Aggressive Physiologic Monitoring of Pediatric Head Trauma Patients with Elevated Intracranial Pressure

Kasoff, Samuel S.; Lansen, Thomas A.; Holder, Donovan O.; Filippo, Joseph San

doi:10.1159/000120397

Cited by 78 publications

(39 citation statements)

References 32 publications

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“…Perhaps, our patients were able to be weaned from barbiturates earlier because they responded to lumbar drainage with lowered ICP while enjoying some form of barbiturate cerebral protection before institution of drain age. Given the potential deleterious effects of barbiturates, including cardiovascular depression, hypotension, sepsis, and dehydration [9], a safer alternative therapy for uncon trollable ICP is appealing. This report contributes to the literature another series of children with uncontrollable ICP, some of whom not only survived but actually had a functional outcome.…”

Section: Resultsmentioning

confidence: 99%

Preliminary Experience with Controlled External Lumbar Drainage in Diffuse Pediatric Head Injury

Baldwin

Rekate²

1991

Pediatr Neurosurg

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Our experience with the use of external lumbar subarachnoid drainage in 5 children with severe diffuse head injuries is presented. All patients had Glasgow Coma Scale scores of 8 or less at 24 h after injury and were initially treated with ventriculostomies. Two children required surgical evacuation of focal mass lesions. Within 72 h of admission, all children manifested high intracranial pressures (ICP) refractory to maximal therapy, including hyperventi-lation, furosemide, mannitol, and barbiturate coma. After the institution of lumbar drainage, 3 of the 5 children had an abrupt and lasting decrease in ICP, obviating the need for continued barbiturates and hyperventilation. Three children survived, 2 of whom made good recoveries; 1 child is functional with disability. ICP varied passively with the height of the drainage bag in these surviving patients. Two patients died, most likely from uncontrolled ICP before the lumbar drain was placed. We conclude that controlled external lumbar subarachnoid drainage is a potentially useful treatment for severe diffuse pediatric head injury when maximal medical therapy and ventricular cerebrospinal fluid (CSF) evacuation have failed to control high ICP. Posttraumatic CSF circulation disruption, white matter cerebral edema, and intracranial venous hypertension can be treated with this modality in the absence of focal mass lesions.

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Section: Resultsmentioning

confidence: 99%

Preliminary Experience with Controlled External Lumbar Drainage in Diffuse Pediatric Head Injury

Baldwin

Rekate²

1991

Pediatr Neurosurg

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“…5 The significance of intracranial hypertension in predicting outcome from TBI has been well studied since the 1960s. 2,4,12,17,19,20 Aside from its prognostic value, ICP monitoring also guides early diagnosis and management of intracranial hypertension. 29 Furthermore, there are now several evidence-based studies showing that ICP monitoring, when used in a protocol-based manner in neurosurgical ICUs, leads to improved outcomes in adjusted mortality rates for patients with severe TBI.…”

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confidence: 99%

Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring

Farahvar

Gerber²,

Chiu³

et al. 2012

JNS

172

128

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Object. Evidence-based guidelines recommend intracranial pressure (ICP) monitoring for patients with severe traumatic brain injury (TBI), but there is limited evidence that monitoring and treating intracranial hypertension reduces mortality. This study uses a large, prospectively collected database to examine the effect on 2-week mortality of ICP reduction therapies administered to patients with severe TBI treated either with or without an ICP monitor.Methods. From a population of 2134 patients with severe TBI (Glasgow Coma Scale [GCS] Score < 9), 1446 patients were treated with ICP-lowering therapies. Of those, 1202 had an ICP monitor inserted and 244 were treated without monitoring. Patients were admitted to one of 20 Level I and two Level II trauma centers, part of a New York State quality improvement program administered by the Brain Trauma Foundation between 2000 and 2009. This database also contains information on known independent early prognostic indicators of mortality, including age, admission GCS score, pupillary status, CT scanning findings, and hypotension.Results. Age, initial GCS score, hypotension, and CT scan findings were associated with 2-week mortality. In addition, patients of all ages treated with an ICP monitor in place had lower mortality at 2 weeks (p = 0.02) than those treated without an ICP monitor, after adjusting for parameters that independently affect mortality.Conclusions. In patients with severe TBI treated for intracranial hypertension, the use of an ICP monitor is associated with significantly lower mortality when compared with patients treated without an ICP monitor. Based on these findings, the authors conclude that ICP-directed therapy in patients with severe TBI should be guided by ICP monitoring. (http://thejns.org/doi/abs/10.3171/2012.7.JNS111816) KeY WorDs • intracranial pressure • mortality rate • traumatic brain injury • evidence-based guidelines 729Abbreviations used in this paper: AANS = American Association of Neurological Surgeons; BTF = Brain Trauma Foundation; CNS = Congress of Neurological Surgeons; GCS = Glasgow Coma Scale; ICP = intracranial pressure; TBI = traumatic brain injury.

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“…In 1979, Marshall et al [14] reported on a series of 25 patients with ICP >40 mm Hg showing a reduction in mortality with the use of barbiturates. In 1988, Kasoff et al [15] reported on 25 TBI children who were treated with barbiturates with ICP, MAP, CPP, and hemodynamic stability monitoring. The authors showed an overall decrease in ICP and stressed the importance of hemodynamic stability.…”

Section: Discussionmentioning

confidence: 99%

Initial Observations of Combination Barbiturate Coma and Decompressive Craniectomy for the Management of Severe Pediatric Traumatic Brain Injury

et al. 2011

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Objective: In the pediatric population, treatment of severely injured children presenting with low Glasgow Coma Score (GCS) and fixed and dilated pupils is controversial. The combination of barbiturate coma and decompressive craniectomy as an aggressive means of controlling intracranial pressure is limited to few studies. In the present series, we report our experience with aggressive combination therapy resulting in good outcomes in pediatric patients with severe traumatic brain injury (TBI). Patients and Methods: Six TBI patients, aged <18 years, either presented with or deteriorated to a GCS <5 with fixed and dilated pupils and CT evidence of surgical lesions with brain edema. Despite hyperventilation, anesthesia, and mannitol, intracranial pressures remained elevated and all patients underwent decompressive craniectomy and external ventricular drainage and were subsequently placed into barbiturate coma for 72 h. Results: One patient died and 1 patient remained vegetative. Two patients had excellent recoveries (GOS 5/Rankin 1 or 0, no cognitive deficits) and 2 patients had good recoveries (GOS 4/Rankin 1, mild cognitive deficits). Conclusions: Combination of barbiturate coma with decompressive craniectomy and external ventricular drainage led to good outcomes in a small group of pediatric patients with severe TBI. Based on this series we recommend further investigation into aggressive combination management.

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Aggressive Physiologic Monitoring of Pediatric Head Trauma Patients with Elevated Intracranial Pressure

Cited by 78 publications

References 32 publications

Preliminary Experience with Controlled External Lumbar Drainage in Diffuse Pediatric Head Injury

Preliminary Experience with Controlled External Lumbar Drainage in Diffuse Pediatric Head Injury

Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring

Initial Observations of Combination Barbiturate Coma and Decompressive Craniectomy for the Management of Severe Pediatric Traumatic Brain Injury

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