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Differences in Medical Therapy Goals for Children With Severe Traumatic Brain Injury—An International Study

Bell, Michael J. MD1,2,3; Adelson, P. David MD4; Hutchison, James S. MD5; Kochanek, Patrick M. MD1,2,3; Tasker, Robert C. MBBS, MD6,7,8; Vavilala, Monica S. MD9; Beers, Sue R. PhD10; Fabio, Anthony PhD11; Kelsey, Sheryl F. PhD11; Wisniewski, Stephen R. PhD11 and the Multiple Medical Therapies for Pediatric Traumatic Brain Injury Workgroup

Pediatric Critical Care Medicine: October 2013 - Volume 14 - Issue 8 - p 811–818
doi: 10.1097/PCC.0b013e3182975e2f
Neurocritical Care

Objectives: To describe the differences in goals for their usual practice for various medical therapies from a number of international centers for children with severe traumatic brain injury.

Design: A survey of the goals from representatives of the international centers.

Setting: Thirty-two pediatric traumatic brain injury centers in the United States, United Kingdom, France, and Spain.

Patients: None.

Interventions: None.

Measurements and Main Results: A survey instrument was developed that required free-form responses from the centers regarding their usual practice goals for topics of intracranial hypertension therapies, hypoxia/ischemia prevention and detection, and metabolic support. Cerebrospinal fluid diversion strategies varied both across centers and within centers, with roughly equal proportion of centers adopting a strategy of continuous cerebrospinal fluid diversion and a strategy of no cerebrospinal fluid diversion. Use of mannitol and hypertonic saline for hyperosmolar therapies was widespread among centers (90.1% and 96.9%, respectively). Of centers using hypertonic saline, 3% saline preparations were the most common but many other concentrations were in common use. Routine hyperventilation was not reported as a standard goal and 31.3% of centers currently use PbO2 monitoring for cerebral hypoxia. The time to start nutritional support and glucose administration varied widely, with nutritional support beginning before 96 hours and glucose administration being started earlier in most centers.

Conclusions: There were marked differences in medical goals for children with severe traumatic brain injury across our international consortium, and these differences seemed to be greatest in areas with the weakest evidence in the literature. Future studies that determine the superiority of the various medical therapies outlined within our survey would be a significant advance for the pediatric neurotrauma field and may lead to new standards of care and improved study designs for clinical trials.

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

2Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA.

3Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA.

4Barrow Neurological Institute at Phoenix Children’s Hospital, Phoenix, AZ.

5Department of Critical Care Medicine, University of Toronto, Toronto, CA.

6Department of Neurology, Harvard Medical School, Boston, MA.

7Department of Anesthesia, Harvard Medical School, Boston, MA.

8Division of Critical Care, Boston Children’s Hospital, Boston, MA.

9Department of Anesthesia, University of Washington, Seattle, WA.

10Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA.

11Department of Epidemiology and Biostatistics, University of Pittsburgh, Pittsburgh, PA.

Dr. Bell (HD0499893, HD08003, and NS072308), Dr. Adelson (NS052478), Dr. Kochanek (NS070324, T32HD040686, W81XWH-09-2-0187, and W81XWH-10-0623), Dr. Vavilala (NS072308), Dr. Beers (MH56612 and MH085722), Dr. Fabio (CE001630), and Dr. Wisniewski (NS052478 and NS069247) received federal grants. Dr. Bell’s institution received grant support (HD0499893, HD08003, and NS072308). Dr. Bell received support for article research from NIH and HD0499893, HD08003, and NS072308. Dr. Adelson is employed by the Phoenix Children's Hospital and provided expert testimony for various medical legal cases. Dr. Adelson’s institution received grant support from Arizona Biomedical Research Commission, Baxter Foundation, and Codman. Dr. Hutchison is employed by SickKids, Toronto; provided expert testimony for CMPA; and lectured for the Japanese Intensive Care Society and as visiting professor. Dr. Hutchinson’s institution received grant support from Ontario Neurotranining, NIH, and CIHR. Dr. Kochanek received grant support from the National Institutes of Health (NIH), the US Army, DARPA, Laerdal Foundation, and AHA (NIH NS070324 and T32HD040686 US Army W81XWH-09-2-0187 and W81XWH-10-0623); is a co-provisional patent holder on 3 patents; and received support for article research from NIH and the US Army. Dr. Tasker received royalties from Oxford University Press (Oxford Handbook of Paediatrics). Dr. Vavilala received support for article research from NIH. Dr. Beers is employed by the University of Pittsburgh and University of Pittsburgh Physicians, provided expert testimony for various institutions, received royalties from John Wiley & Sons and Springer, and received support for travel from the National Academy of Neuropsychology (airfare to Board meeting). Dr. Beers’ institution received grant support from Family Pathways to Early Onset Suicide Attempt, Psychiatric Outcomes of Children with High- and Low-Risk for Depression, Oxidative Lipidomics in Pediatric Traumatic Brain Injury, TBI Biological Diagnosis via High Definition Tractography Asymmetry Screening, High Definition Fiber Tracking Biological Diagnosis of TBI Providing Actionable Clinical Report of Quantified Damage. Dr. Wisniewski consulted for Cyberonic Inc. (2005-2009); Ima RX, Therapeutics, Inc. (2006); Bristol-Myers Squibb Company (2007-2008); Organon (2007); Case-Western University (2007); Singapore Clinical Research Institute (2009); Dey Pharmaceuticals (2010); Venebio (2010); and Dey (2010) and received grant support from Eli Lilly (2012). The remaining authors have disclosed that they do not have any potential conflicts of interest.

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©2013The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies