Pediatric traumatic brain injury

Pediatric traumatic brain injury in 2012: the year with new guidelines and common data elements

Authors: Bell MJ, Kochanek PM.

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.

Variation in Intracranial Pressure Monitoring and Outcomes in Pediatric Traumatic Brain InjuryTBI Intracranial Pressure Monitoring and Outcomes

Authors: Bennett TD, Riva-Cambrin J, Keenan HT, Korgenski EK, Bratton SL.

OBJECTIVES To describe between-hospital and patient-level variation in intracranial pressure (ICP) monitoring and to evaluate ICP monitoring in association with hospital features and outcome in children with traumatic brain injury (TBI). DESIGN Retrospective cohort study. SETTING Children's hospitals participating in the Pediatric Health Information System database (January 2001 to June 2011). PARTICIPANTS Children (aged <18 years) with TBI and head Abbreviated Injury Scale scores of at least 3 who were ventilated for at least 96 consecutive hours or who died in the first 4 days after hospital admission. MAIN OUTCOME MEASURES Monitoring of ICP. RESULTS A total of 4667 children met the study criteria. Hospital mortality was 41% (n = 1919). Overall, 55% of patients (n = 2586) received ICP monitoring. Expected hospital ICP monitoring rates after adjustment for patient age, cardiac arrest, inflicted injury, craniotomy or craniectomy, head Abbreviated Injury Scale score, and Injury Severity Score were 47% to 60%. Observed hospital ICP monitoring rates were 14% to 83%. Hospitals with more observed ICP monitoring, relative to expected, and hospitals with higher patient volumes had lower rates of mortality or severe disability. After adjustment for between-hospital variation and patient severity of injury, ICP monitoring was independently associated with age 1 year and older (odds ratio, 3.1; 95% CI, 2.5-3.8) vs age younger than 1 year. CONCLUSIONS There was significant between-hospital variation in ICP monitoring that cannot be attributed solely to differences in case mix. Hospitals that monitor ICP more frequently and hospitals with higher patient volumes had better patient outcomes. Infants with TBI are less likely to receive ICP monitoring than are older children.

Osmolar therapy in pediatric traumatic brain injury

Authors: Bennett TD, Statler KD, Korgenski EK, Bratton SL.

OBJECTIVES: To describe patterns of use for mannitol and hypertonic saline in children with traumatic brain injury, to evaluate any potential associations between hypertonic saline and mannitol use and patient demographic, injury, and treatment hospital characteristics, and to determine whether the 2003 guidelines for severe pediatric traumatic brain injury impacted clinical practice regarding osmolar therapy.

DESIGN: Retrospective cohort study.

SETTING: Pediatric Health Information System database, January, 2001 to December, 2008.

PATIENTS: Children (age <18 yrs) with traumatic brain injury and head/neck Abbreviated Injury Scale score ≥3 who received mechanical ventilation and intensive care.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: The primary outcome was hospital billing for parenteral hypertonic saline and mannitol use, by day of service. Overall, 33% (2069 of 6238) of the patients received hypertonic saline, and 40% (2500 of 6238) received mannitol. Of the 1,854 patients who received hypertonic saline or mannitol for ≥2 days in the first week of therapy, 29% did not have intracranial pressure monitoring. After adjustment for hospital-level variation, primary insurance payer, and overall injury severity, use of both drugs was independently associated with older patient age, intracranial hemorrhage (other than epidural), skull fracture, and higher head/neck injury severity. Hypertonic saline use increased and mannitol use decreased with publication of the 2003 guidelines, and these trends continued through 2008.

CONCLUSIONS: Hypertonic saline and mannitol are used less in infants than in older children. The patient-level and hospital-level variation in osmolar therapy use and the substantial amount of sustained osmolar therapy without intracranial pressure monitoring suggest opportunities to improve the quality of pediatric traumatic brain injury care. With limited high-quality evidence available, published expert guidelines appear to significantly impact clinical practice in this area.

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