Age-related differences in intracranial pressure and cerebral perfusion pressure in the first 6 hours of monitoring after children's head injury: association with outcome

Intracranial and Cerebral Perfusion Pressure Thresholds Associated With Inhospital Mortality Across Pediatric Neurocritical Care

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.

Noninvasive Transorbital Assessment of the Optic Nerve Sheath in Children: Relationship Between Optic Nerve Sheath Diameter, Deformability Index, and Intracranial Pressure

BACKGROUND

Measurement of optic nerve sheath diameter (ONSD) is a promising technique for noninvasive assessment of intracranial pressure (ICP), but has certain limitations. A recent study showed that the deformability index (DI), a dynamic parameter quantifying the pulsatile nature of the optic nerve sheath, could differentiate between patients with high vs normal ICP.

OBJECTIVE

To further evaluate the diagnostic accuracy of the DI, when interpreted together with ONSD.

METHODS

This prospective study included children undergoing invasive ICP measurement as part of their clinical management. Ultrasound images of the optic nerve sheath were acquired prior to measuring ICP, the images were further processed to obtain the DI. Patients were dichotomized into high (≥20 mm Hg) or normal ICP groups and compared using the Mann-Whitney U-test. Diagnostic accuracy was described using area under the receiver operating characteristic curve (AUC), sensitivity and specificity, correlation between DI, ONSD, and ICP was investigated using linear regression.

RESULTS

A total of 28 patients were included (19 high ICP). The DI was lower in the high ICP group (0.105 vs 0.28, P = .001). AUC was 0.87, and a cut-off value of DI ≤ 0.185 demonstrated sensitivity of 89.5% and specificity of 88.9%. Diagnostic accuracy improved when combining DI with ONSD (AUC 0.98, sensitivity 94.7%, specificity 88.9%) and correlation with ICP improved when combined analysis of DI and ONSD was performed (Pearson correlation coefficient: 0.82 vs 0.42, respectively, P = .012).

CONCLUSION

The DI was significantly lower for patients with high vs normal ICP. This relationship improved further when the DI and ONSD were interpreted together.

Cushing's sign and severe traumatic brain injury in children after blunt trauma: a nationwide retrospective cohort study in Japan

OBJECTIVE

We tested whether Cushing's sign could predict severe traumatic brain injury (TBI) requiring immediate neurosurgical intervention (BI-NSI) in children after blunt trauma.

DESIGN

Retrospective cohort study using Japan Trauma Data Bank.

SETTING

Emergency and critical care centres in secondary and tertiary hospitals in Japan.

PARTICIPANTS

Children between the ages of 2 and 15 years with Glasgow Coma Scale motor scores of 5 or less at presentation after blunt trauma from 2004 to 2015 were included. A total of 1480 paediatric patients were analysed.

PRIMARY OUTCOME MEASURES

Patients requiring neurosurgical intervention within 24 hours of hospital arrival and patients who died due to isolated severe TBI were defined as BI-NSI. The combination of systolic blood pressure (SBP) and heart rate (HR) on arrival, which were respectively divided into tertiles, and its correlation with BI-NSI were investigated using a multiple logistic regression model.

RESULTS

In the study cohort, 297 (20.1%) exhibited BI-NSI. After adjusting for sex, age category and with or without haemorrhage shock, groups with higher SBP and lower HR (SBP ≥135 mm Hg; HR ≤92 bpm) were significantly associated with BI-NSI (OR 2.84, 95% CI 1.68 to 4.80, P<0.001) compared with the patients with normal vital signs. In age-specific analysis, hypertension and bradycardia were significantly associated with BI-NSI in a group of 7-10 and 11-15 years of age; however, no significant association was observed in a group of 2-6 years of age.

CONCLUSIONS

Cushing's sign after blunt trauma was significantly associated with BI-NSI in school-age children and young adolescents.

Brain metabolism and severe pediatric traumatic brain injury

Age-dependent changes in brain metabolism may influence the response to and tolerance of secondary insults, potentially affecting outcomes. More complete characterization of brain metabolism across the clinical trajectory of severe pediatric TBI is needed to improve our ability to measure and better mitigate the impact of secondary insults. Better management of secondary insults will impact clinical care and the probability of success of future neuroprotective clinical trials. Improved bedside monitoring and imaging technologies will be required to achieve these goals. Effective and sustained integration of brain metabolism information into the pediatric critical care setting will be equally challenging and important.

The Anesthesiologist's Role in Treating Abusive Head Trauma

Abusive head trauma (AHT) is the most common cause of severe traumatic brain injury (TBI) in infants and the leading cause of child abuse-related deaths. For reasons that remain unclear, mortality rates after moderate AHT rival those of severe nonintentional TBI. The vulnerability of the developing brain to injury may be partially responsible for the poor outcomes observed after AHT. AHT is mechanistically more complex than nonintentional TBI. The acute-on-chronic nature of the trauma along with synergistic injury mechanisms that include rapid rotation of the brain, diffuse axonal injury, blunt force trauma, and hypoxia-ischemia make AHT challenging to treat. The anesthesiologist must understand the complex injury mechanisms inherent to AHT, as well as the pediatric TBI treatment guidelines, to decrease the risk of persistent neurologic disability and death. In this review, we discuss the epidemiology of AHT, differences between AHT and nonintentional TBI, the severe pediatric TBI treatment guidelines in the context of AHT, anesthetic considerations, and ethical and legal reporting requirements.

Pediatric Traumatic Brain Injury: Characteristic Features, Diagnosis, and Management

Traumatic brain injury (TBI) is the leading cause of death and disability in children. Pediatric TBI is associated with several distinctive characteristics that differ from adults and are attributable to age-related anatomical and physiological differences, pattern of injuries based on the physical ability of the child, and difficulty in neurological evaluation in children. Evidence suggests that children exhibit a specific pathological response to TBI with distinct accompanying neurological symptoms, and considerable efforts have been made to elucidate their pathophysiology. In addition, recent technical advances in diagnostic imaging of pediatric TBI has facilitated accurate diagnosis, appropriate treatment, prevention of complications, and helped predict long-term outcomes. Here a review of recent studies relevant to important issues in pediatric TBI is presented, and recent specific topics are also discussed. This review provides important updates on the pathophysiology, diagnosis, and age-appropriate acute management of pediatric TBI.

Pediatric neurocritical care in the 21st century: from empiricism to evidence

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.

Intracranial Hypertension and Cerebral Hypoperfusion in Children With Severe Traumatic Brain Injury: Thresholds and Burden in Accidental and Abusive Insults

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.

Continuous Multimodality Monitoring in Children after Traumatic Brain Injury-Preliminary Experience

Introduction

Multimodality monitoring is regularly employed in adult traumatic brain injury (TBI) patients where it provides physiologic and therapeutic insight into this heterogeneous condition. Pediatric studies are less frequent.

Methods

An analysis of data collected prospectively from 12 pediatric TBI patients admitted to Addenbrooke’s Hospital, Pediatric Intensive Care Unit (PICU) between August 2012 and December 2014 was performed. Patients’ intracranial pressure (ICP), mean arterial pressure (MAP), and cerebral perfusion pressure (CPP) were monitored continuously using brain monitoring software ICM+^®,) Pressure reactivity index (PRx) and ‘Optimal CPP’ (CPPopt) were calculated. Patient outcome was dichotomized into survivors and non-survivors.

Results

At 6 months 8/12 (66%) of the cohort survived the TBI. The median (±IQR) ICP was significantly lower in survivors 13.1±3.2 mm Hg compared to non-survivors 21.6±42.9 mm Hg (p = 0.003). The median time spent with ICP over 20 mm Hg was lower in survivors (9.7+9.8% vs 60.5+67.4% in non-survivors; p = 0.003). Although there was no evidence that CPP was different between survival groups, the time spent with a CPP close (within 10 mm Hg) to the optimal CPP was significantly longer in survivors (90.7±12.6%) compared with non-survivors (70.6±21.8%; p = 0.02). PRx provided significant outcome separation with median PRx in survivors being 0.02±0.19 compared to 0.39±0.62 in non-survivors (p = 0.02).

Conclusion

Our observations provide evidence that multi-modality monitoring may be useful in pediatric TBI with ICP, deviation of CPP from CPPopt, and PRx correlating with patient outcome.

Effect of administration of neuromuscular blocking agents in children with severe traumatic brain injury on acute complication rates and outcomes: a secondary analysis from a randomized, controlled trial of therapeutic hypothermia

OBJECTIVE

To evaluate the association between neuromuscular blocking agents and outcome, intracranial pressure, and medical complications in children with severe traumatic brain injury.

DESIGN

A secondary analysis of a randomized, controlled trial of therapeutic hypothermia.

SETTING

Seventeen hospitals in the United States, Australia, and New Zealand.

PATIENTS

Children (< 18 yr) with severe traumatic brain injury.

INTERVENTIONS

None for this secondary analysis.

MEASUREMENTS AND MAIN RESULTS

Children received neuromuscular blocking agent on the majority of days of the study (69.6%), and the modified Pediatric Intensity Level of Therapy scores (modified by removing neuromuscular blocking agent administration from the score) were increased on days when neuromuscular blocking agents were used (9.67 ± 0.21 vs 5.48 ± 0.26; p < 0.001). Children were stratified into groups based on exposure to neuromuscular blocking agents (group 1 received neuromuscular blocking agents each study day; group 2 did not). Group 1 had increased number of daily intracranial pressure readings more than 20 mm Hg (4.4 ± 1.1 vs 2.4 ± 0.5;p = 0.015) and longer ICU and hospital length of stay (p = 0.003 and 0.07, respectively, Kaplan-Meier). The Glasgow Outcome Score-Extended for Pediatrics at hospital discharge and 3, 6, and 12 months after traumatic brain injury and medical complications observed during the acute hospitalization were similar between groups.

CONCLUSIONS

Administration of neuromuscular blocking agents was ubiquitous and daily administration of neuromuscular blocking agents was associated with intracranial hypertension but not outcomes-likely indicating that increased injury severity prompted their use. Despite this, neuromuscular blocking agent use was not associated with complications. A different study design-perhaps using randomization or methodologies-of a larger cohort will be required to determine if neuromuscular blocking agent use is helpful after severe traumatic brain injury in children.

Carotid artery blood flow decreases after rapid head rotation in piglets

Modification of cerebral perfusion pressure and cerebral blood flow (CBF) are crucial components of the therapies designed to reduce secondary damage after traumatic brain injury (TBI). Previously we documented a robust decrease in CBF after rapid sagittal head rotation in our well-validated animal model of diffuse TBI. Mechanisms responsible for this immediate (<10 min) and sustained (∼24 h) reduction in CBF have not been explored. Because the carotid arteries are a major source of CBF, we hypothesized that blood flow through the carotid arteries (Q) and vessel diameter (D) would decrease after rapid nonimpact head rotation without cervical spine injury. Four-week-old (toddler) female piglets underwent rapid (<20 msec) sagittal head rotation without impact, previously shown to produce diffuse TBI with reductions in CBF. Ultrasonographic images of the bilateral carotid arteries were recorded at baseline (pre-injury), as well as immediately after head rotation and 15, 30, 45, and 60 min after injury. Diameter (D) and waveform velocity (V) were used to calculate blood flow (Q) through the carotid arteries using the equation Q=(0.25)πD(2)V. D, V, and Q were normalized to the pre-injury baseline values to obtain a relative change after injury in right and left carotid arteries. Three-way analysis of variance and post-hoc Tukey-Kramer analyses were used to assess statistical significance of injury, time, and side. The relative change in carotid artery diameter and flow was significantly decreased in injured animals in comparison with uninjured sham controls (p<0.0001 and p=0.0093, respectively) and did not vary with side (p>0.39). The average carotid blood velocity did not differ between sham and injured animals (p=0.91). These data suggest that a reduction in global CBF after rapid sagittal head rotation may be partially mediated by a reduction in carotid artery flow, via vasoconstriction.

Age-specific cerebral perfusion pressure thresholds and survival in children and adolescents with severe traumatic brain injury*

OBJECTIVES

Evidence-based traumatic brain injury guidelines support cerebral perfusion pressure thresholds for adults at a class 2 level, but evidence is lacking in younger patients. The purpose of this study is to identify the impact of age-specific cerebral perfusion pressure thresholds on short-term survival among patients with severe traumatic brain injury.

DESIGN

Institutional review board-approved, prospective, observational cohort study.

SETTING

Level I or II trauma centers in New York State.

PATIENTS

Data on all patients with a postresuscitation Glasgow Coma Score less than 9 were added in the Brain Trauma Foundation prospective New York State TBI-trac database.

MEASUREMENTS AND MAIN RESULTS

We calculated the survival rates and relative risks of mortality for patients with severe traumatic brain injury based on predefined age-specific cerebral perfusion pressure thresholds. A higher threshold and a lower threshold were defined for each age group: 60 and 50 mm Hg for 12 years old or older, 50 and 35 mm Hg for 6-11 years, and 40 and 30 mm Hg for 0-5 years. Patients were stratified into age groups of 0-11, 12-17, and 18 years old or older. Three exclusive groups of CPP-L (events below low cerebral perfusion pressure threshold), CPP-B (events between high and low cerebral perfusion pressure thresholds), and CPP-H (events above high cerebral perfusion pressure threshold) were defined. As an internal control, we evaluated the associations between cerebral perfusion pressure events and events of hypotension and elevated intracranial pressure. Survival was significantly higher in 0-11 and 18 years old or older age groups for patients with CPP-H events compared with those with CPP-L events. There was a significant decrease in survival with prolonged exposure to CPP-B events for the 0-11 and 18 years old and older age groups when compared with the patients with CPP-H events (p = 0.0001 and p = 0.042, respectively). There was also a significant decrease in survival with prolonged exposure to CPP-L events in all age groups compared with the patients with CPP-H events (p< 0.0001 for 0- to 11-yr olds, p = 0.0240 for 12- to 17-yr olds, and p < 0.0001 for 18-yr old and older age groups). The 12- to 17-year olds had a significantly higher likelihood of survival compared with adults with prolonged exposure to CPP-L events (< 50 mm Hg). CPP-L events were significantly related to systemic hypotension for the 12- to 17-year-old group (p = 0.004) and the 18-year-old and older group (p < 0.0001). CPP-B events were significantly related to systemic hypotension in the 0- to 11-year-old group (p = 0.014). CPP-B and CPP-L events were significantly related to elevated intracranial pressure in all age groups.

CONCLUSIONS

Our data provide new evidence that cerebral perfusion pressure targets should be age specific. Furthermore, cerebral perfusion pressure goals above 50 or 60 mm Hg in adults, above 50 mm Hg in 6- to 17-year olds, and above 40 mm Hg in 0- to 5-year olds seem to be appropriate targets for treatment-based studies. Systemic hypotension had an inconsistent relationship to events of low cerebral perfusion pressure, whereas elevated intracranial pressure was significantly related to all low cerebral perfusion pressure events across all age groups. This may impart a clinically important difference in care, highlighting the necessity of controlling intracranial pressure at all times, while targeting systolic blood pressure in specific instances.

Early cerebral perfusion pressure augmentation with phenylephrine after traumatic brain injury may be neuroprotective in a pediatric swine model

OBJECTIVE

Cerebral perfusion pressure<40 mm Hg following pediatric traumatic brain injury has been associated with increased mortality independent of age, and current guidelines recommend maintaining cerebral perfusion pressure between 40 mm Hg-60 mm Hg. Although adult traumatic brain injury studies have observed an increased risk of complications associated with targeting a cerebral perfusion pressure>70, we hypothesize that targeting a cerebral perfusion pressure of 70 mm Hg with the use of phenylephrine early after injury in the immature brain will be neuroprotective.

DESIGN

Animals were randomly assigned to injury with a cerebral perfusion pressure of 70 mm Hg or 40 mm Hg. Diffuse traumatic brain injury was produced by a single rapid rotation of the head in the axial plane. Cerebral microdialysis, brain tissue oxygen, intracranial pressure, and cerebral blood flow were measured 30 min-6 hrs postinjury. One hour after injury, cerebral perfusion pressure was manipulated with the vasoconstrictor phenylephrine. Animals were euthanized 6 hrs posttraumatic brain injury, brains fixed, and stained to assess regions of cell injury and axonal dysfunction.

SETTING

University center.

SUBJECT

Twenty-one 4-wk-old female swine.

MEASUREMENTS AND MAIN RESULTS

Augmentation of cerebral perfusion pressure to 70 mm Hg resulted in no change in axonal dysfunction, but significantly smaller cell injury volumes at 6 hrs postinjury compared to cerebral perfusion pressure 40 (1.1% vs. 7.4%, p<.05). Microdialysis lactate/pyruvate ratios were improved at cerebral perfusion pressure 70 compared to cerebral perfusion pressure 40. Cerebral blood flow was higher in the cerebral perfusion pressure 70 group but did not reach statistical significance. Phenylephrine was well tolerated and there were no observed increases in serum lactate or intracranial pressure in either group.

CONCLUSIONS

Targeting a cerebral perfusion pressure of 70 mm Hg resulted in a greater reduction in metabolic crisis and cell injury volumes compared to a cerebral perfusion pressure of 40 mm Hg in an immature swine model. Early aggressive cerebral perfusion pressure augmentation to a cerebral perfusion pressure of 70 mm Hg in pediatric traumatic brain injury before severe intracranial hypertension has the potential to be neuroprotective, and further investigations are needed.

Intracranial pressure and cerebral perfusion pressure responses to head elevation changes in pediatric traumatic brain injury

OBJECTIVES

To determine the effect of and dynamic interaction between head elevation on intracranial pressure and cerebral perfusion pressure in severe pediatric traumatic head injury.

DESIGN

Prospective, randomized, interventional cohort study.

SETTING

Two tertiary pediatric critical care referral units.

PATIENTS

Ten children admitted with severe traumatic brain injury defined as Glasgow Coma Score ≤ 8 necessitating intracranial pressure monitoring (10 yrs ± 5 SD; range 2-16 yrs).

INTERVENTIONS

Head elevation was randomly increased or decreased between 0 and 40 degrees from baseline level (30 degrees) in increments or decrements of 10 degrees.

MEASUREMENTS AND MAIN RESULTS

Intracranial pressure and arterial blood pressure were continuously recorded in combination with time-stamped clinical notations. Data were available for analysis in eight subjects (seven males and one female; mean age, 10 yrs ± SD 5; range, 2-16 yrs) during 18 protocol sessions. This resulted in a total of 66 head-of-the-bed challenges. To compare results for a given change in head-of-the-bed elevation across age, we transformed head-of-the-bed angle to change in height (cm) at the level of Monro's foramen. An increase in head elevation of 10 cm resulted in an average change in intracranial pressure of -3.9 mm Hg (SD ± 3.2 mm Hg; p < .001), whereas cerebral perfusion pressure remained unchanged (0.1 ± 5.6 mm Hg; p = .957). Individual subjects showed marked variability in intracranial pressure change (range, -8.4 to +1.9 mm Hg/10 cm). The overall regression analysis for intracranial pressure response was change in intracranial pressure = -0.39/cm Δh, r2 = 0.42, and p < .001, where Δh is the change in vertical height at the level of foramen of Monro attributable to a change in the head of the bed.

CONCLUSIONS

In severe pediatric traumatic brain injury, the relationship between change in head of the bed and change in intracranial pressure was negative and linear. The lowest intracranial pressure was usually, but not always, achieved at highest head-of-the-bed angles. The effect size of a head-of-the-bed angle change depended, in part, on the subject's height. In contrast, cerebral perfusion pressure was mostly unaffected by head-of-the-bed changes.

Pediatric neurocritical care

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.

Effects of hemodilution after traumatic brain injury in juvenile rats

BACKGROUND

Normovolemic hemodilution (HD) in adult animal studies has shown exacerbation of traumatic brain injury (TBI) lesion volumes. Similar studies in juvenile rats have not been reported and outcomes are likely to be different. This study investigated the effects of normovolemic hemodilution (21% hematocrit) in a juvenile TBI (jTBI) model.

METHODS

Twenty 17-day-old rats underwent moderate cortical contusion impact injury (CCI) and were divided into four groups: CCI/hemodilution (HD) (group HD), CCI/no HD (group C), Sham/HD (group SHD), and Sham/no HD (group S). Regional laser Doppler flowmetry (LDF), edema formation (MRI-T2WI), water mobility assessed using diffusion weighted imaging (MRI-DWI), open field activity tests, and histological analyses were evaluated for lesion characteristics.

RESULTS

Hemodilution significantly increased blood flow in the HD compared to the C group after TBI. T2WI revealed a significantly increased extravascular blood volume in HD at 1, 7, and 14 days post-CCI. Edematous tissue and total contusional lesion volume were higher in HD-treated animals at 1 and 14 days. DWI revealed that HD, SHD, and C groups had elevated water mobility compared to S groups in the ipsilateral cortex and striatum. Histology showed a larger cortical lesion in the C than HD group. Open field activity was increased in HD, C, and SHD groups compared to the S group.

CONCLUSIONS

Hemodilution results in significant brain hyperemia with increased edema formation, extravascular blood volume, and water mobility after jTBI. Hemodilution results in less cortical damage but did not alter behavior. Hemodilution is likely not to be clinically beneficial following jTBI.

Common data elements for pediatric traumatic brain injury: recommendations from the working group on demographics and clinical assessment

The Common Data Elements (CDEs) initiative is a National Institutes of Health (NIH) interagency effort to standardize naming, definitions, and data structure for clinical research variables. Comparisons of the results of clinical studies of neurological disorders have been hampered by variability in data coding, definitions, and procedures for sample collection. The CDE project objective is to enable comparison of future clinical trials results in major neurological disorders, including traumatic brain injury (TBI), stroke, multiple sclerosis, and epilepsy. As part of this effort, recommendations for CDEs for research on TBI were developed through a 2009 multi-agency initiative. Following the initial recommendations of the Working Group on Demographics and Clinical Assessment, a separate workgroup developed recommendations on the coding of clinical and demographic variables specific to pediatric TBI studies for subjects younger than 18 years. This article summarizes the selection of measures by the Pediatric TBI Demographics and Clinical Assessment Working Group. The variables are grouped into modules which are grouped into categories. For consistency with other CDE working groups, each variable was classified by priority (core, supplemental, and emerging). Templates were produced to summarize coding formats, guide selection of data points, and provide procedural recommendations. This proposed standardization, together with the products of the other pediatric TBI working groups in imaging, biomarkers, and outcome assessment, will facilitate multi-center studies, comparison of results across studies, and high-quality meta-analyses of individual patient data.

Brain temperature: heat production, elimination and clinical relevance

Neurological insults are a leading cause of morbidity and mortality, both in adults and especially in children. Among possible therapeutic strategies to limit clinical cerebral damage and improve outcomes, hypothermia remains a promising and beneficial approach. However, its advantages are still debated after decades of use. Studies in adults have generated conflicting results, whereas in children recent data even suggest that hypothermia may be detrimental. Is it because brain temperature physiology is not well understood and/or not applied properly, that hypothermia fails to convince clinicians of its potential benefits? Or is it because hypothermia is not, as believed, the optimal strategy to improve outcome in patients affected with an acute neurological insult? This review article should help to explain the fundamental physiological principles of brain heat production, distribution and elimination under normal conditions and discuss why hypothermia cannot yet be recommended routinely in the management of children affected with various neurological insults.

Quo vadis 2010? - carpe diem: challenges and opportunities in pediatric traumatic brain injury

Traumatic brain injury (TBI) in infants and children remains a public health problem of enormous magnitude. It is a complex and heterogeneous condition that presents many diagnostic, therapeutic and prognostic challenges. A number of investigative teams are studying pediatric TBI both in experimental models and in clinical studies at the bedside. This review builds on work presented in a prior supplement to Developmental Neuroscience that was published in 2006, and addresses several active areas of research on this topic, including (1) the application of novel imaging methods, (2) the use of serum and/or CSF biomarkers of injury, (3) advances in neuromonitoring, (4) the development and testing of novel therapies, (5) developments in modeling pediatric TBI, (6) the consideration of a new approach to classification of pediatric TBI, and (7) assessing the potential impact of the development of pediatric and neonatal neurocritical care services on the management and outcome of pediatric TBI.

Common data elements for traumatic brain injury: recommendations from the interagency working group on demographics and clinical assessment

Comparing results across studies in traumatic brain injury (TBI) has been difficult because of the variability in data coding, definitions, and collection procedures. The global aim of the Working Group on Demographics and Clinical Assessment was to develop recommendations on the coding of clinical and demographic variables for TBI studies applicable across the broad spectrum of TBI, and to classify these as core, supplemental, or emerging. The process was consensus driven, with input from experts over a broad range of disciplines. Special consideration was given to military and pediatric TBI. Categorizing clinical elements as core versus supplemental proved difficult, given the great variation in types of studies and their interests. The data elements are contained in modules, which are grouped together in categories. Three levels of detail for coding data elements were developed: basic, intermediate, and advanced, with the greatest level of detail in the advanced version. In every case, the more detailed coding can be collapsed into the basic version. Templates were produced to summarize coding formats, motivation of choices, and recommendations for procedures. Work is ongoing to include more international participation and to provide an electronic data entry format with pull-down menus and automated data checks. This proposed standardization will facilitate comparison of research findings across studies and encourage high-quality meta-analysis of individual patient data.

Relationship of intracranial pressure and cerebral perfusion pressure with outcome in young children after severe traumatic brain injury

Traumatic brain injury (TBI) is the most common cause of death for children less than 18 years of age. Current standards of care for children with severe TBI include monitoring of intracranial pressure (ICP), and goal-directed therapies to minimize ICP and optimize cerebral perfusion pressure (CPP; the mathematical difference between the mean arterial pressure and ICP). Current guidelines for ICP and CPP thresholds suggest that age-based thresholds should be adopted, but few studies have included the youngest children affected by TBI (those <2 years of age). We performed a retrospective analysis of our pediatric neurotrauma database to determine if ICP and CPP thresholds associated with favorable neurological outcome could be determined, or if the number of episodic alterations in the parameters (ICP >15 or >20 mm Hg; CPP <40 mm Hg, <45 mm Hg or <50 mm Hg) was different between children with favorable and unfavorable outcomes (based on dichotomous Glasgow Outcome Scale score at 6 months after TBI). Data from 22 children (of whom 81% had suffered from inflicted childhood neurotrauma) were analyzed in the first 7 days. Children with unfavorable outcome had more hourly readings of CPP of <45 mm Hg compared to children with favorable outcome [median (25-75%): 2 (1-31) vs. 0 (0-2); p <0.05]. There was no difference between the number of hourly readings of ICP of >20 mm Hg between the outcome groups [median (25-75%): favorable 0 (0-1) vs. unfavorable 1 (0-4); p = 0.17]. To our knowledge, this is the first exploratory report to test if CPP and ICP thresholds can be established for this young population of children after TBI, and it suggests a CPP target threshold of 45 mm Hg. Despite good ICP control in this population, there was still a 50% incidence of unfavorable outcome, suggesting that there may be unique physiologic parameters that need to be targeted in infants with severe TBI. A prospective study is needed to fully determine what goals should be targeted for this vulnerable population.

Traumatic brain injury: preferred methods and targets for resuscitation

PURPOSE OF REVIEW

Severe traumatic brain injury (TBI) is the most common cause of death and disability in pediatric trauma. This review looks at the strategies to treat TBI in a temporal fashion. We examine the targets for resuscitation from field triage to definitive care in the pediatric ICU.

RECENT FINDINGS

Guidelines for the management of pediatric TBI exist. The themes of contemporary clinical research have been compliance with these guidelines and refinement of treatment recommendations developing a more sophisticated understanding of the pathophysiology of the injured brain. In the field, the aim has been to achieve routine compliance with the resuscitation goals. In the hospital, efforts have been directed at improving our ability to monitor the injured brain, developing techniques that limit brain swelling, and customizing brain perfusion.

SUMMARY

As our understanding of pediatric TBI evolves, the ambition is that age-specific and perhaps individual brain injury strategies based upon feedback from continuous monitors will be defined. In addition, vogue methods such as hypothermia, hypertonic saline, and aggressive surgical decompression may prove to impact brain swelling and outcomes.

Continuous monitoring of cerebrovascular pressure reactivity after traumatic brain injury in children

OBJECTIVE

We hypothesized that pressure reactivity index (PRx) values indicating preserved cerebrovascular pressure autoregulation would be associated with survival in children with traumatic brain injury (TBI). This hypothesis was tested in a prospective, blinded, observational, pilot study.

METHODS

Twenty-one children admitted between May 2006 and September 2008 with severe TBI necessitating invasive intracranial pressure monitoring were enrolled in this study. The PRx was continuously monitored as a moving, linear correlation coefficient between low-frequency waves of intracranial and arterial blood pressures. Positive values of PRx approaching 1 indicate impaired cerebrovascular pressure reactivity, whereas negative PRx values or values close to 0 indicate preserved cerebrovascular pressure reactivity. Survival was the primary outcome and was compared with the average PRx value obtained during the intracranial pressure-monitoring period.

RESULTS

PRx was associated with survival in this cohort; survivors (N = 15) had a mean PRx +/- SD of 0.08 +/- 0.19, and nonsurvivors (N = 6) had a mean PRx of 0.69 +/- 0.21 (P = .0009). In this sample, continuous PRx monitoring suggested impaired cerebrovascular pressure reactivity at low levels of cerebral perfusion pressure (CPP) and intact cerebrovascular pressure reactivity at higher levels of CPP.

CONCLUSIONS

Intact cerebrovascular pressure reactivity quantified with the PRx is associated with survival after severe head trauma in children. The PRx is CPP dependent in children. The PRx may be useful for defining age-specific and possibly patient-specific optimal targets for CPP after TBI.

Cerebrovascular pathophysiology in pediatric traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI) is the leading cause of traumatic morbidity and mortality in children. Although there is increasing information concerning TBI in adults and experimental animal models, relatively little is known regarding cerebrovascular pathophysiology specific to children.

MATERIALS

A review of the pertinent medical literature.

RESULTS

Systemic and cerebral hemodynamic factors such as hypotension, hypoxia, hyperglycemia, and fever are associated with poor outcome in pediatric TBI. Similarly, cerebral autoregulation is often impaired after TBI and may adversely affect outcome, especially if systemic hemodynamics are altered. Furthermore, CO2 vasoreactivity may be altered after pediatric TBI and lead to either cerebral ischemia or hyperemia.

CONCLUSIONS

Understanding the effect of pediatric TBI on the cerebral circulation is needed to potentially develop protocols to improve outcome in this vulnerable population. Specifically, changes in pediatric cerebrovascular physiology and pathophysiology, including CO2 vasoreactivity and pressure autoregulation, must be understood and their mechanism elucidated.

Pediatric neurointensive care: 2008 update for the Rogers' Textbook of Pediatric Intensive Care

OBJECTIVE

To review important articles, in the field of pediatric neurointensive care, that were published subsequent to the fourth edition of the Rogers' Textbook of Pediatric Intensive Care.

DATA SOURCES

The U.S. National Library of Medicine (http://www.ncbi.nlm.nih.gov/sites/entrezPubMed) was searched for the term pediatric and the following individual terms, cardiac arrest, asphyxia, traumatic brain injury, status epilepticus, stroke, cerebral ischemia, and cerebral hemorrhage, to generate abstracts of additional citations that were then screened for potential inclusion. The authors were also aware of a number of key recent articles in both pediatric and adult neurointensive care and these were also screened.

STUDY SELECTION AND DATA EXTRACTION

Promising articles were reviewed and the decision as to whether they were included was made at the discretion of the section editors.

DATA SYNTHESIS

Articles in four categories were included based on selected chapters in the neurointensive care section of the textbook, using the specific chapter heading in the textbook, namely, head and spinal cord trauma, hypoxic-ischemic encephalopathy, status epilepticus, and cerebrovascular disease and stroke.

CONCLUSION

Developments in the field and practice of pediatric neurocritical care continue with significant additions to the literature and practice recommendations concerning care following traumatic brain injury, cardiac arrest, status epilepticus, and cerebrovascular events. Importantly, the continued progression in knowledge raises the health services issue of whether, in certain settings of high clinical volume, it is time for specialized pediatric neurointensive care services or units.

New concepts in treatment of pediatric traumatic brain injury

Emerging evidence suggests unique age-dependent responses following pediatric traumatic brain injury. The anesthesiologist plays a pivotal role in the acute treatment of the head-injured pediatric patient. This review provides important updates on the pathophysiology, diagnosis, and age-appropriate acute management of infants and children with severe traumatic brain injury. Areas of important clinical and basic science investigations germane to the anesthesiologist, such as the role of anesthetics and apoptosis in the developing brain, are discussed.

Traumatic brain injury in children: recent advances in management

To define and discuss new developments in the field of pediatric traumatic brain injury (TBI). Review of several recent key studies on therapy since publication of the first U.S. traumatic brain injury guidelines in 2003. In addition, we discuss new developments in the use of biomarkers of brain injury in TBI diagnosis and also discuss recent advances in bedside neuromonitoring that may be helpful in the setting of pediatric brain injury. Important new information on optimal cerebral perfusion pressure management, cerebrospinal fluid drainage, decompressive craniectomy, hypothermia, biomarkers of brain injury along with advances in neuromonitoring are presented. The 2003 guidelines have stimulated important new research. This is reshaping bedside care.

Management of critically ill children with traumatic brain injury

The management of critically ill children with traumatic brain injury (TBI) requires a precise assessment of the brain lesions but also of potentially associated extra-cranial injuries. Children with severe TBI should be treated in a pediatric trauma center, if possible. Initial assessment relies mainly upon clinical examination, trans-cranial Doppler ultrasonography and body CT scan. Neurosurgical operations are rarely necessary in these patients, except in the case of a compressive subdural or epidural hematoma. On the other hand, one of the major goals of resuscitation in these children is aimed at protecting against secondary brain insults (SBI). SBI are mainly because of systemic hypotension, hypoxia, hypercarbia, anemia and hyperglycemia. Cerebral perfusion pressure (CPP = mean arterial blood pressure - intracranial pressure: ICP) should be monitored and optimized as soon as possible, taking into account age-related differences in optimal CPP goals. Different general maneuvers must be applied in these patients early during their treatment (control of fever, avoidance of jugular venous outflow obstruction, maintenance of adequate arterial oxygenation, normocarbia, sedation-analgesia and normovolemia). In the case of increased ICP and/or decreased CPP, first-tier ICP-specific treatments may be implemented, including cerebrospinal fluid drainage, if possible, osmotic therapy and moderate hyperventilation. In the case of refractory intracranial hypertension, second-tier therapy (profound hyperventilation with P(a)CO(2) < 35 mmHg, high-dose barbiturates, moderate hypothermia, decompressive craniectomy) may be introduced, after a new cerebral CT scan.

Cerebral blood flow and autoregulation after pediatric traumatic brain injury

Traumatic brain injury is a global health concern and is the leading cause of traumatic morbidity and mortality in children. Despite a lower overall mortality than in adult traumatic brain injury, the cost to society from the sequelae of pediatric traumatic brain injury is very high. Predictors of poor outcome after traumatic brain injury include altered systemic and cerebral physiology, including altered cerebral hemodynamics. Cerebral autoregulation is often impaired after traumatic brain injury and may adversely impact the outcome. Although altered cerebrovascular hemodynamics early after traumatic brain injury may contribute to disability in children, there is little information regarding changes in cerebral blood flow and cerebral autoregulation after pediatric traumatic brain injury. This review addresses normal pediatric cerebral physiology and cerebrovascular pathophysiology after pediatric traumatic brain injury.

ICP and CPP: excellent predictors of long term outcome in severely brain injured children

OBJECTIVE

To determine the predictive powers of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) amongst severely brain injured children.

MATERIALS AND METHODS

ICP and CPP were recorded from thirty-five severely brain injured children who were prospectively recruited after admission to paediatric intensive care. Twenty-five suffered traumatic brain injury (TBI) and ten suffered non-TBI. Peak ICP and minimum CPP recorded for each patient during their admission were related to 5 year Glasgow Outcome Scale outcome. Receiver operator characteristic curves determined that the optimum threshold for unfavourable outcome prediction was >or=40 mmHg for ICP and <or=49 mmHg for CPP. At these thresholds the sensitivity/specificity pairs for the prediction of unfavourable outcome were 33.3/100% and 55.6/100% for ICP and CPP, respectively, amongst patients suffering TBI and were 46.2/100% and 66.2/100% for ICP and CPP, respectively, amongst all patients.

CONCLUSION

ICP and CPP are accurate predictors of unfavourable outcome.

Prediction of raised intracranial pressure complicating severe traumatic brain injury in children: implications for trial design

OBJECTIVES

To describe current patterns of management of raised intracranial pressure (ICP) in traumatic brain injury relevant to clinician buy-in to possible randomized controlled trials of treatments of raised ICP. To examine the feasibility of early identification of children at sufficient risk of developing raised ICP to permit a uniform approach between centers to the initiation of ICP monitoring. This would permit quantification of ICP elevation and enrollment as appropriate to randomized controlled trials of raised ICP interventions.

DESIGN

Logistic regression modeling of death before pediatric intensive care unit discharge and decision tree and logistic regression of development of raised ICP through analysis of a prospectively collected, standardized, national data set.

SETTING

Pediatric intensive care units in the United Kingdom and Eire.

PATIENTS

Patients were 501 children <16 yrs of age primarily admitted to intensive care unit for management of traumatic brain injury in the United Kingdom and Eire between February 2001 and August 2003.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The data analyzed included demographic, acute physiologic, and cranial imaging variables. Death was associated with both raised ICP and the nonmeasurement of ICP. In a subset of 199 patients, an empirically derived decision rule predicted the development of raised ICP at any point during ICU admission with sensitivity of 73% and specificity of 74% (positive predictive value 82% and negative predictive value 63%). Logistic regression modeling performed comparably. The decision rule also predicted raised ICP in 20% of children not undergoing ICP monitoring.

CONCLUSIONS

Simple models based on early clinical data may predict the development of raised ICP sufficiently well to encourage a consistent approach between centers to initiation of ICP monitoring. We estimate studies designed to detect reductions in ICU mortality will require >320 children per arm, although this figure may be higher if more conservative assumptions are made.

Pediatric traumatic brain injury: not just little adults

PURPOSE OF REVIEW

This review will update the reader on the most significant recent findings with regards to both the clinical research and basic science of pediatric traumatic brain injury.

RECENT FINDINGS

The developing brain is not simply a smaller version of the mature brain. Studies have uncovered important distinctions of the younger brain after traumatic brain injury, including an increased propensity for apoptosis, age-dependent parameters for cerebral blood flow and metabolism, development-specific biomarkers, increased likelihood of early posttraumatic seizures, differential sensitivity to commonly used neuroactive medications and altered neuroplasticity during recovery from injury. Specifically, there is strong preclinical evidence for increased neuronal apoptosis in the developing brain being triggered by anesthetics and anticonvulsants, making it paramount that future studies more clearly delineate preferred agents and specific indications for use, incorporating long-term functional outcomes as well as short-term benefits. In addition, the young brain may actually benefit from therapeutic interventions that have been less effective following adult traumatic brain injury, such as decompressive craniectomy and hypothermia.

SUMMARY

An increasing body of evidence demonstrates the importance of establishing age-dependent guidelines for physiological monitoring, pharmacological intervention, management of intracranial pressure and facilitating recovery of function.

Pediatric traumatic brain injury: quo vadis?

In this review, five questions serve as the framework to discuss the importance of age-related differences in the pathophysiology and therapy of traumatic brain injury (TBI). The following questions are included: (1) Is diffuse cerebral swelling an important feature of pediatric TBI and what is its etiology? (2) Is the developing brain more vulnerable than the adult brain to apoptotic neuronal death after TBI and, if so, what are the clinical implications? (3) If the developing brain has enhanced plasticity versus the adult brain, why are outcomes so poor in infants and young children with severe TBI? (4) What contributes to the poor outcomes in the special case of inflicted childhood neurotrauma and how do we limit it? (5) Should both therapeutic targets and treatments of pediatric TBI be unique? Strong support is presented for the existence of unique biochemical, molecular, cellular and physiological facets of TBI in infants and children versus adults. Unique therapeutic targets and enhanced therapeutic opportunities, both in the acute phase after injury and in rehabilitation and regeneration, are suggested.

Critical thresholds of intracranial pressure and cerebral perfusion pressure related to age in paediatric head injury

BACKGROUND

The principal strategy for managing head injury is to reduce the frequency and severity of secondary brain insults from intracranial pressure (ICP) and cerebral perfusion pressure (CPP), and hence improve outcome. Precise critical threshold levels have not been determined in head injured children.

OBJECTIVE

To create a novel pressure-time index (PTI) measuring both duration and amplitude of insult, and then employ it to determine critical insult thresholds of ICP and CPP in children.

METHODS

Prospective, observational, physiologically based study from Edinburgh and Newcastle, using patient monitored blood pressure, ICP, and CPP time series data. The PTI for ICP and CPP for 81 children, using theoretical values derived from physiological norms, was varied systematically to derive critical insult thresholds which delineate Glasgow outcome scale categories.

RESULTS

The PTI for CPP had a very high predictive value for outcome (receiver operating characteristic analyses: area under curve = 0.957 and 0.890 for mortality and favourable outcome, respectively) and was more predictive than for ICP. Initial physiological values most accurately predicted favourable outcome. The CPP critical threshold values determined for children aged 2-6, 7-10, and 11-15 years were 48, 54, and 58 mm Hg. respectively.

CONCLUSIONS

The PTI is the first substantive paediatric index of total ICP and CPP following head injury. The insult thresholds generated are identical to age related physiological values. Management guidelines for paediatric head injuries should take account of these CPP thresholds to titrate appropriate pressor therapy.

Pediatric traumatic brain injury: beyond the guidelines

In 2003, a multidisciplinary group of physicians formulated the first guidelines for the management of severe traumatic brain injury in infants and children. Initial treatment of these patients is focused on stabilization to prevent the occurrence of secondary insults such as hypotension and hypoxemia. However, this article focuses on the established and emerging therapies used in the intensive care unit management of intracranial hypertension--which represents the key target for contemporary therapy of this condition. A critical pathway for the treatment of this condition was established within the guidelines, and this pathway is appropriately focused on limiting intracranial hypertension and optimizing cerebral perfusion during the intensive care unit phase. This includes first- and second-tier therapies. This article contains a brief synopsis of this critical pathway and discusses important new developments for the management of this condition. Key new developments include a better understanding of the optimal cerebral perfusion pressure target for intracranial pressure-directed therapy, with emerging evidence supporting the use of two therapeutic modalities, mild-moderate hypothermia and decompressive craniectomy.