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Naseri Alavi SA, Habibi MA, Majdi A, Hajikarimloo B, Rashidi F, Fathi Tavani S, Minaee P, Eazi SM, Kobets AJ. Investigating the Safety and Efficacy of Therapeutic Hypothermia in Pediatric Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis. CHILDREN (BASEL, SWITZERLAND) 2024; 11:701. [PMID: 38929280 PMCID: PMC11201645 DOI: 10.3390/children11060701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 05/24/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Prior guidelines recommended maintaining normothermia following traumatic brain injury (TBI), but recent studies suggest therapeutic hypothermia as a viable option in pediatric cases. However, some others demonstrated a higher mortality rate. Hence, the impact of hypothermia on neurological symptoms and overall survival remains contentious. METHODS We conducted a systematic review and meta-analysis to evaluate the effects of hypothermia on neurological outcomes in pediatric TBI patients. The PubMed/Medline, Scopus, and Web of Science databases were searched until 1 January 2024 and data were analyzed using appropriate statistical methods. RESULTS A total of eight studies, comprising nine reports, were included in this analysis. Our meta-analysis did not reveal significant differences in mortality (RR = 1.58; 95% CI = 0.89-2.82, p = 0.055), infection (RR = 0.95: 95% CI = 0.79-1.1, p = 0.6), arrhythmia (RR = 2.85: 95% CI = 0.88-9.2, p = 0.08), hypotension (RR = 1.54: 95% CI = 0.91-2.6, p = 0.10), intracranial pressure (SMD = 5.07: 95% CI = -4.6-14.8, p = 0.30), hospital length of stay (SMD = 0.10; 95% CI = -0.13-0.3, p = 0.39), pediatric intensive care unit length of stay (SMD = 0.04; 95% CI = -0.19-0.28, p = 0.71), hemorrhage (RR = 0.86; 95% CI = 0.34-2.13, p = 0.75), cerebral perfusion pressure (SMD = 0.158: 95% CI = 0.11-0.13, p = 0.172), prothrombin time (SMD = 0.425; 95% CI = -0.037-0.886, p = 0.07), and partial thromboplastin time (SMD = 0.386; 95% CI = -0.074-0.847, p = 0.10) between the hypothermic and non-hypothermic groups. However, the heart rate was significantly lower in the hypothermic group (-1.523 SMD = -1.523: 95% CI = -1.81--1.22 p < 0.001). CONCLUSIONS Our findings challenge the effectiveness of therapeutic hypothermia in pediatric TBI cases. Despite expectations, it did not significantly improve key clinical outcomes. This prompts a critical re-evaluation of hypothermia's role as a standard intervention in pediatric TBI treatment.
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Affiliation(s)
| | - Mohammad Amin Habibi
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran 14399, Iran
| | - Alireza Majdi
- Research Group Experimental Oto-Rhino-Laryngology, Department of Neuroscience, Leuven Brain Institute, KU Leuven, 3000 Leuven, Belgium
| | - Bardia Hajikarimloo
- Department of Neurosurgery, Shohada Tajjrish Hospital, Shahid Beheshti University of Medical Science, Tehran 14399, Iran
| | - Farhang Rashidi
- School of Medicine, Tehran University of Medical Sciences, Tehran 14399, Iran
| | - Sahar Fathi Tavani
- School of Medicine, Tehran University of Medical Sciences, Tehran 14399, Iran
| | - Poriya Minaee
- Student Research Committee, Faculty of Medicine, Qom University of Medical Sciences, Qom 999067, Iran
| | - Seyed Mohammad Eazi
- Student Research Committee, Faculty of Medicine, Qom University of Medical Sciences, Qom 999067, Iran
| | - Andrew J. Kobets
- Department of Neurological Surgery, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY 10467, USA
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Han Y, Han Z, Huang X, Li S, Jin G, Feng J, Wu D, Liu H. An injectable refrigerated hydrogel for inducing local hypothermia and neuroprotection against traumatic brain injury in mice. J Nanobiotechnology 2024; 22:251. [PMID: 38750597 PMCID: PMC11095020 DOI: 10.1186/s12951-024-02454-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 04/01/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Hypothermia is a promising therapy for traumatic brain injury (TBI) in the clinic. However, the neuroprotective outcomes of hypothermia-treated TBI patients in clinical studies are inconsistent due to several severe side effects. Here, an injectable refrigerated hydrogel was designed to deliver 3-iodothyronamine (T1AM) to achieve a longer period of local hypothermia for TBI treatment. Hydrogel has four advantages: (1) It can be injected into injured sites after TBI, where it forms a hydrogel and avoids the side effects of whole-body cooling. (2) Hydrogels can biodegrade and be used for controlled drug release. (3) Released T1AM can induce hypothermia. (4) This hydrogel has increased medical value given its simple operation and ability to achieve timely treatment. METHODS Pol/T hydrogels were prepared by a low-temperature mixing method and characterized. The effect of the Pol/T hydrogel on traumatic brain injury in mice was studied. The degradation of the hydrogel at the body level was observed with a small animal imager. Brain temperature and body temperature were measured by brain thermometer and body thermometer, respectively. The apoptosis of peripheral nerve cells was detected by immunohistochemical staining. The protective effect of the hydrogels on the blood-brain barrier (BBB) after TBI was evaluated by the Evans blue penetration test. The protective effect of hydrogel on brain edema after injury in mice was detected by Magnetic resonance (MR) in small animals. The enzyme linked immunosorbent assay (ELISA) method was used to measure the levels of inflammatory factors. The effects of behavioral tests on the learning ability and exercise ability of mice after injury were evaluated. RESULTS This hydrogel was able to cool the brain to hypothermia for 12 h while maintaining body temperature within the normal range after TBI in mice. More importantly, hypothermia induced by this hydrogel leads to the maintenance of BBB integrity, the prevention of cell death, the reduction of the inflammatory response and brain edema, and the promotion of functional recovery after TBI in mice. This cooling method could be developed as a new approach for hypothermia treatment in TBI patients. CONCLUSION Our study showed that injectable and biodegradable frozen Pol/T hydrogels to induce local hypothermia in TBI mice can be used for the treatment of traumatic brain injury.
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Affiliation(s)
- Yuhan Han
- Department of Biomedical Engineering, Southern University of Science and Technology, Shenzhen, 518055, Guangdong, China
- Brain Injury Center, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Institute of Head Trauma, Shanghai, 200127, China
| | - Zhengzhong Han
- Department of Neurosurgery, Xuzhou Children's Hospital, Xuzhou, 221000, Jiangsu, China
| | - Xuyang Huang
- Institute of Nervous System Diseases, Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
- Department of Intensive Care Medicine, The Second Hospital of Jiaxing, Jiaxing, 314000, Zhejiang, China
| | - Shanshan Li
- Department of Forensic Medicine, Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
| | - Guoliang Jin
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
| | - Junfeng Feng
- Brain Injury Center, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Institute of Head Trauma, Shanghai, 200127, China.
| | - Decheng Wu
- Department of Biomedical Engineering, Southern University of Science and Technology, Shenzhen, 518055, Guangdong, China.
| | - Hongmei Liu
- Department of Biomedical Engineering, Southern University of Science and Technology, Shenzhen, 518055, Guangdong, China.
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Goel R, Tiwari G, Varghese M, Bhalla K, Agrawal G, Saini G, Jha A, John D, Saran A, White H, Mohan D. Effectiveness of road safety interventions: An evidence and gap map. CAMPBELL SYSTEMATIC REVIEWS 2024; 20:e1367. [PMID: 38188231 PMCID: PMC10765170 DOI: 10.1002/cl2.1367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
Background Road Traffic injuries (RTI) are among the top ten leading causes of death in the world resulting in 1.35 million deaths every year, about 93% of which occur in low- and middle-income countries (LMICs). Despite several global resolutions to reduce traffic injuries, they have continued to grow in many countries. Many high-income countries have successfully reduced RTI by using a public health approach and implementing evidence-based interventions. As many LMICs develop their highway infrastructure, adopting a similar scientific approach towards road safety is crucial. The evidence also needs to be evaluated to assess external validity because measures that have worked in high-income countries may not translate equally well to other contexts. An evidence gap map for RTI is the first step towards understanding what evidence is available, from where, and the key gaps in knowledge. Objectives The objective of this evidence gap map (EGM) is to identify existing evidence from all effectiveness studies and systematic reviews related to road safety interventions. In addition, the EGM identifies gaps in evidence where new primary studies and systematic reviews could add value. This will help direct future research and discussions based on systematic evidence towards the approaches and interventions which are most effective in the road safety sector. This could enable the generation of evidence for informing policy at global, regional or national levels. Search Methods The EGM includes systematic reviews and impact evaluations assessing the effect of interventions for RTI reported in academic databases, organization websites, and grey literature sources. The studies were searched up to December 2019. Selection Criteria The interventions were divided into five broad categories: (a) human factors (e.g., enforcement or road user education), (b) road design, infrastructure and traffic control, (c) legal and institutional framework, (d) post-crash pre-hospital care, and (e) vehicle factors (except car design for occupant protection) and protective devices. Included studies reported two primary outcomes: fatal crashes and non-fatal injury crashes; and four intermediate outcomes: change in use of seat belts, change in use of helmets, change in speed, and change in alcohol/drug use. Studies were excluded if they did not report injury or fatality as one of the outcomes. Data Collection and Analysis The EGM is presented in the form of a matrix with two primary dimensions: interventions (rows) and outcomes (columns). Additional dimensions are country income groups, region, quality level for systematic reviews, type of study design used (e.g., case-control), type of road user studied (e.g., pedestrian, cyclists), age groups, and road type. The EGM is available online where the matrix of interventions and outcomes can be filtered by one or more dimensions. The webpage includes a bibliography of the selected studies and titles and abstracts available for preview. Quality appraisal for systematic reviews was conducted using a critical appraisal tool for systematic reviews, AMSTAR 2. Main Results The EGM identified 1859 studies of which 322 were systematic reviews, 7 were protocol studies and 1530 were impact evaluations. Some studies included more than one intervention, outcome, study method, or study region. The studies were distributed among intervention categories as: human factors (n = 771), road design, infrastructure and traffic control (n = 661), legal and institutional framework (n = 424), post-crash pre-hospital care (n = 118) and vehicle factors and protective devices (n = 111). Fatal crashes as outcomes were reported in 1414 records and non-fatal injury crashes in 1252 records. Among the four intermediate outcomes, speed was most commonly reported (n = 298) followed by alcohol (n = 206), use of seatbelts (n = 167), and use of helmets (n = 66). Ninety-six percent of the studies were reported from high-income countries (HIC), 4.5% from upper-middle-income countries, and only 1.4% from lower-middle and low-income countries. There were 25 systematic reviews of high quality, 4 of moderate quality, and 293 of low quality. Authors' Conclusions The EGM shows that the distribution of available road safety evidence is skewed across the world. A vast majority of the literature is from HICs. In contrast, only a small fraction of the literature reports on the many LMICs that are fast expanding their road infrastructure, experiencing rapid changes in traffic patterns, and witnessing growth in road injuries. This bias in literature explains why many interventions that are of high importance in the context of LMICs remain poorly studied. Besides, many interventions that have been tested only in HICs may not work equally effectively in LMICs. Another important finding was that a large majority of systematic reviews are of low quality. The scarcity of evidence on many important interventions and lack of good quality evidence-synthesis have significant implications for future road safety research and practice in LMICs. The EGM presented here will help identify priority areas for researchers, while directing practitioners and policy makers towards proven interventions.
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Affiliation(s)
- Rahul Goel
- Transportation Research and Injury Prevention CentreIndian Institute of Technology DelhiNew DelhiIndia
| | - Geetam Tiwari
- Transportation Research and Injury Prevention CentreIndian Institute of Technology DelhiNew DelhiIndia
| | | | - Kavi Bhalla
- Department of Public Health SciencesUniversity of ChicagoChicagoIllinoisUSA
| | - Girish Agrawal
- Transportation Research and Injury Prevention CentreIndian Institute of Technology DelhiNew DelhiIndia
| | | | - Abhaya Jha
- Transportation Research and Injury Prevention CentreIndian Institute of Technology DelhiNew DelhiIndia
| | - Denny John
- Faculty of Life and Allied Health SciencesM S Ramaiah University of Applied Sciences, BangaloreKarnatakaIndia
| | | | | | - Dinesh Mohan
- Transportation Research and Injury Prevention CentreIndian Institute of Technology DelhiNew DelhiIndia
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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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Stein KY, Froese L, Gomez A, Sainbhi AS, Vakitbilir N, Ibrahim Y, Zeiler FA. Intracranial Pressure Monitoring and Treatment Thresholds in Acute Neural Injury: A Narrative Review of the Historical Achievements, Current State, and Future Perspectives. Neurotrauma Rep 2023; 4:478-494. [PMID: 37636334 PMCID: PMC10457629 DOI: 10.1089/neur.2023.0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
Since its introduction in the 1960s, intracranial pressure (ICP) monitoring has become an indispensable tool in neurocritical care practice and a key component of the management of moderate/severe traumatic brain injury (TBI). The primary utility of ICP monitoring is to guide therapeutic interventions aimed at maintaining physiological ICP and preventing intracranial hypertension. The rationale for such ICP maintenance is to prevent secondary brain injury arising from brain herniation and inadequate cerebral blood flow. There exists a large body of evidence indicating that elevated ICP is associated with mortality and that aggressive ICP control protocols improve outcomes in severe TBI patients. Therefore, current management guidelines recommend a cerebral perfusion pressure (CPP) target range of 60-70 mm Hg and an ICP threshold of >20 or >22 mm Hg, beyond which therapeutic intervention should be initiated. Though our ability to achieve these thresholds has drastically improved over the past decades, there has been little to no change in the mortality and morbidity associated with moderate-severe TBI. This is a result of the "one treatment fits all" dogma of current guideline-based care that fails to take individual phenotype into account. The way forward in moderate-severe TBI care is through the development of continuously derived individualized ICP thresholds. This narrative review covers the topic of ICP monitoring in TBI care, including historical context/achievements, current monitoring technologies and indications, treatment methods, associations with patient outcome and multi-modal cerebral physiology, present controversies surrounding treatment thresholds, and future perspectives on personalized approaches to ICP-directed therapy.
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Affiliation(s)
- Kevin Y. Stein
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Logan Froese
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nuray Vakitbilir
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Younis Ibrahim
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Frederick A. Zeiler
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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Utsumi S, Amagasa S, Yasuda H, Oishi T, Kashiura M, Moriya T. Targeted Temperature Management in Pediatric Traumatic Brain Injury: A Systematic Review and Network Meta-Analysis. World Neurosurg 2023; 173:158-166.e2. [PMID: 36682532 DOI: 10.1016/j.wneu.2023.01.056] [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: 12/15/2022] [Revised: 01/15/2023] [Accepted: 01/16/2023] [Indexed: 01/21/2023]
Abstract
BACKGROUND The efficacy of targeted temperature management, including the appropriate length of time, in pediatric traumatic brain injury is inconclusive. We aimed to compare the efficacy of normothermia and therapeutic hypothermia administered for various durations. METHODS We searched four databases without language limitations until December 2021 and included peer-reviewed published randomized controlled trials comparing normothermia (>35.1°C) with therapeutic hypothermia (32°C -35°C) in children aged <18 years with an acute closed severe head injury (Glasgow Coma Scale < 8) requiring hospitalization. A favorable neurological outcome was the primary outcome; secondary outcomes were mortality and arrhythmia. Two reviewers performed screening, extracted data, and assessed the risk of bias. Network meta-analysis was performed using the Grading of Recommendations, Assessment, Development, and Evaluation working group approach. RESULTS We included six trials comprising 448 children. No significant difference was observed in favorable neurological outcomes between normothermia and hypothermia at 24, 48, and 72 h (relative risk, 1.05 [95% confidence interval 0.72-1.54]); 1.14 [0.82-1.57]), and 1.19 [0.77-1.85], respectively). Mortality did not differ significantly between normothermia and hypothermia at 24, 48, and 72 hours (0.56 [0.06-5.44]), (0.63 [0.12-3.36]), and 0.90 [0.10-8.18], respectively). Arrhythmias did not differ significantly between normothermia and hypothermia at 24, 48, and 72 h (0.92 [0.01-14.58], 0.36 [0.09-1.45), and 0.95 [0.03-29.92], respectively). CONCLUSION No conclusive evidence was found on optimal temperature management for pediatric traumatic brain injury. A large randomized controlled trial that considers the temperature control enforcement duration is required.
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Affiliation(s)
- Shu Utsumi
- Division of Emergency and Transport Services, National Center for Child Health and Development, Tokyo, Japan; Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shunsuke Amagasa
- Division of Emergency and Transport Services, National Center for Child Health and Development, Tokyo, Japan
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama City, Saitama, Japan
| | - Takatoshi Oishi
- Division of Emergency and Transport Services, National Center for Child Health and Development, Tokyo, Japan; Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama City, Saitama, Japan
| | - Masahiro Kashiura
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama City, Saitama, Japan.
| | - Takashi Moriya
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama City, Saitama, Japan
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Raikot SR, Polites SF. Current management of pediatric traumatic brain injury. Semin Pediatr Surg 2022; 31:151215. [PMID: 36399949 DOI: 10.1016/j.sempedsurg.2022.151215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Effect of Hypothermia Therapy on Children with Traumatic Brain Injury: A Meta-Analysis of Randomized Controlled Trials. Brain Sci 2022; 12:brainsci12081009. [PMID: 36009072 PMCID: PMC9406098 DOI: 10.3390/brainsci12081009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 07/19/2022] [Accepted: 07/27/2022] [Indexed: 02/04/2023] Open
Abstract
Hypothermia therapy is a promising therapeutic strategy for traumatic brain injury (TBI); however, some trials have shown that hypothermia therapy has a negative effect on patients with TBI. The treatment of hypothermia in children with TBI remains controversial. We conducted a search of six online databases to validate the literature on comparing hypothermia with normal therapy for children with TBI. Eight randomized controlled trials (514 patients) were included. The meta-analysis indicated that hypothermia therapy may increase the Glasgow Outcome Scale (GOS) scores. However, in terms of improving the rate of complications, intracranial pressure (ICP), mortality, cerebral perfusion pressure (CPP), and length of stay both in hospital as well as pediatric ICU, the difference was not statistically significant. Hypothermia therapy may have clinical advantages in improving the GOS scores in children with TBI compared with normothermic therapy, but hypothermia therapy may have no benefit in improving the incidence of complications, ICP, mortality, CPP, and length of stay both in pediatric ICU as well as hospital. The decision to implement hypothermia therapy for children with TBI depends on the advantages and disadvantages from many aspects and these must be considered comprehensively.
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Geng M, Cui W, Cheng J, Li L, Cheng R, Wang X. Effects of therapeutic hypothermia on the safety of children with severe traumatic brain injury: a systematic review and meta-analysis. Transl Pediatr 2022; 11:909-919. [PMID: 35800261 PMCID: PMC9253942 DOI: 10.21037/tp-22-180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 06/01/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Therapeutic hypothermia (TH) is effective to treat adult traumatic brain injury (TBI), but there is still controversy about its safety to treat the children with severe TBI. METHODS Clinical studies on TH in children with severe TBI from January 2000 to September 2020 were screened in PubMed, Web of Science, Embase, Cochrane Library, Nature, NCKI, and Wanfang online databases. Data were meta-analyzed by Rev Man 5.3. Differences in mortality, adverse outcomes, duration of Pediatric Intensive Care Unit (PICU), incidence of infection, and incidence of arrhythmia were compared between experimental group and control group. The heterogeneity of the results was evaluated by chi-square test and I2 test in Rev Man 5.3, and publication bias was evaluated by funnel plot. RESULTS Five articles were included, including 421 children. Cochrane evaluation was B grade or above, and Jadad scale score was over three points. The overall mortality between two groups showed great difference [odds ratio (OR) =1.72, 95% CI: 0.98-3.02, Z=1.87, P=0.04]. The incidence of adverse outcomes (OR =1.39, 95% CI: 0.86-2.25, Z=1.34, P=0.18), the duration of PICU [mean difference (MD) =0.51, 95% CI: -0.33 to 1.35, Z=1.19, P=0.24], the incidence of infection (OR =0.79, 95% CI: 0.51-1.23, Z=1.03, P=0.30), and the incidence of arrhythmia (OR =3.10, 95% CI: 0.77-12.50, Z=1.59, P=0.11) were not considerably different. DISCUSSION TH significantly reduced overall mortality in children with severe TBI, but did not significantly improve the incidence of adverse outcomes, PICU duration, infection rate, or arrhythmia. These results provided a reference for selecting proper clinical treatment methods for children with severe TBI.
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Affiliation(s)
- Min Geng
- Department of Critical Care, Jincheng People's Hospital (Jincheng Hospital Affiliated to Changzhi Medical College), Jincheng, China
| | - Weidong Cui
- Department of Critical Care, Jincheng People's Hospital (Jincheng Hospital Affiliated to Changzhi Medical College), Jincheng, China
| | - Jiang Cheng
- Department of Critical Care, Jincheng People's Hospital (Jincheng Hospital Affiliated to Changzhi Medical College), Jincheng, China
| | - Liheng Li
- Department of Critical Care, Jincheng People's Hospital (Jincheng Hospital Affiliated to Changzhi Medical College), Jincheng, China
| | - Ruini Cheng
- Department of Paediatrics, Jincheng People's Hospital (Jincheng Hospital Affiliated to Changzhi Medical College), Jincheng, China
| | - Xiaofang Wang
- Department of Paediatrics, Jincheng People's Hospital (Jincheng Hospital Affiliated to Changzhi Medical College), Jincheng, China
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10
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Optic Nerve Sheath Diameter Ultrasound: A Non-Invasive Approach to Evaluate Increased Intracranial Pressure in Critically Ill Pediatric Patients. Diagnostics (Basel) 2022; 12:diagnostics12030767. [PMID: 35328319 PMCID: PMC8946972 DOI: 10.3390/diagnostics12030767] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/15/2022] [Accepted: 03/15/2022] [Indexed: 01/16/2023] Open
Abstract
Early diagnosis of increased intracranial pressure (ICP) is crucial for prompt diagnosis and treatment of intracranial hypertension in critically ill pediatric patients, preventing secondary brain damage and mortality. Although the placement of an external ventricular drain coupled to an external fluid-filled transducer remains the gold standard for continuous ICP monitoring, other non-invasive approaches are constantly being improved and can provide reliable estimates. The use of point-of-care ultrasound (POCUS) for the assessment of ICP has recently become widespread in pediatric emergency and critical care settings, representing a valuable extension of the physical examination. The aim of this manuscript is to review and discuss the basic principles of ultra-sound measurement of the optic nerve sheath diameter (ONSD) and summarize current evidence on its diagnostic value in pediatric patients with ICP. There is increasing evidence that POCUS measurement of the ONSD correlates with ICP, thus appearing as a useful extension of the physical examination in pediatrics, especially in emergency medicine and critical care settings for the initial non-invasive assessment of patients with suspected raised ICP. Its role could be of value even to assess the response to therapy and in the follow-up of patients with diagnosed intracranial hypertension if invasive ICP monitoring is not available. Further studies on more homogeneous and extensive study populations should be performed to establish ONSD reference ranges in the different pediatric ages and to define cut-off values in predicting elevated ICP compared to invasive ICP measurement.
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11
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Hartman ME, Anabayan I, Jwa B, Pineda JA, Steed A, Newland JG, Friess SH. Early Antibiotic Exposure in Severe Pediatric Traumatic Brain Injury. J Pediatric Infect Dis Soc 2021:piab087. [PMID: 34555169 DOI: 10.1093/jpids/piab087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Mary E Hartman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Ilakkia Anabayan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Brian Jwa
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Jose A Pineda
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Ashley Steed
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Jason G Newland
- Division of Infectious Diseases, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Stuart H Friess
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
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12
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McCarty TR, Abramo TJ, Maxson RT, Albert G, Rettiganti MR, Saylors ME, Orsborn JW, Hollingsworth AI. Hypothermia as an Outcome Predictor Tool in Pediatric Trauma: A Propensity-Matched Analysis. Pediatr Emerg Care 2021; 37:e284-e291. [PMID: 30106871 DOI: 10.1097/pec.0000000000001588] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Hypothermia is an independent risk factor for mortality in adult trauma patients. Two small studies have shown similar results in pediatric trauma patients. Temperature is not included in any pediatric trauma assessment scores. This study sought to compare mortality and various descriptive outcomes between pediatric hypothermic and normothermic trauma patients. METHODS Data were obtained from the National Trauma Database from 2009 to 2012. Patients meeting inclusion criteria were stratified by presence of isolated head injury, head injury with multiple trauma, and absence of head injury. These groups were then subdivided into hypothermic (temperature ≤36°C) and normothermic groups. We used propensity score matching to 1:1 match hypothermic and normothermic patients. Mortality, neurosurgical interventions, endotracheal intubation, blood transfusion, length of stay, laparotomy, thoracotomy, conversion of cardiac rhythm, and time receiving mechanical ventilation were evaluated. RESULTS Data from 3,011,482 patients were obtained. There were 414,562 patients who met the inclusion criteria. In all patients meeting inclusion criteria, hypothermia was a significant risk factor in all outcomes measured. Following stratification and 1:1 matching, in all groups, hypothermia was associated with increased mortality (P < 0.0001), increased rate of endotracheal intubation (P < 0.0002), increased need for blood transfusion (P < 0.0025), and conversion of cardiac rhythm (P < 0.0027). CONCLUSION Hypothermia has been shown to be a significant prognostic indicator in the pediatric trauma patient with further potential application. Future studies are indicated to evaluate the incorporation of hypothermia into the Pediatric Trauma Score not only to help predict injury severity and mortality but also to improve appropriate and expeditious patient transfer to pediatric trauma centers and potentially facilitate earlier intervention.
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Affiliation(s)
- Thomas R McCarty
- From the Section of Emergency Medicine, Department of Pediatrics
| | - Thomas J Abramo
- From the Section of Emergency Medicine, Department of Pediatrics
| | | | - Gregory Albert
- Section of Pediatric Neurosurgery, Department of Neurosurgery
| | | | - Marie E Saylors
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Jonathan W Orsborn
- Section of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, Aurora, CO
| | - Amanda I Hollingsworth
- Section of Emergency Medicine, Department of Pediatrics, Arkansas Children's Hospital Northwest, Springdale, AR
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13
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Chong SL, Dang H, Ming M, Mahmood M, Zheng CQS, Gan CS, Lee OPE, Ji J, Chan LCN, Ong JSM, Kurosawa H, Lee JH. Traumatic Brain Injury Outcomes in 10 Asian Pediatric ICUs: A Pediatric Acute and Critical Care Medicine Asian Network Retrospective Study. Pediatr Crit Care Med 2021; 22:401-411. [PMID: 33027240 DOI: 10.1097/pcc.0000000000002575] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Traumatic brain injury remains an important cause of death and disability. We aim to report the epidemiology and management of moderate to severe traumatic brain injury in Asian PICUs and identify risk factors for mortality and poor functional outcomes. DESIGN A retrospective study of the Pediatric Acute and Critical Care Medicine Asian Network moderate to severe traumatic brain injury dataset collected between 2014 and 2017. SETTING Patients were from the participating PICUs of Pediatric Acute and Critical Care Medicine Asian Network. PATIENTS We included children less than 16 years old with a Glasgow Coma Scale less than or equal to 13. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We obtained data on patient demographics, injury circumstances, and PICU management. We performed a multivariate logistic regression predicting for mortality and poor functional outcomes. We analyzed 380 children with moderate to severe traumatic brain injury. Most injuries were a result of road traffic injuries (174 [45.8%]) and falls (160 [42.1%]). There were important differences in temperature control, use of antiepileptic drugs, and hyperosmolar agents between the sites. Fifty-six children died (14.7%), and 104 of 324 survivors (32.1%) had poor functional outcomes. Poor functional outcomes were associated with non-high-income sites (adjusted odds ratio, 1.90; 95% CI, 1.11-3.29), Glasgow Coma Scale less than 8 (adjusted odds ratio, 4.24; 95% CI, 2.44-7.63), involvement in a road traffic collision (adjusted odds ratio, 1.83; 95% CI, 1.04-3.26), and presence of child abuse (adjusted odds ratio, 2.75; 95% CI, 1.01-7.46). CONCLUSIONS Poor functional outcomes are prevalent after pediatric traumatic brain injury in Asia. There is an urgent need for further research in these high-risk groups.
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Affiliation(s)
- Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Hongxing Dang
- Department of Pediatric Intensive Care Unit, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Meixiu Ming
- Department of Pediatric Intensive Care Unit, Children's Hospital of Fudan University, Shanghai, China
| | - Maznisah Mahmood
- Department of Paediatrics, Institute of Paediatric, Kuala Lumpur, Malaysia
| | - Charles Q S Zheng
- Department of Epidemiology, Singapore Clinical Research Institute, Singapore
| | - Chin Seng Gan
- Department of Paediatrics, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Olive P E Lee
- Department of Paediatrics, Sarawak General Hospital, Sarawak, Malaysia
| | - Jian Ji
- Department of Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Lawrence C N Chan
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Jacqueline S M Ong
- Khoo Teck Puat National University Children's Medical Institute, National University Hospital, Singapore
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Hiroshi Kurosawa
- Department of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Jan Hau Lee
- Duke-NUS Medical School, Singapore
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
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14
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Woods KS, Horvat CM, Kantawala S, Simon DW, Rakkar J, Kochanek PM, Clark RSB, Au AK. Intracranial and Cerebral Perfusion Pressure Thresholds Associated With Inhospital Mortality Across Pediatric Neurocritical Care. Pediatr Crit Care Med 2021; 22:135-146. [PMID: 33229873 PMCID: PMC7855782 DOI: 10.1097/pcc.0000000000002618] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Targets for treatment of raised intracranial pressure or decreased cerebral perfusion pressure in pediatric neurocritical care are not well defined. Current pediatric guidelines, based on traumatic brain injury, suggest an intracranial pressure target of less than 20 mm Hg and cerebral perfusion pressure minimum of 40-50 mm Hg, with possible age dependence of cerebral perfusion pressure. We sought to define intracranial pressure and cerebral perfusion pressure thresholds associated with inhospital mortality across a large single-center pediatric neurocritical care cohort. DESIGN Retrospective chart review. SETTING PICU, single quaternary-care center. PATIENTS Individuals receiving intracranial pressure monitoring from January 2012 to December 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Intracranial pressure and cerebral perfusion pressure measurements from 262 neurocritical care patients (87 traumatic brain injury and 175 nontraumatic brain injury; 63% male; 8.3 ± 5.8 yr; mortality 11.1%). Mean intracranial pressure and cerebral perfusion pressure had area under the receiver operating characteristic curves of 0.75 and 0.64, respectively, for association of inhospital mortality. Cerebral perfusion pressure cut points increased with age (< 2 yr = 47, 2 to < 8 yr = 58 mm Hg, ≥ 8 yr = 73 mm Hg). In the traumatic brain injury subset, mean intracranial pressure and cerebral perfusion pressure had area under the receiver operating characteristic curves of 0.70 and 0.78, respectively, for association of inhospital mortality. Traumatic brain injury cerebral perfusion pressure cut points increased with age (< 2 yr = 45, 2 to < 8 yr = 57, ≥ 8 yr = 68 mm Hg). Mean intracranial pressure greater than 15 mm Hg, male sex, and traumatic brain injury status were independently associated with inhospital mortality (odds ratio, 14.23 [5.55-36.46], 2.77 [1.04-7.39], and 2.57 [1.03-6.38], respectively; all p < 0.05). Mean cerebral perfusion pressure less than 67 mm Hg and traumatic brain injury status were independently associated with inhospital mortality (odds ratio, 5.16 [2.05-12.98] and 3.71 [1.55-8.91], respectively; both p < 0.01). In the nontraumatic brain injury subset, mean intracranial pressure had an area under the receiver operating characteristic curve 0.77 with an intracranial pressure cut point of 15 mm Hg, whereas mean cerebral perfusion pressure was not predictive of inhospital mortality. CONCLUSIONS We identified mean intracranial pressure thresholds, utilizing receiver operating characteristic and regression analyses, associated with inhospital mortality that is below current guidelines-based treatment targets in both traumatic brain injury and nontraumatic brain injury patients, and age-dependent cerebral perfusion pressure thresholds associated with inhospital mortality that were above current guidelines-based targets in traumatic brain injury patients. Further study is warranted to identify data-driven intracranial pressure and cerebral perfusion pressure targets in children undergoing intracranial pressure monitoring, whether for traumatic brain injury or other indications.
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Affiliation(s)
- Kendra S. Woods
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Division of Critical Care, Department of Pediatrics, Southern Illinois University School of Medicine, Springfield, IL
| | - Christopher M. Horvat
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Health Informatics for Clinical Effectiveness, UPMC Children’s Hospital of Pittsburgh, PA
- Brain Care Institute, UPMC Children’s Hospital of Pittsburgh, PA
| | - Sajel Kantawala
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Health Informatics for Clinical Effectiveness, UPMC Children’s Hospital of Pittsburgh, PA
| | - Dennis W. Simon
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Brain Care Institute, UPMC Children’s Hospital of Pittsburgh, PA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jaskaran Rakkar
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Brain Care Institute, UPMC Children’s Hospital of Pittsburgh, PA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Robert S. B. Clark
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Health Informatics for Clinical Effectiveness, UPMC Children’s Hospital of Pittsburgh, PA
- Brain Care Institute, UPMC Children’s Hospital of Pittsburgh, PA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Alicia K. Au
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Health Informatics for Clinical Effectiveness, UPMC Children’s Hospital of Pittsburgh, PA
- Brain Care Institute, UPMC Children’s Hospital of Pittsburgh, PA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA
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15
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Lin JJ, Hsia SH, Chiang MC, Lin KL. Clinical application of target temperature management in children with acute encephalopathy-A practical review. Biomed J 2020; 43:211-217. [PMID: 32611538 PMCID: PMC7424089 DOI: 10.1016/j.bj.2019.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 12/07/2019] [Accepted: 12/08/2019] [Indexed: 12/29/2022] Open
Abstract
Acute encephalopathy is a life-threatening disease involving acute brain dysfunction, and it is one of the most important causes of mortality and severe neurological sequelae in infants and children. Approximately 30% of cases of acute encephalopathy result in some degree of neurological sequelae. Although many strategies have been proposed, effective therapies to ameliorate the outcomes of acute encephalopathy have not yet been established. Target temperature management (TTM), previously termed therapeutic hypothermia, has been shown to be effective for various brain injuries due to multiple neuroprotective mechanisms, and it may be considered to be the cornerstone of neuroprotective strategies. Consequently, TTM is currently used in the neurocritical care of adult patients with cardiac arrest with shockable rhythm and perinatal asphyxia. In addition, increasing evidence also indicates that TTM could be useful in other acute encephalopathies, including status epilepticus, acute encephalitis/encephalopathy and traumatic brain injury. In this review, we discuss the recent practical aspects of TTM as a potential intervention for various acute encephalopathies in children.
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Affiliation(s)
- Jainn-Jim Lin
- Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Pediatric Neurology, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shao-Hsuan Hsia
- Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Chou Chiang
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Neonatology, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kuang-Lin Lin
- Division of Pediatric Neurology, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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16
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Scimone MT, Cramer HC, Hopkins P, Estrada JB, Franck C. Application of mild hypothermia successfully mitigates neural injury in a 3D in-vitro model of traumatic brain injury. PLoS One 2020; 15:e0229520. [PMID: 32236105 PMCID: PMC7112206 DOI: 10.1371/journal.pone.0229520] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 02/07/2020] [Indexed: 12/12/2022] Open
Abstract
Therapeutic hypothermia (TH) is an attractive target for mild traumatic brain injury (mTBI) treatment, yet significant gaps in our mechanistic understanding of TH, especially at the cellular level, remain and need to be addressed for significant forward progress to be made. Using a recently-established 3D in-vitro neural hydrogel model for mTBI we investigated the efficacy of TH after compressive impact injury and established critical treatment parameters including target cooling temperature, and time windows for application and maintenance of TH. Across four temperatures evaluated (31.5, 33, 35, and 37°C), 33°C was found to be most neuroprotective after 24 and 48 hours post-injury. Assessment of TH administration onset time and duration showed that TH should be administered within 4 hours post-injury and be maintained for at least 6 hours for achieving maximum viability. Cellular imaging showed TH reduced the percentage of cells positive for caspases 3/7 and increased the expression of calpastatin, an endogenous neuroprotectant. These findings provide significant new insight into the biological parameter space that renders TH effective in mitigating the deleterious effects of cellular mTBI and provides a quantitative foundation for the future development of animal and preclinical treatment protocols.
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Affiliation(s)
- Mark T. Scimone
- School of Engineering, Brown University, Providence, RI, United States of America
- Center for Biomedical Engineering, Brown University, Providence, RI, United States of America
| | - Harry C. Cramer
- School of Engineering, Brown University, Providence, RI, United States of America
- Center for Biomedical Engineering, Brown University, Providence, RI, United States of America
| | - Paul Hopkins
- School of Engineering, Brown University, Providence, RI, United States of America
- Center for Biomedical Engineering, Brown University, Providence, RI, United States of America
| | - Jonathan B. Estrada
- Department of Mechanical Engineering, University of Michigan—Ann Arbor, Ann Arbor, MI, United States of America
| | - Christian Franck
- Mechanical Engineering, University of Wisconsin–Madison, Madison, WI, United States of America
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17
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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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18
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Reuter-Rice K, Christoferson E. Critical Update on the Third Edition of the Guidelines for Managing Severe Traumatic Brain Injury in Children. Am J Crit Care 2020; 29:e13-e18. [PMID: 31968082 DOI: 10.4037/ajcc2020228] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Severe traumatic brain injury (TBI) is associated with high rates of death and disability. As a result, the revised guidelines for the management of pediatric severe TBI address some of the previous gaps in pediatric TBI evidence and management strategies targeted to promote overall health outcomes. OBJECTIVES To provide highlights of the most important updates featured in the third edition of the guidelines for the management of pediatric severe TBI. These highlights can help critical care providers apply the most current and appropriate therapies for children with severe TBI. METHODS AND RESULTS After a brief overview of the process behind identifying the evidence to support the third edition guidelines, both relevant and new recommendations from the guidelines are outlined to provide critical care providers with the most current management approaches needed for children with severe TBI. Recommendations for neuroimaging, hyperosmolar therapy, analgesics and sedatives, seizure prophylaxis, ventilation therapies, temperature control/hypothermia, nutrition, and corticosteroids are provided. In addition, the complete guideline document and its accompanying algorithm for recommended therapies are available electronically and are referenced within this article. CONCLUSIONS The evidence base for treating pediatric TBI is increasing and provides the basis for high-quality care. This article provides critical care providers with a quick reference to the current evidence when caring for a child with a severe TBI. In addition, it provides direct access links to the comprehensive guideline document and algorithms developed to support critical care providers.
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Affiliation(s)
- Karin Reuter-Rice
- Karin Reuter-Rice is an associate professor, Duke University School of Nursing, Duke University School of Medicine Department of Pediatrics, and Duke Institute for Brain Sciences, Durham, North Carolina
| | - Elise Christoferson
- Elise Christoferson is an accelerated BSN student at Duke University School of Nursing
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19
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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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20
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Karydakis P, Giakoumettis D, Themistocleous M. The 100 most cited papers about pediatric traumatic brain injury: a bibliometric analysis. Ir J Med Sci 2019; 189:315-325. [PMID: 31418153 DOI: 10.1007/s11845-019-02085-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 08/08/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The high incidence of traumatic brain injury (TBI) in children, combined with the challenges in diagnosis and treatment options, the difficulty of predicting the outcome of each case, and also the wide variety of possibly lifelong complications, has led to an extraordinary number of published papers regarding this topic. This bibliometric analysis is aimed at identifying and reviewing the 100 most cited papers in the most challenging and trending aspects of pediatric traumatic brain injury. METHODS A search was performed using the Web of Science database in October 2018. Results were organized by citation number, and the 100 most cited papers were further reviewed and analyzed. RESULTS Our search resulted in 2754 published papers from 1975 until October 2018, of which 1783 (64.74%) had been published in the last decade (2010-2018). The 100 most cited papers about traumatic brain injury in children have an average citation of 140.59 and have been published in 44 different journals. Four hundred thirty-five authors have contributed to these prominent articles, most of them from the USA. CONCLUSIONS By reviewing those highly cited papers, we sought to offer significant help not only for studying this challenging field but also for designing new studies.
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Affiliation(s)
- Ploutarchos Karydakis
- Department of Neurosurgery, 251 Hellenic Air Force General Hospital, Athanasiou Diakou 9 str., Cholargos, 15562, Athens, Greece.
| | - Dimitrios Giakoumettis
- Department of Neurosurgery, 'Evangelismos Hospital', University of Athens, Athens, Greece
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21
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Appavu B, Foldes ST, Adelson PD. Clinical trials for pediatric traumatic brain injury: definition of insanity? J Neurosurg Pediatr 2019; 23:661-669. [PMID: 31153150 DOI: 10.3171/2019.2.peds18384] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 02/04/2019] [Indexed: 11/06/2022]
Abstract
Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children both in the United States and throughout the world. Despite valiant efforts and multiple clinical trials completed over the last few decades, there are no high-level recommendations for pediatric TBI available in current guidelines. In this review, the authors explore key findings from the major pediatric clinical trials in children with TBI that have shaped present-day recommendations and the insights gained from them. The authors also offer a perspective on potential efforts to improve the efficacy of future clinical trials in children following TBI.
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Affiliation(s)
- Brian Appavu
- 1Barrow Neurological Institute at Phoenix Children's Hospital; and
- 2University of Arizona College of Medicine-Phoenix, Department of Child Health, Phoenix, Arizona
| | - Stephen T Foldes
- 1Barrow Neurological Institute at Phoenix Children's Hospital; and
| | - P David Adelson
- 1Barrow Neurological Institute at Phoenix Children's Hospital; and
- 2University of Arizona College of Medicine-Phoenix, Department of Child Health, Phoenix, Arizona
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Andrews PJ, Sinclair HL, Rodríguez A, Harris B, Rhodes J, Watson H, Murray G. Therapeutic hypothermia to reduce intracranial pressure after traumatic brain injury: the Eurotherm3235 RCT. Health Technol Assess 2019; 22:1-134. [PMID: 30168413 DOI: 10.3310/hta22450] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major cause of disability and death in young adults worldwide. It results in around 1 million hospital admissions annually in the European Union (EU), causes a majority of the 50,000 deaths from road traffic accidents and leaves a further ≈10,000 people severely disabled. OBJECTIVE The Eurotherm3235 Trial was a pragmatic trial examining the effectiveness of hypothermia (32-35 °C) to reduce raised intracranial pressure (ICP) following severe TBI and reduce morbidity and mortality 6 months after TBI. DESIGN An international, multicentre, randomised controlled trial. SETTING Specialist neurological critical care units. PARTICIPANTS We included adult participants following TBI. Eligible patients had ICP monitoring in place with an ICP of > 20 mmHg despite first-line treatments. Participants were randomised to receive standard care with the addition of hypothermia (32-35 °C) or standard care alone. Online randomisation and the use of an electronic case report form (CRF) ensured concealment of random treatment allocation. It was not possible to blind local investigators to allocation as it was obvious which participants were receiving hypothermia. We collected information on how well the participant had recovered 6 months after injury. This information was provided either by the participant themself (if they were able) and/or a person close to them by completing the Glasgow Outcome Scale - Extended (GOSE) questionnaire. Telephone follow-up was carried out by a blinded independent clinician. INTERVENTIONS The primary intervention to reduce ICP in the hypothermia group after randomisation was induction of hypothermia. Core temperature was initially reduced to 35 °C and decreased incrementally to a lower limit of 32 °C if necessary to maintain ICP at < 20 mmHg. Rewarming began after 48 hours if ICP remained controlled. Participants in the standard-care group received usual care at that centre, but without hypothermia. MAIN OUTCOME MEASURES The primary outcome measure was the GOSE [range 1 (dead) to 8 (upper good recovery)] at 6 months after the injury as assessed by an independent collaborator, blind to the intervention. A priori subgroup analysis tested the relationship between minimisation factors including being aged < 45 years, having a post-resuscitation Glasgow Coma Scale (GCS) motor score of < 2 on admission, having a time from injury of < 12 hours and patient outcome. RESULTS We enrolled 387 patients from 47 centres in 18 countries. The trial was closed to recruitment following concerns raised by the Data and Safety Monitoring Committee in October 2014. On an intention-to-treat basis, 195 participants were randomised to hypothermia treatment and 192 to standard care. Regarding participant outcome, there was a higher mortality rate and poorer functional recovery at 6 months in the hypothermia group. The adjusted common odds ratio (OR) for the primary statistical analysis of the GOSE was 1.54 [95% confidence interval (CI) 1.03 to 2.31]; when the GOSE was dichotomised the OR was 1.74 (95% CI 1.09 to 2.77). Both results favoured standard care alone. In this pragmatic study, we did not collect data on adverse events. Data on serious adverse events (SAEs) were collected but were subject to reporting bias, with most SAEs being reported in the hypothermia group. CONCLUSIONS In participants following TBI and with an ICP of > 20 mmHg, titrated therapeutic hypothermia successfully reduced ICP but led to a higher mortality rate and worse functional outcome. LIMITATIONS Inability to blind treatment allocation as it was obvious which participants were randomised to the hypothermia group; there was biased recording of SAEs in the hypothermia group. We now believe that more adequately powered clinical trials of common therapies used to reduce ICP, such as hypertonic therapy, barbiturates and hyperventilation, are required to assess their potential benefits and risks to patients. TRIAL REGISTRATION Current Controlled Trials ISRCTN34555414. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 45. See the NIHR Journals Library website for further project information. The European Society of Intensive Care Medicine supported the pilot phase of this trial.
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Affiliation(s)
- Peter Jd Andrews
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - H Louise Sinclair
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Aryelly Rodríguez
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Bridget Harris
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | | | - Gordon Murray
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
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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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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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Benedetti GM, Silverstein FS. Targeted Temperature Management in Pediatric Neurocritical Care. Pediatr Neurol 2018; 88:12-24. [PMID: 30309737 DOI: 10.1016/j.pediatrneurol.2018.07.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 07/14/2018] [Indexed: 12/19/2022]
Abstract
Targeted temperature management encompasses a range of clinical interventions to regulate systemic temperature, and includes both induction of varying degrees of hypothermia and fever prevention ("targeted normothermia"). Targeted temperature management plays a key role in the contemporary management of critically ill neonates and children with acute brain injury. Yet, many unanswered questions remain regarding optimal temperature management in pediatric neurocritical care. The introduction highlights experimental studies that have evaluated the neuroprotective efficacy of therapeutic hypothermia and explored possible mechanisms of action in several brain injury models. The next section focuses on three major clinical conditions in which therapeutic hypothermia has been evaluated in randomized controlled trials in pediatric populations: neonatal hypoxic-ischemic encephalopathy, postcardiac arrest encephalopathy, and traumatic brain injury. Clinical implications of targeted temperature management in pediatric neurocritical care are also discussed. The final section examines some of the factors that may underlie the limited neuroprotective efficacy of hypothermia that has been observed in several major pediatric clinical trials, and outlines important directions for future research.
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Affiliation(s)
- Giulia M Benedetti
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois.
| | - Faye S Silverstein
- Departments of Pediatrics and Neurology, University of Michigan, Ann Arbor, Michigan
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Hale AT, Pekala K, Theobald B, Kelly K, Wolf M, Wellons JC, Le T, Shannon CN. Predictors of post-discharge seizures in children with traumatic brain injury. Childs Nerv Syst 2018; 34:1361-1365. [PMID: 29564537 DOI: 10.1007/s00381-018-3779-9] [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: 02/15/2018] [Accepted: 03/15/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE In traumatic brain injury (TBI), hyperglycemia and hypothermia are thought to be associated with poor outcomes, but have not been systematically studied in children. Thus, our aim was to evaluate whether serum glucose and temperature at admission, among other clinical variables, were associated with need for post hospital-discharge seizure medication in children diagnosed with TBI. METHODS We performed a retrospective study of 1814 children who were diagnosed with TBI at a tertiary pediatric hospital. Serum glucose levels at admission and temperature at initial presentation, 12, and 24 h were collected. Ongoing seizure activity was defined as discharge prescription of a seizure-modifying medication. RESULTS We identified 121 patients with need for continued seizure medications, and 80 patients expired. Independent predictors of prolonged seizures included serum glucose levels above 140 mg/dl (p < 0.003) and 199 mg/dl (p < 0.001), hypothermia (<35 °C), subdural hematoma (p < 0.001), midline shift (p < 0.001), and > 1% temperature change in the first 24 h (p < 0.001). Multivariate regression adjusting for GCS revealed that bilateral bleed (p = 0.008), body-temperature instability (p = 0.026), subdural hematoma (p < 0.001), and mechanism of injury (p = 0.007) were predictive of prolonged seizure activity. CONCLUSIONS In summary, we conclude that body temperature may be playing a more significant role than glycemic control in propensity for ongoing seizure activity in children sustaining TBI.
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Affiliation(s)
- Andrew T Hale
- Surgical Outcomes Center for Kids, Monroe Carrell Jr. Children's Hospital at Vanderbilt University, Nashville, TN, USA. .,Vanderbilt University School of Medicine, 2200 Pierce Avenue, 610 RRB, Nashville, TN, 37232, USA.
| | - Kelly Pekala
- Surgical Outcomes Center for Kids, Monroe Carrell Jr. Children's Hospital at Vanderbilt University, Nashville, TN, USA.,Vanderbilt University School of Medicine, 2200 Pierce Avenue, 610 RRB, Nashville, TN, 37232, USA
| | - Benjamin Theobald
- Surgical Outcomes Center for Kids, Monroe Carrell Jr. Children's Hospital at Vanderbilt University, Nashville, TN, USA.,Vanderbilt University School of Medicine, 2200 Pierce Avenue, 610 RRB, Nashville, TN, 37232, USA
| | - Katherine Kelly
- Surgical Outcomes Center for Kids, Monroe Carrell Jr. Children's Hospital at Vanderbilt University, Nashville, TN, USA
| | - Michael Wolf
- Department of Pediatrics, Monroe Carrell Jr. Children's Hospital at Vanderbilt University, Nashville, TN, USA
| | - John C Wellons
- Surgical Outcomes Center for Kids, Monroe Carrell Jr. Children's Hospital at Vanderbilt University, Nashville, TN, USA.,Department of Neurological Surgery, Division of Pediatric Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Truc Le
- Department of Pediatrics, Monroe Carrell Jr. Children's Hospital at Vanderbilt University, Nashville, TN, USA.,Department of Neurological Surgery, Division of Pediatric Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chevis N Shannon
- Surgical Outcomes Center for Kids, Monroe Carrell Jr. Children's Hospital at Vanderbilt University, Nashville, TN, USA.,Department of Neurological Surgery, Division of Pediatric Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Abstract
Head trauma is a leading cause of brain injury in children, and it can have profound lifelong physical, cognitive, and behavioral consequences. Optimal acute care of children with traumatic brain injury (TBI) requires rapid stabilization and early neurosurgical evaluation by a multidisciplinary team. Meticulous attention is required to limit secondary brain injury after the initial trauma. This review discusses pathophysiology, acute stabilization, and monitoring, as well as supportive and therapeutic measures to help minimize ongoing brain injury and optimize recovery in children with TBI. [Pediatr Ann. 2018;47(7):e274-e279.].
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Sarnaik A, Ferguson NM, O'Meara AMI, Agrawal S, Deep A, Buttram S, Bell MJ, Wisniewski SR, Luther JF, Hartman AL, Vavilala MS. Age and Mortality in Pediatric Severe Traumatic Brain Injury: Results from an International Study. Neurocrit Care 2018; 28:302-313. [PMID: 29476389 PMCID: PMC10655613 DOI: 10.1007/s12028-017-0480-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Although small series have suggested that younger age is associated with less favorable outcome after severe traumatic brain injury (TBI), confounders and biases have limited our understanding of this relationship. We hypothesized that there would be an association between age and mortality in children within an ongoing observational, cohort study. METHODS The first 200 subjects from the Approaches and Decisions for Acute Pediatric TBI trial were eligible for this analysis (inclusion criteria: severe TBI (Glasgow Coma Scale [GCS] score ≤ 8], age 18 years, and intracranial pressure (ICP) monitor placed; exclusion: pregnancy). Children with suspected abusive head trauma (AHT) were excluded to avoid bias related to the association between AHT and mortality. Demographics, and prehospital and resuscitation events were collected/analyzed, and children were stratified based on age at time of injury (< 5, 5-< 11, 11-18 years) and presented as mean ± standard error of the mean (SEM). Analyses of variance were used to test the equality of the means across the group for continuous variable, and Chi-square tests were used to compare percentages for discrete variables (post hoc comparisons were made using t test and Bonferroni corrections, as needed). Kaplan-Meier curves were generated for each age subgroup describing the time of death, and log-rank was used to compare the curves. Cox proportional hazards regression models were used to assess the effect of age on time to death while controlling for covariates. RESULTS In the final cohort (n = 155, 45 excluded for AHT), overall age was 9.2 years ± 0.4 and GCS was 5.3 ± 0.1. Mortality was similar between strata (14.0, 20.0, 20.9%, respectively, p = 0.58). Motor vehicle accidents were the most common mechanism across all strata, while falls tended to be more common in the youngest stratum (p = 0.08). The youngest stratum demonstrated increased incidence of spontaneous hypothermia at presentation and decreased hemoglobin concentrations and coagulopathies, while the oldest demonstrated lower platelet counts. CONCLUSIONS In contrast to previous reports, we failed to detect mortality differences across age strata in children with severe TBI. We have discerned novel associations between age and various markers of injury-unrelated to AHT-that may lead to testable hypotheses in the future.
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Affiliation(s)
- Ajit Sarnaik
- Departments of Pediatrics, Wayne State University, Detroit, MI, USA
| | | | - A M Iqbal O'Meara
- Departments of Pediatrics, Virginia Commonwealth University, Richmond, VA, USA
| | - Shruti Agrawal
- Departments of Pediatrics, Addenbrookes Hospital, Cambridge, UK
| | - Akash Deep
- Departments of Pediatrics, Kings College Hospital, London, UK
| | - Sandra Buttram
- Departments of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Michael J Bell
- Critical Care Medicine, Neurological Surgery and Pediatrics, University of Pittsburgh, 3434 Fifth Avenue, Pittsburgh, PA, 15260, USA.
| | | | - James F Luther
- Departments of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Adam L Hartman
- The Office of Clinical Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Monica S Vavilala
- Departments of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
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Luyet FM, Feldman KW, Knox BL. The Big Black Brain: Subdural Hemorrhage with Hemispheric Swelling and Low Attenuation. JOURNAL OF CHILD & ADOLESCENT TRAUMA 2018; 11:241-247. [PMID: 32318153 PMCID: PMC7163906 DOI: 10.1007/s40653-017-0132-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The term "Big Black Brain" was first coined in 1993 to describe cases of abusive head trauma associated with subdural hematoma(s), brain swelling, and uni- or bilateral hypo-density involving the entire supratentorial compartment on CT scan imaging. This constellation of findings was invariably followed by extensive cerebral parenchymal destruction and a dismal neurological outcome or death. We describe two such cases and review the pathophysiology and differential diagnosis of this entity.
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Affiliation(s)
- Francois M. Luyet
- Department of Pediatrics, University of Wisconsin American Family Children’s Hospital, 600 Highland Ave, H4/428 Clinical Science Center, Madison, WI 53792-4108 USA
| | - Kenneth W. Feldman
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA USA
| | - Barbara L. Knox
- Department of Pediatrics, University of Wisconsin American Family Children’s Hospital, 600 Highland Ave, H4/428 Clinical Science Center, Madison, WI 53792-4108 USA
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Abstract
PURPOSE OF REVIEW Traumatic brain injury (TBI) is a leading cause of death and disability in children. Prognostication of outcome following TBI is challenging in this population and likely requires complex, multimodal models to achieve clinically relevant accuracy. This review highlights injury characteristics, physiological indicators, biomarkers and neuromonitoring modalities predictive of outcome that may be integrated for future development of sensitive and specific prognostic models. RECENT FINDINGS Paediatric TBI is responsible for physical, psychosocial and neurocognitive deficits that may significantly impact quality of life. Outcome prognostication can be difficult in the immature brain, but is aided by the identification of novel biomarkers (neuronal, astroglial, myelin, inflammatory, apoptotic and autophagic) and neuromonitoring techniques (electroencephalogram and MRI). Investigation in the future may focus on assessing the prognostic ability of combinations of biochemical, protein, neuroimaging and functional biomarkers and the use of mathematical models to develop multivariable predication tools to improve the prognostic ability following childhood TBI. SUMMARY Prognostication of outcome following paediatric TBI is multidimensional, influenced by injury severity, age, physiological factors, biomarkers, electroencephalogram and neuroimaging. Further development, integration and validation of combinatorial prognostic algorithms are necessary to improve the accuracy and timeliness of prognosis in a meaningful fashion.
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Da Dalt L, Parri N, Amigoni A, Nocerino A, Selmin F, Manara R, Perretta P, Vardeu MP, Bressan S. Italian guidelines on the assessment and management of pediatric head injury in the emergency department. Ital J Pediatr 2018; 44:7. [PMID: 29334996 PMCID: PMC5769508 DOI: 10.1186/s13052-017-0442-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 12/18/2017] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE We aim to formulate evidence-based recommendations to assist physicians decision-making in the assessment and management of children younger than 16 years presenting to the emergency department (ED) following a blunt head trauma with no suspicion of non-accidental injury. METHODS These guidelines were commissioned by the Italian Society of Pediatric Emergency Medicine and include a systematic review and analysis of the literature published since 2005. Physicians with expertise and experience in the fields of pediatrics, pediatric emergency medicine, pediatric intensive care, neurosurgery and neuroradiology, as well as an experienced pediatric nurse and a parent representative were the components of the guidelines working group. Areas of direct interest included 1) initial assessment and stabilization in the ED, 2) diagnosis of clinically important traumatic brain injury in the ED, 3) management and disposition in the ED. The guidelines do not provide specific guidance on the identification and management of possible associated cervical spine injuries. Other exclusions are noted in the full text. CONCLUSIONS Recommendations to guide physicians practice when assessing children presenting to the ED following blunt head trauma are reported in both summary and extensive format in the guideline document.
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Affiliation(s)
- Liviana Da Dalt
- Pediatric Emergency Department-Intensive Care Unit, Department of Woman's and Child's Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Niccolo' Parri
- Department of Pediatric Emergency Medicine and Trauma Center, Meyer University Children's Hospital, Florence, Italy
| | - Angela Amigoni
- Pediatric Emergency Department-Intensive Care Unit, Department of Woman's and Child's Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Agostino Nocerino
- Department of Pediatrics, S. Maria della Misericordia University Hospital, University of Udine, Udine, Italy
| | - Francesca Selmin
- Pediatric Emergency Department-Intensive Care Unit, Department of Woman's and Child's Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Renzo Manara
- Department of Radiology, Neuroradiology Unit, University of Salerno, Salerno, Italy
| | - Paola Perretta
- Neurosurgery Unit, Regina Margherita Pediatric Hospital, Torino, Italy
| | - Maria Paola Vardeu
- Pediatric Emergency Department, Regina Margherita Pediatric Hospital, Torino, Italy
| | - Silvia Bressan
- Pediatric Emergency Department-Intensive Care Unit, Department of Woman's and Child's Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy.
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Alarcon JD, Rubiano AM, Okonkwo DO, Alarcón J, Martinez‐Zapata MJ, Urrútia G, Bonfill Cosp X. Elevation of the head during intensive care management in people with severe traumatic brain injury. Cochrane Database Syst Rev 2017; 12:CD009986. [PMID: 29283434 PMCID: PMC6486002 DOI: 10.1002/14651858.cd009986.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major public health problem and a fundamental cause of morbidity and mortality worldwide. The burden of TBI disproportionately affects low- and middle-income countries. Intracranial hypertension is the most frequent cause of death and disability in brain-injured people. Special interventions in the intensive care unit are required to minimise factors contributing to secondary brain injury after trauma. Therapeutic positioning of the head (different degrees of head-of-bed elevation (HBE)) has been proposed as a low cost and simple way of preventing secondary brain injury in these people. The aim of this review is to evaluate the evidence related to the clinical effects of different backrest positions of the head on important clinical outcomes or, if unavailable, relevant surrogate outcomes. OBJECTIVES To assess the clinical and physiological effects of HBE during intensive care management in people with severe TBI. SEARCH METHODS We searched the following electronic databases from their inception up to March 2017: Cochrane Injuries' Specialised Register, CENTRAL, MEDLINE, Embase, three other databases and two clinical trials registers. The Cochrane Injuries' Information Specialist ran the searches. SELECTION CRITERIA We selected all randomised controlled trials (RCTs) involving people with TBI who underwent different HBE or backrest positions. Studies may have had a parallel or cross-over design. We included adults and children over two years of age with severe TBI (Glasgow Coma Scale (GCS) less than 9). We excluded studies performed in children of less than two years of age because of their unfused skulls. We included any therapeutic HBE including supine (flat) or different degrees of head elevation with or without knee gatch or reverse Trendelenburg applied during the acute management of the TBI. DATA COLLECTION AND ANALYSIS Two review authors independently checked all titles and abstracts, excluding references that clearly didn't meet all selection criteria, and extracted data from selected studies on to a data extraction form specifically designed for this review. There were no cases of multiple reporting. Each review author independently evaluated risk of bias through assessing sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting, and other sources of bias. MAIN RESULTS We included three small studies with a cross-over design, involving a total of 20 participants (11 adults and 9 children), in this review. Our primary outcome was mortality, and there was one death by the time of follow-up 28 days after hospital admission. The trials did not measure the clinical secondary outcomes of quality of life, GCS, and disability. The included studies provided information only for the secondary outcomes intracranial pressure (ICP), cerebral perfusion pressure (CPP), and adverse effects.We were unable to pool the results as the data were either presented in different formats or no numerical data were provided. We included narrative interpretations of the available data.The overall risk of bias of the studies was unclear due to poor reporting of the methods. There was marked inconsistency across studies for the outcome of ICP and small sample sizes or wide confidence intervals for all outcomes. We therefore rated the quality of the evidence as very low for all outcomes and have not included the results of individual studies here. We do not have enough evidence to draw conclusions about the effect of HBE during intensive care management of people with TBI. AUTHORS' CONCLUSIONS The lack of consistency among studies, scarcity of data and the absence of evidence to show a correlation between physiological measurements such as ICP, CCP and clinical outcomes, mean that we are uncertain about the effects of HBE during intensive care management in people with severe TBI.Well-designed and larger trials that measure long-term clinical outcomes are needed to understand how and when different backrest positions can affect the management of severe TBI.
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Affiliation(s)
- Jose D Alarcon
- Iberoamerican Cochrane Network, Surcolombian UniversityNeivaHuliaColombia
| | | | - David O Okonkwo
- Department of Neurological Surgery, University of PittsburghBrain Trauma Research CentreUPMC Presbyterian, Suite B‑400200 Lothrop StreetPittsburghPAUSA15213
| | - Jairo Alarcón
- Universidad del ValleDepartment of PediatricsCaliValle del CaucaColombia760001
| | - Maria José Martinez‐Zapata
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 167Pavilion 18BarcelonaCatalunyaSpain08025
- Equinoccial Technological UniversityCochrane Ecuador. Center for Research in Public Health and Clinical Epidemiology (CISPEC). Eugenio Espejo School of Health SciencesAvenida República de El Salvador 733 y Portugal Edificio Gabriela 3. Of. 403 Casilla Postal 17‐17‐525QuitoEcuador
| | - Gerard Urrútia
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 167Pavilion 18BarcelonaCatalunyaSpain08025
| | - Xavier Bonfill Cosp
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 167Pavilion 18BarcelonaCatalunyaSpain08025
- Universitat Autònoma de BarcelonaSant Antoni Maria Claret, 167Pavilion 18 (D‐13)BarcelonaCatalunyaSpain08025
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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: 99] [Impact Index Per Article: 14.1] [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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Empfehlung zum Temperaturmanagement nach Atem-Kreislauf-Stillstand und schwerem Schädel-Hirn-Trauma im Kindesalter jenseits der Neonatalperiode. Monatsschr Kinderheilkd 2017. [DOI: 10.1007/s00112-017-0306-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Gardner MT, O’Meara AMI, Miller Ferguson N. Pediatric Traumatic Brain Injury: an Update on Management. CURRENT PEDIATRICS REPORTS 2017. [DOI: 10.1007/s40124-017-0144-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Challenges and opportunities for pediatric severe TBI-review of the evidence and exploring a way forward. Childs Nerv Syst 2017; 33:1663-1667. [PMID: 29149394 DOI: 10.1007/s00381-017-3530-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 07/06/2017] [Indexed: 02/05/2023]
Abstract
Traumatic brain injury (TBI) is a leading killer of children in the developed and developing world. Despite evidence-based guidelines and several recent clinical trials, the progress in developing best practices for children with severe TBI has been slow. This article describes (i) the burden of the disease, (ii) the inadequacies of the evidence-based guidelines, (iii) the failure of the largest clinical trials to prove their primary hypotheses, and (iv) possible advances from an observational cohort study called the Approaches and Decisions for Acute Pediatric TBI (ADAPT) Trial that has recently completed enrollment.
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Abstract
BACKGROUND Hypothermia has been used in the treatment of brain injury for many years. Encouraging results from small trials and laboratory studies led to renewed interest in the area and some larger trials. OBJECTIVES To determine the effect of mild hypothermia for traumatic brain injury (TBI) on mortality, long-term functional outcomes and complications. SEARCH METHODS We ran and incorporated studies from database searches to 21 March 2016. We searched the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE (OvidSP), Embase Classic+Embase (OvidSP), PubMed, ISI Web of science (SCI-EXPANDED, SSCI, CPCI-S & CPSI-SSH), clinical trials registers, and screened reference lists. We also re-ran these searches pre-publication in June 2017; the result from this search is presented in 'Studies awaiting classification'. SELECTION CRITERIA We included randomised controlled trials of participants with closed TBI requiring hospitalisation who were treated with hypothermia to a maximum of 35 ºC for at least 12 consecutive hours. Treatment with hypothermia was compared to maintenance with normothermia (36.5 to 38 ºC). DATA COLLECTION AND ANALYSIS Two review authors assessed data on mortality, unfavourable outcomes according to the Glasgow Outcome Scale, and pneumonia. MAIN RESULTS We included 37 eligible trials with a total of 3110 randomised participants; nine of these were new studies since the last update (2009) and five studies had been previously excluded but were re-assessed and included during the 2017 update. We identified two ongoing studies from searches of clinical trials registers and database searches and two studies await classification.Studies included both adults and children with TBI. Most studies commenced treatment immediately on admission to hospital or after craniotomies and all treatment was maintained for at least 24 hours. Thirty-three studies reported data for mortality, 31 studies reported data for unfavourable outcomes (death, vegetative state or severe disability), and 14 studies reported pneumonia. Visual inspection of the results for these outcomes showed inconsistencies among studies, with differences in the direction of effect, and we did not pool these data for meta-analysis. We considered duration of hypothermia therapy and the length of follow-up in collected data for these subgroups; differences in study data remained such that we did not perform meta-analysis.Studies were generally poorly reported and we were unable to assess risk of bias adequately. Heterogeneity was evident both in the trial designs and participant inclusion. Inconsistencies in results may be explained by heterogeneity among study participants or bias introduced by individual study methodology but we did not explore this in detail in subgroup or sensitivity analyses. We used the GRADE approach to judge the quality of the evidence for each outcome and downgraded the evidence for mortality and unfavourable outcome to very low. We downgraded the evidence for the pneumonia outcome to low. AUTHORS' CONCLUSIONS Despite a large number studies, there remains no high-quality evidence that hypothermia is beneficial in the treatment of people with TBI. Further research, which is methodologically robust, is required in this field to establish the effect of hypothermia for people with TBI.
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Affiliation(s)
- Sharon R Lewis
- Royal Lancaster InfirmaryPatient Safety Research DepartmentPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - David JW Evans
- Lancaster UniversityLancaster Health HubLancasterUKLA1 4YG
| | - Andrew R Butler
- Royal Lancaster InfirmaryPatient Safety Research DepartmentPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Oliver J Schofield‐Robinson
- Royal Lancaster Infirmary, University Hospitals of Morecambe Bay, NHSResearch and DevelopmentLancasterUKLA1 4RP
| | - Phil Alderson
- National Institute for Health and Care ExcellenceLevel 1A, City Tower,Piccadilly PlazaManchesterUKM1 4BD
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Meta-Analysis of Therapeutic Hypothermia for Traumatic Brain Injury in Adult and Pediatric Patients. Crit Care Med 2017; 45:575-583. [PMID: 27941370 DOI: 10.1097/ccm.0000000000002205] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Therapeutic hypothermia has been used to attenuate the effects of traumatic brain injuries. However, the required degree of hypothermia, length of its use, and its timing are uncertain. We undertook a comprehensive meta-analysis to quantify benefits of hypothermia therapy for traumatic brain injuries in adults and children by analyzing mortality rates, neurologic outcomes, and adverse effects. DATA SOURCES Electronic databases PubMed, Google Scholar, Web of Science, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov and manual searches of studies were conducted for relevant publications up until February 2016. STUDY SELECTION Forty-one studies in adults (n = 3,109; age range, 18-81 yr) and eight studies in children (n = 454; age range, 3 mo to 18 yr) met eligibility criteria. DATA EXTRACTION Baseline patient characteristics, enrollment time, methodology of cooling, target temperature, duration of hypothermia, and rewarming protocols were extracted. DATA SYNTHESIS Risk ratios with 95% CIs were calculated. Compared with adults who were kept normothermic, those who underwent therapeutic hypothermia were associated with 18% reduction in mortality (risk ratio, 0.82; 95% CI, 0.70-0.96; p = 0.01) and a 35% improvement in neurologic outcome (risk ratio, 1.35; 95% CI, 1.18-1.54; p < 0.00001). The optimal management strategy for adult patients included cooling patients to a minimum of 33°C for 72 hours, followed by spontaneous, natural rewarming. In contrast, adverse outcomes were observed in children who underwent hypothermic treatment with a 66% increase in mortality (risk ratio, 1.66; 95% CI, 1.06-2.59; p = 0.03) and a marginal deterioration of neurologic outcome (risk ratio, 0.90; 95% CI, 0.80-1.01; p = 0.06). CONCLUSIONS Therapeutic hypothermia is likely a beneficial treatment following traumatic brain injuries in adults but cannot be recommended in children.
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Updating Evidence for Using Hypothermia in Pediatric Severe Traumatic Brain Injury: Conventional and Bayesian Meta-Analytic Perspectives. Pediatr Crit Care Med 2017; 18:355-362. [PMID: 28230712 DOI: 10.1097/pcc.0000000000001098] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate clinical trials of hypothermia management on outcome in pediatric patients with severe traumatic brain injury using conventional and Bayesian meta-analyses. DATA SOURCES Screening of PubMed and other databases to identify randomized controlled trials of hypothermia for pediatric severe traumatic brain injury published before September 2016. STUDY SELECTION Four investigators assessed and reviewed randomized controlled trial data. DATA EXTRACTION Details of trial design, patient number, Glasgow Coma Scale score, hypothermia and control normothermia therapy, and outcome of mortality were collated. DATA SYNTHESIS In conventional meta-analysis, random-effects models were expressed as odds ratio (odds ratio with 95% credible-interval). Bayesian outcome probabilities were calculated as probability of odds ratio greater than or equal to 1. In seven randomized controlled trials (n = 472, patients 0-17 yr old), there was no difference in mortality (hypothermia vs normothermia) with pooled estimate 1.42 (credible-interval, 0.77-2.61; p = 0.26). Duration of hypothermia (24, 48, or 72 hr) did not show difference in mortality. (Similar results were found using poor outcome.) Bayesian analyses of randomized controlled trials ordered by time of study completed recruitment showed, after the seventh trial, chance of relative risk reduction of death by greater than 20% is 1-in-3. An optimistic belief (0.90 probability that relative risk reduction of death > 20% hypothermia vs normothermia) gives a chance of relative risk reduction of death by greater than 20% of 1-in-2. CONCLUSIONS Conventional meta-analysis shows the null hypothesis-no difference between hypothermia versus normothermia on mortality and poor outcome-cannot be rejected. However, Bayesian meta-analysis shows chance of relative risk reduction of death greater than 20% with hypothermia versus normothermia is 1-in-3, which may be further altered by one's optimistic or skeptical belief about a patient.
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Ichkova A, Rodriguez-Grande B, Bar C, Villega F, Konsman JP, Badaut J. Vascular impairment as a pathological mechanism underlying long-lasting cognitive dysfunction after pediatric traumatic brain injury. Neurochem Int 2017; 111:93-102. [PMID: 28377126 DOI: 10.1016/j.neuint.2017.03.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 03/29/2017] [Accepted: 03/31/2017] [Indexed: 12/11/2022]
Abstract
Traumatic brain injury (TBI) is the leading cause of death and disability in children. Indeed, the acute mechanical injury often evolves to a chronic brain disorder with long-term cognitive, emotional and social dysfunction even in the case of mild TBI. Contrary to the commonly held idea that children show better recovery from injuries than adults, pediatric TBI patients actually have worse outcome than adults for the same injury severity. Acute trauma to the young brain likely interferes with the fine-tuned developmental processes and may give rise to long-lasting consequences on brain's function. This review will focus on cerebrovascular dysfunction as an important early event that may lead to long-term phenotypic changes in the brain after pediatric TBI. These, in turn may be associated with accelerated brain aging and cognitive dysfunction. Finally, since no effective treatments are currently available, understanding the unique pathophysiological mechanisms of pediatric TBI is crucial for the development of new therapeutic options.
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Affiliation(s)
| | | | - Claire Bar
- CNRS UMR 5287, INCIA, University of Bordeaux, France; Department of Pediatric Neurology, University Children's Hospital of Bordeaux, France
| | - Frederic Villega
- Department of Pediatric Neurology, University Children's Hospital of Bordeaux, France
| | | | - Jerome Badaut
- CNRS UMR 5287, INCIA, University of Bordeaux, France; Department of Basic Sciences, Loma Linda University School of Medicine, Loma Linda, CA, USA.
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Brenner S, Eich C, Rellensmann G, Schuhmann MU, Nicolai T, Hoffmann F. [Recommendation on temperature management after cardiopulmonary arrest and severe traumatic brain injury in childhood beyond the neonatal period : Statement of the German Society for Neonatology and Pediatric Intensive Care Medicine (GNPI) and the scientific Working Group for Paediatric Anaesthesia (WAKKA) of the German Society of Anaesthesiology and Intensive Care (DGAI)]. Anaesthesist 2017; 66:128-133. [PMID: 28091756 DOI: 10.1007/s00101-016-0256-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The available data on the effectiveness of therapeutic hypothermia in different patient groups are heterogeneous. Although the benefits have been proven for some collectives, recommendations for the use of hypothermia treatment in other groups are based on less robust data and conclusions by analogy. This article gives a review of the current evidence of temperature management in all age groups and based on this state of knowledge, recommends active temperature management with the primary aim of strict normothermia (36-36.5 °C) for 72 hours after cardiopulmonary arrest or severe traumatic brain injury for children beyond the neonatal period.
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Affiliation(s)
- S Brenner
- Neonatologie und pädiatrische Intensivmedizin, Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | - C Eich
- Abteilung Anästhesie, Kinderintensiv- und Notfallmedizin, Kinder- und Jugendkrankenhaus AUF DER BULT, Hannover, Deutschland
| | - G Rellensmann
- Neonatologie und pädiatrische Intensivmedizin, Klinik für Kinder- und Jugendmedizin - Allgemeine Pädiatrie, Universitätsklinikum Münster, Münster, Deutschland
| | - M U Schuhmann
- Bereich Pädiatrische Neurochirurgie, Klinik für Neurochirurgie, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - T Nicolai
- Interdisziplinäre Kinderintensivstation, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Klinikum der Universität München, München, Deutschland
| | - F Hoffmann
- Interdisziplinäre Kinderintensivstation, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Klinikum der Universität München, München, Deutschland
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Abstract
OBJECTIVE Traumatic brain injury causes substantial morbidity and mortality in children. Posttraumatic seizures may worsen outcomes after traumatic brain injury. Posttraumatic seizures risk factors are not completely understood. Our objective was to clarify posttraumatic seizures risk factors in a large cohort of children with severe traumatic brain injury. DESIGN Retrospective cohort study of a probabilistically linked dataset from the National Trauma Data Bank and the Pediatric Health Information Systems database, 2007-2010. SETTING Twenty-nine U.S. children's hospitals. PATIENTS A total of 2,122 children (age, < 18 yr old at admission) with linked National Trauma Data Bank and Pediatric Health Information Systems records, severe (emergency department Glasgow Coma Scale, < 8) traumatic brain injury, hospital length of stay more than 24 hours, and nonmissing disposition. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The outcome was posttraumatic seizures, identified using validated International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes. Prespecified candidate predictors of posttraumatic seizures included age, injury mechanism, emergency department Glasgow Coma Scale, intracranial hemorrhage type, hypoxia, hypotension, and cardiac arrest. Posttraumatic seizures were diagnosed in 25.2% of children with severe traumatic brain injury. In those without abuse/assault or subdural hemorrhage, the posttraumatic seizures rate varied between 36.6% in those less than 2 years old and 16.4% in those 14-17 years old. Age, abusive mechanism, and subdural hemorrhage are each significant predictors of posttraumatic seizures. The risk of posttraumatic seizures has a complex relationship with these predictors. The estimated odds of posttraumatic seizures decrease with advancing age, odds ratio equal to 0.929 (0.905-0.954) per additional year of age with no abuse/assault and no subdural hemorrhage; odds ratio equal to 0.820 (0.730-0.922) per additional year of age when abuse and subdural hemorrhage are present. An infant with accidental traumatic brain injury and subdural hemorrhage has approximately the same estimated probability of posttraumatic seizures as an abused infant without subdural hemorrhage (47% [95% CI, 39-55%] vs 50% [95% CI, 41-58%]; p = 0.69). The triad of young age, injury by abuse/assault, and subdural hemorrhage confers the greatest estimated probability for posttraumatic seizures (60% [95% CI, 53-66%]). CONCLUSIONS Posttraumatic seizures risk in children with severe traumatic brain injury is greatest with a triad of younger age, injury by abuse/assault, and subdural hemorrhage. However, posttraumatic seizures are common even in the absence of these factors.
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Affiliation(s)
- Kimberly Statler Bennett
- Pediatric Critical Care, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, CO
| | - Peter E. DeWitt
- Department of Bioinformatics and Biostatistics, University of Colorado Denver, Aurora, CO
| | - Nicole Harlaar
- Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, CO
| | - Tellen D. Bennett
- Pediatric Critical Care, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, CO
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), Aurora, CO
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Abstract
The application of targeted temperature management has become common practice in the neurocritical care setting. It is important to recognize the pathophysiologic mechanisms by which temperature control impacts acute neurologic injury, as well as the clinical limitations to its application. Nonetheless, when utilizing temperature modulation, an organized approach is required in order to avoid complications and minimize side-effects. The most common clinically relevant complications are related to the impact of cooling on hemodynamics and electrolytes. In both instances, the rate of complications is often related to the depth and rate of cooling or rewarming. Shivering is the most common side-effect of hypothermia and is best managed by adequate monitoring and stepwise administration of medications specifically targeting the shivering response. Due to the impact cooling can have upon pharmacokinetics of commonly used sedatives and analgesics, there can be significant delays in the return of the neurologic examination. As a result, early prognostication posthypothermia should be avoided.
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Affiliation(s)
- N Badjatia
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA.
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Shen L, Wang Z, Su Z, Qiu S, Xu J, Zhou Y, Yan A, Yin R, Lu B, Nie X, Zhao S, Yan R. Effects of Intracranial Pressure Monitoring on Mortality in Patients with Severe Traumatic Brain Injury: A Meta-Analysis. PLoS One 2016; 11:e0168901. [PMID: 28030638 PMCID: PMC5193438 DOI: 10.1371/journal.pone.0168901] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 12/05/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The Brain Trauma Foundation (BTF) guidelines published in 2007 suggest some indications for intracranial pressure (ICP) monitoring in severe traumatic brain injury (TBI). However, some studies had not shown clinical benefit in patients with severe TBI; several studies had even reported that ICP monitoring was associated with an increased mortality rate. The effect of ICP monitoring has remained controversial, regardless of the ICP monitoring guidelines. Here we performed a meta-analysis of published studies to assess the effects of ICP monitoring in patients with severe TBI. METHODS We searched three comprehensive databases, the Cochrane Library, PUBMED, and EMBASE, for studies without limitations published up to September 2015. Mortality, ICU LOS, and hospital LOS were analyzed with Review Manager software according to data from the included studies. RESULTS Eighteen eligible studies involving 25229 patients with severe TBI were included in our meta-analysis. The results indicated no significant reduction in the ICP monitored group in mortality (hospitalized before 2007), hospital mortality (hospitalized before 2007), mortality in randomized controlled trials. However, overall mortality, mortality (hospitalized after 2007), hospital mortality (hospitalized after 2007), mortality in observational studies (hospitalized after 2007), 2-week mortality, 6-month mortality, were reduced in ICP monitored group. Patients with an increased ICP were more likely to require ICP monitoring. CONCLUSION Superior survival was observed in severe TBI patients with ICP monitoring since the third edition of "Guidelines for the Management of Severe Traumatic Brain Injury," which included "Indications for intracranial pressure monitoring," was published in 2007.
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Affiliation(s)
- Liang Shen
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, Zhejiang, China
| | - Zhuo Wang
- Department of Medical College, Nursing College of Huzhou University, Huzhou, Zhejiang, China
| | - Zhongzhou Su
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, Zhejiang, China
| | - Sheng Qiu
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, Zhejiang, China
| | - Jie Xu
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, Zhejiang, China
| | - Yue Zhou
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, Zhejiang, China
| | - Ai Yan
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, Zhejiang, China
| | - Rui Yin
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, Zhejiang, China
| | - Bin Lu
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, Zhejiang, China
| | - Xiaohu Nie
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, Zhejiang, China
| | - Shufa Zhao
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, Zhejiang, China
| | - Renfu Yan
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, Zhejiang, China
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Abstract
PURPOSE OF REVIEW Approximately one in five children admitted to a pediatric ICU have a new central nervous system injury or a neurological complication of their critical illness. The spectrum of neurologic insults in children is diverse and clinical practice is largely empirical, as few randomized, controlled trials have been reported. This lack of data poses a substantial challenge to the practice of pediatric neurocritical care (PNCC). PNCC has emerged as a novel subspecialty, and its presence is expanding within tertiary care centers. This review highlights the recent advances in the field, with a focus on traumatic brain injury (TBI), cardiac arrest, and stroke as disease models. RECENT FINDINGS Variable approaches to the structure of a PNCC service have been reported, comprising multidisciplinary teams from neurology, critical care, neurosurgery, neuroradiology, and anesthesia. Neurologic morbidity is substantial in critically ill children and the increased use of continuous electroencephalography monitoring has highlighted this burden. Therapeutic hypothermia has not proven effective for treatment of children with severe TBI or out-of-hospital cardiac arrest. However, results of studies of severe TBI suggest that multidisciplinary care in the ICU and adherence to guidelines for care can reduce mortality and improve outcome. SUMMARY There is an unmet need for clinicians with expertise in the practice of brain-directed critical care for children. Although much of the practice of PNCC may remain empiric, a focus on the regionalization of care, creating defined training paths, practice within multidisciplinary teams, protocol-directed care, and improved measures of long-term outcome to quantify the impact of such care can provide evidence to direct the maturation of this field.
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Bragge P, Synnot A, Maas AI, Menon DK, Cooper DJ, Rosenfeld JV, Gruen RL. A State-of-the-Science Overview of Randomized Controlled Trials Evaluating Acute Management of Moderate-to-Severe Traumatic Brain Injury. J Neurotrauma 2016; 33:1461-78. [PMID: 26711675 PMCID: PMC5003006 DOI: 10.1089/neu.2015.4233] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Moderate-to-severe traumatic brain injury (TBI) remains a major global challenge, with rising incidence, unchanging mortality and lifelong impairments. State-of-the-science reviews are important for research planning and clinical decision support. This review aimed to identify randomized controlled trials (RCTs) evaluating interventions for acute management of moderate/severe TBI, synthesize key RCT characteristics and findings, and determine their implications on clinical practice and future research. RCTs were identified through comprehensive database and other searches. Key characteristics, outcomes, risk of bias, and analysis approach were extracted. Data were narratively synthesized, with a focus on robust (multi-center, low risk of bias, n > 100) RCTs, and three-dimensional graphical figures also were used to explore relationships between RCT characteristics and findings. A total of 207 RCTs were identified. The 191 completed RCTs enrolled 35,340 participants (median, 66). Most (72%) were single center and enrolled less than 100 participants (69%). There were 26 robust RCTs across 18 different interventions. For 74% of 392 comparisons across all included RCTs, there was no significant difference between groups. Positive findings were broadly distributed with respect to RCT characteristics. Less than one-third of RCTs demonstrated low risk of bias for random sequence generation or allocation concealment, less than one-quarter used covariate adjustment, and only 7% employed an ordinal analysis approach. Considerable investment of resources in producing 191 completed RCTs for acute TBI management has resulted in very little translatable evidence. This may result from broad distribution of research effort, small samples, preponderance of single-center RCTs, and methodological shortcomings. More sophisticated RCT design, large multi-center RCTs in priority areas, increased focus on pre-clinical research, and alternatives to RCTs, such as comparative effectiveness research and precision medicine, are needed to fully realize the potential of acute TBI research to benefit patients.
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Affiliation(s)
- Peter Bragge
- Centre of Excellence in Traumatic Brain Injury Research, National Trauma Research Institute, Monash University and The Alfred Hospital, Victoria, Australia
- BehaviourWorks Australia, Monash Sustainability Institute, Monash University, Victoria, Australia
| | - Anneliese Synnot
- Centre of Excellence in Traumatic Brain Injury Research, National Trauma Research Institute, Monash University and The Alfred Hospital, Victoria, Australia
- Cochrane Consumers and Communication Review Group, Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Victoria, Australia
| | - Andrew I. Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David K. Menon
- Division of Anaesthesia, University of Cambridge; Neurosciences Critical Care Unit, Addenbrooke's Hospital; Queens' College, Cambridge, United Kingdom
| | - D. James Cooper
- Department of Intensive Care, Alfred Hospital, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia
| | - Jeffrey V. Rosenfeld
- Centre of Excellence in Traumatic Brain Injury Research, National Trauma Research Institute, Monash University and The Alfred Hospital, Victoria, Australia
- Monash Institute of Medical Engineering (MIME); Division of Clinical Sciences and Department of Surgery, Central Clinical School, Monash University, Victoria, Australia; Department of Neurosurgery, Alfred Hospital, Victoria, Australia; F. Edward Hébert School of Medicine, Uniformed Services University of The Health Sciences (USUHS), Bethesda, Maryland
| | - Russell L. Gruen
- Centre of Excellence in Traumatic Brain Injury Research, National Trauma Research Institute, Monash University and The Alfred Hospital, Victoria, Australia
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
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Elbahtiti A, Aly NY, Abo-Lila R, Al-Sawan R. Therapeutic hypothermia for infants with hypoxic ischemic encephalopathy: A five years' single center experience in Kuwait. J Neonatal Perinatal Med 2016; 9:179-185. [PMID: 27197929 DOI: 10.3233/npm-16915090] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE We aimed to evaluate the effect of therapeutic hypothermia (TH) on brain MRI findings, neurological outcome, and mortality in patients with perinatal hypoxic ischemic encephalopathy (HIE) and compare between two modalities of TH: whole body cooling (WBC) and selective head cooling (SHC). PATIENTS AND METHODS Sixty-two inborn babies with HIE admitted to the NICU of a Kuwaiti teaching hospital between 2006 and 2013 were retrospectively reviewed. Patients were divided into two groups: group 1 (2006-2008, n = 30) never received hypothermia, and group 2 (2009-2013, n = 32) treated with hypothermia. Group 2 patients were chronologically divided into two subgroups: 2a, the SHC, (2009-2010, n = 15) and 2b, the WBC, (2011-2013, n = 17). Brain MRI taken 7-10 days after birth, neurological status and mortality at time of hospital discharge were evaluated. RESULTS Patients who received TH showed significantly fewer MRI hypoxic changes (P = 0.04) and had better neurological outcome. Their need for anticonvulsants diminished (P = 0.04). However, their need for inotropes and duration of mechanical ventilation were increased (P = 0.001 & 0.02 respectively). No significant difference in mortality was found between the two groups (P = 0.6). In regression analysis, only MRI hypoxic changes predicted the occurrence of neurological abnormalities (P = 0.001). No difference in brain MRI findings, neurological outcome and mortality was observed between subgroups 2a and 2b (P > 0.05). CONCLUSION TH improved the neurological outcome of HIE patients but had no effect on mortality. There was no difference between the two modalities of TH on patients' outcome.
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Affiliation(s)
- A Elbahtiti
- Department of Neonatology, Farwaniya Hospital, Ministry of Health, Kuwait city, Kuwait
| | - N Yehia Aly
- Department of Infection Control, Farwaniya Hospital, Ministry of Health, Kuwait city, Kuwait
- Department of Tropical Medicine and Hygiene, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - R Abo-Lila
- Department of Neonatology, Farwaniya Hospital, Ministry of Health, Kuwait city, Kuwait
| | - R Al-Sawan
- Department of Neonatology, Farwaniya Hospital, Ministry of Health, Kuwait city, Kuwait
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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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