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|Year : 2016 | Volume
| Issue : 5 | Page : 958-961
Is intracranial pressure monitoring useful in children with severe traumatic brain injury?
Sekar Arunkumar1, Bhagavatula Indira Devi1, Dhaval Shukla1, Madhusudhan Reddy2
1 Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
2 Department of Neuroanesthesiology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
|Date of Web Publication||12-Sep-2016|
Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore - 560 029, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Intracranial pressure monitoring (ICP) is considered as optional for management of severe traumatic brain injury (TBI) in children.
Aims: This study was performed to determine whether ICP monitoring is beneficial in the managing severe TBI in children.
Settings and Design: Neurosurgical intensive care unit (ICU) of a tertiary care referral center; prospective observational study.
Materials and Methods: Children aged 16 years or less with severe TBI defined as “postresuscitation Glasgow Coma Scale (GCS) score of 8 or less admitted to an ICU” were enrolled. All children underwent standard treatment for TBI as indicated. ICP monitoring was done in 30 cases and was not done in 20 cases. The outcome in both the groups was assessed using Glasgow outcome scale.
Statistical Analysis: The characteristics of the patients in the two groups were compared using independent sample T test for continuous variables and chi-square and Mann–Whitney test for nonparametric variables.
Results: The children who did not undergo ICP monitoring required more number of doses of hyperosmolar agents. However, the duration of ventilation and length of ICU stay were significantly shorter in children who did not undergo ICP monitoring. The outcome was unfavorable in 16.7% of children who underwent ICP monitoring as compared with 55% of children who did not undergo ICP monitoring; this difference was significant.
Conclusions: ICP-targeted therapy results in significantly better outcome in children with severe TBI.
Keywords: Children; hyperosmolar therapy; intracranial pressure; traumatic brain injury
|How to cite this article:|
Arunkumar S, Devi BI, Shukla D, Reddy M. Is intracranial pressure monitoring useful in children with severe traumatic brain injury?. Neurol India 2016;64:958-61
| » Introduction|| |
Intracranial pressure (ICP) monitoring is a cornerstone of neuromonitoring in intensive care units (ICUs). The ICP monitoring is widely accepted for management of severe traumatic brain injury (TBI) in adults. The association of intracranial hypertension and poor neurologic outcome, and the concordance of protocol-based intracranial hypertension therapy with best clinical outcomes, is widely reported.,, Although the incidence of intracranial hypertension (ICH) in children with severe TBI is high, ICP monitoring is not universally practiced for children. Intracranial hypertension is difficult to diagnose and is associated with poor neurologic outcomes and death in infants and young children., Intracranial hypertension may be present in children with open fontanelles and sutures. ICP monitoring is of significant use in these patient populations, but guidelines are not universally accepted., The indications for ICP monitoring have not been unequivocaly established according to the second edition of guidelines for the acute management of severe TBI in children by the Brain Trauma Foundation (BTF). These guidelines were derived from class 3 studies. The guidelines state that the “use of ICP monitoring may be considered in infants and children with severe TBI” as level 3 recommendation.” This lacuna in literature calls for further studies to determine the utility of ICP monitoring in children with severe TBI. We conducted a prospective study of children with severe TBI, with an intention to determine whether or not ICP monitoring reduces mortality.
| » Materials and Methods|| |
This is a prospective observational study for which a previous approval from the institute's ethics committee was taken. The study was later registered with clinical trials registry of India (REF/2015/03/008696). The study was conducted in a neurosurgery ICU of a tertiary neurosurgical center during the period from January 2012 to June 2014. All patients with severe head injury and aged ≤16 years were enrolled in the study after obtaining an informed consent from the available relative. Severe head injury was defined as pediatric Glasgow Coma Scale score (GCS) ≤8 after resuscitation. Children with systemic injuries that required immediate treatment were excluded. A computed tomographic (CT) scan of the head was obtained at admission. Any patient with traumatic lesion requiring immediate surgery were operated on, and then managed in the ICU in the postoperative period. Patients not requiring surgery were shifted directly to the ICU. The children were sedated and mechanically ventilated, with head-end elevation. A routine CT scan of the head was repeated after 24 hours and 5 days. A CT scan was also repeated in between if there was any neurological deterioration. The ICP monitoring using ventricular catheter was considered for all children; however, many children did not undergo ICP monitoring and formed a control group. The duration of ICP monitoring was 5 days. If the patient improved in consciousness to the extent of obeying commands or the ICP remained within the normal range for 48 hours, the catheter was removed early. The aim of the therapy was to maintain the ICP below 15 mmHg in children 1–10 years of age and below 18 mmHg in children 11–16 years of age., The initial treatment for a raised ICP episode was release of cerebrospinal fluid (CSF). Despite CSF release, if the ICP remained persistently above the cutoff value for more than 5 minutes, the patient received hyperosmolar therapy, which included equiosmolar dose of 3% saline (2.5 ml/kg) or 20% mannitol (0.5 g/kg), infused as a bolus through the central venous line over a period of 5 minutes. If the ICP did not decrease even after three doses of the hyperosmolar agent, it was considered refractory to therapy, and the third-tier treatment including hyperventilation, decompressive craniectomy, or continuous CSF drainage, based on the imaging and clinical findings, was instituted. Follow-up was done after 6 months using Glasgow Outcome Scale (GOS) modified for children. The primary end point was an unfavorable outcome (death or vegetative state) after 6 months versus a favorable outcome (severe disability, moderate disability, or a good recovery).
OpenEpi Version 3.03 was used for statistical analysis. The baseline characteristics of the patients in the two groups were compared using independent sample T test for continuous variables and chi-square and Mann–Whitney test for nonparametric variables. A P < 0.05 was considered as significant. A P value closer to 1 was mentioned as not significant (NS).
| » Results|| |
A total of 50 children with severe TBI were enrolled between January 2012 and June 2014. The ICP could not be monitored in 20 children owing to various reasons, and they formed the control group. The ICP monitoring was done in 30 children, who formed the intervention group. The baseline demographic, clinical, and imaging characteristics of both groups of patients is given in [Table 1]. Both groups were comparable in all the variables measured except age and surgical intervention. The mean GCS and motor score was 7 and 4.4 in each group, respectively. The mean Marshall CT scan grade was 2.5 in the ICP-monitored group and 3.2 in the control group. The children who underwent ICP monitoring were older. More number of children in whom ICP was not monitored underwent surgery. The children who did not undergo ICP monitoring required more number of doses of the hyperosmolar agent. However, the duration of ventilation and the length of ICU stay were significantly shorter in children who did not undergo ICP monitoring. The outcome was unfavorable in 16.7% of children who underwent ICP monitoring as compared with 55% of children who did not underwent ICP monitoring; this difference was significant [Table 2]. One child who underwent ICP monitoring died of ventriculitis.
| » Discussion|| |
Intracranial hypertension is a key variable associated with secondary brain injury after severe TBI. Intracranial hypertension is associated with a poor neurological outcome and death in children. Intracranial hypertension can be effectively managed by ICP monitoring. The ICP monitoring is practiced for management of severe traumatic brain injury (TBI) in adults. The BTF has laid the criteria for ICP monitoring for severe TBI in adults. However, ICP monitoring is not frequently practiced for children even though they have a higher incidence of intracranial hypertension after severe TBI.5 In a study from all the pediatric critical care units of North Carolina, only 33% of children with severe TBI underwent ICP monitoring. In a recent survey of the National Trauma Data Bank, ICP monitoring was performed in only 7.7% of children who met the monitoring criteria recommended by the BTF. Moreover, there is no consensus on the threshold of ICP for treatment. In a survey of 32 centers that routinely monitor ICP for children with severe TBI, all centers reported that they use an ICP threshold of 20 mmHg for the majority of subjects. Eight (25%) centers reported that they use slightly lower ICP thresholds for the youngest children (10 mmHg at one center, 15 mmHg at four centers, and 18 mmHg at three centers). The reason for the lack of compliance to BTF guidelines is that it is still unclear whether ICP monitoring improves outcome of severe TBI in children. The National Trauma Data Bank survey revealed that ICP monitoring in children was associated with a reduction in mortality only for patients with a GCS score of 3 (odds ratio, 0.64; 95% confidence interval, 0.43-1.00). However, the ICP monitoring group had a significantly longer length of hospital stay (21.0 days vs. 10.4 days; P < 0.001), longer ICU stay (12.6 vs. 6.3 days; P < 0.001), and more days on ventilator (9.2 vs. 4.7; P < 0.001). The BTF reviewed 11 class 3 studies to give recommendations on ICP monitoring in children. However, none of the studies compared the effect of ICP-directed therapy on outcome. The pooled result of these studies was that ICP monitoring-based therapy is associated with a better survival advantage and neurological outcome. Owing to these shortcomings, the BTF guidelines for management of severe TBI in children have recommended ICP monitoring as an option.
In the present study, we prospectively studied children with severe TBI, with an intention to monitor ICP monitoring in all the subjects. Unfortunately, ICP could not be monitored in a few children owing to various logistic reasons, and hence, they formed the control group. We could not conduct a randomized trial. We used age-specific thresholds for treatment of intracranial hypertension. We compared the effect of ICP-targeted therapy. The children who underwent ICP monitoring were significantly younger. More number of children who did not undergo ICP monitoring underwent surgery. However, there were no differences between the key predictors of outcome, that is, GCS, pupillary reaction, and CT scan grade, between the two groups. The high incidence of unfavorable outcome in children who did not undergo ICP monitoring may be due to more number of cases requiring surgical intervention in this group, indicating a more severe injury. We found that ICP monitoring was associated with reduced incidence of an unfavorable outcome. The possible reason for the reduction in an unfavorable outcome in this group was the administration of a more aggressive therapy. We instituted a multilayered approach for ICP reduction: first, CSF drainage, and then, administration of hyperosmolar therapy. The children who did not undergo ICP monitoring were given only hyperosmolar therapy based on clinical and CT scan findings. These children received significantly more number of doses of hyperosmolar therapy. There is a high possibility that these children may have had untreated raised ICP episodes in between the doses of hyperosmolar therapy. These missed episodes of intracranial hypertension may have been the reason for the poor outcome. Moreover, CSF drainage was not available for children who did not undergo ICP monitoring. ICP monitoring also comes at a cost. The children who underwent ICP monitoring had significantly more number of days of stay in the ICU and ventilation. One child who underwent ICP monitoring died of ventriculitis.
The major limitation of our study was that it was not a randomized trial, and a high quality of evidence could not be generated. We did not adjust for the variables (age and surgery) that were different in the two groups because the number of cases were too less to perform a multivariable analysis. However, there was no difference between the two groups for the variables that were strong predictors of outcome.
| » Conclusion|| |
Although our study indicated that ICP monitoring using an EVD and ICP-targeted therapy with CSF drainage and hyperosmolar therapy results in a significantly better outcome in children with severe TBI, this result should be interpreted cautiously because more number of children who did not undergo ICP monitoring required surgery, indicating probably the presence of a more severe injury in them. As the ICP monitoring is not practiced frequently for children, a large prospective randomized trial is required to generate a strong evidence for the utility of ICP monitoring in children with severe TBI.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]