelet agents, blood transfusion and surgery. Adult studies, pediatric case studies and expert opinion form the basis for these treatment strategies. Thrombolytic agents are increasingly used but, as in adults, the majority of arterial ischemic strokes in children are treated with antiplatelet and antithrombotic agents. Sickle-cell patients, a distinct subset of the pediatric stroke population, are treated primarily with transfusion therapy. Pediatric arterial ischemic stroke studies are needed to determine the most appropriate course of treatment. An international study is currently in progress to formally study the incidence, risk factors, treatment strategies and outcomes of stroke in children.
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Affiliation(s)
- Jessica Carpenter
- Children's National Medical Center, Department of Neurology, Washington, DC 20010, USA.
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35
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Allen BB, Chiu YL, Gerber LM, Ghajar J, Greenfield JP. Age-specific cerebral perfusion pressure thresholds and survival in children and adolescents with severe traumatic brain injury*. Pediatr Crit Care Med 2014; 15:62-70. [PMID: 24196011 PMCID: PMC4077612 DOI: 10.1097/pcc.0b013e3182a556ea] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Evidence-based traumatic brain injury guidelines support cerebral perfusion pressure thresholds for adults at a class 2 level, but evidence is lacking in younger patients. The purpose of this study is to identify the impact of age-specific cerebral perfusion pressure thresholds on short-term survival among patients with severe traumatic brain injury. DESIGN Institutional review board-approved, prospective, observational cohort study. SETTING Level I or II trauma centers in New York State. PATIENTS Data on all patients with a postresuscitation Glasgow Coma Score less than 9 were added in the Brain Trauma Foundation prospective New York State TBI-trac database. MEASUREMENTS AND MAIN RESULTS We calculated the survival rates and relative risks of mortality for patients with severe traumatic brain injury based on predefined age-specific cerebral perfusion pressure thresholds. A higher threshold and a lower threshold were defined for each age group: 60 and 50 mm Hg for 12 years old or older, 50 and 35 mm Hg for 6-11 years, and 40 and 30 mm Hg for 0-5 years. Patients were stratified into age groups of 0-11, 12-17, and 18 years old or older. Three exclusive groups of CPP-L (events below low cerebral perfusion pressure threshold), CPP-B (events between high and low cerebral perfusion pressure thresholds), and CPP-H (events above high cerebral perfusion pressure threshold) were defined. As an internal control, we evaluated the associations between cerebral perfusion pressure events and events of hypotension and elevated intracranial pressure. Survival was significantly higher in 0-11 and 18 years old or older age groups for patients with CPP-H events compared with those with CPP-L events. There was a significant decrease in survival with prolonged exposure to CPP-B events for the 0-11 and 18 years old and older age groups when compared with the patients with CPP-H events (p = 0.0001 and p = 0.042, respectively). There was also a significant decrease in survival with prolonged exposure to CPP-L events in all age groups compared with the patients with CPP-H events (p< 0.0001 for 0- to 11-yr olds, p = 0.0240 for 12- to 17-yr olds, and p < 0.0001 for 18-yr old and older age groups). The 12- to 17-year olds had a significantly higher likelihood of survival compared with adults with prolonged exposure to CPP-L events (< 50 mm Hg). CPP-L events were significantly related to systemic hypotension for the 12- to 17-year-old group (p = 0.004) and the 18-year-old and older group (p < 0.0001). CPP-B events were significantly related to systemic hypotension in the 0- to 11-year-old group (p = 0.014). CPP-B and CPP-L events were significantly related to elevated intracranial pressure in all age groups. CONCLUSIONS Our data provide new evidence that cerebral perfusion pressure targets should be age specific. Furthermore, cerebral perfusion pressure goals above 50 or 60 mm Hg in adults, above 50 mm Hg in 6- to 17-year olds, and above 40 mm Hg in 0- to 5-year olds seem to be appropriate targets for treatment-based studies. Systemic hypotension had an inconsistent relationship to events of low cerebral perfusion pressure, whereas elevated intracranial pressure was significantly related to all low cerebral perfusion pressure events across all age groups. This may impart a clinically important difference in care, highlighting the necessity of controlling intracranial pressure at all times, while targeting systolic blood pressure in specific instances.
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Affiliation(s)
- Baxter B Allen
- 1Department of Neurology, Weill Cornell Medical College, New York, NY. 2Department of Public Health, Weill Cornell Medical College, New York, NY. 3Department of Surgery, Jamaica Hospital Medical Center, New York, NY. 4Brain Trauma Foundation, New York, NY. 5Department of Neurological Surgery, Weill Cornell Medical College, New York, NY
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37
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Sabayan B, van der Grond J, Westendorp RG, Jukema JW, Ford I, Buckley BM, Sattar N, van Osch MJP, van Buchem MA, de Craen AJM. Total cerebral blood flow and mortality in old age: a 12-year follow-up study. Neurology 2013; 81:1922-9. [PMID: 24174588 DOI: 10.1212/01.wnl.0000436618.48402.da] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To examine the association of total cerebral blood flow (CBF) with all-cause, noncardiovascular, and cardiovascular mortality in older subjects at risk of cardiovascular disease. METHODS We included 411 subjects with a mean age of 74.5 years from the MRI substudy of the Prospective Study of Pravastatin in the Elderly at Risk. Total CBF was measured at baseline, and occurrence of death was recorded in an average follow-up period of 11.8 years. For each participant, total CBF was standardized for brain parenchymal volume. Cox regression models were used to estimate risk of all-cause, noncardiovascular, and cardiovascular mortality in relation to CBF. RESULTS Mortality rates among participants in low, middle, and high thirds of total CBF were 52.1, 41.5, and 28.7 per 1,000 person-years, respectively. Compared with participants in the high third of CBF, participants in the low third had 1.88-fold (95% confidence interval [CI]: 1.30-2.72) higher risk of all-cause mortality, 1.66-fold (95% CI: 1.06-2.59) higher risk of noncardiovascular mortality, and 2.50-fold (95% CI: 1.28-4.91) higher risk of cardiovascular mortality. Likewise, compared with participants in the high third of CBF, participants in the middle third had 1.44-fold (95% CI: 0.98-2.11) higher risk of all-cause mortality, 1.29-fold (95% CI: 0.82-2.04) higher risk of noncardiovascular mortality, and 1.86-fold (95% CI: 0.93-3.74) higher risk of cardiovascular mortality. These associations were independent of prevalent vascular status and risk factors. CONCLUSIONS Low total CBF is linked with higher risk of all-cause, noncardiovascular, and cardiovascular mortality in older people independent of clinical cardiovascular status.
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Affiliation(s)
- Behnam Sabayan
- From the Departments of Radiology (B.S., J.v.d.G., M.J.P.v.O., M.A.v.B.), Gerontology and Geriatrics (B.S., R.G.W., A.J.M.d.C.), and Cardiology (J.W.J.), Leiden University Medical Center; Netherlands Consortium for Healthy Ageing (R.G.W., A.J.M.d.C.), Leiden, the Netherlands; Robertson Center for Biostatistics (I.F.), and Glasgow Cardiovascular Research Centre (N.S.), University of Glasgow, UK; and Department of Pharmacology and Therapeutics (B.M.B.), University College Cork, Ireland
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Bell MJ, Kochanek PM. Pediatric traumatic brain injury in 2012: the year with new guidelines and common data elements. Crit Care Clin 2013; 29:223-38. [PMID: 23537673 DOI: 10.1016/j.ccc.2012.11.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Traumatic brain injury (TBI) remains the leading cause of death of children in the developing world. In 2012, several international efforts were completed to aid clinicians and researchers in advancing the field of pediatric TBI. The second edition of the Guidelines for the Medical Management of Traumatic Brain Injury in Infants, Children and Adolescents updated those published in 2003. This article highlights the processes involved in developing the Guidelines, contrasts the new guidelines with the previous edition, and delineates new research efforts needed to advance knowledge. The impact of common data elements within these potential new research fields is reviewed.
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Affiliation(s)
- Michael J Bell
- Department of Critical Care Medicine, Safar Center for Resuscitation Research, University of Pittsburgh, 3434 Fifth Avenue, Pittsburgh, PA 15260, USA.
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Giustini A, Pistarini C, Pisoni C. Traumatic and nontraumatic brain injury. NEUROLOGICAL REHABILITATION 2013; 110:401-9. [DOI: 10.1016/b978-0-444-52901-5.00034-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Shein SL, Bell MJ, Kochanek PM, Tyler-Kabara EC, Wisniewski SR, Feldman K, Makoroff K, Scribano PV, Berger RP. Risk factors for mortality in children with abusive head trauma. J Pediatr 2012; 161:716-722.e1. [PMID: 22578583 PMCID: PMC3437227 DOI: 10.1016/j.jpeds.2012.03.046] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Revised: 02/03/2012] [Accepted: 03/22/2012] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We sought to identify risk factors for mortality in a large clinical cohort of children with abusive head trauma. STUDY DESIGN Bivariate analysis and multivariable logistic regression models identified demographic, physical examination, and radiologic findings associated with in-hospital mortality of children with abusive head trauma at 4 pediatric centers. An initial Glasgow Coma Scale (GCS) ≤ 8 defined severe abusive head trauma. Data are shown as OR (95% CI). RESULTS Analysis included 386 children with abusive head trauma. Multivariable analysis showed children with initial GCS either 3 or 4-5 had increased mortality vs children with GCS 12-15 (OR = 57.8; 95% CI, 12.1-277.6 and OR = 15.6; 95% CI, 2.6-95.1, respectively, P < .001). Additionally, retinal hemorrhage (RH), intraparenchymal hemorrhage, and cerebral edema were independently associated with mortality. In the subgroup with severe abusive head trauma and RH (n = 117), cerebral edema and initial GCS of 3 or 4-5 were independently associated with mortality. Chronic subdural hematoma was independently associated with survival. CONCLUSIONS Low initial GCS score, RH, intraparenchymal hemorrhage, and cerebral edema are independently associated with mortality in abusive head trauma. Knowledge of these risk factors may enable researchers and clinicians to improve the care of these vulnerable children.
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Affiliation(s)
- Steven L. Shein
- Department of Critical Care Medicine, Children’s Hospital of Pittsburgh of UPMC, Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA
| | - Michael J. Bell
- Departments of Critical Care Medicine and Neurological Surgery, Children’s Hospital of Pittsburgh of UPMC, Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, Children’s Hospital of Pittsburgh of UPMC, Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA
| | - Elizabeth C. Tyler-Kabara
- Departments of Neurological Surgery and Physical Medicine and Rehabilitation, Children’s Hospital of Pittsburgh of UPMC, Department of Bioengineering and McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | - Kenneth Feldman
- Seattle Children’s Hospital/Harborview Medical Center, Seattle, WA
| | - Kathi Makoroff
- Cincinnati Children’s Hospital Medical Center. Cincinnati, OH
| | | | - Rachel P. Berger
- Department of Pediatrics, Children’s Hospital of Pittsburgh of UPMC, Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania
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Bhalla T, Dewhirst E, Sawardekar A, Dairo O, Tobias JD. Perioperative management of the pediatric patient with traumatic brain injury. Paediatr Anaesth 2012; 22:627-40. [PMID: 22502728 DOI: 10.1111/j.1460-9592.2012.03842.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
TBI and its sequelae remain a major healthcare issue throughout the world. With an improved understanding of the pathophysiology of TBI, refinements of monitoring technology, and ongoing research to determine optimal care, the prognosis of TBI continues to improve. In 2003, the Society of Critical Care Medicine published guidelines for the acute management of severe TBI in infants, children, and adolescents. As pediatric anesthesiologists are frequently involved in the perioperative management of such patients including their stabilization in the emergency department, familiarity with these guidelines is necessary to limit preventable secondary damage related to physiologic disturbances. This manuscript reviews the current evidence-based medicine regarding the care of pediatric patients with TBI as it relates to the perioperative care of such patients. The issues reviewed include those related to initial stabilization, airway management, intra-operative mechanical ventilation, hemodynamic support, administration of blood and blood products, positioning, and choice of anesthetic technique. The literature is reviewed regarding fluid management, glucose control, hyperosmolar therapy, therapeutic hypothermia, and corticosteroids. Whenever possible, management recommendations are provided.
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Affiliation(s)
- Tarun Bhalla
- Departments of Anesthesiology, Nationwide Children's Hospital and the Ohio State University, Columbus, OH, USA
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Kamat P, Kunde S, Vos M, Vats A, Gupta N, Heffron T, Romero R, Fortenberry JD. Invasive intracranial pressure monitoring is a useful adjunct in the management of severe hepatic encephalopathy associated with pediatric acute liver failure. Pediatr Crit Care Med 2012; 13:e33-8. [PMID: 21263362 PMCID: PMC3108011 DOI: 10.1097/pcc.0b013e31820ac08f] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Pediatric acute liver failure is often accompanied by hepatic encephalopathy, cerebral edema, and raised intracranial pressure. Elevated intracranial pressure can be managed more effectively with intracranial monitoring, but acute-liver-failure-associated coagulopathy is often considered a contraindication for invasive monitoring due to risk for intracranial bleeding. We reviewed our experience with use of early intracranial pressure monitoring in acute liver failure in children listed for liver transplantation. DESIGN AND PATIENTS Retrospective review of all intubated pediatric acute liver failure patients with grade III and grade IV encephalopathy requiring intracranial pressure monitoring and evaluated for potential liver transplant who were identified from an institutional liver transplant patient database from 1999 to 2009. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 14 patients were identified who met the inclusion criteria. Their ages ranged from 7 months to 20 yrs. Diagnoses of acute liver failure were infectious (three), drug-induced (seven), autoimmune hepatitis (two), and indeterminate (two). Grade III and IV encephalopathy was seen in ten (71%) and four (29%) patients, respectively. Computed tomography scans before intracranial pressure monitor placement showed cerebral edema in five (35.7%) patients. Before intracranial pressure monitor placement, fresh frozen plasma, vitamin K, and activated recombinant factor VIIa were given to all 14 patients, with significant improvement in coagulopathy (p < .04). The initial intracranial pressure ranged from 5 to 50 cm H2O; the intracranial pressure was significantly higher in patients with cerebral edema by computed tomography (p < .05). Eleven of 14 (78%) patients received hypertonic saline, and three (22%) received mannitol for elevated intracranial pressure. Eight of 14 (56%) monitored patients were managed to liver transplant, with 100% surviving neurologically intact. Four of 14 (28%) patients had spontaneous recovery without liver transplant. Two of 14 (14%) patients died due to multiple organ failure before transplant. One patient had a small 9-mm intracranial hemorrhage but survived after receiving a liver transplant. No patient developed intracranial infection. CONCLUSIONS In our series of patients, intracranial pressure monitoring had a low complication rate and was associated with a high survival rate despite severe hepatic encephalopathy and cerebral edema in the setting of pediatric acute liver failure. In our experience, monitoring of intracranial pressure allowed interventions to treat increased intracranial pressure and provided additional information regarding central nervous system injury before liver transplant. Further study is warranted to confirm if monitoring allows more directed intracranial pressure therapy and improves survival in pediatric acute liver failure.
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Affiliation(s)
- Pradip Kamat
- Division of Critical Care, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA.
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SHIGEMORI M, ABE T, ARUGA T, OGAWA T, OKUDERA H, ONO J, ONUMA T, KATAYAMA Y, KAWAI N, KAWAMATA T, KOHMURA E, SAKAKI T, SAKAMOTO T, SASAKI T, SATO A, SHIOGAI T, SHIMA K, SUGIURA K, TAKASATO Y, TOKUTOMI T, TOMITA H, TOYODA I, NAGAO S, NAKAMURA H, PARK YS, MATSUMAE M, MIKI T, MIYAKE Y, MURAI H, MURAKAMI S, YAMAURA A, YAMAKI T, YAMADA K, YOSHIMINE T. Guidelines for the Management of Severe Head Injury, 2nd Edition Guidelines from the Guidelines Committee on the Management of Severe Head Injury, the Japan Society of Neurotraumatology. Neurol Med Chir (Tokyo) 2012; 52:1-30. [PMID: 22278024 DOI: 10.2176/nmc.52.1] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Brief episodes of intracranial hypertension and cerebral hypoperfusion are associated with poor functional outcome after severe traumatic brain injury. ACTA ACUST UNITED AC 2011; 71:364-73; discussion 373-4. [PMID: 21825940 DOI: 10.1097/ta.0b013e31822820da] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Management strategies after severe traumatic brain injury (TBI) target prevention and treatment of intracranial hypertension (ICH) and cerebral hypoperfusion (CH). We have previously established that continuous automated recordings of vital signs (VS) are more highly correlated with outcome than manual end-hour recordings. One potential benefit of automated vital sign data capture is the ability to detect brief episodes of ICH and CH. The purpose of this study was to establish whether a relationship exists between brief episodes of ICH and CH and outcome after severe TBI. MATERIALS Patients at the R Adams Cowley Shock Trauma Center were prospectively enrolled over a 2-year period. Inclusion criteria were as follows: age >14 years, admission within the first 6 hours after injury, Glasgow Coma Scale score <9 on admission, and placement of a clinically indicated ICP monitor. From high-resolution automated VS data recording system, we calculated the 5-minute means of intracranial pressure (ICP), cerebral perfusion pressure (CPP), and Brain Trauma Index (BTI = CPP/ICP). Patients were stratified by mortality and 6-month Extended Glasgow Outcome Score (GOSE). RESULTS Sixty subjects were enrolled with a mean admission Glasgow Coma Scale score of 6.4 ± 3.1, a mean Head Abbreviated Injury Severity Scale score of 4.2 ± 0.7, and a mean Marshall CT score of 2.5 ± 0.9. Significant differences in the mean number of brief episodes of CPP <50 and BTI <2 in patients with a GOSE 1-4 versus GOSE 5-8 (9.4 vs. 4.7, p = 0.02 and 9.3 vs. 4.9, p = 0.03) were found. There were significantly more mean brief episodes per day of ICP >30 (0.52 vs. 0.29, p = 0.02), CPP <50 (0.65 vs. 0.28, p < 0.001), CPP <60 (1.09 vs. 0.7, p = 0.03), BTI <2 (0.66 vs. 0.31, p = 0.002), and BTI <3 (1.1 vs. 0.64, p = 0.01) in those patients with GOSE 1-4. Number of brief episodes of CPP <50, CPP <60, BTI <2, and BTI <3 all demonstrated high predictive power for unfavorable functional outcome (area under the curve = 0.65-0.75, p < 0.05). CONCLUSIONS This study demonstrates that the number of brief 5-minute episodes of ICH and CH is predictive of poor outcome after severe TBI. This finding has important implications for management paradigms which are currently targeted to treatment rather than prevention of ICH and CH. This study demonstrates that these brief episodes may play a significant role in outcome after severe TBI.
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Exo J, Kochanek PM, Adelson PD, Greene S, Clark RSB, Bayir H, Wisniewski SR, Bell MJ. Intracranial pressure-monitoring systems in children with traumatic brain injury: combining therapeutic and diagnostic tools. Pediatr Crit Care Med 2011; 12:560-5. [PMID: 20625341 PMCID: PMC3670608 DOI: 10.1097/pcc.0b013e3181e8b3ee] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To compare the correlation of intracranial pressure (ICP) measurement and time to detection of ICP crises (defined as ICP ≥ 20 mm Hg for ≥ 5 mins) between an intraparenchymal (IP) monitor and external ventricular drain (EVD) in children for whom continuous cerebrospinal fluid diversion was used as a therapy for severe traumatic brain injury. SETTING Academic, pediatric intensive care unit. DESIGN Retrospective review of a prospectively collected pediatric neurotrauma database. PATIENTS Children with severe traumatic brain injury (Glasgow Coma Scale score of ≤ 8) who underwent ICP monitoring with both IP and EVD techniques were studied. In cohort 1 (n = 58), hourly ICP measurements were extracted from the medical record; in cohort 2 (n = 4), ICP measurements were collected every minute by an automated data-collection system. MEASUREMENTS AND MAIN RESULTS The mean absolute difference in ICP (|N5ICP|N5) and intraclass correlation coefficients were calculated. Timing to detection of ICP crises was analyzed. Data were expressed as mean ± sem. For cohort 1, 7,387 hrs of data were analyzed; 399 hrs (23,940 mins) were analyzed for cohort 2. In cohort 1, the |N5ICP|N5 was 3.10 ± 0.04 mm Hg (intraclass correlation coefficients = 0.98, p < .001). The |N5ICP|N5 in cohort 2 was 3.30 ± 0.05 mm Hg (intraclass correlation coefficients = 0.98, p < .001). In cohort 2, a total of 75 ICP crises were observed. Fifty-five (73%) were detected first by the IP monitor, of which 35 were not identified by the EVD monitor. Time between IP and EVD detection of a crisis was 12.60 ± 2.34 mins. CONCLUSION EVD and IP measurements of ICP were highly correlated, although intermittent EVD ICP measurements may fail to identify ICP events when continuously draining cerebrospinal fluid. In institutions that use continuous cerebrospinal fluid diversion as a therapy, a two-monitor system may be valuable for accomplishing monitoring and therapeutic goals.
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Affiliation(s)
- Jennifer Exo
- Departments of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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Ursachen des Schädel-Hirn-Traumas im Kindesalter. Rechtsmedizin (Berl) 2011. [DOI: 10.1007/s00194-011-0751-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Di Gennaro JL, Mack CD, Malakouti A, Zimmerman JJ, Armstead W, Vavilala MS. Use and effect of vasopressors after pediatric traumatic brain injury. Dev Neurosci 2010; 32:420-30. [PMID: 21124016 PMCID: PMC3073759 DOI: 10.1159/000322083] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2010] [Accepted: 10/15/2010] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Vasopressors are commonly used to increase mean arterial blood pressure (MAP) and cerebral perfusion pressure (CPP) after traumatic brain injury (TBI), but there are few data comparing vasopressor effectiveness after pediatric TBI. OBJECTIVE To determine which vasopressor is most effective at increasing MAP and CPP in children with moderate-to-severe TBI. METHODS After institutional review board approval, we performed a retrospective cohort study of children 0-17 years old admitted to a level 1 trauma center (Harborview Medical Center, Seattle, Wash., USA) between 2002 and 2007 with moderate-to-severe TBI who received a vasopressor to increase blood pressure. Baseline demographic and physiologic characteristics and hourly physiologic monitoring for 3 h after having started a vasopressor were abstracted. We evaluated differences in MAP and CPP at 3 h after initiation of therapy between phenylephrine, dopamine and norepinephrine among patients who did not require a second vasopressor during this time. Multivariate linear regression was used to adjust for age, gender, injury severity score and baseline MAP or CPP and to cluster by subject. RESULTS Eighty-two patients contributed data to the entire dataset. The most common initial medication was phenylephrine for 47 (57%). Patients receiving phenylephrine and norepinephrine tended to be older than those receiving dopamine and epinephrine. Thirteen (16%) of the patients received a second vasopressor during the first 3 h of treatment and were thus not included in the regression analyses; these patients received more fluid resuscitation and exhibited higher in-hospital mortality (77 vs. 32%; p = 0.004) compared to patients receiving a single vasopressor. The norepinephrine group exhibited a 5 mm Hg higher MAP (95% CI: -4 to 13; p = 0.31) and a 12 mm Hg higher CPP (95% CI: -2 to 26; p = 0.10) than the phenylephrine group, and a 5 mm Hg higher MAP (95% CI: -4 to 15; p = 0.27) and a 10 mm Hg higher CPP (95% CI: -5 to 25; p = 0.18) than the dopamine group. However, in post hoc analysis, after adjusting for time to start of vasopressor, hypertonic saline and pentobarbital, the effect on MAP was lost, but the CPP was 8 mm Hg higher (95% CI: -10 to 25; p = 0.39) than in the phenylephrine group, and 5 mm Hg higher (95% CI: -14 to 24; p = 0.59) than in the dopamine group. CONCLUSIONS Vasopressor use varied by age. While there was no statistically significant difference in MAP or CPP between vasopressor groups, norepinephrine was associated with a clinically relevant higher CPP and lower intracranial pressure at 3 h after start of vasopressor therapy compared to the other vasopressors examined.
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Affiliation(s)
- Jane L Di Gennaro
- Department of Pediatrics, University of Washington, Seattle, Wash., USA
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Abstract
Brain injuries represent the most common cause of mortality and long-term morbidity from trauma in children. The management of closed head injuries focuses on prevention of secondary injury by optimizing the delivery of oxygen and nutrients to the injured brain while minimizing neuronal metabolic demand. Despite the known differences between the immature and mature brain, treatments used in head-injured children are mainly extrapolated from those employed in adults due to the paucity of class one and two studies focused on the pediatric age group. Therapies intended to minimize secondary brain injury, such as cerebrospinal fluid drainage, hypertonic saline infusion, barbiturate coma induction, brain cooling, and decompressive craniectomy, vary widely in their clinical application among practitioners and trauma centers and have unclear indications, benefits, and long-term consequences. Prospective studies on brain injury management in children are needed to develop treatment strategies that optimize outcomes.
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Affiliation(s)
- Stephen E Morrow
- Department of Pediatric Surgery, Monroe Carell, Jr. Children's Hospital, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN 37232, USA.
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Mehta A, Kochanek PM, Tyler-Kabara E, Adelson PD, Wisniewski SR, Berger RP, Sidoni MD, Bell RL, Clark RSB, Bell MJ. Relationship of intracranial pressure and cerebral perfusion pressure with outcome in young children after severe traumatic brain injury. Dev Neurosci 2010; 32:413-9. [PMID: 20847542 DOI: 10.1159/000316804] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Accepted: 06/02/2010] [Indexed: 11/19/2022] Open
Abstract
Traumatic brain injury (TBI) is the most common cause of death for children less than 18 years of age. Current standards of care for children with severe TBI include monitoring of intracranial pressure (ICP), and goal-directed therapies to minimize ICP and optimize cerebral perfusion pressure (CPP; the mathematical difference between the mean arterial pressure and ICP). Current guidelines for ICP and CPP thresholds suggest that age-based thresholds should be adopted, but few studies have included the youngest children affected by TBI (those <2 years of age). We performed a retrospective analysis of our pediatric neurotrauma database to determine if ICP and CPP thresholds associated with favorable neurological outcome could be determined, or if the number of episodic alterations in the parameters (ICP >15 or >20 mm Hg; CPP <40 mm Hg, <45 mm Hg or <50 mm Hg) was different between children with favorable and unfavorable outcomes (based on dichotomous Glasgow Outcome Scale score at 6 months after TBI). Data from 22 children (of whom 81% had suffered from inflicted childhood neurotrauma) were analyzed in the first 7 days. Children with unfavorable outcome had more hourly readings of CPP of <45 mm Hg compared to children with favorable outcome [median (25-75%): 2 (1-31) vs. 0 (0-2); p <0.05]. There was no difference between the number of hourly readings of ICP of >20 mm Hg between the outcome groups [median (25-75%): favorable 0 (0-1) vs. unfavorable 1 (0-4); p = 0.17]. To our knowledge, this is the first exploratory report to test if CPP and ICP thresholds can be established for this young population of children after TBI, and it suggests a CPP target threshold of 45 mm Hg. Despite good ICP control in this population, there was still a 50% incidence of unfavorable outcome, suggesting that there may be unique physiologic parameters that need to be targeted in infants with severe TBI. A prospective study is needed to fully determine what goals should be targeted for this vulnerable population.
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Affiliation(s)
- Amit Mehta
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA.
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Kapapa T, König K, Pfister U, Sasse M, Woischneck D, Heissler H, Rickels E. Head trauma in children, part 2: course and discharge with outcome. J Child Neurol 2010; 25:274-83. [PMID: 19638637 DOI: 10.1177/0883073809332699] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
To minimize the secondary brain damage, we analyzed the effect of cerebral perfusion pressure-orientated management and tried to find factors of clinical management and biochemical findings that influence clinical, cognitive, and psychosocial outcome. Management at intensive care unit was standardized. A standardized (short form 36 health survey) and nonstandardized split questionnaire explored long-term outcome. Glutamic-oxaloacetic-transaminase, creatine kinase MB or glucose are markers for bad outcome (P < .05). Patients with cerebral perfusion pressure values below the recommended standard for just a single occurrence had significantly worse outcome (P = .0132). Mean arterial pressure, central venous pressure, and heart rate alone do not correlate with outcome. At least 1 occurrence of mean arterial pressure and central venous pressure below the lower limits resulted in a poor outcome (P = .035). Cerebral perfusion pressure-guided therapy seems to prevent further brain damage and results in outcome scores that are comparable to those children with head trauma exhibiting symptoms of mild brain edema.
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Affiliation(s)
- Thomas Kapapa
- Department of Neurosurgery, University of Ulm, Ulm, Germany.
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