Clinical Features of Fever Associated With Poor Outcome in Severe Pediatric Traumatic Brain Injury

Protocol for a magnetic resonance imaging study of participants in the fever RCT: Does fever control prevent brain injury in malaria?

BACKGROUND

Despite eradication efforts, ~135,000 African children sustained brain injuries as a result of central nervous system (CNS) malaria in 2021. Newer antimalarial medications rapidly clear peripheral parasitemia and improve survival, but mortality remains high with no associated decline in post-malaria neurologic injury. A randomized controlled trial of aggressive antipyretic therapy with acetaminophen and ibuprofen (Fever RCT) for malarial fevers being conducted in Malawi and Zambia began enrollment in 2019. We propose to use neuroimaging in the context of the RCT to further evaluate neuroprotective effects of aggressive antipyretic therapy.

METHODS

This observational magnetic resonance imaging (MRI) ancillary study will obtain neuroimaging and neurodevelopmental and behavioral outcomes in children previously enrolled in the Fever RCT at 1- and 12-months post discharge. Analysis will compare the odds of any brain injury between the aggressive antipyretic therapy and usual care groups based upon MRI structural abnormalities. For children unable to undergo imaging without deep sedation, neurodevelopmental and behavioral outcomes will be used to identify brain injury.

DISCUSSION

Neuroimaging is a well-established, valid proxy for neurological outcomes after brain injury in pediatric CNS malaria. This MRI ancillary study will add value to the Fever RCT by determining if treatment with aggressive antipyretic therapy is neuroprotective in CNS malaria. It may also help elucidate the underlying mechanism(s) of neuroprotection and expand upon FEVER RCT safety assessments.

Utility of Early Magnetic Resonance Imaging to Enhance Outcome Prediction in Critically Ill Children with Severe Traumatic Brain Injury

BACKGROUND

Many children with severe traumatic brain injury (TBI) receive magnetic resonance imaging (MRI) during hospitalization. There are insufficient data on how different patterns of injury on early MRI inform outcomes.

METHODS

Children (3-17 years) admitted in 2010-2021 for severe TBI (Glasgow Coma Scale [GCS] score < 9) were identified using our site's trauma registry. We used multivariable modeling to determine whether the hemorrhagic diffuse axonal injury (DAI) grade and the number of regions with restricted diffusion (subcortical white matter, corpus callosum, deep gray matter, and brainstem) on MRI obtained within 7 days of injury were independently associated with time to follow commands and with Functional Independence Measure for Children (WeeFIM) scores at the time of discharge from inpatient rehabilitation. We controlled for the clinical variables age, preadmission cardiopulmonary resuscitation, pupil reactivity, motor GCS score, and fever (> 38 °C) in the first 12 h.

RESULTS

Of 260 patients, 136 (52%) underwent MRI within 7 days of injury at a median of 3 days (interquartile range [IQR] 2-4). Patients with early MRI were a median age of 11 years (IQR 7-14), 8 (6%) patients received cardiopulmonary resuscitation, 19 (14%) patients had bilateral unreactive pupils, the median motor GCS score was 1 (IQR 1-4), and 82 (60%) patients had fever. Grade 3 DAI was present in 46 (34%) patients, and restricted diffusion was noted in the corpus callosum in 75 (55%) patients, deep gray matter in 29 (21%) patients, subcortical white matter in 23 (17%) patients, and the brainstem in 20 (15%) patients. After controlling for clinical variables, an increased number of regions with restricted diffusion, but not hemorrhagic DAI grade, was independently associated with longer time to follow commands (hazard ratio 0.68, 95% confidence interval 0.53-0.89) and worse WeeFIM scores (estimate β - 4.67, 95% confidence interval - 8.33 to - 1.01).

CONCLUSIONS

Regional restricted diffusion on early MRI is independently associated with short-term outcomes in children with severe TBI. Multicenter cohort studies are needed to validate these findings and elucidate the association of early MRI features with long-term outcomes in children with severe TBI.

Protocol for a Magnetic Resonance Imaging (MRI) Study of Participants in the Fever Randomized Controlled Trial: Does fever control prevent brain injury in malaria?

Background

Despite eradication efforts, ~135,000 African children sustained brain injuries as a result of central nervous system (CNS) malaria in 2021. Newer antimalarial medications rapidly clear peripheral parasitemia and improve survival, but mortality remains high with no associated decline in post-malaria neurologic injury. A randomized controlled trial of aggressive antipyretic therapy with acetaminophen and ibuprofen (Fever RCT) for malarial fevers being conducted in Malawi and Zambia began enrollment in 2019. We propose to use neuroimaging in the context of the RCT to further evaluate neuroprotective effects of aggressive antipyretic therapy.

Methods

This observational magnetic resonance imaging (MRI) ancillary study will obtain neuroimaging and neurodevelopmental and behavioral outcomes in children previously enrolled in the Fever RCT at 1- and 12-months post discharge. Analysis will compare the odds of any brain injury between the aggressive antipyretic therapy and usual care groups based upon MRI structural abnormalities. For children unable to undergo imaging without deep sedation, neurodevelopmental and behavioral outcomes will be used to identify brain injury.

Discussion

Neuroimaging is a well-established, valid proxy for neurological outcomes after brain injury in pediatric CNS malaria. This MRI ancillary study will add value to the Fever RCT by determining if treatment with aggressive antipyretic therapy is neuroprotective in CNS malaria. It may also help elucidate the underlying mechanism(s) of neuroprotection and expand upon FEVER RCT safety assessments.

Associations Between Core Temperature Disorders and Outcomes of Pediatric Intensive Care Unit Patients

BACKGROUND

The few studies of associations between fever and outcomes in pediatric intensive care unit (PICU) patients have conflicting findings. Associations between hypothermia and patient outcomes have not been studied.

OBJECTIVE

To investigate the incidence and characteristics of fever and hypothermia and their associations with adverse outcomes among PICU patients.

METHODS

Patients consecutively admitted to 2 PICUs in a 2-year period were prospectively studied. Core temperature was mainly measured by rectal or axillary thermometry. Fever and hypothermia were defined as core temperatures of greater than 38.0 °C and less than 36.0 °C, respectively. Prolonged mechanical ventilation, prolonged PICU stay, and PICU mortality were the adverse patient outcomes studied. Associations between patient outcomes and core temperature disorders were evaluated with univariate comparisons and multivariate analyses.

RESULTS

Of 545 patients enrolled, fever occurred in 299 (54.9%) and hypothermia occurred in 161 (29.5%). Both temperature disorders were independently associated with prolonged mechanical ventilation and prolonged PICU stay (P < .001) but not with PICU mortality. Late onset of fever (P < .001) and hypothermia (P = .009) were independently associated with prolonged mechanical ventilation, fever magnitude and duration (both P < .001) were independently associated with prolonged PICU stay, and fever magnitude (P < .001) and infectious cause of hypothermia (P= .01) were independently associated with higher PICU mortality.

CONCLUSIONS

These findings provide evidence that the manifestation and characteristics of fever and hypothermia are independent predictors of adverse outcomes in PICU patients.

Approaches to neuroprotection in pediatric neurocritical care

Acute neurologic injuries represent a common cause of morbidity and mortality in children presenting to the pediatric intensive care unit. After primary neurologic insults, there may be cerebral brain tissue that remains at risk of secondary insults, which can lead to worsening neurologic injury and unfavorable outcomes. A fundamental goal of pediatric neurocritical care is to mitigate the impact of secondary neurologic injury and improve neurologic outcomes for critically ill children. This review describes the physiologic framework by which strategies in pediatric neurocritical care are designed to reduce the impact of secondary brain injury and improve functional outcomes. Here, we present current and emerging strategies for optimizing neuroprotective strategies in critically ill children.

Aggressive antipyretics in central nervous system malaria: Study protocol of a randomized-controlled trial assessing antipyretic efficacy and parasite clearance effects (Malaria FEVER study)

BACKGROUND

Malaria remains a major public health challenge in Africa where annually, ~250,000 children with malaria experience a neurologic injury with subsequent neuro-disability. Evidence indicates that a higher temperature during the acute illness is a risk factor for post-infectious neurologic sequelae. As such, aggressive antipyretic therapy may be warranted among children with complicated malaria at substantial risk of brain injury. Previous clinical trials conducted primarily in children with uncomplicated malaria and using only a single antipyretic medication have shown limited benefits in terms of fever reduction; however, no studies to date have examined malaria fever management using dual therapies. In this clinical trial of aggressive antipyretic therapy, children hospitalized with central nervous system (CNS) malaria will be randomized to usual care (acetaminophen every 6 hours for a temperature ≥ 38.5°C) vs. prophylactic acetaminophen and ibuprofen every 6 hours for 72 hours.

METHODS

In this double-blinded, placebo controlled, two-armed clinical trial, we will enroll 284 participants from three settings at Queen Elizabeth Central Hospital in Blantyre, Malawi; at the University Teaching Hospitals Children's Hospital in Lusaka, Zambia and at Chipata Central Hospital, Chipata, Zambia. Parents or guardians must provide written informed consent. Eligible participants are 2-11 years with evidence of P. falciparum malaria infection by peripheral blood smear or rapid diagnostic test with CNS symptoms associated with malaria. Eligible children will receive treatment allocation randomization either to standard of care for fever management or to prophylactic, scheduled treatment every 6 hours for 72 hours with dual antipyretic therapies using acetaminophen and ibuprofen. Assignment to treatment groups will be with 1:1 allocation using blocked randomization. The primary outcome will be maximum temperature in the 72 hours after enrolment. Secondary outcomes include parasite clearance as determined by quantitative Histidine Rich Protein II and seizures through 72 hours after enrolment.

DISCUSSION

This clinical trial seeks to challenge the practice paradigm of limited fever treatment based upon hyperpyrexia by evaluating the fever-reduction efficacy of more aggressive antipyretic using two antipyretics and prophylactic administration and will elucidate the impact of antipyretics on parasite clearance and acute symptomatic seizures. If aggressive antipyretic therapy is shown to safely reduce the maximum temperature, a clinical trial evaluating the neuroprotective effects of temperature reduction in CNS malaria is warranted.

Effects of inpatient rehabilitation after acute care on functional and quality-of-life outcomes in children with severe traumatic brain injury

OBJECTIVE

Few studies have assessed the effectiveness of the rehabilitation process in children surviving severe traumatic brain injury (TBI). We evaluated whether receiving inpatient rehabilitation after acute hospitalization was associated with better functional outcomes compared to receiving only non-inpatient rehabilitation in children with severe TBI and explored an effect modification for Glasgow Coma Scale (GCS) score at hospital discharge.

METHODS

We included 254 children who received rehabilitation following severe TBI from a multinational observational study. The Pediatric Glasgow Outcome Scale - Extended (GOS-E Peds), parent/guardian-reported and child-reported Pediatric Quality of Life Inventory (PedsQL) at 12 months post-injury were assessed and described using summary statistics. Unadjusted and propensity score-weighted linear/ordinal logistic regression modeling were also performed.

RESULTS

180 children received inpatient rehabilitation and 74 children received only non-inpatient rehabilitation after acute hospitalization. Among children with a GCS<13 at discharge, those receiving inpatient rehabilitation had a more favorable GOS-E Peds score (OR = 0.12, p = 0.045). However, no such association was observed in children with a higher GCS. We found no differences in PedsQL scores between rehabilitation groups.

CONCLUSIONS

Future studies are warranted to confirm the benefits of inpatient rehabilitation for children with more severely impaired consciousness when medically stable.

Trajectory of Long-Term Outcome in Severe Pediatric Diffuse Axonal Injury: An Exploratory Study

Introduction: Pediatric severe traumatic brain injury (TBI) is one of the leading causes of disability and death. One of the classic pathoanatomic brain injury lesions following severe pediatric TBI is diffuse (multifocal) axonal injury (DAI). In this single institution study, our overarching goal was to describe the clinical characteristics and long-term outcome trajectory of severe pediatric TBI patients with DAI.

Methods: Pediatric patients (<18 years of age) with severe TBI who had DAI were retrospectively reviewed. We evaluated the effect of age, sex, Glasgow Coma Scale (GCS) score, early fever ≥ 38.5°C during the first day post-injury, the extent of ICP-directed therapy needed with the Pediatric Intensity Level of Therapy (PILOT) score, and MRI within the first week following trauma and analyzed their association with outcome using the Glasgow Outcome Score—Extended (GOS-E) scale at discharge, 6 months, 1, 5, and 10 years following injury.

Results: Fifty-six pediatric patients with severe traumatic DAI were analyzed. The majority of the patients were >5 years of age and male. There were 2 mortalities. At discharge, 56% (30/54) of the surviving patients had unfavorable outcome. Sixty five percent (35/54) of surviving children were followed up to 10 years post-injury, and 71% (25/35) of them made a favorable recovery. Early fever and extensive DAI on MRI were associated with worse long-term outcomes.

Conclusion: We describe the long-term trajectory outcome of severe pediatric TBI patients with pure DAI. While this was a single institution study with a small sample size, the majority of the children survived. Over one-third of our surviving children were lost to follow-up. Of the surviving children who had follow-up for 10 years after injury, the majority of these children made a favorable recovery.

Inflammation in Traumatic Brain Injury

There is an increasing evidence that inflammation contributes to clinical and functional outcomes in traumatic brain injury (TBI). Many successful target-engaging, lesion-reducing, symptom-alleviating, and function-improving interventions in animal models of TBI have failed to show efficacy in clinical trials. Timing and immunological context are paramount for the direction, quality, and intensity of immune responses to TBI and the resulting neuroanatomical, clinical, and functional course. We present components of the immune system implicated in TBI, potential immune targets, and target-engaging interventions. The main objective of our article is to point toward modifiable molecular and cellular mechanisms that may modify the outcomes in TBI, and contribute to increasing the translational value of interventions that have been identified in animal models of TBI.

Amount of Brain Edema Correlates With Neurologic Recovery in Pediatric Cerebral Malaria

BACKGROUND

Cerebral malaria (CM) remains a leading cause of mortality and morbidity in children in sub-Saharan Africa. Recent studies using brain magnetic resonance imaging have revealed increased brain volume as a major predictor of death. Similar morphometric predictors of morbidity at discharge are lacking. The aim of this study was to investigate the utility of serial cranial cisternal cerebrospinal fluid (CSF) volume measurements in predicting morbidity at discharge in pediatric CM survivors.

METHODS

In this case-control study, 54 Malawian pediatric CM survivors with neurologic sequelae evident at discharge who underwent serial magnetic resonance imaging scans while comatose were matched to concurrently admitted children with serial imaging who made full recoveries. Serial cranial cisternal CSF volume quantified by radiologists blinded to outcome was evaluated as a predictor of neurologic deficits at discharge. The probability of neurologic sequelae was determined using a model that included coma duration and changes in cisternal CSF volume over time.

RESULTS

Coma duration before admission was similar between cases and controls (16.1 vs. 15.3; P = 0.81), but overall coma was longer among children with sequelae (60 vs. 38 hours; P < 0.01). Lower initial CSF volumes and decreased volumes over time were both associated with a higher probability of neurologic sequelae at discharge.

CONCLUSIONS

Among pediatric CM survivors with prolonged coma, lower initial CSF volume and decreasing volume during coma is associated with neurologic sequelae at discharge. These findings suggest that cerebral edema is an underlying contributor to both morbidity and mortality in pediatric CM.

Mortality And Morbidity of Severe Traumatic Brain Injuries; A Pediatric Intensive Care Unit Experience Over 15 Years

Objective

To determine the mortality, morbidity, types of intracranial hemorrhages, and factors associated with length of stay (LOS) associated with accidental traumatic brain injury (TBI) at a pediatric intensive care unit (PICU) of a regional trauma center in an Asian city.

Methods

This study is a retrospective review of types of head injury, mortality and morbidity demographics of patients admitted to a PICU with TBI. All patients with accidental TBI were included, namely road traffic injury (RTI) and fall, and their demographics compared. Non-accidental injuries (NAI) were excluded.

Results

95 children (78% males) were admitted to a PICU with RTI or falls from 2002 to 2017. They accounted for 3.7% of PICU admissions. Comparing with falls, victims of RTI were older (p<0.001) and more likely to suffer from skull fracture (p=0.017). There were 4 deaths with falls (6.8%) but none with RTI. Subarachnoid hemorrhages, extradural hemorrhages, the use of mechanical ventilation, inotropes and neurological supports were associated with longer LOS in PICU in these injuries (p<0.001).

Conclusion

A longer PICU LOS is associated with extradural and subarachnoid hemorrhages, usage of inotropes, mechanical ventilation and neurological supports in falls and RTI. Three-quarters of victims are males. Preventive health education should be especially directed to boys to reduce severe TBI in this Asian city.

Chronic Alterations in Systemic Immune Function after Traumatic Brain Injury

There is a compelling link between severe brain trauma and immunosuppression in patients with traumatic brain injury (TBI). Although acute changes in the systemic immune compartment have been linked to outcome severity, the long-term consequences of TBI on systemic immune function are unknown. Here, adult male C57Bl/6 mice underwent moderate-level controlled cortical impact (CCI) or sham surgery, and systemic immune function was evaluated at 1, 3, 7, 14, and 60 days post-injury. Bone marrow, blood, thymus, and spleen were examined by flow cytometry to assess changes in immune composition, reactive oxygen species (ROS) production, phagocytic activity, and cytokine production. Bone marrow derived macrophages (BMDMs) from sham and 60-day CCI mice were cultured for immune challenge studies using lipopolysaccharide (LPS) and interleukin-4 (IL-4) models. Acutely, TBI caused robust bone marrow activation and neutrophilia. Neutrophils and monocytes exhibited impairments in respiratory burst, cytokine production, and phagocytosis; in contrast, ROS levels and pro-inflammatory cytokine production were chronically elevated at 60 days post-injury. Cultures of BMDMs from chronic CCI mice demonstrated defects in LPS- and IL-4-induced polarization when compared with stimulated BMDMs from sham mice. TBI also caused thymic involution, inverted CD4:CD8 ratios, chronic T lymphopenia, greater memory conversion, increased T cell activation, impaired interferon γ induction, and chronically elevated Th1 cytokine and ROS production. Collectively, our in-depth phenotypic and functional analyses demonstrate that TBI induces widespread suppression of innate and adaptive immune responses after TBI. Moreover, at chronic time points, TBI mice exhibit hallmarks of accelerated immune aging, displaying chronic deficits in systemic immune function.

Reduction of hyperthermia in pediatric patients with severe traumatic brain injury: a quality improvement initiative

OBJECTIVE Severe traumatic brain injury remains a leading cause of morbidity and mortality in the pediatric population. Providers focus on reducing secondary brain injury by avoiding hypoxemia, avoiding hypotension, providing normoventilation, treating intracranial hypertension, and reducing cerebral metabolic demand. Hyperthermia is frequently present in patients with severe traumatic brain injury, contributes to cerebral metabolic demand, and is associated with prolonged hospital admission as well as impaired neurological outcome. The objective of this quality improvement initiative was to reduce the duration of hyperthermia for pediatric patients with severe traumatic brain injury during the initial 72 hours of admission to the pediatric intensive care unit. METHODS A retrospective chart review was performed to evaluate the incidence and duration of hyperthermia within a preintervention cohort. The retrospective phase was followed by three 6-month intervention periods (intervention Phase 1, the maintenance phase, and intervention Phase 2). Intervention Phase 1 entailed placement of a cooling blanket on the bed prior to patient arrival and turning it on once the patient's temperature rose above normothermia. The maintenance phase focused on sustaining the results of Phase 1. Intervention Phase 2 focused on total prevention of hyperthermia by initiating cooling blanket use immediately upon patient arrival to the intensive care unit. RESULTS The median hyperthermia duration in the preintervention cohort (n = 47) was 135 minutes. This was reduced in the Phase 1 cohort (n = 9) to 45 minutes, increased in the maintenance phase cohort (n = 6) to 88.5 minutes, and decreased again in the Phase 2 cohort (n = 9) to a median value of 0 minutes. Eight percent of patients in the intervention cohorts required additional sedation to tolerate the cooling blanket. Eight percent of patients in the intervention cohorts became briefly hypothermic while on the cooling blanket. No patient required neuromuscular blockade to tolerate the cooling blanket, experienced an arrhythmia, had new coagulopathy, or developed a pressure ulcer. CONCLUSIONS The placement of a cooling blanket on the bed prior to patient arrival and actively targeting normothermia successfully reduced the incidence and duration of hyperthermia with minimal adverse events.

Retrospective evaluation of 140 dogs involved in road traffic accidents

This study has retrospectively reviewed the medical records of 140 dogs sustaining road traffic accident (RTA), and has examined the population characteristics, medical history, injury type, physical examination, emergency laboratory tests and radiography findings, the animal trauma triage (ATT) score, the length of hospitalisation, the complications and the outcome. The survival rate was 83.2 per cent. Younger dogs sustained more frequently lung contusions and limb fractures, while larger dogs more frequently suffered limb fractures, and smaller dogs and older ones sustained more frequently pelvic fractures and sacroiliac luxation (P<0.05 for all). Dogs sustaining orthopaedic injuries required longer hospitalisation (P<0.001). The survival rates of non-ambulatory dogs (P<0.001) and those with neurological abnormalities (P<0.001), abnormal body temperature (P=0.001), hyperglycaemia (P=0.026) or hypoproteinaemia (P=0.04) at presentation were lower compared with those in which these were absent. The number of injured body systems was significantly (P<0.001) and positively associated with death. Dogs surviving RTA to presentation to the hospital have a good prognosis for survival to discharge. Older age, and high ATT score, abnormal body temperature, neurological deficits, hyperglycaemia and hypoproteinaemia at presentation, and occurrence of multiorgan trauma are negative prognostic indicators in such dogs.

Development and implementation of a standardized pathway in the Pediatric Intensive Care Unit for children with severe traumatic brain injuries

Severe traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children. In 2003 and 2012, the Brain Trauma Foundation established and refined evidence-based guidelines for management of severe TBI in children. A recent multicenter study demonstrated an association between TBI guideline adherence and improved discharge survival. However, this study also showed large variation in adherence to pediatric TBI management at our level 1 pediatric trauma center, where overall adherence to fourteen pediatric intensive care unit (PICU) TBI clinical indicators was 64%. The aim of this quality improvement project was to increase TBI guideline adherence by implementing a standard care pathway for PICU management of children with severe TBI. A multi-disciplinary approach was utilized to develop the Pediatric Guideline Adherence and Outcomes (PEGASUS) care pathway, and iterative PDCA cycles were performed. Over an 18 month period following pathway implementation, overall PICU clinical guideline adherence rate increased to 80%.

Keep the brain cool--endovascular cooling in patients with severe traumatic brain injury: a case series study

BACKGROUND

As brain temperature is reported to be extensively higher than core body temperature in traumatic brain injury (TBI) patients, posttraumatic hyperthermia is of particular relevance in the injured brain.

OBJECTIVE

To study the influence of prophylactic normothermia on brain temperature and the temperature gradient between brain and core body in patients with severe TBI using an intravascular cooling system and to assess the relationship between brain temperature and intracranial pressure (ICP) under endovascular temperature control.

METHODS

Prospective case series study conducted in the neurologic intensive care unit of a tertiary care university hospital. Seven patients with severe TBI with a Glasgow Coma Scale score of 8 or less were consecutively enrolled. Prophylactic normothermia, defined as a target temperature of 36.5°C, was maintained using an intravascular cooling system. Simultaneous measurements of brain and urinary bladder temperature and ICP were taken over a 72-hour period.

RESULTS

The mean bladder temperature in normothermic patients was 36.3 ± 0.4°C, and the mean brain temperature was determined as 36.4 ± 0.5°C. The mean temperature difference between brain and bladder was 0.1°C. We found a significant direct correlation between brain and bladder temperature (r = 0.95). In 52.4% of all measurements, brain temperature was higher than core body temperature. The mean ICP was 18 ± 8 mm Hg.

CONCLUSION

Intravascular temperature management stabilizes both brain and body core temperature; prophylactic normothermia reduces the otherwise extreme increase of intracerebral temperature in patients with severe TBI. The intravascular cooling management proved to be an efficacious and feasible method to control brain temperature and to avoid hyperthermia in the injured brain. We could not find a statistically significant correlation between brain temperature and ICP.

Temperature patterns in the early postresuscitation period after pediatric inhospital cardiac arrest

OBJECTIVE

To describe the prevalence of postarrest hyperthermia among children during the first 24 hrs after inhospital cardiac arrest and to determine the association of persistent postarrest hyperthermia with neurologic outcome and death before hospital discharge.

DESIGN

Multicenter, national registry of inhospital cardiopulmonary resuscitation.

SETTING

A total of 196 hospitals reporting to the American Heart Association's National Registry of Cardiopulmonary Resuscitation from January 1, 2005 to December 31, 2007.

PATIENTS

A total of 547 pediatric patients who suffered inhospital pulseless cardiac arrests reported to the National Registry of Cardiopulmonary Resuscitation, who survived resuscitative efforts and who had the maximum and the minimum temperature in the first 24 hrs postresuscitation reported to the National Registry of Cardiopulmonary Resuscitation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Among 547 children with pulseless cardiac arrests, 238 (43.5%) had at least one temperature of ≥38°C, and 30 (5.5%) had "persistent hyperthermia" (i.e., both the minimum and the maximum temperature of ≥38°C) during the first 24 hrs postarrest. After adjusting for potential confounders by multivariate logistic regression, persistent hyperthermia in the first 24 hrs postarrest was associated with unfavorable neurologic outcome (adjusted odds ratio, 2.7; 95% confidence interval, 1.1-6.7), but not with death before hospital discharge (adjusted odds ratio, 1.2; 95% confidence interval, 0.4-3.4).

CONCLUSIONS

Despite current guidelines to avoid postarrest hyperthermia, a temperature of ≥38°C occurred commonly among children in the first 24 hrs postarrest. Persistent postarrest hyperthermia was associated with unfavorable neurologic outcomes, even after controlling for potential confounding factors.

Cerebrovascular pathophysiology in pediatric traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI) is the leading cause of traumatic morbidity and mortality in children. Although there is increasing information concerning TBI in adults and experimental animal models, relatively little is known regarding cerebrovascular pathophysiology specific to children.

MATERIALS

A review of the pertinent medical literature.

RESULTS

Systemic and cerebral hemodynamic factors such as hypotension, hypoxia, hyperglycemia, and fever are associated with poor outcome in pediatric TBI. Similarly, cerebral autoregulation is often impaired after TBI and may adversely affect outcome, especially if systemic hemodynamics are altered. Furthermore, CO2 vasoreactivity may be altered after pediatric TBI and lead to either cerebral ischemia or hyperemia.

CONCLUSIONS

Understanding the effect of pediatric TBI on the cerebral circulation is needed to potentially develop protocols to improve outcome in this vulnerable population. Specifically, changes in pediatric cerebrovascular physiology and pathophysiology, including CO2 vasoreactivity and pressure autoregulation, must be understood and their mechanism elucidated.

Fever During Pediatric Intensive Care Unit Admission Is Independently Associated With Increased Morbidity

Aims: To investigate the occurrence and etiology of fever at anytime during pediatric intensive care unit (PICU) admission, and to study its possible effects on clinical outcome in a heterogeneous population of critically ill children. Methods: Retrospective, observational single-center study, comprising 202 patients aged 0 to 18 years, admitted during a 6-month period between January and June 2004. Demographic and clinical data were collected. Fever was defined by a core temperature ≥38.3°C. Outcomes of interest were duration of mechanical ventilation (MV) and PICU stay. Statistical analyses were done using nonparametric univariate analysis and multivariate Cox’s regression analysis. Results: Fever during PICU stay occurred in 82 of 202 children (40.6%). Demographic, clinical, and laboratory data of febrile patients were compared to data of nonfebrile patients. In 76 of the febrile patients (92.7%), fever occurred in the first 48 hours of admission and was associated with primary diagnosis in all cases. Six patients developed fever after 48 hours of admission and 8 patients developed a new febrile period after 48 nonfebrile hours. At least 50% of the late-onset fever was caused by cultured proven nosocomial infections, in the other cases a nosocomial infection was suspected. Fever after 48 hours of PICU admission or a secondary episode of fever was independently associated with prolonged length of ventilatory support and prolonged length of PICU stay. Conclusions: Fever in critically ill children occurs frequently during PICU stay. Fever after 48 hours of admission or new episodes of fever after 48 nonfebrile hours were mainly caused by nosocomial infections and was independently associated with prolonged length of ventilatory support and PICU stay.

Induced normothermia attenuates intracranial hypertension and reduces fever burden after severe traumatic brain injury

INTRODUCTION

Hyperthermia following a severe traumatic brain injury (TBI) is common, potentiates secondary injury, and worsens neurological outcome. Conventional fever treatment is often ineffective. An induced normothermia protocol, utilizing intravascular cooling, was used to assess the impact on fever incidence and intracranial pressure (ICP) in patients with severe TBI.

METHODS

A comparative cohort study of 21 adult patients with severe TBI (GCS <or= 8) treated with induced normothermia [36-36.5 degrees C rectal probe setting; intravascular cooling catheter (CoolLine, Alsius Corporation, Irvine, CA)] were matched by age, gender, and severity of injury to 21 historical control severe TBI patients treated with conventional fever control methods. ICP was measured via an external ventricular catheter and time duration for ICP > 25 mmHg was calculated for the initial 72-h monitoring period. Non-parametric rank tests were performed.

RESULTS

Mean (+/-SD) or median [range] demographics did not differ between groups [total N = 42 (6 female, 36 male, age 36.4 +/- 14.8 years and initial GCS 7 [3-8], median and range]. Fever burden in the first 3 days (time >38 degrees C) in the induced normothermia versus control group was significantly less at 1.6% versus 10.6%, respectively (P = 0.03). Mean ICP for patients with induced normothermia versus control was 12.74 +/- 4.0 and 16.37 +/- 6.9 mmHg, respectively. Furthermore, percentage of time with ICP > 25 mmHg was significantly less in the induced normothermia group (P = 0.03).

CONCLUSION

Induced normothermia (fever prophylaxis via intravascular cooling catheter) is effective in reducing fever burden and may offer a means to attenuate secondary injury, as evidenced by a reduction in the intracranial hypertension burden.

The significance of altered temperature after traumatic brain injury: an analysis of investigations in experimental and human studies: part 2

Raised body temperature is a common occurrence after severe traumatic brain injury (TBI). It is widely accepted that experimental evidence points to a harmful effect of raised temperature both during and after TBI. Consequently, the policy of many neurocritical care units is to implement therapies for body temperature control. This article reviews the evidence that links spontaneous temperature changes with worsened outcome after experimentally-induced and human brain trauma. The current evidence-base and rationale for treatment of raised temperature after TBI is presented with discussion positing areas for further work to explore the notion that raised temperature may not be deleterious in all neurosurgical patients.

Cytokines and Brain Injury: Invited Review

The brain reacts to injury or disease by cascades of cellular and molecular responses. Evidence suggests that immune-inflammatory processes are key elements in the physiopathological processes associated with brain injury or damage. Cytokines are among major mediators implicated in these processes. Cytokine responses in the initial phase of brain injury might have a role in aggravating brain damage. However, in later stages, these molecular mediators might contribute to recovery or repair. Hemodynamic stabilization and optimalization of oxygen delivery to the brain remain cornerstones in the management of acute brain injury. New approaches might use anticytokine therapy to limit progression and halt or attenuate secondary brain damage. Progress toward such novel neuroprotection strategies, however, awaits better understanding of the optimal timing and dosing of those neuromodulatory therapies and better knowledge of the numerous interactions of those mediators. This also requires understanding of how and when precisely immune mechanisms shift from noxious to protective or restorative actions.

Antipyretic treatment of noninfectious fever in children with severe traumatic brain injury

OBJECTIVE

The purpose of this study was to describe the treatment of noninfectious fever in children with severe traumatic brain injury (TBI).

MATERIALS AND METHODS

We conducted a retrospective study to compare type of and response to antipyretic treatment strategies in children less than or equal to 17 years and Glasgow Coma Scale (GCS) score less than 9.

RESULTS

The average admission GCS score was 4. Forty children (35 boys, 5 girls), age 7.8 +/- 5.2 years, had noninfectious fever. Seventy percent (28 of 40) received acetaminophen only, and 30% (12 of 40) received acetaminophen plus either ibuprofen or physical cooling. Time to next febrile episode was longer in patients receiving combination therapy than those receiving monotherapy (p = 0.03). Fever refractory to treatment dose or strategy occurred in more than 40% of the patients.

CONCLUSIONS

Early combination antipyretic therapy may be needed to effectively maintain normothermia in children with severe TBI.

Cerebral blood flow and autoregulation after pediatric traumatic brain injury

Traumatic brain injury is a global health concern and is the leading cause of traumatic morbidity and mortality in children. Despite a lower overall mortality than in adult traumatic brain injury, the cost to society from the sequelae of pediatric traumatic brain injury is very high. Predictors of poor outcome after traumatic brain injury include altered systemic and cerebral physiology, including altered cerebral hemodynamics. Cerebral autoregulation is often impaired after traumatic brain injury and may adversely impact the outcome. Although altered cerebrovascular hemodynamics early after traumatic brain injury may contribute to disability in children, there is little information regarding changes in cerebral blood flow and cerebral autoregulation after pediatric traumatic brain injury. This review addresses normal pediatric cerebral physiology and cerebrovascular pathophysiology after pediatric traumatic brain injury.

Neuroanesthesiology review--2006

In this article, we will provide a review of the 2006 literature of interest to those readers who provide perioperative care to patients with neurologic disease. This evaluation of the literature is not intended to be comprehensive, nor were systematic criteria used to include or exclude articles. Instead, the authors attempted to highlight those articles of greatest clinical relevance or those that provided unique insights into the physiology, pharmacology, and pathomechanisms of neurologic function for practicing clinicians and clinician-investigators. This article focuses on intracranial hemorrhage, anesthetic considerations in neurosurgical patients, cerebral hemodynamics, electrophysiologic monitoring, neuroprotection, and traumatic brain injury.

Hyperthermia and central nervous system injury

Fever is a common occurrence in patients following brain and spinal cord injury (SCI). In intensive care units, large numbers of patients demonstrate febrile periods during the first several days after injury. Over the last several years, experimental studies have reported the detrimental effects of fever in various models of central nervous system (CNS) injury. Small elevations in temperature during or following an insult have been shown to worsen histopathological and behavioral outcome. Thus, the control of fever after brain or SCI may improve outcome if more effective strategies for monitoring and treating hyperthermia were developed. Because of the clinical importance of fever as a potential secondary injury mechanism, mechanisms underlying the detrimental effects of mild hyperthermia after injury have been evaluated. To this end, studies have shown that mild hyperthermia (>37 degrees C) can aggravate multiple pathomechanisms, including excitotoxicity, free radical generation, inflammation, apoptosis, and genetic responses to injury. Recent data indicate that gender differences also play a role in the consequences of secondary hyperthermia in animal models of brain injury. The observation that dissociations between brain and body temperature often occur in head-injured patients has again emphasized the importance of controlling temperature fluctuations after injury. Thus, increased emphasis on the ability to monitor CNS temperature and prevent periods of fever has gained increased attention in the clinical literature. Cooling blankets, body vests, and endovascular catheters have been shown to prevent elevations in body temperature in some patient populations. This chapter will summarize evidence regarding hyperthermia and CNS injury.