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Intensive care for pediatric traumatic brain injury

A. Sigurtà| C. Zanaboni| K. Canavesi| G. Citerio| L. Beretta| N. Stocchetti
Pediatric Original
Volume 39, Issue 1 / January , 2013

Pages 129 - 136

Abstract

Purposes

The aims of this study are to describe a cohort of head-injured pediatric patients, focusing on current practice for intracranial pressure (ICP) monitoring and treatment and to verify the relationship between clinical and radiological parameters and the six-month outcome in a multivariable statistical model.

Methods

A retrospective review was done of a prospectively collected database considering patients younger than 19 years admitted to three neuro-intensive care units (ICU). Patients were divided into four age groups: 0–5 (infant), 6–12 (children), 13–16 (pre-adolescent) and 17–18 years (adolescent). The ICP and cerebral perfusion pressure (CPP) were analyzed calculating average data and values exceeding thresholds for more than 5 min. Outcome was assessed 6 months after trauma using the Glasgow Outcome Score.

Results

There were 199 patients, 155 male, included. Sixty percent had extracranial injuries. Pupils were abnormal in 38 %. Emergency evacuation of intracranial hematomas was necessary in 81 cases. The ICP was monitored in 117 patients; in 87 cases ICP was higher than 20 mmHg, with no differences among age groups. All but six patients received therapy to prevent raised ICP; barbiturates, deep hyperventilation or surgical decompression were used in 31 cases. At 6 months, mortality was 21 % and favorable outcome was achieved by 72 %. Significant predictors of outcome in the multivariable model were the Glasgow Coma Scale (GCS) motor score, pupils and ICP.

Conclusions

Pediatric head injury is associated with a high incidence of intracranial hypertension. Early surgical treatment and intensive care may achieve favorable outcome in the majority of cases.

Keywords

References

  1. Sookplung P, Vavilala MS (2009) What is new in pediatric traumatic brain injury? Curr Opin Anaesthesiol 22:572–578
    • View reference on PubMed
    • View reference on publisher's website
  2. Marmarou A, Lu J, Butcher I, McHugh GS, Mushkudiani NA, Murray GD, Steyerberg EW, Maas AI (2007) IMPACT database of traumatic brain injury: design and description. J Neurotrauma 24:239–250
    • View reference on PubMed
    • View reference on publisher's website
  3. Padayachy LC, Figaji AA, Bullock MR (2010) Intracranial pressure monitoring for traumatic brain injury in the modern era. Childs Nerv Syst 26:441–452
    • View reference on PubMed
    • View reference on publisher's website
  4. Citerio G, Stocchetti N, Cormio M, Beretta L (2000) Neuro-Link, a computer-assisted database for head injury in intensive care. Acta Neurochir (Wien) 142:769–776
    • View reference on publisher's website
  5. Stocchetti N, Pagan F, Calappi E, Canavesi K, Beretta L, Citerio G, Cormio M, Colombo A (2004) Inaccurate early assessment of neurological severity in head injury. J Neurotrauma 21:1131–1140
    • View reference on PubMed
    • View reference on publisher's website
  6. Stocchetti N, Colombo A, Ortolano F, Videtta W, Marchesi R, Longhi L, Zanier ER (2007) Time course of intracranial hypertension after traumatic brain injury. J Neurotrauma 24:1339–1346
    • View reference on PubMed
    • View reference on publisher's website
  7. Stocchetti N, Zanaboni C, Colombo A, Citerio G, Beretta L, Ghisoni L, Zanier ER, Canavesi K (2008) Refractory intracranial hypertension and “second-tier” therapies in traumatic brain injury. Intensive Care Med 34:461–467
  8. Gopinath SP, Robenson CS, Contant CF, Hayes C, Feldman Z, Narayan RK, Grossman RG (1994) Jugular venous desaturation and outcome after head injury. J Neurol Neurosurg Psichiatr 57:717–723
    • View reference on publisher's website
  9. Wilson JT, Pettigrew LE, Teasdale GM (1998) Structured interviews for the Glasgow outcome scale and the extended Glasgow outcome scale: guidelines for their use. J Neurotrauma 15:573–585
    • View reference on PubMed
    • View reference on publisher's website
  10. Ross JS, Normand SL, Wang Y, Ko DT, Chen J, Drye EE, Keenan PS, Lichtman JH, Bueno H, Schreiner GC, Krumholz HM (2010) Hospital volume and 30-day mortality for three common medical conditions. N Engl J Med 362:1110–1118
    • View reference on PubMed
    • View reference on publisher's website
  11. Heros RC (2003) Case volume and mortality. J Neurosurg 99:805–806
    • View reference on PubMed
    • View reference on publisher's website
  12. Cross DT 3rd, Tirschwell DL, Clark MA, Tuden D, Derdeyn CP, Moran CJ, Dacey RG Jr (2003) Mortality rates after subarachnoid hemorrhage: variations according to hospital case volume in 18 states. J Neurosurg 99:810–817
    • View reference on PubMed
    • View reference on publisher's website
  13. Nathens AB, Jurkovich GJ, Maier RV, Grossman DC, MacKenzie EJ, Moore M, Rivara FP (2001) Relationship between trauma center volume and outcomes. JAMA 285:1164–1171
    • View reference on PubMed
    • View reference on publisher's website
  14. Hartman M, Watson RS, Linde-Zwirble W, Clermont G, Lave J, Weissfeld L, Kochanek P, Angus D (2008) Pediatric traumatic brain injury is inconsistently regionalized in the United States. Pediatrics 122:e172–e180
    • View reference on PubMed
    • View reference on publisher's website
  15. Eisenberg HM, Gary HE, Aldrich EF, Saydjary C, Turner B, Foulkes MA, Jane JA, Marmarou A, Marshall LP, Young HF (1990) Initial CT findings in 753 patients with severe head injury. J Neurosurg 73:688–698
    • View reference on PubMed
    • View reference on publisher's website
  16. Kochanek PM, Carney N, Adelson PD, Ashwal S, Bell MJ, Bratton S, Carson S, Chesnut RM, Ghajar J, Goldstein B, Grant GA, Kissoon N, Peterson K, Selden NR, Tasker RC, Tong KA, Vavilala MS, Wainwright MS, Warden CR, American Academy of Pediatrics-Section on Neurological Surgery, American Association of Neurological Surgeons/Congress of Neurological Surgeons, Child Neurology Society, European Society of Pediatric and Neonatal Intensive Care, Neurocritical Care Society, Pediatric Neurocritical Care Research Group, Society of Critical Care Medicine, Paediatric Intensive Care Society UK, Society for Neuroscience in Anesthesiology and Critical Care, World Federation of Pediatric Intensive and Critical Care Societies (2012) Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents—second edition. Indications for intracranial pressure monitoring, chapter 3. Pediatr Crit Care Med 13(Suppl 1):S1–S82
  17. Stocchetti N, Penny KI, Dearden M, Braakman R, Cohadon F, Iannotti F, Lapierre F, Karimi A, Maas A Jr, Murray GD, Ohman J, Persson L, Servadei F, Teasdale GM, Trojanowski T, Unterberg A, European Brain Injury Consortium (2001) Intensive care management of head-injured patients in Europe. A survey from the European Brain Injury Consortium. Intensive Care Med 27:400–406
  18. Mauritz W, Steltzer H, Bauer P, Dolanski-Aghamanoukjan L, Metnitz P (2008) Monitoring of intracranial pressure in patients with severe traumatic brain injury: an Austrian prospective multicenter study. Intensive Care Med 34:1208–1215
  19. Morris KP, Forsyth RJ, Parslow RC, Tasker RC, Hawley CA, UK Paediatric Traumatic Brain Injury Study Group, Paediatric Intensive Care Society Study Group (2006) Intracranial pressure complicating severe traumatic brain injury in children: monitoring and management. Intensive Care Med 32:1606–1612
  20. Madikians A, Giza CC (2009) Treatment of traumatic brain injury in pediatrics. Curr Treat Options Neurol 11:393–404
    • View reference on PubMed
    • View reference on publisher's website
  21. Wiegand C, Richards P (2007) Measurement of intracranial pressure in children: a critical review of current methods. Dev Med Child Neurol 49:935–941
    • View reference on PubMed
    • View reference on publisher's website
  22. Jagannathan J, Okonkwo DO, Dumont AS, Ahmed H, Bahari A, Prevedello DM, Jane JA Sr, Jane JA Jr (2007) Outcome following decompressive craniectomy in children with severe traumatic brain injury: a 10-year single-center experience with long-term follow up. J Neurosurg 106(4 Suppl):268–275
    • View reference on PubMed
  23. Chibbaro S, Marsella M, Romano A, Ippolito S, Benericetti E (2008) Combined internal uncusectomy and decompressive craniectomy for the treatment of severe closed head injury: experience with 80 cases. J Neurosurg 108:74–79
    • View reference on PubMed
    • View reference on publisher's website
  24. Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, D’Urso P, Kossmann T, Ponsford J, Seppelt I, Reilly P, Wolfe R, the DECRA Trial Investigators and the Australian and New Zealand Intensive Care Society Clinical Trials Group (2011) Decompressive Craniectomy in Diffuse Traumatic Brain Injury. N Engl J Med 364:1493–502
  25. Cremer OL, van Dijk GW, van Wensen E, Brekelmans GJ, Moons KG, Leenen LP, Kalkman CJ (2005) Effect of intracranial pressure monitoring and targeted intensive care on functional outcome after severe head injury. Crit Care Med 33:2207–2213
    • View reference on PubMed
    • View reference on publisher's website
  26. Jagannathan J, Okonkwo DO, Yeoh HK, Dumont AS, Saulle D, Haizlip J, Barth JT, Jane JA Sr, Jane JA Jr (2008) Long-term outcomes and prognostic factors in pediatric patients with severe traumatic brain injury and elevated intracranial pressure. J Neurosurg Pediatr 2:240–249
    • View reference on PubMed
    • View reference on publisher's website
  27. Tude Melo JR, Rocco FD, Blanot S, Oliveira-Filho J, Roujeau T, Sainte-Rose C, Duracher C, Vecchione A, Meyer P, Zerah M (2010) Mortality in children with severe head trauma: predictive factors and proposal for a new predictive scale. Neurosurgery 67:1542–1547
    • View reference on PubMed
    • View reference on publisher's website
  28. Kochanek PM, Carney N, Adelson PD, Ashwal S, Bell MJ, Bratton S, Carson S, Chesnut RM, Ghajar J, Goldstein B, Grant GA, Kissoon N, Peterson K, Selden NR, Tasker RC, Tong KA, Vavilala MS, Wainwright MS, Warden CR, American Academy of Pediatrics-Section on Neurological Surgery, American Association of Neurological Surgeons/Congress of Neurological Surgeons, Child Neurology Society, European Society of Pediatric and Neonatal Intensive Care, Neurocritical Care Society, Pediatric Neurocritical Care Research Group, Society of Critical Care Medicine, Paediatric Intensive Care Society UK, Society for Neuroscience in Anesthesiology and Critical Care, World Federation of Pediatric Intensive and Critical Care Societies (2012) Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents—second edition. Methods, chapter 2. Pediatr Crit Care Med 13(Suppl 1):S1–S82
  29. Morray JP, Tyler DC, Jones TK, Stuntz JT, Lemire RJ (1984) Coma scale for use in brain-injured children. Crit Care Med 12:1018–1020
    • View reference on PubMed
    • View reference on publisher's website
  30. Reilly PL, Simpson DA, Sprod I, Thomas L (1988) Assessing the conscious level in infants and young children. A paediatric version of the Glasgow coma scale. Childs Nerv Syst 4:30–33
    • View reference on PubMed

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