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Kochar A, Hildebrandt K, Silverstein R, Appavu B. Approaches to neuroprotection in pediatric neurocritical care. World J Crit Care Med 2023; 12:116-129. [PMID: 37397588 PMCID: PMC10308339 DOI: 10.5492/wjccm.v12.i3.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/30/2023] [Accepted: 04/12/2023] [Indexed: 06/08/2023] Open
Abstract
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.
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Affiliation(s)
- Angad Kochar
- Department of Neurosciences, Phoenix Children's Hospital, Phoenix, AZ 85213, United States
| | - Kara Hildebrandt
- Department of Neurosciences, Phoenix Children's Hospital, Phoenix, AZ 85213, United States
| | - Rebecca Silverstein
- Department of Neurosciences, Phoenix Children's Hospital, Phoenix, AZ 85213, United States
| | - Brian Appavu
- Department of Neurosciences, Phoenix Children's Hospital, Phoenix, AZ 85213, United States
- Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, AZ 85016, United States
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Eser P, Corabay S, Ozmarasali AI, Ocakoglu G, Taskapilioglu MO. The association between hematologic parameters and intracranial injuries in pediatric patients with traumatic brain injury. Brain Inj 2022; 36:740-749. [PMID: 35608540 DOI: 10.1080/02699052.2022.2077442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVE Analyzing the association between hematologic parameters and abnormal cranial computerized tomography (CT) findings after head trauma. MATERIAL AND METHODS A total of 287 children with isolated traumatic brain injury (TBI) were divided into the 'normal' (NG), 'linear fracture' (LFG) and 'intraparenchymal injury' groups (IPG) based on head CT findings. Demographical/clinical data and laboratory results were obtained from medical records. RESULTS The neutrophil-lymphocyte ratio was markedly higher in the LFG (p = 0.010 and p = 0.016, respectively) and IPG (p = 0.004 and p < 0.001, respectively) compared with NG. Lower lymphocyte-monocyte ratio (p = 0.044) and higher red cell distribution width-platelet ratio (RPR) (p = 0.030) were associated with intraparenchymal injuries. Patients requiring neurosurgical intervention had higher neutrophil-lymphocyte ratio (p = 0.026) and RPR values (p = 0.031) and lower platelet counts (p = 0.035). Lower levels of erythrocytes (p = 0.005), hemoglobin (p = 0.003) and hematocrit (p = 0.002) were associated with severe TBI and unfavorable outcome (p = 0.012, p = 0.004 and p = 0.006, respectively). CONCLUSIONS Hematologic parameters are useful in predicting the presence of abnormal cranial CT findings in children with TBI in association with injury severity; surgery need and clinical outcome.
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Affiliation(s)
- Pinar Eser
- Department of Neurosurgery, Bursa Uludag University Faculty of Medicine, Turkey, Bursa
| | - Seniha Corabay
- Department of Biostatistics, Bursa Uludag University Faculty of Medicine, Turkey, Bursa
| | - Ali Imran Ozmarasali
- Department of Neurosurgery, Bursa Uludag University Faculty of Medicine, Turkey, Bursa
| | - Gokhan Ocakoglu
- Department of Biostatistics, Bursa Uludag University Faculty of Medicine, Turkey, Bursa
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Ashraf M, Kamboh UA, Zubair M, Sultan KA, Raza MA, Hussain SS, Ashraf N. Prevalence of anemia in pediatric patients of traumatic brain injury and problems associated with management in a developing country: Unfolding of an underrated comorbidity. Surg Neurol Int 2021; 12:75. [PMID: 33767879 PMCID: PMC7982091 DOI: 10.25259/sni_944_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 02/05/2021] [Indexed: 11/04/2022] Open
Abstract
Background Pediatric anemia has a high prevalence in developing countries such as Pakistan. It is common knowledge among hospital specialties but little is done to manage this condition by hospitalists. The issue is compounded with a poor primary care infrastructure nationally. The aim of this study is to bring to light the high prevalence of anemic children in neurosurgery and to describe the difficulties in managing their anemia in a tertiary hospital setting. A literature review is presented highlighting the socioeconomic difficulties that contribute to this widespread comorbidity and the difficulty in managing it from a hospital specialty point of view. Methods A prospective descriptive case series was carried out between March 2020 and September 2020. All patients under the age of 13 who presented to our department for traumatic brain injury (TBI) meeting our inclusion and exclusion criteria were enrolled and assessed for the presence and severity of anemia. Demographic data were collected. Following discharge, patients were referred to our hospital's pediatrics' anemia clinic which was before their first neurosurgery follow-up 2 weeks following discharge and attendance to follow up was documented. Results The prevalence of anemia was 78.9%. Over 95% of patients attended their neurosurgery follow-up but only 28% of patients attended their referral to the anemia clinic. Conclusion Anemia is highly prevalent in children presenting to neurosurgery for TBI and its longitudinal management has difficulties with lost to follow up in a tertiary hospital setting. There is a need for national initiatives to reduce the prevalence of anemia but concurrently better strategies need to be devised to manage anemic children in a hospital setting.
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Affiliation(s)
- Mohammad Ashraf
- Medical Student, Wolfson School of Medicine, University of Glasgow, Glasgow, Scotland, United Kingdom.,Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Lahore, Punjab, Pakistan
| | - Usman Ahmad Kamboh
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Lahore, Punjab, Pakistan
| | - Mohammad Zubair
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Lahore, Punjab, Pakistan
| | - Kashif Ali Sultan
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Lahore, Punjab, Pakistan
| | - Muhammad Asif Raza
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Lahore, Punjab, Pakistan
| | - Syed Shahzad Hussain
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Lahore, Punjab, Pakistan
| | - Naveed Ashraf
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Lahore, Punjab, Pakistan
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Even KM, Subramanian S, Berger RP, Kochanek PM, Zuccoli G, Gaines BA, Fink EL. The Presence of Anemia in Children with Abusive Head Trauma. J Pediatr 2020; 223:148-155.e2. [PMID: 32532650 DOI: 10.1016/j.jpeds.2020.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/03/2020] [Accepted: 04/02/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To evaluate the incidence of anemia in patients with abusive head trauma (AHT), noninflicted traumatic brain injury (TBI), and physical abuse without AHT and the effect of anemia on outcome. STUDY DESIGN In a retrospective, single-center cohort study, we included children under the age of 3 years diagnosed with either AHT (n = 75), noninflicted TBI (n = 77), or physical abuse without AHT (n = 60) between January 1, 2014, and December 31, 2016. Neuroimaging was prospectively analyzed by pediatric neuroradiologists. Primary outcome was anemia at hospital presentation. Secondary outcomes included unfavorable outcome at hospital discharge, defined as a Glasgow Outcome Scale between 1 and 3, and intracranial hemorrhage (ICH) volume. RESULTS Patients with AHT had a higher rate of anemia on presentation (47.3%) vs noninflicted TBI (15.6%) and physical abuse without AHT (10%) (P < .001). Patients with AHT had larger ICH volumes (33.3 mL [10.1-76.4 mL] vs 1.5 mL [0.6-5.2 mL] ; P < .001) and greater ICH/total brain volume percentages than patients with noninflicted TBI (4.6% [1.4-8.2 %] vs 0.2% [0.1-0.7%]; P < .001). Anemia was associated with AHT (OR, 4.7; 95% CI, 2.2-10.2) and larger ICH/total brain volume percentage (OR, 1.1; 95% CI, 1.1-1.2) in univariate analysis. Unfavorable outcome at hospital discharge was associated with anemia (OR, 4.4; 95% CI, 1.6-12.6) in univariate analysis, but not after controlling for covariates. CONCLUSIONS Patients with AHT were more likely to present to the hospital with anemia and increased traumatic ICH volume than patients with noninflicted TBI or physical abuse without AHT. Children with anemia and AHT may be at increased risk for an unfavorable outcome.
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Affiliation(s)
- Katelyn M Even
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA.
| | - Subramanian Subramanian
- Department of Radiology, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Rachel P Berger
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA; Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Patrick M Kochanek
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA; Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Giulio Zuccoli
- Department of Radiology, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Barbara A Gaines
- Department of Surgery, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA; Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Luo HC, Fu YQ, You CY, Liu CJ, Xu F. Comparison of admission serum albumin and hemoglobin as predictors of outcome in children with moderate to severe traumatic brain injury: A retrospective study. Medicine (Baltimore) 2019; 98:e17806. [PMID: 31689863 PMCID: PMC6946495 DOI: 10.1097/md.0000000000017806] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Hypoalbuminemia and anemia are frequent among in patients with traumatic brain injury (TBI). We assess whether serum albumin and hemoglobin at admission can predict outcome in children with moderate to severe TBI.This retrospective study was conducted in a tertiary pediatric hospital between May 2012 and Jun 2018 included children with an admission Glasgow Coma Scale of ≤13.A total of 213 patients were included of whom 45 died in hospital. Multivariate logistic regression showed that hypoalbuminemia (serum albumin <30 g/L) was independently associated with mortality (adjusted odds ratio [OR] = 3.059; 95% confidence interval [CI]: 1.118-8.371; P = .030) in children with moderate to severe TBI, while anemia (hemoglobin <90 g/L) was not independently associated with mortality (adjusted OR = 1.742; 95% CI: 0.617-4.916; P = .295). Serum albumin was significantly superior to hemoglobin (area under the curve [AUC] 0.738 vs AUC 0.689, P < .05) under receiver operating characteristic curve analysis. Hypoalbuminemia was also associated with reduced 14-day ventilation-free days, 14-day intensive care unit (ICU)-free days, and 28-day hospital-free days.Serum albumin at admission was superior to hemoglobin in predicting the mortality in children with moderate to severe TBI and also associated with reduced ventilator-free, ICU-free, and hospital-free days.
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Affiliation(s)
- Hong-chun Luo
- Department of Infectious Diseases, The First Affiliated Hospital
| | - Yue-qiang Fu
- Department of Critical Care Medicine, Children's Hospital, Chongqing Medical University
- Ministry of Education Key Laboratory of Child Development and Disorders
- National Clinical Research Center for Child Health and Disorders (Chongqing)
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Cheng-yan You
- Department of Critical Care Medicine, Children's Hospital, Chongqing Medical University
- Ministry of Education Key Laboratory of Child Development and Disorders
- National Clinical Research Center for Child Health and Disorders (Chongqing)
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Cheng-jun Liu
- Department of Critical Care Medicine, Children's Hospital, Chongqing Medical University
- Ministry of Education Key Laboratory of Child Development and Disorders
- National Clinical Research Center for Child Health and Disorders (Chongqing)
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Feng Xu
- Department of Critical Care Medicine, Children's Hospital, Chongqing Medical University
- Ministry of Education Key Laboratory of Child Development and Disorders
- National Clinical Research Center for Child Health and Disorders (Chongqing)
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
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Effect of Age on Glasgow Coma Scale in Patients with Moderate and Severe Traumatic Brain Injury: An Approach with Propensity Score-Matched Population. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:ijerph14111378. [PMID: 29137197 PMCID: PMC5708017 DOI: 10.3390/ijerph14111378] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 11/09/2017] [Accepted: 11/11/2017] [Indexed: 12/29/2022]
Abstract
Background: The most widely used methods of describing traumatic brain injury (TBI) are the Glasgow Coma Scale (GCS) and the Abbreviated Injury Scale (AIS). Recent evidence suggests that presenting GCS in older patients may be higher than that in younger patients for an equivalent anatomical severity of TBI. This study aimed to assess these observations with a propensity-score matching approach using the data from Trauma Registry System in a Level I trauma center. Methods: We included all adult patients (aged ≥20 years old) with moderate to severe TBI from 1 January 2009 to 31 December 2016. Patients were categorized into elderly (aged ≥65 years) and young adults (aged 20–64 years). The severity of TBI was defined by an AIS score in the head (AIS 3‒4 and 5 indicate moderate and severe TBI, respectively). We examined the differences in the GCS scores by age at each head AIS score. Unpaired Student’s t- and Mann–Whitney U-tests were used to analyze normally and non-normally distributed continuous data, respectively. Categorical data were compared using either the Pearson chi-square or two-sided Fisher’s exact tests. Matched patient populations were allocated in a 1:1 ratio according to the propensity scores calculated using NCSS software with the following covariates: sex, pre-existing chronic obstructive pulmonary disease, systolic blood pressure, hemoglobin, sodium, glucose, and alcohol level. Logistic regression was used to evaluate the effects of age on the GCS score in each head AIS stratum. Results: The study population included 2081 adult patients with moderate to severe TBI. These patients were categorized into elderly (n = 847) and young adults (n = 1234): each was exclusively further divided into three groups of patients with head AIS of 3, 4, or 5. In the 162 well-balanced pairs of TBI patients with head AIS of 3, the elderly demonstrated a significantly higher GCS score than the young adults (14.1 ± 2.2 vs. 13.1 ± 3.3, respectively; p = 0.002). In the 362 well-balanced pairs of TBI patients with head AIS of 4, the elderly showed a significantly higher GCS score than the young adults (13.1 ± 3.3 vs. 12.2 ± 3.8, respectively; p = 0.002). In the 89 well-balance pairs of TBI patients with head AIS of 5, no significant differences were observed for the GCS scores. Conclusions: This study demonstrated that elderly patients with moderate TBI present higher GCS score than younger patients. This study underscores the importance of determining of TBI severity in this group of elderly patients based on the GCS score alone. A lower threshold of GCS cutoff should be adopted in the management of the elderly patients with TBI.
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