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Guidelines for the management of pediatric severe traumatic brain injury

Mullen, Tiffany A. MSN, RN, CCRN, ACCNS-P; Cartwright, Cathy C. MSN, RN-BC, FAAN, PCNS

doi: 10.1097/01.CCN.0000578820.52281.0f
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Abstract: A 2019 update to the 2012 guidelines for the management of pediatric severe traumatic brain injury was published in March. This article highlights the changes released in the update regarding monitoring, thresholds, and treatments.

This article summarizes the 2019 update to the 2012 guidelines for the management of pediatric severe traumatic brain injury, which was published in March. Highlighted updates include changes regarding monitoring, thresholds, and treatments.

Tiffany A. Mullen is a pediatric clinical nurse specialist on the pediatric ICU at Children's Mercy, Kansas City, Mo.

Cathy C. Cartwright is the Director of Advanced Practice Education at Children's Mercy, Kansas City, Mo.

The authors have disclosed no financial relationships related to this article.

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The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies recently published the Third Edition of the Guidelines for the Management of Pediatric Severe Traumatic Brain Injury (TBI) as a supplement to the March issue of Pediatric Critical Care Medicine.1 A group of multidisciplinary experts, including critical care medicine physicians, neurosurgeons, and experts in the nursing field, collaborated to update the Guidelines' second edition, which was published in 2012. Although a total of 48 new studies were included, the overall level of evidence remains low. The Third Edition consists of 22 evidence-based recommendations, with 9 of these recommendations newly created or significantly changed from the previous edition.2 A total of 19 recommendations are level III, indicating support by low-level evidence. The update also includes three level-II recommendations supported by moderate-quality evidence. The highest quality of evidence from randomized controlled trials remains absent. No new topics were added to the Guidelines' third edition, and the original 15 topics remain organized into three categories: monitoring, thresholds, and treatments. In addition to the Guidelines update, the authors also published a companion article with a critical pathway algorithm of care for both tier-I and tier-II approaches.3

The Guidelines are not meant to be used as a comprehensive stepwise approach to medical management of pediatric patients with severe TBI, but rather provide the foundation for consistency in patient care by way of protocol development and standardization for future investigations.2,3 The group of clinical investigators took a two-pronged approach to revising the Guidelines' second edition, starting with a systematic review and synthesis, followed by recommendations development.1 Standardization of institutional clinical practice guidelines could be guided with the updated guidelines as a means to treat a patient population in a consistent stepwise approach, rather than management solely dependent on provider preference. Standardization of management could also contribute to the reliability of future research on the various interventions. This article highlights the changes released in the third edition based on its three main categories.

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Monitoring

Monitoring recommendations involve intracranial pressure (ICP) monitoring, advanced neuromonitoring, and neuroimaging. Recommendations for ICP monitoring were unchanged, but three new studies were added to the evidence base. The recommendation remains that ICP monitoring provides an objective measure used to direct therapies and ultimately improve outcomes. Use of advanced neuromonitoring in the form of brain tissue oxygenation (PbrO2) also remains unchanged from the previous recommendation to maintain a level greater than 10 mm Hg, but two related notes were added. The first note indicates insufficient evidence to support the use of monitoring PbrO2 to improve outcomes. The second note states the use of advanced neuromonitoring should be reserved only for patients with no contraindications to invasive monitoring, such as coagulopathy, and patients who have not been given a diagnosis of brain death.

There is a new recommendation regarding head computed tomography (CT). The previous edition did not support the use of CT more than 24 hours after admission and initial follow-up unless there was evidence of neurologic deterioration. The 2019 Guidelines add that it is not suggested to obtain CT on a comatose patient 0 to 6 hours after injury to exclude elevated ICP. One supporting study concluded normal initial head CT was not predictive of normal ICP.4 Further, it is difficult to assess the association of CT results and ICP levels when not all patients undergoing CT also have ICP monitoring. Although CT is the preferred imaging tool to detect intracranial injury and/or cerebral edema following TBI, recommendations indicate the need for caution when interpreting CT results. Use of clinical assessments and the astute assessments of bedside clinicians is needed to identify changes in neurologic status, warranting the discussion of the need for additional imaging.

The overuse of diagnostic tools that do not contribute to the plan of care is the foundation for campaigns such as Choosing Wisely. The Choosing Wisely campaign aims to reduce waste in healthcare and avoid unnecessary tests and procedures, lessening patient risks and costs.5 Currently, there are no Choosing Wisely recommendations related to pediatric severe TBI and the diagnostic tools related to management; however, there is a recommendation not to routinely obtain a CT scan of children with mild head injuries.6 This recommendation from the American Academy of Pediatrics calls attention to diligence in ordering head CT because of the unwarranted cost to the healthcare system and the dangers of ionizing radiation to the sensitive brain tissue in children.6

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Thresholds

The updated Guidelines include no changes to the level-III recommendations to target an ICP threshold of less than 20 mm Hg and a cerebral perfusion pressure (CPP) threshold greater than 40 mm Hg. A CPP between 40 mm Hg and 50 mm Hg is suggested, with infants at the lower end and adolescents at or above the upper end of this range. Although there were no content changes on these thresholds, there were new studies added to each body of evidence supporting current recommendations.7-10

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Treatments

The treatment section had the largest number of modifications because of the addition of 28 new studies. Of the 15 recommendations in the treatment section of the Guidelines, 7 are new or revised. Medical and surgical management recommendations are discussed below, with a focus on the medical management regarding medications, temperature control, and nutrition.

Hyperosmolar therapy recommendations have evolved over the course of the Guidelines' three editions. The third edition features a level-II recommendation of 3% hypertonic saline (HTS) for intracranial hypertension with an effective dose ranging between 2 and 5 mL/kg to be given over 10 to 20 minutes. The recommendation for continuous hyperosmolar therapy remains the same with effective dosing for continuous 3% HTS ranging between 0.1 and 1.0 mL/kg/h with a sliding scale to maintain ICP less than 20 mm Hg. A new recommendation for a bolus of 23.4% HTS is suggested for refractory ICP with a suggested dose of 0.5 mL/kg and maximum dose of 30 mL. When using hyperosmolar therapy, sustained (more than 72 hours) serum sodium levels greater than 170 mEq/L should be avoided to prevent complications such as thrombocytopenia and anemia, and sustained serum sodium levels greater than 160 mEq/L should be avoided to prevent deep vein thrombosis. There remains insufficient evidence to support the use of mannitol to reduce ICP in pediatric TBI.

There were a few changes in the medical management of TBI in terms of analgesics, sedation, and use of neuromuscular blockade. Bolus doses of midazolam and/or fentanyl are not recommended to decrease ICP because of the risk of cerebral hypoperfusion. Previous recommendations for thiopental have been removed, and a note discouraging the prolonged use of continuous propofol infusion for sedation and management in refractory intracranial hypertension remains. Prolonged propofol use is not recommended by the FDA related to biological differences and increased sensitivity in children compared with adults.11 Medical management for seizure prophylaxis has a low level of evidence but the Guidelines do in fact recommend use of medication to reduce the occurrence of early (within 7 days) posttraumatic seizures (PTS). It is unclear based on the evidence if levetiracetam or phenytoin is the drug of choice based on efficacy in preventing PTS or toxicity. Ultimately, it is left to the clinical decision-making of the provider to choose an appropriate medication to prevent PTS that can lead to secondary injury in pediatric patients with severe TBI.

There were no content changes for the recommendations on the use of barbiturates in the third edition. Use of high-dose barbiturate therapy is suggested in hemodynamically stable patients who continue to have intracranial hypertension, despite medical and surgical management. Due to the common occurrence of cardiorespiratory instability in the use of barbiturates, continuous hemodynamic monitoring with arterial BP monitoring and cardiovascular support is recommended in the use of high-dose barbiturate therapy to maintain adequate CPP.

There has not been much growth in the evidence relating to the use of corticosteroids in the pediatric TBI population. The level-II recommendation in the second edition has been downgraded to a level-III recommendation. Use of corticosteroids is not suggested to improve outcomes or reduce ICP; however, corticosteroid use may be indicated for patients needing chronic steroid replacement therapy, those with adrenal suppression, and those with injury to the hypothalamic-pituitary steroid axis.1 Adult studies did not demonstrate benefit regarding mortality, but steroid treatment was associated with increased risk of ventilator-associated pneumonia.12 Similar studies are lacking in the pediatric population.

A more comprehensive term of ventilation therapies is used in the third edition as opposed to hyperventilation therapies in previous editions. Ventilation therapies targeting normal arterial levels of CO2 (35 mm Hg to 45 mm Hg) remain the recommendation. Prophylactic severe hyperventilation to a PaCO2 less than 30 mm Hg in the initial 48 hours after injury is not suggested. Neuromonitoring is suggested for evaluation of cerebral ischemia in cases when hyperventilation strategies are used in the management of refractory intracranial hypertension. Strategies for ventilation therapies are further discussed in the companion article of the TBI treatment algorithm.

Temperature control recommendations seem to contradict one another, but on careful review the overall recommendation is that maintaining normothermia is best. Moderate hypothermia (32-33°C) does have a place in treating increased ICP for an immediate response. A level-II recommendation regarding rewarming from the Second Edition is now more detailed and is a safety recommendation. Rewarming at a rate of 0.5 to 1° C every 12 to 24 hours or slower should be performed to avoid complications such as hypotension.13 In addition, monitoring and dosing adjustments should be followed to minimize toxicity of phenytoin during hypothermia, particularly during the rewarming phase. Phenytoin is affected by therapeutic hypothermia because the drug is metabolized by CYP2C9/19 and therapeutic hypothermia is known to decrease cytochrome p450 (CYP).14 Toxic levels of phenytoin can lead to hypotension and bradycardia.14 Challenges in dosing, a narrow therapeutic range, and effects on metabolizing the drug during rewarming require frequent monitoring of drug levels.

Nutrition has been identified as a topic of focus in not only the management of patients with severe TBI, but all critically ill patients. Based on the evidence, an immune-modulating diet is not recommended for patients with severe TBI. Enteral nutrition is suggested to improve outcomes, if started within 72 hours of injury; however, comorbidities and injuries may impede the feasibility of initiating enteral nutrition in patients with severe TBI. Comorbidities may necessitate the initiation of parenteral nutrition until the gastrointestinal tract is able to be utilized for nutritional intake.

Surgical management of TBI may be warranted when medical management has been maximized and refractory intracranial hypertension persists. There are some cases in which surgical management is deemed appropriate immediately following the injury and prior to medical management, but there remains a need for additional investigation in the timing and utility of these therapies. The second edition's recommendation on the use of a lumbar drain to drain excess cerebrospinal fluid (CSF) was removed from the third edition. An external ventricular drainage system is recommended to manage increased ICP and has the benefit of both measuring ICP and allowing for CSF drainage.

The second edition of the guidelines recommended a decompressive craniectomy “...with duraplasty, leaving the bone flap out...,” but that specific guidance was removed from the third edition. A decompressive craniectomy is currently suggested to treat neurologic deterioration, herniation, or intracranial hypertension that is refractory to medical management. Despite 14 newly added studies, the recommendations for decompressive craniectomy are not prescriptive in the indications of when to perform the surgery.

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Summary

Despite encouraging growth in the number of studies added to the evidence base for pediatric patients with severe TBI, further investigation is needed to implement evidence-based systematic approaches to treating this population. Guidelines developed by content experts and a sound method for review of the available literature are essential in the development of local protocols. The gaps in literature identified in this work should serve as a guide for clinical investigators on future research.

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REFERENCES

1. Kochanek PM, Tasker RC, Carney N, et al Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines. Pediatr Crit Care Med. 2019;20(3S suppl 1):S1–S82.
2. Kochanek PM, Tasker RC, Carney N, et al Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines, Executive Summary. Pediatr Crit Care Med. 2019;20(3):280–289.
3. Kochanek PM, Tasker RC, Bell MJ, et al Management of Pediatric Severe Traumatic Brain Injury: 2019 Consensus and Guidelines-Based Algorithm for First and Second Tier Therapies. Pediatr Crit Care Med. 2019;20(3):269–279.
4. Bailey BM, Liesemer K, Statler KD, Riva-Cambrin J, Bratton SL. Monitoring and prediction of intracranial hypertension in pediatric traumatic brain injury: clinical factors and initial head computed tomography. J Trauma Acute Care Surg. 2012;72(1):263–270.
5. American Board of Internal Medicine Foundation. Choosing Wisely. 2019. https://abimfoundation.org/what-we-do/choosing-wisely.
7. Mehta A, Kochanek PM, Tyler-Kabara E, et al Relationship of intracranial pressure and cerebral perfusion pressure with outcome in young children after severe traumatic brain injury. Dev Neurosci. 2010;32(5–6):413–419.
8. Miller Ferguson N, Shein SL, Kochanek PM, et al Intracranial hypertension and cerebral hypoperfusion in children with severe traumatic brain injury: thresholds and burden in accidental and abusive insults. Pediatr Crit Care Med. 2016;17(5):444–450.
9. Allen BB, Chiu YL, Gerber LM, Ghajar J, Greenfield JP. Age-specific cerebral perfusion pressure thresholds and survival in children and adolescents with severe traumatic brain injury. Pediatr Crit Care Med. 2014;15(1):62–70.
10. Vavilala MS, Kernic MA, Wang J, et al Acute care clinical indicators associated with discharge outcomes in children with severe traumatic brain injury. Crit Care Med. 2014;42(10):2258–2266.
11. Felmet K, Nguyen T, Clark RS, Orr D, Carcillo J. The FDA warning against prolonged sedation with propofol in children remains unwarranted. Pediatrics. 2003;112(4):1002–1003.
12. Annane D, Pastores SM, Rochwerg B, et al Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017. Intensive Care Med. 2017;43(12):1751–1763.
13. Hutchison JS, Ward RE, Lacroix J, et al Hypothermia therapy after traumatic brain injury in children. N Engl J Med. 2008;358(23):2447–2456.
14. Empey PE, Velez de Mendizabal N, Bell MJ, et al Therapeutic hypothermia decreases phenytoin elimination in children with traumatic brain injury. Crit Care Med. 2013;41(10):2379–2387.
Keywords:

advanced neuromonitoring; computed tomography; guidelines; hyperosmolar therapy; intracranial pressure; traumatic brain injury

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