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Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents. Chapter 7. Intracranial pressure monitoring technology
... Special features should be considered in patients with traumatic brain injury (TBI), in which lesions may be heterogeneous, and several factors often contribute to increase the ICP [12]: 1. Traumatically induced masses: epidural or subdural hematomas, hemorrhagic contusions, foreign body, and depressed skull fractures 2. Cerebral edema [13] 3. Hyperemia owing to vasomotor paralysis or loss of autoregulation [14] 4. Hypoventilation that leads to hypercarbia with subsequent cerebral vasodilation 5. Hydrocephalus resulting from obstruction of the CSF pathways or its absorption 6. Increased intrathoracic or intra-abdominal pressure as a result of mechanical ventilation, posturing, agitation, or Valsalva maneuvers ...
... Monitoring of ICP is an invasive technique and has some associated risks. For a favorable riskto-benefit ratio, ICP monitoring is indicated only in patients with significant risk of intracranial hypertension [12] (Box 2). Patients with TBI who are particularly at risk for developing an elevated ICP include those with Glasgow Coma Scale of 8 or less after cardiopulmonary resuscitation and who have an abnormal admission head CT scan. ...
... Patients with a Glasgow Coma Scale score greater than 8 also might be considered for ICP monitoring if they require treatment that would not allow serial neurologic examinations, such as prolonged anesthesia for surgery of multiple injuries or prolonged pharmacologic paralysis for ventilatory management, or if they require a treatment that might increase ICP, such as positive end-expiratory pressure (PEEP). Other, less common indications include patients with multiple systemic injuries with altered level of consciousness and subsequent to removal of an intracranial mass (eg, hematoma, tumor) [12]. ICP monitoring also must be considered in nontraumatic conditions in which an intracranial mass lesion is present (eg, cerebral infarction, spontaneous intracerebral hemorrhage) and has a likelihood of expansion leading to intracranial hypertension and clinical deterioration. ...
Effective management of intracranial hypertension involves meticulous avoidance of factors that precipitate or aggravate increased intracranial pressure. When intracranial pressure becomes elevated, it is important to rule out new mass lesions that should be surgically evacuated. Medical management of increased intracranial pressure should include sedation, drainage of cerebrospinal fluid, and osmotherapy with either mannitol or hypertonic saline. For intracranial hypertension refractory to initial medical management, barbiturate coma, hypothermia, or decompressive craniectomy should be considered. Steroids are not indicated and may be harmful in the treatment of intracranial hypertension resulting from traumatic brain injury.
... Le capteur intraparenchymateux peut quant à lui être placé par le neurochirurgien au bloc opératoire (Fig. 6), ou par le réanimateur au lit du patient [32]. Les indications de monitorage de la PIC chez l'enfant sont basées sur des considérations cliniques, mais il existe un consensus général pour affirmer que la PIC doit être monitorée dans les cas les plus sévères, avec un GCS < 9 [33]. Les valeurs normales de la PIC et de la pression de perfusion cérébrale (PPC) ainsi que les seuils nécessitant l'administration de thérapeutiques actives ne sont pas clairement définies chez l'enfant. ...
... Les valeurs normales de la PIC et de la pression de perfusion cérébrale (PPC) ainsi que les seuils nécessitant l'administration de thérapeutiques actives ne sont pas clairement définies chez l'enfant. En pratique, une valeur de PIC > 20 mmHg est généralement admise comme valeur seuil pour reconnaître une HTIC [33,34]. Pour les nouveau-nés et les nourrissons, des valeurs normales de PIC peuvent même être proposées [35,36]. ...
The mainmechanism of injury in Afghanistan is the explosion of improvised explosive devices, associated with a high fatality rate and severe blast injuries. The head/neck area is particularly involved in children. Craniocerebral injuries account for more than 25% of the war wounds in children and are the first cause of death. The Kabul role 3 medical treatment facility was improved for children care with craniocerebal trauma. At reception of the MedEvac request, the emergency room is prepared to be ready and organized at arrival of the casualty. A head computerized tomography (CT)-scan is systematically realized, except in cases of life-threatening hemorrhage. Neurosurgical care of cerebral wounds focuses on the prevention of infection and increased intracranial pressure. Neurosurgery care of craniocerebral injuries is based on necrotic tissues debridement, dura mater repair and closure. Decompressive craniectomy is sometimes required. Neurointensive care is based on the prevention of systemic secondary brain insults, based on intracranial pressure monitoring. Infectious and seizure risks are also prevented. Significant ethical issues are considered in this country in war. Pediatric war neurotraumatology is a specific but daily activity in the intensive care unit at the Kabul role 3 medical treatment facility. In this article, the authors report the experience of the neurointensive care of Afghan children, who are unintended casualties of various devices explosion.
... There are several ways to monitor ICP based on the anatomical location of the monitor (Table 1). Intraventricular catheters sit in the ventricle and are considered the most accurate method to monitor ICP [6]. They are easy to recalibrate and have the additional therapeutic advantage of CSF drainage that can be helpful in intracranial lesions when edema is not the primary cause of elevated ICP. ...
Management of intracranial hypertension secondary to traumatic brain injury is crucial to optimizing outcomes. Use of pharmacological and/or surgical management is often needed to prevent secondary brain injury and its immediate and long-term effects. In addition to discussing medical and surgical options for approaching intracranial hypertension, this chapter will review its pathophysiology and discuss key aspects of intracranial pressure monitoring.
... Cerebral perfusion pressure is relatively easy to measure. The main reason for undertaking the invasive monitoring required for calculating this number is to titrate treatment using the level of each of the constituent parameters as a guide (i.e., CPP, ICP, and MAP) (1,2). There are three main limitations in comparing CPP data from various studies for the purpose of identifying whether low CPP is harmful or whether there is an age-related "critical threshold" that should be targeted in treatment. ...
... MRI can pick up early stroke, venous thromboses, posterior fossa tumors and demyelinating lesions which might be missed on CT. Invasive ICP Monitoring ICP monitoring is used mainly to guide therapy, such as in determining when to drain CSF or administer [4]. The role and benefit of ICP monitoring in other conditions such as subarachnoid hemorrhage, hydrocephalus, intracranial infections, and Reyes syndrome remains unclear. ...
Appropriate management of raised intracranial pressure begins with stabilization of the patient and simultaneous assessment of the level of sensorium and the cause of raised intracranial pressure. Stabilization is initiated with securing the airway, ventilation and circulatory function. The identification of surgically remediable conditions is a priority. Emergent use of external ventricular drain or ventriculo-peritoneal shunt may be lifesaving in selected patients. In children with severe coma, signs of herniation or acutely elevated intracranial pressure, treatment should be started prior to imaging or invasive monitoring. Emergent use of hyperventilation and mannitol are life saving in such situations. Medical management involves careful use of head elevation, osmotic agents, and avoiding hypotonic fluids. Appropriate care also includes avoidance of aggravating factors. For refractory intracranial hypertension, barbiturate coma, hypothermia, or decompressive craniectomy should be considered.
Trauma patients present a unique challenge to anesthesiologists, since they require resource-intensive care, often complicated by pre-existing medical conditions. This fully revised new edition focuses on a broad spectrum of traumatic injuries and the procedures anesthesiologists perform to care for trauma patients perioperatively, surgically, and post-operatively. Special emphasis is given to assessment and treatment of co-existing disease, including surgical management of trauma patients with head, spine, orthopedic, cardiac, and burn injuries. Topics such as training for trauma (including use of simulation) and hypothermia in trauma are also covered. Six brand new chapters address pre-hospital and ED trauma management, imaging in trauma, surgical issues in head trauma and in abdominal trauma, anesthesia for oral and maxillofacial trauma, and prevention of injuries. The text is enhanced with numerous tables and 300 illustrations showcasing techniques of airway management, shock resuscitation, echocardiography and use of ultrasound for the performance of regional anesthesia in trauma.
Background:
Transcranial Doppler has been tested in the evaluation of cerebral hemodynamics as a non-invasive assessment of intracranial pressure (ICP), but there is controversy in the literature about its actual benefit and usefulness in this situation.
Objective:
To investigate cerebral blood flow assessed by Doppler technique and correlate with the variations of the ICP in the acute phase of intracranial hypertension in an animal model.
Methods:
An experimental animal model of intracranial hypertension was used. The experiment consisted of two groups of animals in which intracranial balloons were implanted and inflated with 4 mL (A) and 7 mL (B) for controlled simulation of different volumes of hematoma. The values of ICP and Doppler parameters (systolic [FVs], diastolic [FVd], and mean [FVm] cerebral blood flow velocities and pulsatility index [PI]) were collected during the entire procedure (before and during hematoma simulations and venous hypertonic saline infusion intervention). Comparisons between Doppler parameters and ICP monitoring were performed.
Results:
Twenty pigs were studied, 10 in group A and 10 in group B. A significant correlation between PI and ICP was obtained, especially shortly after abrupt elevation of ICP. There was no correlation between ICP and FVs, FVd or FVm separately. There was also no significant change in ICP after intravenous infusion of hypertonic saline solution.
Conclusions:
These results demonstrate the potential of PI as a parameter for the evaluation of patients with suspected ICP elevation.
Donation after cardiac death (DCD) describes the retrieval of organs for the purposes of transplantation that follows death confirmed using circulatory criteria (the cessation of the heart beat). The persisting shortfall in the availability of organs for transplantation has prompted many countries to reintroduce DCD schemes not only for kidney procurement but increasingly for other organs with a lower tolerance for warm ischemia such as the liver, pancreas, and lungs. Compared with donation after brain death, the challenge in the practice of DCD includes how to identify patients as suitable potential DCD donors, and how to manage the consequences of warm ischemia in a fashion that is professionally, ethically, and legally acceptable. Since the organ procurement from the uncontrolled DCD is hard to practice, this chapter mainly focuses on the practice of controlled DCD. DCD after the withdrawal of life-sustaining treatment accounts for a substantial proportion of deceased organ donors overall. Generally speaking, after the withdrawal of life-sustaining treatment, DCD accounts for a substantial proportion of deceased organ donors. Where this occurs, there is an increasing consensus that organ and tissue donation might be considered a alternative part of end-of-life care in intensive care unit.
Background:
In the last 20 yr, the rate of neurosurgical guideline publication has increased. However, despite the higher volume and increasing emphasis on quality there remains no reliable means of measuring the overall impact of clinical practice guidelines (CPGs).
Objective:
To utilize citation analysis to evaluate the dispersion of neurosurgical CPGs.
Methods:
A list of neurosurgical guidelines was compiled by performing electronic searches using the Scopus (Elsevier, Amsterdam, Netherlands) and National Guideline Clearinghouse databases. The Scopus database was queried to obtain current publication and citation data for all included documents and categorized based upon recognized neurosurgical specialties. The h-index, R-index, h2-index, i10-index, and dissemination index (D-Index) were manually calculated for each subspecialty.
Results:
After applying screening criteria the search yielded 372 neurosurgical CPGs, which were included for bibliometric analysis. The overall calculated h-index for neurosurgery was 56. When broken down by subspecialty trauma/critical care had the highest value at 35, followed by spine and peripheral nerve at 30, cerebrovascular at 28, tumor at 16, pediatrics at 14, miscellaneous at 11, and functional/stereotactic/pain at 6. Cerebrovascular neurosurgery was noted to have the highest D-Index at 3.4.
Conclusion:
A comprehensive framework is useful for guideline impact analysis. Bibliometric data provides a novel and adequate means of evaluating the successful dissemination of neurosurgical guidelines. There remains a paucity of data regarding implementation and clinical outcomes of individual guidelines.
Objectives:
Little is known about how clinicians make the complex decision regarding whether to place an intracranial pressure monitor in children with traumatic brain injury. The objective of this study was to identify the decisional needs of multidisciplinary clinician stakeholders.
Design:
Semi-structured qualitative interviews with clinicians who regularly care for children with traumatic brain injury.
Setting:
One U.S. level I pediatric trauma center.
Subjects:
Twenty-eight clinicians including 17 ICU nurses, advanced practice providers, and physicians and 11 pediatric surgeons and neurosurgeons interviewed between August 2017 and February 2018.
Interventions:
None.
Measurements and main results:
Participants had a mean age of 43 years (range, 30-66 yr), mean experience of 10 years (range, 0-30 yr), were 46% female (13/28), and 96% white (27/28). A novel conceptual model emerged that related the difficulty of the decision about intracranial pressure monitor placement (y-axis) with the estimated outcome of the patient (x-axis). This model had a bimodal shape, with the most difficult decisions occurring for patients who 1) had a good opportunity for recovery but whose neurologic examination had not yet normalized or 2) had a low but uncertain likelihood of neurologically functional recovery. Emergent themes included gaps in medical knowledge and information available for decision-making, differences in perspective between clinical specialties, and ethical implications of decision-making about intracranial pressure monitoring. Experienced clinicians described less difficulty with decision-making overall.
Conclusions:
Children with severe traumatic brain injury near perceived transition points along a spectrum of potential for recovery present challenges for decision-making about intracranial pressure monitor placement. Clinician experience and specialty discipline further influence decision-making. These findings will contribute to the design of a multidisciplinary clinical decision support tool for intracranial pressure monitor placement in children with traumatic brain injury.
Background:
It could be shown in traumatic brain injury (TBI) in adults that the functional status of cerebrovascular autoregulation (AR), determined by the pressure reactivity index (PRx), correlates to and even predicts outcome. We investigated PRx, cerebral perfusion pressure (CPP) and intracranial pressure (ICP) and their correlation to outcome in severe infant and paediatric TBI.
Methods:
Seventeen patients (range, 1 day to 14 years) with severe TBI (median GCS at presentation, 4) underwent long-term computerised ICP and mean arterial pressure (MAP) monitoring using dedicated software to determine CPP and PRx and optimal CPP (CPP level where PRx shows best autoregulation) continuously. Outcome was determined at discharge and at follow-up using the Glasgow Outcome Scale.
Results:
Favourable outcome was reached in eight patients, unfavourable outcome in seven patients. Two patients died. Nine patients underwent decompressive craniectomy to control ICP during Intensive Care Unit treatment. When dichotomised to outcome, no significant difference was found for overall ICP, CPP and PRx. The time with severely impaired AR (PRx >0.2) was significantly longer for patients with unfavourable outcome (64 h vs 6 h, p = 0.001). Continuously impaired AR of ≥24 h and age <1 year was associated to unfavourable outcome. Children with favourable outcome spent the entire monitoring time at or above the optimal CPP.
Conclusions:
Integrity of AR has a similar role for outcome after TBI in the paediatric population as in adults. The amount of time spent with deranged AR seems to be associated with outcome; a factor especially critical for infant patients. The results of this preliminary study need to be validated in the future.
Clinically, brain edema can come along or be a sequel of various diseases. Yet, its management is mostly independent from the original pathology and focuses on diagnosis and management of increased intracranial pressure (ICP), maintenance of cerebral perfusion pressure, and optimal cerebral oxygenation levels. For measuring ICP, tissue oxygenation, and other factors, various modalities are at hand. Thus, this chapter provides an overview on such techniques, scientific evidence, and clinical usability.
Background
Various physical markers have been used to predict outcome of traumatic brain injury in children. However, the utility of metabolic alterations for prognostication has been poorly described. Thus, we aim to correlate arterial blood gas markers and lactate levels with outcomes in children with moderate to severe traumatic brain injury.
Methods
This is a retrospective cohort study that included all patients <16 years old who presented to the Emergency Department with moderate to severe traumatic brain injury (Glasgow Coma Scale ⩽13). Serial arterial blood gas results and lactate levels in the first five days of admission to a pediatric intensive care unit (PICU) were reviewed. Primary outcome was in-hospital mortality. Secondary outcomes were 28-day ventilator-free and PICU-free days. A stepwise logistic regression analysis in conjunction with receiver operating characteristic analysis were used to identify variables that were associated with in-hospital mortality. Secondary outcomes were analyzed using multiple linear regression.
Results
Among the 43 patients analyzed, more than half of the patients (60%) had severe traumatic brain injury (Glasgow Coma Scale 8). Twenty-seven of the 43 (65%) patients underwent neurosurgical intervention and overall mortality was 9/43 (20.9%). The worst base excess and lactate levels of Day 2 of PICU stay were found to be most predictive for mortality with maximal area-under-curve (95% confidence interval) of 0.967 (0.906, 1.000). Worst lactate level on day 2 of PICU stay was also found to be associated with ventilator-free days and PICU-free days.
Conclusion
In children with moderate to severe traumatic brain injury, base excess and lactate on Day 2 of PICU stay were predictors of mortality, duration of mechanical ventilation and length of PICU stay.
Assessing intracranial pressure (ICP) remains a cornerstone in neurosurgical care. Invasive techniques for monitoring ICP remain the gold standard. The need for a reliable, safe and reproducible technique to non-invasively assess ICP in the context of early screening and in the neurocritical care environment is obvious. Numerous techniques have been described with several novel advances. While none of the currently available techniques appear independently accurate enough to quantify raised ICP, there is some promising work being undertaken.
Traumatic brain injury (TBI) is the most common cause of long-term morbidity and mortality in pediatric trauma. It is estimated that over 400,000 children in the United States are evaluated in emergency departments after sustaining a TBI annually, resulting in over 3,000 deaths and ten times as many hospitalizations. This chapter reviews the epidemiology, pathophysiology, clinical presentation, and imaging findings associated with TBI in children. A diagnostic and management algorithm is then reviewed. Finally, the representative evidence and risks/benefits of intracranial pressure monitoring, hyperosmolar therapy, barbiturate coma, decompressive craniectomy, and other therapeutic modalities are explained in detail.
Under both normal and abnormal circumstances intracranial pressure is the result of the interaction of multiple factors including blood pressure (and flow); cerebrospinal fluid dynamics; brain tissue and abnormal fluid or masses. Under pathological conditions these interactions are more complex than has previously been understood, but rational critical care for children with intracranial pathology requires an understanding of these interactions and their effects on brain metabolism. Intracranial pressure may be measured using a variety of techniques. Management of intracranial hypertension requires appropriate monitoring of multiple factors (relating both to parameters such as blood pressure, cardiac output and blood oxygen content and parameters such as the presence of seizure activity, brain oxygen content and brain metabolism); attention to basic parameters; optimization of blood pressure, cardiac output, blood oxygen content and pCO2 as well as appropriate surgical intervention. It is essential to integrate the information from brain imaging, physiological measurements and responses to therapy in order to understand the optimal management strategy. Surgical interventions may include removal of abnormal mass lesions and appropriate drainage of cerebrospinal fluid, and in particular circumstances may extend to procedures such as decompressive craniotomy. It is likely that appropriate management of brain injury will be dependent on a more complex understanding of the potential interactions of all the factors that determine intracranial pressure and the consequences for the brain.
De nombreuses pathologies « médicales » (encéphalopathie anoxique, infections du système nerveux central, troubles métaboliques, hydrocéphalie de cause congénitale ou acquise, pathologie tumorale ou vasculaire…), même si l’atteinte neurologique n’est pas toujours au premier plan, peuvent s’accompagner d’une hypertension intracrânienne (HTIC), quelle qu’en soit la cause, et conduire les enfants en réanimation [1]. L’HTIC résulte de l’altération de la compliance cérébrale en relation avec la présence d’un œdème cérébral (vasogénique, cytotoxique ou interstitiel), d’un processus expansif intracrânien (extra- ou intraparenchymateux) ou de l’augmentation du volume sanguin cérébral ou de la quantité de LCR. Au cours d’une affection qui conduit à l’HTIC, plusieurs mécanismes peuvent s’associer [1]. La littérature est dominée par l’HTIC d’origine traumatique. L’objectif du réanimateur doit être de dépister cette HTIC et d’éviter l’évolution vers l’ischémie cérébrale en mettant en place un monitorage adapté et en instaurant un traitement spécifique. En effet, une proportion importante des enfants présentant une HTIC est prise en charge en dehors de structures spécialisées avec un accès limité aux avis neurochirurgicaux et à la mise en place d’un monitorage invasif [2].
OBJECT
Well-designed studies linking intracranial pressure (ICP) monitoring with improved outcomes among children with severe traumatic brain injury (TBI) are lacking. The main objective of this study was to examine the relationship between ICP monitoring in children and in-hospital mortality following severe TBI.
METHODS
An observational study was conducted using data derived from 153 adult or mixed (adult and pediatric) trauma centers participating in the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) and 29 pediatric trauma centers participating in the pediatric pilot TQIP between 2010 and 2012. Random-intercept multilevel modeling was used to examine the association between ICP monitoring and in-hospital mortality among children with severe TBI ≤16 years of age after adjusting for important confounders. This association was evaluated at the patient level and at the hospital level. In a sensitivity analysis, this association was reexamined in a propensity-matched cohort.
RESULTS
A total of 1705 children with severe TBI were included in the study cohort. The overall in-hospital mortality was 14.3% of patients (n = 243), whereas the mortality of the 273 patients (16%) who underwent invasive ICP monitoring was 11% (n = 30). After adjusting for patient- and hospital-level characteristics, ICP monitoring was associated with lower in-hospital mortality (adjusted OR 0.50; 95% CI 0.30–0.85; p = 0.01). It is possible that patients who were managed with ICP monitoring were selected because of an anticipated favorable or unfavorable outcome. To further address this potential selection bias, the analysis was repeated with the hospital-specific rate of ICP monitoring use as the exposure. The adjusted OR for death of children treated at high ICP–use hospitals was 0.49 compared with those treated at low ICP-use hospitals (95% CI 0.31–0.78; p = 0.003). Variations in ICP monitoring use accounted for 15.9% of the interhospital variation in mortality among children with severe TBI. Similar results were obtained after analyzing the data using propensity score-matching methods.
CONCLUSIONS
In this observational study, ICP monitoring use was associated with lower hospital mortality at both the patient and hospital levels. However, the contribution of variable ICP monitoring rates to interhospital variation in pediatric TBI mortality was modest.
The need for improved cerebral resuscitation was born out of progress – advancements in resuscitation, intensive care, and rehabilitation have decreased mortality associated with brain injury in infants and children, but increased the number living with disability. Indeed morbidity, and mortality for that matter, remains unacceptably high. To date, cerebral resuscitation after ischemic and traumatic brain injury (TBI) remains largely supportive, although many promising therapies are being explored at the bench. Now the challenge is to move therapies to the bedside, to assist patients in attaining improved outcomes and quality of life. In the interim, optimizing patient care management in the prehospital setting, emergency department, pediatric intensive care unit (PICU), and rehabilitation facilities, is our greatest opportunity for improving outcome in these pediatric patients.
Traumatic brain injury (TBI) remains the leading cause of death of children in the developing world. In 2012, several international efforts were completed to aid clinicians and researchers in advancing the field of pediatric TBI. The second edition of the Guidelines for the Medical Management of Traumatic Brain Injury in Infants, Children and Adolescents updated those published in 2003. This article highlights the processes involved in developing the Guidelines, contrasts the new guidelines with the previous edition, and delineates new research efforts needed to advance knowledge. The impact of common data elements within these potential new research fields is reviewed.
Introduction Oncological emergencies Central venous access devices Symptom care Immunity and infections Anemia Thrombocytopenia Venous thromboembolism Multidisciplinary team working and supportive care References
This article reviews aspects of management of traumatic brain and spinal cord injury. A discussion of management of intracranial pressure after traumatic brain injury is followed by a discourse on cerebrovascular trauma and pediatric injuries. Specific management methods are discussed, including medical and surgical management in intracranial hypertension. A special attempt is made to include the current recommendations for management of brain and spinal cord injuries. Spinal cord injuries are discussed in the final section. With an increasing number of patients surviving after devastating spinal cord injuries, the special issues in their management are evaluated.
To investigate whether ventilatory management using a temperature-corrected (pH-stat) or uncorrected (alpha-stat) blood gas analysis strategy improves brain tissue oxygen tension (PbrO(2)) in children prophylactically treated with moderate hypothermia for traumatic brain injury.
Double crossover study conducted in the intensive care unit of a tertiary children's hospital. Nine children aged 3-14 years with severe traumatic brain injury were randomly allocated twice to a 6-hour period of either alpha- or pH-stat management while being kept hypothermic at 32.5°C.
PbrO(2), intracranial pressure (ICP) and PbrO(2)/PaO(2).
PbrO(2) was significantly higher during pH-stat management (alpha-stat, 23.2mmHg [95% CI, 22.4- 24.0mmHg] v pH-stat, 28.7mmHg [95% CI, 27.9- 29.5mmHg]; P < 0.001). PbrO(2)/PaO(2) was significantly higher during pH-stat (alpha-stat, 0.190 [95% CI, 0.187- 0.193] v pH-stat, 0.251 [95% CI, 0.246-0.259]; P < 0.05). ICP was non-significantly higher during pH-stat (alpha-stat, 8.8mmHg [95% CI, 8.1-9.5mmHg] v ph-stat,10.2mmHg [95% CI, 9.6-10.8]).
PbrO(2) may be improved using a pH-stat blood gas management strategy in prophylactic hypothermia for paediatric patients with traumatic brain injury without any clinically relevant increase in ICP.
Pediatric neurocritical care is an emerging multidisciplinary field of medicine and a new frontier in pediatric critical care and pediatric neurology. Central to pediatric neurocritical care is the goal of improving outcomes in critically ill pediatric patients with neurological illness or injury and limiting secondary brain injury through optimal critical care delivery and the support of brain function. There is a pressing need for evidence based guidelines in pediatric neurocritical care, notably in pediatric traumatic brain injury and pediatric stroke. These diseases have distinct clinical and pathophysiological features that distinguish them from their adult counterparts and prevent the direct translation of the adult experience to pediatric patients. Increased attention is also being paid to the broader application of neuromonitoring and neuroprotective strategies in the pediatric intensive care unit, in both primary neurological and primary non-neurological disease states. Although much can be learned from the adult experience, there are important differences in the critically ill pediatric population and in the circumstances that surround the emergence of neurocritical care in pediatrics.
The abdominal compartment syndrome (ACS) is a potentially fatal entity that occurs as a result of an acute increase in intra-abdominal pressure (IAP). The authors report on a girl with a giant ovarian cystic mass, and clinical signs of ACS and intracranial hypertension (ΙΗ). The possible mechanism of IH secondary to ACS is discussed.
A high incidence of secondary adrenal insufficiency (AI) has been reported several months after a traumatic brain injury (TBI) in pediatric patients. Data from studies in adults suggest that AI may occur during the acute phase of TBI, with potential negative effects in the management of these vulnerable patients. The aim of this study was to describe the prevalence and the characteristics of AI in the acute phase of pediatric TBI.
Adrenal function was systematically evaluated in patients admitted to the pediatric intensive care unit following a TBI. Serial measurements of cortisol (9 samples) and adrenocorticotropic hormone (ACTH) were drawn from the second morning to the third morning post admission. Secondary AI was defined as all cortisols < 200 nmol/l (6 μg/dl) with ACTH < 12 pmol/l.
Twenty-eight patients (2-15 years old) were evaluated. Secondary AI occurred in ten (36%) patients. AI was more frequent in patients with intracranial hypertension (p < 0.05). Patients with AI required longer mechanical ventilation (p < 0.05), and a non-significant trend for a higher Pediatric Logistic Organ Dysfunction score (p = 0.09) and greater norepinephrine dose (p = 0.11) was observed.
Secondary AI is frequent during the acute phase of pediatric TBI, particularly when intracranial hypertension is present. Systematic assessment of pituitary function after TBI appears to be essential. A randomized clinical trial is warranted to evaluate the benefits of hormonal replacement therapy in TBI patients with AI.
Raised intracranial pressure (ICP) is a life threatening condition that is common to many neurological and non-neurological illnesses. Unless recognized and treated early it may cause secondary brain injury due to reduced cerebral perfusion pressure (CPP), and progress to brain herniation and death. Management of raised ICP includes care of airway, ventilation and oxygenation, adequate sedation and analgesia, neutral neck position, head end elevation by 20 degrees-30 degrees, and short-term hyperventilation (to achieve PCO(2) 32-35 mm Hg) and hyperosmolar therapy (mannitol or hypertonic saline) in critically raised ICP. Barbiturate coma, moderate hypothermia and surgical decompression may be helpful in refractory cases. Therapies aimed directly at keeping ICP <20 mmHg have resulted in improved survival and neurological outcome. Emerging evidence suggests that cerebral perfusion pressure targeted therapy may offer better outcome than ICP targeted therapies.
Head injury is an important cause of morbidity and mortality in pediatrics. Comprehensive studies on outcome are scarce despite significant clinical concern that multiple areas of functioning may be impaired following moderate to severe head injury. The literature suggests that sequelae include not only medical problems but also impairments in cognitive functioning.
A retrospective medical and psychology chart review of patients, age 1-18 years, admitted to the Children's Hospital of Eastern Ontario with moderate (Glasgow Coma Scale [GCS] 9-12) or severe head injury (GCS < or = 8) from November 1, 1993 until December 31, 1998 was conducted. Correlations were performed between medical variables (i.e., GCS, Pediatric Risk of Mortality [PRISM] III score, duration of ICU and hospital stay) and measures of intelligence and memory functioning.
Eighty-three children age 1 to 18 were included. Seventy percent of the children were classified as having a severe head injury. There was a mortality rate of thirteen percent. Younger age at injury, lower GCS, and higher PRISM III scores predicted higher mortality. Medical complications were documented systematically. Forty-four patients underwent at least one cognitive assessment and 17 of these children had intelligence testing at three points in time: baseline (< four months), early recovery (five to 15 months) and follow-up (16 to 38 months). The mean intelligence and memory scores fell within the average range at the latest point in follow-up. For those children who underwent three serial assessments, the mean verbal and performance IQ fell within the low average range at baseline improving significantly to fall within the average range by early recovery. Continued improvements were apparent in verbal memory beyond early recovery, with the mean obtained at follow-up falling within 1 SD of the normative mean. Despite the return to normal ranges for the group means the proportion of scores falling below 1.5 standard deviations from the mean was greater than population norms for verbal IQ, performance IQ and verbal memory. Lower GCS scores and longer duration of stay in ICU or hospital were predictive of lower nonverbal intelligence. Lower GCS was also predictive of lower visual memory scores.
This study describes a population of Canadian children who suffered moderate or severe traumatic brain injury. Initial GCS was the best predictor of mortality and cognitive outcome. These children demonstrated a temporal improvement in intelligence and memory functioning, with their mean performance on these cognitive measures falling within the average range at 16 to 38 months postinjury, although there was considerable variability in the outcomes between individuals.
Our aim was to analyze prognostic factors and their association with outcome among children with severe head injury.
We conducted a retrospective study among children (n=55) with severe head injury [Glasgow Coma Score (GCS) ?8] who were admitted to our Neurosurgical Intensive Care Unit (ICU) from January 1996 to September 2003. The patients were immediately evaluated with cranial computed tomography (CT) for the severity of head injury as well as for the causes of secondary insults such as hypoxia and hypotension, metabolic and hematological alterations. Outcome analysis was assessed according to Glasgow Outcome Scale Score (GOS) six months after the injury.
A poor result occurred in 31 patients (57%) while 24 patients (43%) had favourable results. Multivariate analysis showed significant independent prognostic effect for admission mean systolic blood pressure, presence of hypoxia, multiple trauma, admission GCS score and multiple intracranial lesions (p<0.05). Admission WBC counts and serum glucose levels were not correlated with GOS.
This study describes clinicoradiologic findings and prognostic factors regarding severe head injury in pediatric patients. The goals of managements of pediatric patients with severe traumatic head injury include normalizing intracranial pressure, optimizing arterial blood gases and systemic blood pressure, and prevention of factors that exacerbate secondary brain injury.
Effective treatment of intracranial hypertension involves meticulous avoidance of factors that precipitate or aggravate increased intracranial pressure. When intracranial pressure becomes elevated, it is important to rule out new mass lesions that should be surgically evacuated. medical management of increased intracranial pressure should include sedation and paralysis, drainage of cerebrospinal fluid, and osmotherapy with either mannitol or hypertonic saline. For intracranial hypertension refractory to initial medical management, barbiturate coma, hypothermia, or decompressive craniectomy should be considered. Steroids are not indicated and may be harmful in the treatment of intracranial hypertension resulting from traumatic brain injury.
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