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

Miller Ferguson, Nikki MD; Shein, Steven L. MD; Kochanek, Patrick M. MD; Luther, Jim MA; Wisniewski, Stephen R. PhD; Clark, Robert S. B. MD; Tyler-Kabara, Elizabeth C. MD; Adelson, P. David MD; Bell, Michael J. MD

Pediatric Critical Care Medicine: May 2016 - Volume 17 - Issue 5 - p 444–450
doi: 10.1097/PCC.0000000000000709
Neurocritical Care

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.

1Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

2Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA.

3Department of Epidemiology and Biostatistics, University of Pittsburgh School of Medicine, Pittsburgh, PA.

4Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA.

5Barrow Neurological Institute at Phoenix Children’s Hospital, Department of Neurological Surgery, Phoenix, AZ.

The authors of this work received National Institutes of Health grants (Drs. Ferguson and Shein: T32 HD040686; Dr. Wisniewski: NS052478 and NS069247; Dr. Clark: NS069247; Dr. Adelson: NS081041 and NS052478, Dr. Bell: NS081041, HD0499893, NS072308, and NS052478).

Dr. Bell received support for article research from the National Institutes of Health (NIH). Dr. Ferguson received support for article research from the NIH. Her institution received funding from the NIH/NICHD- 5T32HD040686. Dr. Shein received support for article research from the NIH. His institution received funding from NIH (T32). Dr. Kochanek is also the editor and/or contributor to multiple textbooks in the field. He received support for article research from the NIH, received funding from the Society of Critical Care Medicine, he serves as a guest professor and lectures frequently at Medical Centers and other Institutions of Higher Education, and he has served as an expert witness in legal cases. His institution received funding from the NIH. Dr. Wisniewski received support for article research from the NIH. His institution received funding from the NIH. Dr. Clark received funding from Elsevier book royalties. His institution received funding from NIH grants unrelated to present work. Dr. Tyler-Kabara received funding from Consulting through TKGroup, LLC (No monies personally received) and from University of Toronto. Her institution received funding from DARPA NIH. Dr. Adelson consulted for Adelson Medical Consulting, LLC; is employed by Phoenix Children's Hospital; provided expert testimony for various medical legal case; and received royalties from Thieme Publishing. His institution received grant support from Codman Neuro and the NIH. Dr. Luther disclosed that he does not have any potential conflicts of interest.

For information regarding this article, E-mail: bellmj4@upmc.edu

©2016The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies